Comparison of quadriceps and hamstring tendon autograft in primary anterior cruciate ligament reconstruction: A meta-analysis and systematic review of randomized controlled trials

Background and Aims: Anterior cruciate ligament reconstruction (ACLR) is commonly performed using autografts. Hamstring tendon (HT) grafts are traditionally favored, and in recent times, quadriceps tendon (QT) grafts are gaining popularity. This systematic review and meta-analysis aimed to compare patient-reported outcomes, graft failure rates, adverse events, and donor site morbidity between QT and HT autografts in primary ACLR. Materials and Methods: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Multiple databases were searched to identify randomized controlled trials (RCTs) comparing QT and HT autografts in primary ACLR. Outcomes included International Knee Documentation Committee (IKDC) scores, Lysholm Knee Questionnaire, Tegner Activity Scale, graft failure rates, adverse events, and donor site morbidity. Meta-analysis was performed using standardized mean differences and odds ratios with assessment of heterogeneity. The quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation framework. Results: Six RCTs comprising 426 patients were included. Meta-analysis demonstrated no significant differences between QT and HT autografts in IKDC scores, Lysholm scores, or Tegner activity levels at final follow-up. Graft failure rates and overall adverse event rates were also comparable between groups. However, QT autografts were associated with significantly lower donor site morbidity scores at 24 months. The overall quality of evidence ranged from low to moderate, with generally low heterogeneity across pooled outcomes. Conclusion: QT autografts provide clinical outcomes, graft survival, and safety profiles comparable to HT autografts in primary ACLR, with the added advantage of reduced donor site morbidity. These findings support that QT autografts are a safe and effective alternative to HT autografts.