ACL Revision Rates: BPTB vs Quadriceps Tendon Autografts
Based on the highest quality recent evidence, BPTB autograft demonstrates significantly lower revision rates (1.2% at 2 years) compared to quadriceps tendon autograft (3.6% at 2 years), representing a 60% lower risk of revision surgery. 1
Primary Evidence on Revision Risk
BPTB Autograft Performance
- BPTB autograft has the lowest 2-year revision rate at 1.2% in a large registry study of 24,790 primary ACL reconstructions 1
- When compared directly to quadriceps tendon, BPTB demonstrates a hazard ratio of 0.4 (95% CI 0.2-0.7, p<0.001), indicating 60% lower revision risk 1
- This represents the most robust comparative data available from the Norwegian Knee Ligament Register spanning 2004-2021 1
Quadriceps Tendon Autograft Performance
- Quadriceps tendon autograft shows a 2-year revision rate of 3.6%, which is the highest among the three major autograft types 1
- Despite theoretical biomechanical advantages (70% greater ultimate load than patellar tendon, 20% more collagen fibrils per cross-sectional area), clinical revision rates remain elevated 2
- The most common reasons for revision with quadriceps tendon are traumatic graft rupture and nontraumatic graft failure 1
Comparative Analysis with Hamstring Tendon
- Hamstring tendon autograft demonstrates an intermediate 2-year revision rate of 2.5% 1
- No statistically significant difference exists between quadriceps tendon and hamstring tendon revision risk (HR 1.1,95% CI 0.7-1.8) 1
- In revision ACL reconstruction settings, hamstring grafts show a 19% failure rate compared to 10% for both quadriceps tendon and BPTB 3
Patient-Reported Outcomes
Functional Recovery
- All three graft types (BPTB, quadriceps tendon, hamstring) demonstrate equivalent patient-reported outcomes at 2-year follow-up with no significant differences in KOOS Sport and Quality of Life subscores 1
- Meta-analysis confirms no significant differences in IKDC subjective scores between quadriceps tendon and BPTB (p=0.39) or between quadriceps tendon and hamstring (p=0.25) 4
- Side-to-side stability differences show no significant variation between graft types 4
Donor Site Morbidity Trade-offs
- Quadriceps tendon demonstrates significantly lower donor site morbidity compared to BPTB (RR 0.17,95% CI 0.09-0.33, p<0.001) 4
- Quadriceps tendon also shows lower donor site morbidity than hamstring tendon (RR 0.60,95% CI 0.39-0.93, p=0.02) 4
- BPTB grafts are associated with increased anterior knee pain and kneeling pain compared to other autograft options 5
Clinical Decision Algorithm
When to Choose BPTB
- Primary indication: Patients requiring the lowest possible revision risk, particularly young athletes in high-demand sports 1
- Acceptable trade-off: Higher donor site morbidity and anterior knee pain for superior graft survival 5, 4
- Contraindications: Patients with pre-existing patellofemoral pain or occupations requiring frequent kneeling 5
When to Consider Quadriceps Tendon
- Patients where donor site morbidity is the primary concern over revision risk 4
- Revision ACL reconstruction cases where BPTB or hamstring sites have been previously harvested 3
- Patients requiring customizable graft dimensions (7-11mm diameter possible) 2
- Critical caveat: Accept 3-fold higher revision risk compared to BPTB 1
Important Clinical Pitfalls
Patient Demographics Matter
- Younger patients demonstrate higher revision rates across all graft types, with every 5-year increase in age reducing revision risk by 33% (HR 0.67,95% CI 0.61-0.73) 6
- Male patients show 47% higher revision risk compared to females (HR 1.47,95% CI 1.04-2.07) 6
- The quadriceps tendon cohort in registry data was younger (mean 23.5 years) and had more female patients (58.2%), potentially confounding direct comparisons 1
Rehabilitation Protocol Considerations
- For BPTB grafts: Open kinetic chain exercises can begin at 4 weeks postoperatively in 90-45° ROM with added resistance 7, 5
- For quadriceps tendon grafts: Similar rehabilitation timeline but requires specific donor site protection strategies 8
- Closed kinetic chain exercises should be prioritized from week 2 for both graft types to minimize patellofemoral stress 7, 8
Long-term Osteoarthritis Risk
- Graft source (patellar tendon vs other autografts) does not influence long-term osteoarthritis development (very low certainty evidence) 7, 9
- Concomitant meniscectomy dramatically increases OA risk: partial meniscectomy OR 1.87 (95% CI 1.45-2.42), total medial meniscectomy OR 3.14 (95% CI 2.20-4.48) 7, 9
- Cartilage injury at time of reconstruction increases OA odds 2.31-fold (95% CI 1.35-3.94) 7, 9