In primary anterior cruciate ligament reconstruction, is a hamstring tendon autograft preferred over a quadriceps tendon autograft?

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ACL Graft Choice: Hamstring vs Quadriceps Tendon

Neither hamstring nor quadriceps tendon autograft is definitively preferred over the other for primary ACL reconstruction, as both demonstrate equivalent graft failure rates, knee stability, and functional outcomes. However, the choice should be guided by specific patient priorities regarding donor site morbidity and postoperative complications.

Current Guideline Framework

The 2023 AAOS Clinical Practice Guidelines 1 provide moderate evidence recommendations for autograft selection but do not specifically address quadriceps tendon autografts. The guidelines focus on bone-patellar tendon-bone (BTB) versus hamstring comparisons, stating surgeons may favor:

  • BTB to reduce graft failure or infection risk
  • Hamstring to reduce anterior knee pain or kneeling pain

Notably, quadriceps tendon is not mentioned in these guidelines, representing a significant gap given emerging evidence.

Evidence-Based Comparison: Hamstring vs Quadriceps

Graft Failure & Stability (Primary Outcomes for Morbidity/Mortality)

The most recent and highest quality evidence shows no difference in graft failure rates between hamstring and quadriceps autografts:

  • 2025 systematic review and meta-analysis 2 of RCTs found identical graft failure rates (RR = 1.00; 95% CI = 0.97-1.04; p = 0.83) with high certainty evidence
  • 2024 RCT 3 showed no difference in knee laxity at 6,12, or 24 months (HT mean 1.1-1.2mm vs QT mean 1.2-1.3mm; p = 0.487)
  • 2024 systematic review 4 confirmed no difference in graft failure (p = 0.92) or overall adverse events (p = 0.83)

Donor Site Morbidity (Quality of Life Outcome)

Quadriceps tendon demonstrates significantly lower donor site morbidity:

  • 2025 meta-analysis 2: QT showed lower donor site morbidity (RR = 1.45; 95% CI = 1.24-1.70; p < 0.001) with high certainty evidence
  • 2023 matched-pairs study 5: QT had 11.5% donor site morbidity vs 46.7% for hamstring (p = 0.008) at mean 6.5-year follow-up
  • 2024 systematic review 4: Donor site morbidity scores significantly lower with QT (MD -4.67; p = 0.05)

Functional Outcomes & Patient-Reported Measures

No clinically meaningful differences exist:

  • IKDC scores: No difference at 12 or 24 months 2, 3, 4
  • Lysholm scores: Equivalent between groups 3, 4
  • Tegner activity levels: No difference 3, 5
  • Return to sport rates: Similar (QT 82.1% vs HT 86.7%) 5

Important caveat: The 2024 RCT 3 found hamstring patients had significantly better ACL-RSI (psychological readiness) scores at 3,6, and 12 months (p = 0.008-0.014), though this difference resolved by 24 months.

Strength Deficits (Quality of Life Consideration)

Each graft creates predictable, opposite strength deficits:

  • Hamstring grafts: Greater quadriceps strength preservation (LSI advantage at 6-12 months) 3
  • Quadriceps grafts: Greater hamstring strength preservation (LSI advantage at 6,12, and 24 months) 3

This represents a trade-off rather than superiority of either graft.

Clinical Decision Algorithm

Choose Quadriceps Tendon when:

  1. Minimizing donor site morbidity is the priority (strongest evidence advantage)
  2. Patient has concerns about anterior knee or kneeling pain
  3. Hamstring strength preservation is important for sport/occupation
  4. Patient is highly active (trend toward lower failure in QT for high-activity patients) 5

Choose Hamstring Tendon when:

  1. Quadriceps strength preservation is critical for sport/occupation
  2. Patient prioritizes early psychological readiness to return to sport
  3. Surgeon has greater technical experience/comfort with hamstring harvest
  4. Following AAOS guideline framework to reduce anterior knee pain risk 1

Consider Augmentation with hamstring:

  • The AAOS guidelines 1 recommend considering ALL reconstruction or lateral extra-articular tenodesis with hamstring autografts in select patients to reduce graft failure (moderate evidence), though long-term outcomes remain unclear

Critical Pitfalls to Avoid

  1. Don't assume hamstring is "safer" based on older guidelines—quadriceps has equivalent failure rates with better donor site outcomes
  2. Don't ignore the strength deficit trade-off—counsel patients that each graft sacrifices different muscle groups
  3. Don't overlook high-activity patients—there's a concerning trend toward higher hamstring failure rates in highly active patients (37.5% vs 22.2% for QT, though not statistically significant) 5
  4. Don't dismiss donor site morbidity—this significantly impacts quality of life and is where quadriceps shows clear superiority

Strength of Evidence Assessment

The evidence comparing hamstring to quadriceps is stronger and more recent than the AAOS guideline evidence comparing hamstring to BTB. Multiple high-quality RCTs and systematic reviews from 2024-2025 2, 3, 4 provide level I evidence with high certainty for equivalent graft survival but superior donor site outcomes with quadriceps tendon.

The absence of quadriceps tendon from the 2023 AAOS guidelines represents a significant evidence gap that clinicians should recognize when counseling patients.

References

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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