Quadriceps tendon autograft ACL reconstruction has less pivot shift laxity and lower failure rates than hamstring tendon autografts



Quadriceps tendon (QT) autograft ACL reconstruction was hypothesized to possess less anterior knee laxity, pivot shift laxity, and lower failure rates than hamstring tendon (HT) autografts.


Terms “hamstring tendon autograft” and “ACL reconstruction” or “quadriceps tendon autograft” and “ACL reconstruction” were searched in Embase and PubMed. Inclusion criteria required that studies included patients treated for primary ACL injury with reconstruction using either a QT autograft (Group 1) or a HT autograft (Group 2) and instrumented anterior knee laxity assessment. Extracted information included surgical fixation method, graft type, graft thickness or diameter, single vs. double bundle surgical method, publication year, time between the index knee injury and surgery, % women, initial and final subject number, subject age, follow-up length, side-to-side anterior knee laxity difference, Lysholm Score, Subjective IKDC score, anterior knee laxity side-to-side difference grade, ipsilateral pivot shift laxity grade, and failure rate. The Methodological Index for Nonrandomized Studies was used to evaluate study methodological quality.


The QT group (Group 1) had 17 studies and the HT group (Group 2) had 61 studies. Overall, Group 2 had greater pivot shift laxity (OR 1.29, 95% CI 1.05–1.59, p = 0.005). Group 2 suspensory femoral fixation had greater pivot shift laxity (OR 1.26, 95% CI 1.01–1.58, p = 0.02) than Group 1 compression femoral fixation. Group 2 compression femoral fixation also had more anterior knee laxity (OR 1.25, 95% CI 1.03–1.52, p = 0.01) than Group 1 compression femoral fixation and higher failure rates based on initial (OR 1.69, 95% CI 1.18–2.4, p = 0.002) and final (OR 1.89, 95% CI 1.32–2.71, p = 0.0003) subject number. Failure rate for HT compression femoral fixation was greater than suspensory femoral fixation based on initial (OR 2.08, 95% CI 1.52–2.84, p < 0.0001) and final (OR 2.26, 95% CI 1.63–3.16, p < 0.0001) subject number.


Overall, QT autografts had less pivot shift laxity and lower failure rates based on final subject number than HT autografts. Compression QT autograft femoral fixation had lower pivot shift laxity than suspensory HT autograft femoral fixation. Compression QT autograft femoral fixation had less anterior knee laxity and lower failure rates than compression HT autograft femoral fixation. Suspensory HT autograft femoral fixation had lower failure rates than compression HT autograft femoral fixation. Greater knee laxity and failure rates may be related to a combination of HT autograft diameter and configuration (tissue quality and dimensions, strands, bundles, and suturing method) variability and fixation mode.

Level of evidence

Level IV.

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Thanks to Dr. Kenneth Linfield, PhD, Director of Graduate Education, Clinical Psychology Program, Spalding University, Louisville, Kentucky, USA for his statistical consultation.


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Correspondence to John Nyland.

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Nyland, J., Collis, P., Huffstutler, A. et al. Quadriceps tendon autograft ACL reconstruction has less pivot shift laxity and lower failure rates than hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc 28, 509–518 (2020). https://doi.org/10.1007/s00167-019-05720-y

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  • Anterior cruciate ligament
  • Reconstruction
  • Patient outcome
  • Laxity