Quadriceps tendon ACL grafts were reoperated for stiffness or pain twice as often as hamstring grafts

Design

Retrospective registry cohort, 2-year follow-up

Population

5,653 primary ACL reconstructions with hamstring, patellar tendon or quadriceps tendon autograft

Primary outcome

Non-revision reoperation within 2 years

Effect

Extension deficit or pain: 11.9% vs 5.5% (hamstring); adjusted OR 1.96 (1.44–2.67)

This Swedish retrospective cohort, published in August, compared 5,653 primary ACL reconstructions with hamstring, bone–patellar tendon–bone or quadriceps tendon autografts over two years. Revisions and graft failures were excluded; the outcome was other reoperations.

Quadriceps tendon grafts had the highest reoperation rate (19.2% vs 8.9% hamstring and 6.9% patellar tendon), mostly for extension deficit or pain (11.9% vs 5.5% and 4.7%). After adjustment, quadriceps grafts remained associated with these reoperations (OR 1.96, 95% CI 1.44–2.67) and with lower odds of meaningful improvement in knee scores than hamstring grafts (OR 0.56, 0.41–0.77). Women with larger grafts of 9.5–12 mm had higher odds of reoperation for extension deficit or pain (OR 1.72).

Quadriceps tendon grafts have become popular on the strength of comparable stability. These data suggest a price in early stiffness that deserves attention in rehabilitation and in how grafts are sized, particularly in women.

• Discuss the higher early reoperation rate when offering a quadriceps tendon graft
• Prioritise early full extension in rehabilitation after quadriceps tendon reconstruction
• Avoid oversizing grafts, especially in women with smaller notches
• Review extension at 6 weeks and act early on a deficit

Why it matters

A graft chosen for its stability may be carrying a hidden cost in early stiffness and reoperation.

Don't overread it

This was a retrospective cohort — graft choice was not randomised, so surgeon and patient selection may explain part of the difference.

The statistics, in plain English

An adjusted odds ratio of 1.96 means about double the odds of reoperation for stiffness or pain after accounting for measured differences. Because graft choice was not randomised, surgeon preference and case mix may explain part of the gap. The sex and graft-size finding is a subgroup result.

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