This 2019 meta-analysis (27 studies, 2856 patients) is the largest quantitative comparison of quadriceps tendon (QT) autograft against both BPTB and hamstring tendon (HT) autografts for ACL reconstruction. It evaluates stability, functional outcomes, donor-site pain, and graft survival across all three graft types.
The graft selection debate in ACL reconstruction has historically centered on BPTB (the traditional "gold standard" for stability) versus hamstring tendon (favored for lower anterior knee morbidity). QT was largely viewed as a niche or salvage option, with limited comparative data.
This meta-analysis reframes that choice. When you have a patient who kneels at work, practices a religion requiring floor kneeling, or has pre-existing anterior knee symptoms, QT gives you equivalent stability and graft survival with dramatically less harvest-site pain than BPTB.
When comparing QT to hamstring, the functional score advantage (Lysholm +3.81 points) is modest in absolute terms but statistically real. Add in the biomechanical advantages (greater cross-sectional area, higher load to failure, more collagen), and QT becomes a defensible first-line choice across a broad patient population.
The residual extensor mechanism is actually stronger after QT harvest than after patellar tendon harvest (2430 N vs 1920 N) — a key fact that counters the historical concern about weakening the quad with this approach.
This 2019 meta-analysis (27 studies, 2856 patients) is the largest quantitative comparison of quadriceps tendon (QT) autograft against both BPTB and hamstring tendon (HT) autografts for ACL reconstruction. It evaluates stability, functional outcomes, donor-site pain, and graft survival across all three graft types.
The graft selection debate in ACL reconstruction has historically centered on BPTB (the traditional "gold standard" for stability) versus hamstring tendon (favored for lower anterior knee morbidity). QT was largely viewed as a niche or salvage option, with limited comparative data.
This meta-analysis reframes that choice. When you have a patient who kneels at work, practices a religion requiring floor kneeling, or has pre-existing anterior knee symptoms, QT gives you equivalent stability and graft survival with dramatically less harvest-site pain than BPTB.
When comparing QT to hamstring, the functional score advantage (Lysholm +3.81 points) is modest in absolute terms but statistically real. Add in the biomechanical advantages (greater cross-sectional area, higher load to failure, more collagen), and QT becomes a defensible first-line choice across a broad patient population.
The residual extensor mechanism is actually stronger after QT harvest than after patellar tendon harvest (2430 N vs 1920 N) — a key fact that counters the historical concern about weakening the quad with this approach.