Background: Anterior Cruciate Ligament (ACL) reconstructions are performed using a tendinous graft that mirrors the properties of the ACL. While hamstring and bone-patella tendon-bone (BTB) are traditionally the autografts used for ACL reconstruction, recently, the quadriceps tendon autograft has received significant interest due to its clinical stability and low harvesting complications. This study aims to compare post-operative knee stability, functional outcomes, and complications following ACL reconstruction using BTB versus quadriceps tendon graft. Methods: PubMed, Embase, and Cochrane Library were searched for studies published after 2002. Studies which were randomized controlled trials (RCT), included patients who underwent ACL reconstruction using BTB or quadriceps tendon graft (all soft tissue or B-QT), and reported measures of post-operative stability and functional outcomes were included in this study. Studies that were not written in English, analyzed animals or cadavers, were not RCTs, or used other grafts (i.e., hamstring) were excluded.

Results: Six studies were included in this systematic review. Two studies found no significant difference in performance outcomes or complications between quadriceps or BTB graft use. One study found that quadriceps grafts exhibit improved knee functional status compared to BTB grafts. Another study found that quadriceps grafts result in a significantly reduced Quadriceps Index post-operatively compared to BTB recipients but that no differences exist in post-operative quadriceps strength. An additional study found that outcomes of quadriceps tendon and BTB grafts are equivalent, but anterior knee pain is less severe with quadriceps tendon utilization. Furthermore, one study revealed overall IDKC score was reported as normal significantly more often in BTB graft recipients and that donor site morbidity was greater in quadriceps graft recipients.

Conclusions: Patients undergoing either BTB or quadriceps-transfer for ACL reconstruction both reported improved post-operative knee stability and functional outcomes. No statistically significant difference was found in complications requiring reoperation. This study consistently demonstrated that revision rates secondary to graft failure were not statistically significant between patients undergoing either BTB or quadriceps transfer. The quadriceps tendon graft is comparable in utility to the BTB graft, and preferences of the orthopaedic surgeon performing the procedure will ultimately determine graft selection on a case-by-case basis.