GRAFTS FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: SYSTEMATIC REVIEW AND META-ANALYSIS

ANDREZ, TÁSSIO NAVAJAS; CHAGAS, JÚLIA BEZERRA MARTINS; D’OLIVEIRA, LÍVIA BAPTISTA

doi:10.1590/1413-785220223006e256048

TÁSSIO NAVAJAS ANDREZ

conception

data collection

data analysis for the work

writing of intellectual work

final approval of the manuscript

Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.

https://orcid.org/0000-0003-0252-2788

JÚLIA BEZERRA MARTINS CHAGAS

conception

data collection

data analysis for the work

writing of intellectual work

final approval of the manuscript

Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.

https://orcid.org/0000-0002-5183-7658

LÍVIA BAPTISTA D’OLIVEIRA

conception

data collection

data analysis for the work

writing of intellectual work

final approval of the manuscript

Independent researcher, São Paulo, SP, Brazil.

https://orcid.org/0000-0002-1408-5338

Correspondence: Tássio Navajas Andrez. Av. Albert Einstein, 627, São Paulo, SP, Brazil, 05652900. tassio_navajas@hotmail.com

All authors declare no potential conflict of interest related to this article.

Figures (5)
Tables (4)

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Figure 1
Flowchart of the screening of the articles.

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Figure 2
Funnel plot showing the mean difference in Lysholm scores between quadriceps tendon and hamstring tendon autografts.

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Figure 3
Funnel plot showing the proportion of risk (A) and mean difference (B) of pain after surgical intervention for reconstruction with autografts of the quadriceps tendon and hamstring tendon.

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Figure 4
Funnel plot showing the proportion of risk of ruptures after surgical intervention for reconstruction with autografts of the quadriceps tendon and hamstring tendon.

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Figure 5
Assessment of the risk of bias from (A) randomized clinical trials and (B) non-randomized trials.

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Table 1
Characteristics of the studies on quadriceps tendon autograft versus hamstring autograft for anterior cruciate ligament reconstruction.

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Table 2
Quality assessment.

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Databases Search Strategy MEDLINE/PubMed Search: ((((Anterior Cruciate Ligament Reconstruction) OR (ACL reconstruction)) AND (quadriceps tendon autograft)) OR (quadriceps graft)) AND (Hamstring-Tendon Autografts) Filters: from 2000 - 2021 06/10/2021 Total: 197 EMBASE 1 (Anterior Cruciate Ligament Reconstruction or ACL reconstruction).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] 16283 2 (quadriceps tendon autograft or quadriceps graft).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] 156 3 anterior cruciate ligament/ or anterior cruciate ligament reconstruction/ or tendon graft/ or Hamstring-Tendon Autografts.mp. or hamstring/ or hamstring tendon/ 06/10/2021 30642 41 and 2 and 3 Total: 119 Cochrane Central Register of Controlled Trials (Anterior Cruciate Ligament Reconstruction OR ACL reconstruction) AND (quadriceps tendon autograft OR quadriceps graft) AND (Hamstring-Tendon Autografts) 06/10/2021 Total: 34

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Number Title Reason for exclusion 1 Hamstring tendon autograft versus quadriceps tendon autograft for anterior cruciate ligament reconstruction: a randomised controlled trial [Internet]. Hoboken: Cochrane Central Register of Controlled Trials (CENTRAL); 2018 [accessed on 2022 Oct 24]. Available from: https://trialsearch.who.int/Trial2.aspx?TrialID=ACTRN12618001520224 1 2 A randomized controlled trial comparing the outcomes of quadriceps autograft vs. hamstring autograft in acl reconstruction [Internet]. Hoboken: Cochrane Central Register of Controlled Trials (CENTRAL); 2019 [accessed on 2022 Oct 24]. Available from: https://trialsearch.who.int/Trial2.aspx?TrialID=ACTRN12619001396112 1 3 Cristiani R, Mikkelsen C, Wange P, Olsson D, Stålman A, Engström B. Autograft type affects muscle strength and hop performance after ACL reconstruction. A randomised controlled trial comparing patellar tendon and hamstring tendon autografts with standard or accelerated rehabilitation. Knee Surg Sports Traumatol Arthrosc. 2021;29(9):3025-3036. 2 4 Feller JA, Webster KE. A randomized comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction. Am J Sports Med. 2003;31(4):564-73. 2 5 Gupta R, Kapoor D, Kapoor L, Malhotra A, Masih GD, Kapoor A, Joshi S. Immediate post-operative pain in anterior cruciate ligament reconstruction surgery with bone patellar tendon bone graft versus hamstring graft. J Orthop Surg Res. 2016;11(1):67. 2 6 Comparing two surgical techniques for anterior cruciate ligament (ACL) reconstruction [Internet]. Hoboken: Cochrane Central Register of Controlled Trials (CENTRAL); 2020 [accessed on 2022 Oct 24]. Available from: https://trialsearch.who.int/Trial2.aspx?TrialID=ISRCTN55542036 1 7 A double blind randomized comparative study of two autografts in arthroscopic ACL reconstruction [Internet]. SICOT 40th Orthopaedic World Congress; 2019; Muscat. Hoboken: Cochrane Central Register of Controlled Trials (CENTRAL); 2019 [accessed on 2022 Oct 24]. Available from: https://www.cochranelibrary.com/central/doi/10.1002/central/CN-02072196/full 4 8 Kondo E, Yasuda K, Miyatake S, Kitamura N, Tohyama H, Yagi T. Clinical comparison of two suspensory fixation devices for anatomic double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2012;20(7):1261-7. 3 9 Martin-Alguacil JL, Arroyo-Morales M, Martin-Gómez JL, Lozano-Lozano M, Galiano-Castillo N, Cantarero-Villanueva I. Comparison of knee sonography and pressure pain threshold after anterior cruciate ligament reconstruction with quadriceps tendon versus hamstring tendon autografts in soccer players. Acta Orthop Traumatol Turc. 2019;53(4):260-5. 3 10 Anterior cruciate ligament-reconstruction: quadriceps tendon or hamstrings tendon? A prospective randomised controlled trial [Internet]. Bethesda: NML; 2019 [acessed on 2022 Oct 24]. Available from: https://clinicaltrials.gov/show/NCT02173483 1 11 Comparative study of anterior cruciate ligament reconstruction (quadriceps versus hamstring tendon) [Internet]. Bethesda: NML; 2018 [acessed on 2022 Oct 24]. Available from: https://clinicaltrials.gov/ct2/show/NCT02832791 1 12 Recovery of soccer players after anterior cruciate ligament reconstruction [Internet]. Bethesda: NML; 2021 [acessed on 2022 Oct 24]. Available from: https://clinicaltrials.gov/ct2/show/NCT04742868 1 13 Setuain I, Izquierdo M, Idoate F, Bikandi E, Gorostiaga EM, Aagaard P, et al. Differential effects of 2 rehabilitation programs following anterior cruciate ligament reconstruction. J Sport Rehabil. 2017;26(6):544-55. 2 14 Tashiro T, Kurosawa H, Kawakami A, Hikita A, Fukui N. Influence of medial hamstring tendon harvest on knee flexor strength after anterior cruciate ligament reconstruction. A detailed evaluation with comparison of single- and double-tendon harvest. Am J Sports Med. 2003;31(4):522-9. 2 15 Wipfler B, Donner S, Zechmann CM, Springer J, Siebold R, Paessler HH. Anterior cruciate ligament reconstruction using patellar tendon versus hamstring tendon: a prospective comparative study with 9-year follow-up. Arthroscopy. 2011;27(5):653-65. 2 16 Yoo SH, Song EK, Shin YR, Kim SK, Seon JK. Comparison of clinical outcomes and second-look arthroscopic findings after ACL reconstruction using a hamstring autograft or a tibialis allograft. Knee Surg Sports Traumatol Arthrosc. 2017;25(4):1290-7. 2 17 Chen CH, Chen WJ, Shih CH. Arthroscopic reconstruction of the posterior cruciate ligament: a comparison of quadriceps tendon autograft and quadruple hamstring tendon graft. Arthroscopy. 2002;18(6):603-12. 2 18 Chen CH, Chen WJ, Shih CH, Jiang CC. Quadriceps tendon-patellar bone autograft for arthroscopic anterior cruciate ligament reconstruction. Journal of Surgical Association Republic of China. 1998;31(3):166-72. 5 19 A study comparing two grafts for treatment of knee instability [Internet]. Hoboken: Cochrane Central Register of Controlled Trials (CENTRAL); 2019 [acessed on 2022 Oct 24]. Available from: https://trialsearch.who.int/Trial2.aspx?TrialID=CTRI/2017/03/008098 1 20 Is quadriceps tendon a better choice than hamstring tendons for repairing anterior cruciate ligament lesion? [Internet]. Hoboken: Cochrane Central Register of Controlled Trials; 2019 [acessed on 2022 Oct 24]. Available from: https://trialsearch.who.int/Trial2.aspx?TrialID=ISRCTN12967309 1 21 Ouabo EC, Gillain L, Saithna A, Blanchard J, Siegrist O, Sonnery-Cottet B. Combined anatomic anterior cruciate and anterolateral ligament reconstruction with quadriceps tendon autograft and gracilis allograft through a single femoral tunnel. Arthrosc Tech. 2019;8(8):e827-34. 6 22 Sanada T, Iwaso H, Fukai A, Honda E, Yoshitomi H, Inagawa M. Anatomic anterior cruciate ligament reconstruction using rectangular bone-tendon-bone autograft versus double-bundle hamstring tendon autograft in young female athletes. Arthrosc Sports Med Rehabil. 2021;3(1):e47-55. 2 23 Shibata Y, Matsushita T, Araki D, Kida A, Takiguchi K, Ueda Y, et al. Prediction of quadriceps strength recovery after anterior cruciate ligament reconstruction with a hamstring autograft: decision tree analysis. J Orthop Sci. 2019;24(2):301-5. 3 24 Fischer F, Fink C, Herbst E, Hoser C, Hepperger C, Blank C, Gföller P. Higher hamstring-to-quadriceps isokinetic strength ratio during the first post-operative months in patients with quadriceps tendon compared to hamstring tendon graft following ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2018;26(2):418-25. 3 25 Shaieb MD, Kan DM, Chang SK, Marumoto JM, Richardson AB. A prospective randomized comparison of patellar tendon versus semitendinosus and gracilis tendon autografts for anterior cruciate ligament reconstruction. Am J Sports Med. 2002;30(2):214-20. 2 26 Martin-Alguacil JL, Arroyo-Morales M, Martín-Gomez JL, Monje-Cabrera IM, Abellán-Guillén JF, Esparza-Ros F, et al. Strength recovery after anterior cruciate ligament reconstruction with quadriceps tendon versus hamstring tendon autografts in soccer players: a randomized controlled trial. Knee. 2018;25(4):704-14. (e-mail sent to authors) 7 1Clinical trial record; 2Another comparison; 3Another outcome; 4Summary of congress; 5Another language; 6Article of revision of surgical technique; 7Incomplete data - deleted after contact with authors.

Author, year	Type of study and follow-up	Sample size/sex/age (years)	Surgical technique	Intervention/placebo or control	Outcomes	Adverse events or complications	Approval of the ethics committee
CLINICAL TRIALS
Buescu et al.,¹⁷17. Häner M, Bierke S, Petersen W. Anterior cruciate ligament revision surgery: ipsilateral quadriceps versus contralateral semitendinosus-gracilis autografts. Arthroscopy. 2016;32(11):2308-17. 2017	Parallel randomized clinical trial	N = 48	Anatomical arthroscopic reconstruction of the ACL in single-bundle	(1) QT (n = 24 patients).	Pain: VAS - patients who required complementary analgesia (n/%)	None	Yes
		N = 48			(1) QT 0-1 2h: 12 (50%)
		Male: 45			QT 25-48 h: 4 (16.66%)
Romania	Average follow-up: 0-48 h	Female: 3		(1) HT (n = 24 patients).	(2) HT 0-1 2h: 18 (75%)
		Age: 28.35 ± 7.19			HT 25-48 h: 9 (37.50%)
		Age: 28.35 ± 7.19			(p = 0.002).
Horstmann et al.,¹⁸18. Horstmann H, Petri M, Tegtbur U, Felmet G, Krettek C, Jagodzinski M. Quadriceps and hamstring tendon autografts in ACL reconstruction yield comparably good results in a prospective, randomized controlled trial. Arch Orthop Trauma Surg. 2022;142(2):281-9. 2022	Randomized, controled clinical trial	N = 51	Press-fit fixation techniques without implant.	(1) QT (n = 24 patients).	Functional results by Lysholm:	Yes	Yes
		N = 51			(1) QT Preoperative: 72.3 ± 13.2
		Sex:			QT two years postoperatively:
		Sex:			90.4 ± 11.9
	Follow-up: 2 years	Male/Female			(2) HT Preoperative: 60.4 ± 18.5
		(1) QT: 21/3			HT two years postoperatively:
Germany		(2) HT: 12/15		(1) HT (n = 27 patients).	83.5 ± 17.4
		Age:			p < 0.131
	Evaluation: 3, 6, 12, and 24 months after surgery.	(1) QT:24.1 ± 3.6			Return to sport (in days):
		(1) QT:24.1 ± 3.6			(1) QT: 82.1 ± 45.6
		(2) HT:32.7 ± 11.4			(2) HT: 95.2 ± 45.5
		(2) HT:32.7 ± 11.4			p < 0.131
Sinding et al.,²³23. Sinding KS, Nielsen TG, Hvid LG, Lind M, Dalgas U. Effects of autograft types on muscle strength and functional capacity in patients having anterior cruciate ligament reconstruction: a randomized controlled trial. Sports Med. 2020;50(7):1393-403. 2020	Randomized, controled clinical trial	N = 85	ACL Reconstruction	(1) QT (n = 42 patients).	Function: When comparing the two groups of patients with autograft, 4%-11% less muscle strength was observed during knee extensor at 0 degrees/s (isometric, MVIC) and 60 degrees/s (concentric dynamics) in QT vs. HT, along with knee extensor 4% lower RFD200ms.	NR	Yes
		Sex:
		Male/Female
		(1) QT: 25/17
Denmark	Follow-up: 1 year	(2) HT: 23/20		(1) HT (n = 43 patients).	Functional Capacity (single leg hop distance - SHD): There was no difference in SHD between HT and QT.
		Age:
		(1) QT:28.7 ± 6.4
		(2) HT: 28.3 ± 6.2
Vilchez-Cavazos et al.,²⁶26. Vilchez-Cavazos F, Dávila-Martínez A, Garza-Castro S, Simental-Mendía M, Garay-Mendoza D, Tamez-Mata Y, et al. Anterior cruciate ligament injuries treated with quadriceps tendon autograft versus hamstring autograft: a randomized controlled trial. Cir Cir. 2020;88(1):76-81. 2020	Randomized clinical trial	N = 28	ACL Reconstruction	(1) QT (n = 14 patients).	Functional results by Lysholm (median and interquartile range):	NR	Yes
		N = 28			(1) QT baseline: 75.0 (61.5-83.5)
		Sex:			QT 12 months: 95.0 (91.0-100.0)
		Male/Female			(2) HT baseline: 61.0 (37.0-74.0)
	Follow-up:	(1) QT: 11/2			HT 12 months: 98.0 (90.0-100.0)
Mexico	2 weeks and 1, 3, 6 and 12 months.	(2) HT: 12/3		(1) HT (n = 14 patients).	Pain (VAS) (median and interquartile range):
		Age:			(1) QT baseline: 3.0 (1.5-7.0)
		(1) QT: 30.64 ± 8.71			QT 12 months: 0.0 (0.0-1.5)
		(2) HT: 28.60 ± 6.74			(2) HT baseline: 4.0 (3.0-7.0)
		(2) HT: 28.60 ± 6.74			HT 12 months: 0.0 (0.0-1.0)
OBSERVATIONAL STUDIES
Akoto et al.,⁸8. Akoto R, Albers M, Balke M, Bouillon B, Höher J. ACL reconstruction with quadriceps tendon graft and press-fit fixation versus quadruple hamstring graft and interference screw fixation - a matched pair analysis after one year follow up. BMC Musculoskelet Disord. 2019;20(1):109. 2019	Retrospective cohort study	N = 82	Isolated ACL reconstruction	(1) QT (n = 41 patients).	Functional results by IKDC scores:	Graft failure:	Yes
		N = 82			(1) QT: 86.4 ± 14.2	(1) QT: n = 3
		Male: 64			(2) HT: 86.7 ± 10.9	(2) HT: n = 4
		Female: 18			p = 0.9	Contralateral ACL rupture:
Germany	Follow-up: 12 months	Age:		(1) HT (n = 41 patients).	Functional tests	(1) QT: n = 1
		(1) QT: 29 ± 10			(One-Leg Hop test):	(2) HT: n = 2
		(1) QT: 29 ± 10			(1) QT: 96.2 ± 8.5	Infection:
		(2) HT: 28 ± 10			(2) HT: 95.5 ± 8.5	(1) QT: n = 1
		(2) HT: 28 ± 10			p = 0.8	(2) HT: n = 2
Cavaignac et al.,¹⁶16. Cavaignac E, Coulin B, Tscholl P, Nik Mohd Fatmy N, Duthon V, Menetrey J. Is quadriceps tendon autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? A comparative study with a mean follow-up of 3.6 years. Am J Sports Med. 2017;45(6):1326-32. 2017	Cohort study	N = 86	Isolated ACL reconstruction	(1) QT (n = 45 patients).	Functional results by Lysholm:	QT group, there was 1 re-rupture	Yes
		N = 86			(1) QT: 89 ± 6.9
		Male: 45			(2) HT: 83.1 ± 5.3
		Female: 41			p < 0.05
Switzerland	Average follow-up: 3.6 6 0.4 years, and the minimum follow-up was 3 years	Age:		(1) HT (n = 41 patients).	Pain:	In the HT group, there were 2 cases of graft rupture.
		(1) QT: 32.1 ± 8			(1) QT: 90 ± 6.8
		(2) HT: 30.9 ± 9			(2) HT: 86 ± 7.2
		(2) HT: 30.9 ± 9			p = 0.23
Häner et al.,¹⁷17. Häner M, Bierke S, Petersen W. Anterior cruciate ligament revision surgery: ipsilateral quadriceps versus contralateral semitendinosus-gracilis autografts. Arthroscopy. 2016;32(11):2308-17. 2016	Cohort study	N = 51	ACL Reconstruction homologous autograft (HT and QT)	(1) QT (n = 25 patients).	Functional results by Lysholm:	No rerupture occurred during postoperative follow-up. No early superficial or meniscal infection.	Yes
		N = 51			(1) QT: 88
		Sex:			(2) HT: 78.1
		Sex:			p = 0.06
		Male/Female
		Male/Female			Pain:
		(1) QT: 17/8			When kneeling
		(1) QT: 17/8			(1) QT: 7
Germany	Average follow-up: 24 months	(2) HT: 18/8		(1) HT (n = 26 patients).	(2) HT: 11	Lesion was found in either group.
		(2) HT: 18/8			When squatting
		Age:			(1) QT: 7
		Age:			Climb stairs
		(1) QT: 35.9 ± 10.4			(1) QT:4
		(1) QT: 35.9 ± 10.4			(2) HT: 4
		(2) HT: 35.8 ± 13.1			In squats
		(2) HT: 35.8 ± 13.1			(2) HT:8
Johnston et al.,¹⁹19. Johnston PT, Feller JA, McClelland JA, Webster KE. Strength deficits and flexion range of motion following primary anterior cruciate ligament reconstruction differ between quadriceps and hamstring autografts. J ISAKOS. 2021;6(2):88-93. 2021	Cohort study	N = 111	Arthroscopy-assisted ACL reconstruction with femoral tunnel perforated via anteromedial portal	(1) QT (n = 37 patients).	Previous knee pain:	NR	Yes
		Sex:			(1) QT: 67%
		Male/Female			(2) HT: 63%
		(1) QT: 29/8			p = N.S.
Australia	Follow-up: 6 months	(2) HT: 58/16		(1) HT (n = 74 patients).	Active knee flexion amplitude while standing (p < 0.001), active knee flexion amplitude measured in lateral decubitus (p < 0.001), and passive knee flexion amplitude (p = 0.016) in the HT Group when compared with the QT group.
		Age:
		(1) QT: 20.0 (15-34)
		(2) HT: 20.5 (15-32)
Lee et al.,²⁰20. Lee JK, Lee S, Lee MC. Outcomes of anatomic anterior cruciate ligament reconstruction: bone-quadriceps tendon graft versus double-bundle hamstring tendon graft. Am J Sports Med. 2016;44(9):2323-9. 2016	Cohort study	N = 96	ACL Reconstruction	(1) QT (n = 48 patients).	Lysholm scores:	NR	Yes
		Sex:			(1) QT Preoperative: 70.2 ± 9.6
		Male/Female			QT final follow-up: 92.1 ± 8.7
		(1) QT: 44/4			(2) HT Preoperative: 69.4 ± 18.0
Korea	Follow-up: 2 years	(2) HT: 44/4		(1) HT (n = 48 patients).	HT final follow-up: 88.4 ± 11.9
		Age:			p = 0.30
		(1) QT: 31.1 (17-57)			The recovery of flexor muscle strength was better in the quadriceps group (86.6% vs. 92.2% at 60 degrees/s, p = 0.22; 87.1% vs. 99.6% at 180 degrees/s, p = 0.01).
		(2) HT: 29.9 (17-58)
Ortmaier et al.,²¹21. Ortmaier R, Fink C, Schobersberger W, Kindermann H, Leister I, Runer A, et al. Return to sports after anterior cruciate ligament injury: a matched-pair analysis of repair with internal brace and reconstruction using hamstring or quadriceps tendons. Sportverletz Sportschaden. 2021;35(1):36-44. 2021	Retrospective cohort study	N = 45 patients	ACL Reconstruction homologous autograft (HT and QT)	(1) QT (n = 20 patients).	Knee pain (VAS): Subjective assessments of pain during and after sports worsened significantly for almost all parameters with no significant difference between pre- and postoperative groups.	NR	Yes
		Sex:
		Male/Female
Austria	Follow-up: 12 months	(1) QT: 17/8		(1) HT (n = 25 patients).
		(2) HT: 12/8			Rate of return to sports was 91.3%.
		Age (average): 33.4 years			Rate of return to sports was 91.3%.
Runer et al.,²²22. Runer A, Wierer G, Herbst E, Hepperger C, Herbort M, Gföller P, et al. There is no difference between quadriceps- and hamstring tendon autografts in primary anterior cruciate ligament reconstruction: a 2-year patient-reported outcome study. Knee Surg Sports Traumatol Arthrosc. 2018;26(2):605-14. 2018	Prospective cohort study	N = 80 patients	ACL Reconstruction homologous autograft (HT and QT)	(1) QT (n = 40 patients).	Lysholm scores:	During the QT graft collection process, no joint capsule opening or patellar fracture was observed. Postoperatively, no major quadriceps bleeding or hematoma was reported or observed.	Yes
		N = 80 patients			(1) QT Preoperative: 94.7 ± 8.2
		Sex:			QT final follow-up: 93.4 ± 7.5
		Male/Female			(2) HT Preoperative: 94.1 ± 9.9
		(1) QT: 23/17			HT final follow-up: 93.4 ± 8.7	None of the QT patients reported tenderness, numbness, or irritation at the graft collection site.
Austria	Follow-up: 6, 12, and 24 months after surgery.	(2) HT: 23/17		(1) HT (n = 40 patients).	Pain (VAS):
		Age (average):			(1) QT Preoperative: 0.90 ± 1.1	Rerupture: Over the 2 years of follow-up, one graft rupture occurred in the HT group, while no further ruptures were recorded in the QT group (n.s.). The re-rupture occurred as a result of the player's contact during a football game.
		(1) QT: 34.6 ± 11.0			QT final follow-up: 0.6 ± 1.0
		(2) HT: 34.4 (± 11.0)			(2) HT Preoperative: 0.8 ± 1.0
		(2) HT: 34.4 (± 11.0)			HT final follow-up: 0.8 ± 1.2
Sofu et al.,²⁴24. Sofu H, Sahin V, Gürsu S, Yildirim T, Issin A, Ordueri M. Use of quadriceps tendon versus hamstring tendon autograft for arthroscopic anterior cruciate ligament reconstruction: a comparative analysis of clinical results. Eklem Hastalik Cerrahisi. 2013;24(3):139-43. 2013	Retrospective cohort study	N = 44 patients	ACL Reconstruction homologous autograft (HT and QT)	(1) QT (n = 23 patients).	Lysholm scores < 64 (poor):	NR	Yes
		Sex:			Lysholm scores < 64 (poor):
		Male/Female			(1) QT Preoperative: 22 (95.6%)
		(1) QT: 21/02			QT final follow-up: 1 (4.3%)
Turkey	Follow-up: 37.6 months	(2) HT: 21/0		(1) HT (n = 21 patients).	(2) HT Preoperative: 19 (90.5%)
		Age (average):
		(1) QT: 26.8			HT final follow-up: 0 (0%)
		(2) HT: 28.6			HT final follow-up: 0 (0%)
Todor et al.,²⁵25. Todor A, Nistor DV, Caterev S. Clinical outcomes after ACL reconstruction with free quadriceps tendon autograft versus hamstring tendons autograft. A retrospective study with a minimal follow-up two years. Acta Orthop Traumatol Turc. 2019;53(3):180-3. 2019	Retrospective cohort study	N = 72 patients	ACL Reconstruction homologous autograft (HT and QT)	(1) QT (n = 39 patients).	Lysholm scores:	In both groups, there were no readmissions or reoperations due to complications. There was one patient in the QT group with a lateral difference of 5 mm in the KT-1000 test and was considered a failure. No patient in the HT group had a difference of more than 3 mm.	Yes
		Sex:			Lysholm scores:
		Male/Female			(1) QT Post-operative: 89.20 ± 9.97
		(1) QT: 26/13			(1) QT Post-operative: 89.20 ± 9.97
Romania	Follow-up: 24 months	(2) HT: 23/10		(1) HT (n = 33 patients).	(1) HT Post-operative: 91.33 ± 6.65	5 patients in the QT group (12.82%) reported an unsatisfactory aesthetic appearance of the suprapatellar incision and 8 patients in the HT group (24.24%) reported mild numbness in the anteromedial face of the leg.
		Age (average):			(1) HT Post-operative: 91.33 ± 6.65
		(1) QT: 30.64 ± 8.71			p = 0.299
		(2) HT: 28.60 ± 6.74			p = 0.299

Summary of findings:
Quadriceps tendon autograft compared with hamstring tendon autograft for anterior cruciate ligament reconstruction
Patient or population: anterior cruciate ligament reconstruction
Setting:
Intervention: Quadriceps tendon autograft
Comparison: hamstring tendon autograft
Outcomes	Anticipated absolute effects ^* (95% CI)		Relative effect (95% CI)	Nº of participants (studies)	Certainty of the evidence (GRADE)	Comments
Outcomes	Risk with hamstring tendon autograft	Risk with Quadriceps tendon autograft	Relative effect (95% CI)	Nº of participants (studies)	Certainty of the evidence (GRADE)	Comments
Function follow-up: mean 3 years	The mean function was 89.43	mean 85.59 higher (0 to 0)	-	436 (6 RCTs)	⨁⨁⨁◯ MODERATE	There were no differences in knee function between quadriceps tendon autograft and hamstring autograft (p = 0.08).
Pain follow-up: range 48 Years to 24 months	383 per 1.000	341 per 1.000 (218 to 533)	RR 0.89 (0.57 to 1.39)	254 (4 RCTs)	⨁⨁⨁◯ MODERATE	There were no differences in pain between the groups analyzed after the intervention (p = 0.60).
Return to sport follow-up: median 2 years	The mean return to sport was 82.1	mean 95.2 higher (0 to 0)	-	51 (1 RCT)	⨁⨁⨁⨁ HIGH	There were no significant differences (p < 0.131) in time to return to sport between groups.
Complications - Re-rupture follow-up: range 12 months to 3 years	11 per 1.000	0 per 1.000 (0 to 0)	no estimates	371 (5 observational studies)	⨁⨁◯◯ LOW	There were no differences in rupture following quadriceps tendon autograft and hamstring autograft (p = 0.38).
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the estimated effect: The true effect is likely to be close to the estimated effect, but there is a possibility that it is substantially different
Low certainty: Our confidence in the estimated effect is limited: The true effect may be substantially different from the estimated effect
Very low certainty: We have very little confidence in the estimated effect: The true effect is likely to be substantially different from the estimated effect

Databases	Search Strategy
MEDLINE/PubMed	Search: ((((Anterior Cruciate Ligament Reconstruction) OR (ACL reconstruction)) AND (quadriceps tendon autograft)) OR (quadriceps graft)) AND (Hamstring-Tendon Autografts) Filters: from 2000 - 2021
06/10/2021	*Total: 197*
EMBASE	1 (Anterior Cruciate Ligament Reconstruction or ACL reconstruction).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] 16283
	2 (quadriceps tendon autograft or quadriceps graft).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word] 156
	3 anterior cruciate ligament/ or anterior cruciate ligament reconstruction/ or tendon graft/ or Hamstring-Tendon Autografts.mp. or hamstring/ or hamstring tendon/
06/10/2021	30642
	41 and 2 and 3
	*Total: 119*
Cochrane Central Register of Controlled Trials	(Anterior Cruciate Ligament Reconstruction OR ACL reconstruction) AND (quadriceps tendon autograft OR quadriceps graft) AND (Hamstring-Tendon Autografts)
06/10/2021	*Total: 34*

Number	Title	Reason for exclusion
1	Hamstring tendon autograft versus quadriceps tendon autograft for anterior cruciate ligament reconstruction: a randomised controlled trial [Internet]. Hoboken: Cochrane Central Register of Controlled Trials (CENTRAL); 2018 [accessed on 2022 Oct 24]. Available from: https://trialsearch.who.int/Trial2.aspx?TrialID=ACTRN12618001520224	1
2	A randomized controlled trial comparing the outcomes of quadriceps autograft vs. hamstring autograft in acl reconstruction [Internet]. Hoboken: Cochrane Central Register of Controlled Trials (CENTRAL); 2019 [accessed on 2022 Oct 24]. Available from: https://trialsearch.who.int/Trial2.aspx?TrialID=ACTRN12619001396112	1
3	Cristiani R, Mikkelsen C, Wange P, Olsson D, Stålman A, Engström B. Autograft type affects muscle strength and hop performance after ACL reconstruction. A randomised controlled trial comparing patellar tendon and hamstring tendon autografts with standard or accelerated rehabilitation. Knee Surg Sports Traumatol Arthrosc. 2021;29(9):3025-3036.	2
4	Feller JA, Webster KE. A randomized comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction. Am J Sports Med. 2003;31(4):564-73.	2
5	Gupta R, Kapoor D, Kapoor L, Malhotra A, Masih GD, Kapoor A, Joshi S. Immediate post-operative pain in anterior cruciate ligament reconstruction surgery with bone patellar tendon bone graft versus hamstring graft. J Orthop Surg Res. 2016;11(1):67.	2
6	Comparing two surgical techniques for anterior cruciate ligament (ACL) reconstruction [Internet]. Hoboken: Cochrane Central Register of Controlled Trials (CENTRAL); 2020 [accessed on 2022 Oct 24]. Available from: https://trialsearch.who.int/Trial2.aspx?TrialID=ISRCTN55542036	1
7	A double blind randomized comparative study of two autografts in arthroscopic ACL reconstruction [Internet]. SICOT 40th Orthopaedic World Congress; 2019; Muscat. Hoboken: Cochrane Central Register of Controlled Trials (CENTRAL); 2019 [accessed on 2022 Oct 24]. Available from: https://www.cochranelibrary.com/central/doi/10.1002/central/CN-02072196/full	4
8	Kondo E, Yasuda K, Miyatake S, Kitamura N, Tohyama H, Yagi T. Clinical comparison of two suspensory fixation devices for anatomic double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2012;20(7):1261-7.	3
9	Martin-Alguacil JL, Arroyo-Morales M, Martin-Gómez JL, Lozano-Lozano M, Galiano-Castillo N, Cantarero-Villanueva I. Comparison of knee sonography and pressure pain threshold after anterior cruciate ligament reconstruction with quadriceps tendon versus hamstring tendon autografts in soccer players. Acta Orthop Traumatol Turc. 2019;53(4):260-5.	3
10	Anterior cruciate ligament-reconstruction: quadriceps tendon or hamstrings tendon? A prospective randomised controlled trial [Internet]. Bethesda: NML; 2019 [acessed on 2022 Oct 24]. Available from: https://clinicaltrials.gov/show/NCT02173483	1
11	Comparative study of anterior cruciate ligament reconstruction (quadriceps versus hamstring tendon) [Internet]. Bethesda: NML; 2018 [acessed on 2022 Oct 24]. Available from: https://clinicaltrials.gov/ct2/show/NCT02832791	1
12	Recovery of soccer players after anterior cruciate ligament reconstruction [Internet]. Bethesda: NML; 2021 [acessed on 2022 Oct 24]. Available from: https://clinicaltrials.gov/ct2/show/NCT04742868	1
13	Setuain I, Izquierdo M, Idoate F, Bikandi E, Gorostiaga EM, Aagaard P, et al. Differential effects of 2 rehabilitation programs following anterior cruciate ligament reconstruction. J Sport Rehabil. 2017;26(6):544-55.	2
14	Tashiro T, Kurosawa H, Kawakami A, Hikita A, Fukui N. Influence of medial hamstring tendon harvest on knee flexor strength after anterior cruciate ligament reconstruction. A detailed evaluation with comparison of single- and double-tendon harvest. Am J Sports Med. 2003;31(4):522-9.	2
15	Wipfler B, Donner S, Zechmann CM, Springer J, Siebold R, Paessler HH. Anterior cruciate ligament reconstruction using patellar tendon versus hamstring tendon: a prospective comparative study with 9-year follow-up. Arthroscopy. 2011;27(5):653-65.	2
16	Yoo SH, Song EK, Shin YR, Kim SK, Seon JK. Comparison of clinical outcomes and second-look arthroscopic findings after ACL reconstruction using a hamstring autograft or a tibialis allograft. Knee Surg Sports Traumatol Arthrosc. 2017;25(4):1290-7.	2
17	Chen CH, Chen WJ, Shih CH. Arthroscopic reconstruction of the posterior cruciate ligament: a comparison of quadriceps tendon autograft and quadruple hamstring tendon graft. Arthroscopy. 2002;18(6):603-12.	2
18	Chen CH, Chen WJ, Shih CH, Jiang CC. Quadriceps tendon-patellar bone autograft for arthroscopic anterior cruciate ligament reconstruction. Journal of Surgical Association Republic of China. 1998;31(3):166-72.	5
19	A study comparing two grafts for treatment of knee instability [Internet]. Hoboken: Cochrane Central Register of Controlled Trials (CENTRAL); 2019 [acessed on 2022 Oct 24]. Available from: https://trialsearch.who.int/Trial2.aspx?TrialID=CTRI/2017/03/008098	1
20	Is quadriceps tendon a better choice than hamstring tendons for repairing anterior cruciate ligament lesion? [Internet]. Hoboken: Cochrane Central Register of Controlled Trials; 2019 [acessed on 2022 Oct 24]. Available from: https://trialsearch.who.int/Trial2.aspx?TrialID=ISRCTN12967309	1
21	Ouabo EC, Gillain L, Saithna A, Blanchard J, Siegrist O, Sonnery-Cottet B. Combined anatomic anterior cruciate and anterolateral ligament reconstruction with quadriceps tendon autograft and gracilis allograft through a single femoral tunnel. Arthrosc Tech. 2019;8(8):e827-34.	6
22	Sanada T, Iwaso H, Fukai A, Honda E, Yoshitomi H, Inagawa M. Anatomic anterior cruciate ligament reconstruction using rectangular bone-tendon-bone autograft versus double-bundle hamstring tendon autograft in young female athletes. Arthrosc Sports Med Rehabil. 2021;3(1):e47-55.	2
23	Shibata Y, Matsushita T, Araki D, Kida A, Takiguchi K, Ueda Y, et al. Prediction of quadriceps strength recovery after anterior cruciate ligament reconstruction with a hamstring autograft: decision tree analysis. J Orthop Sci. 2019;24(2):301-5.	3
24	Fischer F, Fink C, Herbst E, Hoser C, Hepperger C, Blank C, Gföller P. Higher hamstring-to-quadriceps isokinetic strength ratio during the first post-operative months in patients with quadriceps tendon compared to hamstring tendon graft following ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2018;26(2):418-25.	3
25	Shaieb MD, Kan DM, Chang SK, Marumoto JM, Richardson AB. A prospective randomized comparison of patellar tendon versus semitendinosus and gracilis tendon autografts for anterior cruciate ligament reconstruction. Am J Sports Med. 2002;30(2):214-20.	2
26	Martin-Alguacil JL, Arroyo-Morales M, Martín-Gomez JL, Monje-Cabrera IM, Abellán-Guillén JF, Esparza-Ros F, et al. Strength recovery after anterior cruciate ligament reconstruction with quadriceps tendon versus hamstring tendon autografts in soccer players: a randomized controlled trial. Knee. 2018;25(4):704-14. (e-mail sent to authors)	7
¹Clinical trial record; ²Another comparison; ³Another outcome; ⁴Summary of congress; ⁵Another language; ⁶Article of revision of surgical technique; ⁷Incomplete data - deleted after contact with authors.

[1] Correspondence: Tássio Navajas Andrez. Av. Albert Einstein, 627, São Paulo, SP, Brazil, 05652900. tassio_navajas@hotmail.com

Brasil

Brasil

GRAFTS FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: SYSTEMATIC REVIEW AND META-ANALYSIS

ENXERTOS PARA RECONSTRUÇÃO DO LIGAMENTO CRUZADO ANTERIOR: REVISÃO SISTEMÁTICA E METANÁLISE

ABSTRACT

Objective:

Methods:

Results:

Conclusion: