Precision anterior cruciate ligament (ACL) reconstruction in high-level athletes

Background:Anterior cruciate ligament (ACL) injuries commonly occur in athletes, and ACL reconstruction (ACLR) after ACL injury can predictably allow athletes to return to sports (RTS). However, the time to RTS can be variable and dependent on a variety of patient and surgical factors.Purpose:To evaluate the associations between hamstring tendon (HT), quadriceps tendon (QT), and bone-patellar tendon-bone (BPTB) autograft choice and RTS data for athletes after primary ACLR.Study Design:Cohort study; Level of evidence, 3.Methods:Recreational and competitive athletes aged between 13 and 24 years, undergoing primary ACLR at an academic tertiary institution located in the central United States from 2010 to 2022, were included in the study. RTS outcome variables, including time from procedure to RTS clearance, return to previous level, return to competition, and reinjury (ACL retear and meniscus tear), if found to be significantly associated with autograft type, were subsequently assessed using Wilcoxon rank-sum tests with Bonferroni correction and logistic regression, with the HT autograft as the reference, to investigate the relationship between different autograft types and patients' recovery and clearance status. Graft failure was based on clinical history of reinjury, physical examination, magnetic resonance imaging, and/or revision surgery.Results:A total of 200 patients who had ACLR were included in this study. Athletes with hamstring tendon autografts were cleared at 25.4 weeks postoperatively, while those treated with BPTB and QT autografts were cleared at 41.1 and 37.6 weeks, respectively (P < .001). Of 55 athletes treated with the HT, 53 (96.4%) returned to competition. Also, 43 of 43 (100%) of athletes treated with BPTB autografts, and 22 of 22 (100%) athletes treated with QT autografts returned to competition. Moreover, 34 of 88 (38.6%) of HT autografts, 8 of 83 (9.6%) BPTB autografts, and 3 of 28 (10.7%) QT autografts had a subsequent ACL graft failure (P < .001). After adjusting for sports level, QT and BPTB autografts continued to have reduced rates of reinjury and subsequent meniscal tear when compared with HT autografts.Conclusion:HT autograft patients, on average, were cleared sooner and more likely to suffer an ACL graft tear compared with BPTB or QT patients. However, all 3 graft choices demonstrated similar RTS rates. This study is important for shared decision-making between orthopaedic surgeons and athletes when determining the optimal, patient-specific graft for ACLR.

Background: In recent years, anterior cruciate ligament (ACL) injuries in children and adolescents (age ≤18 years) have been increasing, and the quadriceps tendon (QT) autograft has been gaining popularity for ACL reconstruction. However, there is no consensus regarding the graft choice for ACL reconstruction in these young patients. There has been a paucity of literature comparing the functional outcomes of hamstring tendon (HT) and QT autografts for ACL reconstruction in patients aged ≤18 years. Purpose/Hypothesis: The purpose of this study was to compare the outcomes of HT and QT autografts for ACL reconstruction in pediatric and adolescent patients (age ≤18 years) in terms of patient-reported outcome measure (PROM) scores, knee stability, graft failure rates, and sports participation after ACL reconstruction. The hypothesis was that the QT autograft would result in better functional outcomes with a high rate of return to sporting activity and a low rate of graft failure after ACL reconstruction compared with the HT autograft in this population. Study Design: Retrospective cohort study; Level of evidence, 3. Methods: From 2010 to 2022, there were 2417 ACL reconstruction procedures performed at our institution. The inclusion criteria were primary ACL reconstruction using an HT or QT autograft and age ≤18 years. The exclusion criteria were revision ACL reconstruction; utilization of a graft type other than HT and QT autografts; and concomitant posterior cruciate ligament injuries, contralateral knee injuries, and conditions that might interfere with a standard postoperative rehabilitation protocol. A minimally invasive technique was used for QT autograft harvesting. The size of the QT graft ranged from 8 to 9 mm with specific instrumentation. Similarly, the size of the HT graft ranged from 8 to 9 mm. Patients were evaluated preoperatively and at 2-year follow-up for the Lysholm knee score, Tegner activity level, and visual analog scale (VAS) for pain; knee stability (Lachman and pivot-shift tests); graft failure; and sports participation. The Lachman test and pivot-shift test were performed preoperatively under anesthesia and postoperatively at 2-year follow-up. Results: The number of patients in the HT and QT groups was 77 and 80, respectively. The 2 groups did not differ significantly in terms of age, sex, and concomitant injuries. No significant difference was found in preinjury PROM scores (Lysholm, Tegner, and VAS) and knee stability between the 2 groups (P > .05). Similarly, no significant difference was observed at 2-year follow-up between the 2 groups for PROM scores and knee stability (P > .05). The Lysholm, Tegner, and VAS scores improved to preinjury values in both the groups, and no significant difference was found in Lysholm, Tegner, and VAS scores between preinjury and 2-year follow-up (P > .05). At 2-year follow-up, both the groups achieved sports participation at the preinjury level (P > .05). Graft failure occurred in 11 (14%) and 8 (10%) patients of the HT and QT groups, respectively. The rate of failure did not differ significantly between groups (P > .05). Conclusion: A QT autograft for ACL reconstruction led to similar clinical outcomes, revision rates, and sports participation compared with an HT autograft in pediatric and adolescent patients.

Quadriceps tendon (QT) autograft represents an excellent option for anterior cruciate ligament (ACL) reconstruction (ACLR), with minimal donor site morbidity and failure rates comparable with bone-patellar tendon-bone (BPTB) autograft. This video aims to provide technical tips for ACLR using all-soft-tissue QT autograft. ACLR with QT autograft is indicated in young, active ACL-injured patients who desire a return to sport. It represents a viable option in both primary and revision ACLR, as well as in skeletally immature patients. It is particularly indicated in those who kneel frequently, such as wrestlers or laborers, due to the lower incidence of postoperative anterior knee pain. A vertical incision is used to harvest a 10 mm × 70 mm partial thickness, all-soft-tissue QT graft. Care is taken not to violate the capsule or musculature. If necessary, graft size is modified based on preoperative magnetic resonance imaging (MRI) measurement of the notch width. The graft is then prepared with continuous loop suspensory fixation on the femoral side and draw sutures on the tibial side. The lateral femoral notch is debrided to allow for visualization of the posterior wall to enable anatomic tunnel placement. When possible, the tibial stump is preserved. The femoral tunnel is drilled via an anteromedial portal and the tibial tunnel via a tibial guide. The graft is then passed through the tibial stump into the femur. It is fixed on the tibial side with a PEEK interference screw in full extension with application of a posterior drawer. Outcomes following ACLR with QT autograft are excellent, with laxity and patient-reported outcomes comparable with those following ACLR with BPTB and hamstring autograft. Furthermore, QT ACLR has been shown to result in less donor site morbidity than BPTB autograft, and lower rates of failure and infection compared with hamstring autograft. ACLR with QT autograft is a good option in young, active patients in both the primary and revision settings. Advantages of QT ACLR include less donor site morbidity than BPTB, and lower rates of failure compared with hamstring autograft in young patients. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: The best type of autograft for anterior cruciate ligament (ACL) reconstruction remains debatable. Hypothesis: Compared with bone–patellar tendon–bone (BPTB) and hamstring tendon (HT) autografts, the quadriceps tendon (QT) autograft has comparable graft survival as well as clinical function and pain outcomes. Study Design: Meta-analysis; Level of evidence, 4. Methods: A systematic literature search was conducted in PubMed, Embase, Scopus, and the Cochrane Library to July 2020. Randomized controlled trials (RCTs) and observational studies reporting comparisons of QT versus BPTB or HT autografts for ACL reconstruction were included. All analyses were stratified according to study design: RCTs or observational studies. Results: A total of 24 studies were included: 7 RCTs and 17 observational studies. The 7 RCTs included 388 patients, and the 17 observational studies included 19,196 patients. No significant differences in graft failure (P = .36), the International Knee Documentation Committee (IKDC) subjective score (P = .39), or the side-to-side difference in stability (P = .60) were noted between QT and BPTB autografts. However, a significant reduction in donor site morbidity was noted in the QT group compared with the BPTB group (risk ratio [RR], 0.17 [95% CI, 0.09-0.33]; P < .001). No significant differences in graft failure (P = .57), the IKDC subjective score (P = .25), or the side-to-side stability difference (P = .98) were noted between QT and HT autografts. However, the QT autograft was associated with a significantly lower rate of donor site morbidity than the HT autograft (RR, 0.60 [95% CI, 0.39-0.93]; P = .02). A similar graft failure rate between the QT and control groups was observed after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. However, a significantly lower rate of donor site morbidity was observed in the QT group compared with the control group after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. No difference in effect estimates was seen between RCTs and observational studies. Conclusion: The QT autograft had comparable graft survival, functional outcomes, and stability outcomes compared with BPTB and HT autografts. However, donor site morbidity was significantly lower with the QT autograft than with BPTB and HT autografts.

The use of quadriceps tendon (QT) autograft for anterior cruciate ligament (ACL) reconstruction has been increasing since 2014. Studies have shown that QT is comparable to hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts in terms of outcomes, although QT autograft has lower rates of donor site morbidity. Systematic reviews and meta-analyses have been previously conducted on this topic, although none have focused solely on data of patients at least 5 years out from surgery. The purpose of this meta-analysis was to demonstrate that QT may not be superior to BTB and HT autografts and that long-term studies must be performed before recommending QT over other graft choices. It was hypothesized that there would be less available data at ≥5 years of follow-up for patients with QT than those with HT and BTB autografts, and that patient-reported outcomes would be similar between all 3 graft choices. Meta-analysis; Level of evidence, 4. The PubMed/MEDLINE, Scopus (Elsevier), Embase, and Cochrane Library databases were queried for studies that reported on QT, BTB, or HT outcomes at ≥5 years after ACL reconstruction (ACLR). In total, 27 studies were included; patient and outcome data were collected from each. Summary odds ratios were calculated for each outcome and compared between all graft types. The sheer volume of available patient data on QT autografts at ≥5 years after ACLR is vastly different from what is available on HT and BTB autografts (which have almost 3 times the amount of patient data as compared with QT). HT had the highest failure rate (12.7%), followed by QT (9.1%) and BTB (6.4%); summary odds ratios favored BTB over both QT and HT in terms of failure rate. Patient-reported outcomes were comparable between graft types, although some comparisons were not adequately powered. This meta-analysis reveals critical information on the current state of the literature surrounding QT use in ACLR. Most notably, additional mid-term and long-term patient data are needed on those undergoing ACLR with QT autograft. There is not enough long-term outcome data on QT to recommend it over HT or BTB for primary ACLR.

Quadriceps Tendon: The Forgotten Graft

Quadriceps Tendon Autograft for Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review of Comparative Studies With Minimum 2-Year Follow-Up

Graft choice for anterior cruciate ligament (ACL) reconstruction is crucial, however the optimal graft source remains a topic of controversy. The purpose of this study is to compare subjective and functional patient-reported outcomes (PRO) after single-bundle ACL reconstruction using quadriceps tendon (QT) or hamstring tendon (HT) autografts for single-bundle ACL reconstruction. We hypothesize that there is no difference in patient-reported functional outcomes after ACL reconstruction using either HT- or QT autograft. All data were extracted from a prospectively collected ACL registry. A total of 80 patients with at least 2-year follow-up were included in this study. A total of 40 patients with primary ACL reconstruction using a QT autograft harvested via a minimally invasive technique were matched by sex, age and pre-injury Tegner and Lysholm score to 40 patients who received HT autografts. Subjective and functional PRO scores including Lysholm score, Tegner activity level and visual analogue scale for pain were obtained at 6, 12 and 24months after index surgery. No significant difference between the QT and the HT group was seen at any follow-up in regard to any of the PRO scores for function or pain. 24months post-surgery the mean Tegner activity score of the HT group was significantly (p=0.04) lower compared to the pre-injury status. At final follow-up, 27 patients (67.5%) in the QT group and 32 patients (80.0%) in the HT returned to their pre-injury activity level (n.s.). A total of 37 patients (92.5%) of the QT cohort and 35 patients (87.5%) of the HT cohort reported "good" or "excellent" results according to the Lysholm score (n.s.). "No pain" or "slight pain" during severe exertion was reported by 33 patients (82.5%) with QT autograft and 28 patients (82.4%) with HT autograft (n.s.). There is no significant difference between PRO 2years post-operative using either QT or HT autografts. Both QT and HT grafts show acceptable and comparable PRO scores making the QT a reliable graft alternative to HT for primary ACL reconstruction. III.

Substantial developments in physeal-sparing surgical techniques for anterior cruciate ligament (ACL) reconstruction (ACLR) have demonstrated safety and efficacy in treating skeletally immature patients. However, outcomes using all-soft tissue quadriceps tendon (QT) autograft in this population are unknown. To evaluate outcomes including return to sport (RTS) and reinjury risk in skeletally immature patients ≥2 years after undergoing hybrid transepiphyseal ACLR using QT autograft. Case series; Level of evidence, 4. A consecutive series of skeletally immature patients who underwent primary QT autograft ACLR using a hybrid transepiphyseal technique with ≥2 years of follow-up were retrospectively analyzed. Outcomes included RTS (primary), ability to return to preinjury level of competition, and subsequent ipsilateral/contralateral knee injury (secondary). A total of 50 patients were identified and contacted, of which 40 (80.0%) (35 male; mean age, 12.6 years [range, 9.4-16.0 years]) completed the survey at 5.7 ± 2.8 years (range, 2.0-11.5 years) postoperation. Of those, 26 (65.0%) were competitive middle/high school athletes and 18 (45.0%) competed in ≥2 sports. At a mean of 10.6 ± 2.3 months (range, 6-17 months) postoperatively, 37 patients (92.5%) returned to unrestricted sports participation, and 35 patients (87.5%) resumed competition at their preinjury level. Five patients required subsequent ipsilateral knee surgery for ACL revision (n = 2; 5.0%), meniscal injury (n = 2; 5.0%), or symptomatic hardware (n = 1; 2.5%) after a mean of 4.4 ± 1.7 years (range, 2.8-7.1 years). Three patients (7.5%) sustained a subsequent contralateral ACL injury, and 1 patient sustained a contralateral posterior cruciate ligament sprain. Findings of this study suggest that midterm outcomes of patients treated with hybrid transepiphyseal ACLR using QT autograft are promising, with a high and expedited RTS and relatively low graft tear risk.

BackgroundThe selection of graft remains a subject of ongoing debate in anterior cruciate ligament (ACL) reconstruction, with distinct maturation processes having been observed among different graft types. A thorough understanding of these differences in graft maturation is crucial for optimizing rehabilitation protocols and ensuring a safe return to sports. This study aimed to systematically review the differences in graft maturation among different graft types following ACL reconstruction.MethodsA comprehensive literature search was conducted in PubMed, Embase, and the Cochrane Library in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included only if they compared intra-articular ACL graft maturity across different graft types.ResultsTwenty-one studies met the inclusion criteria. Graft maturity was assessed using magnetic resonance imaging (MRI) in 15 studies, second-look arthroscopy in 4 studies, and histological biopsy in 1 study; one additional study utilized both MRI and second-look arthroscopy. Hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts showed similar maturity, as assessed by MRI signal intensity (SI) and histological findings, after ACL reconstruction. However, results from second-look arthroscopy were inconclusive. HT autografts exhibited MRI SI comparable to soft-tissue allografts within the first postoperative year, but demonstrated superior maturity and graft appearances at approximately 2 years postoperatively. Quadriceps tendon (QT) autografts, both with and without a patellar bone block, revealed lower MRI SI compared to HT autografts, suggesting better graft maturity. HT autografts with preserved tibial insertion maintained relatively lower SI during the early maturation phase (6 and 12 months) than free HT autografts, though no significant differences were observed at later stages (24 and 60 months).ConclusionMRI, second-look arthroscopy, and histological biopsy analysis indicated distinct graft maturation levels following ACL reconstruction. No conclusive evidence established whether HT or BPTB autografts are superior in terms of graft maturity. Compared to free HT autografts and soft-tissue allografts, QT autografts and HT autografts with preserved tibial insertion may mature earlier, which may allow for consideration of an earlier return to sports in clinical decision-making. These grafts may therefore represent viable alternatives to HT and BPTB grafts, particularly in young and active patients.Level of EvidenceIII, systematic review of level Ⅰ-Ⅲ investigation.

Objectives:The quadriceps tendon (QT) autograft has been successfully utilized for anterior cruciate ligament (ACL) reconstruction for decades. While many studies have shown QT autografts are an effective graft choice, few have prospectively examined short and intermediate-term clinical outcomes following revision procedures. This study examines prospectively collected intermediate-term clinical outcomes, including complication rates, following primary ACL reconstruction with all soft tissue QT autograft.Methods:353 patients undergoing primary ACL reconstruction with an all soft tissue QT autograft were prospectively followed. All procedures were performed by a single surgeon, utilizing a minimally invasive graft harvest technique and suspensory fixation. All patients received aggressive rehabilitation without functional bracing post-operatively. Subjective assessment of knee function was obtained using pre-operative and post-operative IKDC scores, with a minimum of 1-year follow-up. Postoperative KT-1000 arthrometer and isokinetic strength testing measurements were collected at regular intervals. The incidence of graft harvest site hematoma, arthrofibrosis, and graft failure were recorded.Results:The mean age of the study population was 20.4 ± 6.4 (mean ± SD) years, with an average follow up of 2.53 ± 1.04 years. Primary ACL reconstruction was performed in 353 patients. The patient population was approximately evenly split by gender with 27 male (56%) and 21 female (44%). and the preoperative mean IKDC score was 44.9 ± 15.5, and postoperative mean IKDC score was 85.2 ± 14.3, (p<0.0001). The percentage of patients with ≤3 mm side-to-side difference on KT-1000 arthrometer testing at 6-weeks, 3-months, and 6-months was found to be 97%, 96%, and 93%, respectively. No significant increase (p>0.05) in side-to-side measurements was found between the 6-week to 3-month or the 3-month to 6-month intervals. Isokinetic strength testing at 6 months post-operatively showed the mean extension torque at 60°/s and 180°/s was 75.2% and 80.3% respectively. These values increased significantly at 1 year to 86.1% (p<.0006) and 87.5% (p = .018). Graft harvest site hematoma developed in 11 patients (2.7%) and arthrofibrosis occurred in 30 (7.5%). Graft failure requiring revision occurred in 17 (4.2%) patients, with a mean time to revision procedure of 542 ± 210 days post-operatively.Conclusion:ACL reconstruction with an all soft tissue QT autograft using a minimally invasive harvest technique and suspensory fixation has acceptable short and intermediate-term clinical outcomes. No evidence of early graft failure or lengthening was discovered, confirming suspensory fixation is sufficient for aggressive rehabilitation in a young, athletic patient population. The low complication and failure rates in patients that received QT autograft for ACL reconstruction compare favorably to published data on alternate autograft options. The results of this study support the use of all soft tissue QT autograft in ACL reconstruction.

Restoration of knee muscle strength is associated with better outcomes following anterior cruciate ligament (ACL) reconstruction, but little is known about the outcome of strength following quadriceps tendon autograft (QT) ACL reconstruction in relation to other graft types. The aim of this review was to evaluate strength outcomes of the knee extensors and knee flexors following QT ACL reconstruction compared to (1) the non-reconstructed contralateral limb and (2) alternative ACL graft types. Four electronic databases were searched up until 21st February 2020. Summary meta-analyses were performed comparing knee strength outcomes following QT ACL reconstruction to the contralateral limb by way of limb symmetry index (LSI). Comparative meta-analyses were performed comparing QT ACL reconstruction to alternative ACL grafts for the two most frequently reported strength outcome measures which were peak knee extensor torque LSI, and peak knee flexor torque LSI at the following post-operative periods: 3, 5-8, 9-15, 24, 36-60months. In total, 18 studies met the inclusion criteria. Knee strength outcomes of 952 QT ACL reconstructions were included and compared to either the contralateral limb or 1 of 4 alternative ACL graft types; 245 hamstring tendon autograft (HT), 143 patellar tendon autograft (PT), 45 quadriceps tendon allograft, and 21 tibialis anterior allograft. Knee extensor strength LSI following QT ACL reconstruction did not reach 90% even at 24 months post-operatively. Conversely, knee flexor strength LSI following QT ACL reconstruction exceeded 90% at the 9-15months post-operative period. Knee extensor strength at 5-8months following QT ACL reconstruction appears similar to PT but weaker than HT ACL reconstruction. In addition, peak knee flexor LSI was significantly greater at 5-8months in QT ACL reconstruction patients compared to HT patients. The decision to utilize a QT graft for ACL reconstruction should include consideration of strength outcomes. Knee extensor strength recovery following QT ACL reconstruction appears not to be restored before 24months. Level IV.

Objectives:We sought to determine the overall return to play (RTP) rate of female collegiate soccer athletes after anterior cruciate ligament (ACL) reconstruction in the Southeastern Conference (SEC). Additionally, we examined particular athlete related and surgical technique related variables as they correlated to RTP. We hypothesized that RTP after ACL reconstruction would be higher than previously published results and that it would be independent of graft type utilization or surgical techniques employed.Methods:Head team physicians and athletic training staff of the 14 institutions of the SEC were contacted to request participation in the study. All institutions were sent information regarding the nature of the study, a standardized spreadsheet with standardized response choices for the purpose of data collection from the participating institutions, and instructions regarding athlete inclusion criteria. The spreadsheet provided queried certain athlete and technical surgical related variables for ACL reconstructions performed at the participating institutions over the previous 8 years (2005-2013).Results:All 14 of the SEC institutions chose to participate and provided data. 79 reconstructions were reported with RTP data available for 78 women soccer athletes. Overall RTP rate was 84.6%. There was statistical significance in RTP rates favoring athletes in earlier years of eligibility versus later years (p<0.05). Athletes in eligibility years 4 and 5 combined had a RTP rate of 40%. Scholarship status likewise showed statistical significance (p<0.001) favoring RTP rate for scholarship athletes (91%) vs. non-scholarship athletes (45.5%). Athlete position (p=0.242) and depth chart status (p=0.110) showed no significant effect on RTP. In examining surgery specific variables; RTP rate for autograft (87.9%), allograft (75%), and combined graft (50%) demonstrated no difference (p=0.218). RTP rates were similar for the two most commonly used grafts: patellar tendon autograft and hamstring autograft (p=0.186). Femoral tunnel drilling technique showed no effect (p=0.725) on RTP rate for transtibial, accessory medial portal, or two incision techniques. When comparing multiple graft fixation constructs on both the femoral and tibial side, no difference was observed as it relates to RTP. RTP in isolated ACL reconstruction (77.3%) versus ACL reconstruction with concomitant procedures (88.9%) showed no difference. For players undergoing revision ACL reconstruction versus primary, RTP rate was 77.3% and 87.3% respectively, without significant difference (p=0.499).Conclusion:Of Division I collegiate women soccer athletes undergoing ACL reconstruction, overall RTP rate approaches 85%. Undergoing ACL reconstruction earlier in the college career before the 4th year of eligibility as well as the presence of a scholarship had a positive effect on RTP. Surgical factors including graft type, fixation methods, tunnel placement technique, concomitant knee surgery, and revision status played showed no significant effect on RTP rate.

Background:Quadriceps tendon (QT)–bone autografts used during anterior cruciate ligament (ACL)reconstruction have provided comparable outcomes and decreased donor-site morbidity whencompared with bone–patellar tendon–bone (BPTB) autografts. No study has directlycompared the outcomes of the all–soft tissue QT autograft with that of the BPTBautograft.Hypothesis:Patient-reported knee outcome scores and rates of postoperative complication afterprimary ACL reconstruction with QT autografts are no different from BPTB autografts at aminimum 2-year follow-up.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 75 patients who underwent primary autograft ACL reconstruction with QT orBPTB autografts between January 1, 2015, and March 31, 2016, at a single hospital centerwere contacted by telephone and asked to complete the International Knee DocumentationCommittee (IKDC) Subjective Knee Evaluation, Tegner activity level scale, and Lysholmknee scoring scale. Information about the subsequent surgeries performed on theoperative knee was also collected. Statistical analysis was performed using theKruskal-Wallis test and the Fisher exact test for categorical data.Results:Fifty patients (28 QT, 22 BPTB) completed the surveys at a mean follow-up of 33.04months (range, 24-44 months). For the QT versus the BPTB group respectively, the medianIKDC scores were 94.83 (interquartile range [IQR], 7.61) versus 94.83 (IQR, 10.92)(P = .47), the median Tegner scores were 6 (IQR, 2.5) versus 6 (IQR,2.75) (P = .48), and the median Lysholm scores were 95 (IQR, 9) versus95 (IQR, 13) (P = .27). Additionally, 2 QT patients and 3 BPTB patientsrequired follow-up arthroscopy for arthrolysis (P = .64). There was 1graft failure in the QT group requiring revision surgery.Conclusion:There was no statistical difference in patient-reported knee outcomes or graftcomplication rates between the QT and BPTB autograft groups at a minimum 2-yearfollow-up after primary ACL reconstruction. This study highlights that the all–softtissue QT autograft may be a suitable graft choice for primary ACL reconstruction.

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) using quadriceps tendon (QT) autograft is associated with lower rates of graft rupture and favorable functional outcomes compared with hamstring (HS) autograft in adolescents. The ACL-deficient knee is at increased risk of injury to secondary stabilizers of the knee, including the menisci, although studies have not reported differences in rates of subsequent meniscal tear between HS and QT groups. Purpose: The goal of this study was to compare rates of graft rupture and subsequent meniscal tear after adolescent ACLR using HS or QT autograft. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective review of adolescent patients (age, 10-19 years) who underwent ACLR with either HS or QT autograft between 2009 and 2023 at an urban tertiary care pediatric hospital. Patients with ≥2 years of clinical follow-up were included. Patient characteristics, surgical details, and reinjury rates were calculated and compared between the 2 subgroups. Multivariable logistic regression was performed to evaluate the relationship between graft failure and relevant variables. Results: A total of 467 patients (52.0% female) with mean age 14.6 ± 1.9 years and median follow-up of 3.1 (range, 2.0-13.4) years were included. The QT subgroup more commonly underwent concomitant anterolateral ligament reconstruction/lateral extra-articular tenodesis at the time of primary ACLR ( P &lt; .001), were slightly older ( P = .04), had higher baseline body mass index ( P = .01), had a shorter period of follow-up ( P &lt; .001), and more commonly had concomitant medial meniscal tear compared with the HS group ( P = .047). Graft rupture was lower among patients treated with QT versus HS (7.2% vs 23.2%; P &lt; .001). The rate of subsequent meniscal tear was not statistically significantly different among patients treated with QT versus HS (4.6% vs 9.2%, respectively; P = .08). Regression analysis showed that graft type was associated with risk of graft failure (QT vs HS: odds ratio, 0.29; P &lt; .001) but was not clearly associated with subsequent meniscal tear (QT vs HS: odds ratio, 0.47; P = .09). Conclusion: Adolescent patients undergoing ACLR with QT autograft have significantly lower risk of graft rupture compared with those treated with HS autograft. There was no statistically significant difference in rate of subsequent meniscal tear between the QT and HS groups.