Varying Definitions of Return to Sport, Study Quality, and Outcome Measurements Limit Comparison of Primary Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autografts to Hamstring and Bone–Patellar Tendon–Bone Autografts: A Systematic Review

Abstract

Purpose

To systematically review the existing literature on return-to-sport (RTS) outcomes for quadricep tendon (QT) autografts compared to hamstring tendon (HT) and/or bone–patellar tendon–bone (BPTB) autografts for primary anterior cruciate ligament reconstruction (ACLR).

Methods

PubMed/Medline, Scopus, Embase, and Cochrane Library databases were queried for studies comparing RTS data for ACLR with QT autografts versus HT and/or BPTB autografts in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were randomized and nonrandomized prospective or retrospective studies evaluating primary ACLR containing RTS data for QT autograft and at least 1 other graft type. Exclusion criteria included patients <18 years of age, patients undergoing revision ACLR, cadaveric/animal studies, and studies lacking graft outcome data. Included studies were analyzed for methodologic data, RTS data, quality, and risk of bias.

Results

Ten articles (2 randomized controlled trials, 3 prospective studies, and 5 retrospective studies) comprising 1,006 reconstructions with a level of evidence of II to III and average follow-up of 8 to 120 months were included. Nonrandomized studies most frequently possessed a Methodological Index for Non-Randomized Studies quality rating of “moderate,” while half of the randomized studies had a Risk of Bias 2.0 rating of “some concern of bias.” Four subjective definitions of RTS were identified: (1) return to preinjury activity level based on the Tegner activity scale, (2) return to play, (3) return to level I/II (cutting) sports, and (4) return to preinjury sports. RTS and mean time to RTS rates ranged from 16% to 100% and 8.4 to 11.1 months for QT autografts, 32% to 100% and 8.8 months for HT autografts, and 64% to 85% and 8.1 months for BPTB autografts.

Conclusions

Primary ACLR with QT autografts shows similar overall RTS rates and mean time to RTS as HT and BPTB autografts. However, insufficient quality and quantity of studies investigating RTS outcomes for QT autografts underscore the unreliability of the current literature and need for high-quality, prospective studies.

Level of Evidence

Level III, systematic review of Level II and III studies.