Abstract Background The quadriceps tendon (QT) has emerged as a reliable autograft for anterior cruciate ligament reconstruction (ACLR), but uncertainty remains regarding several key comparative aspects—particularly donor-site morbidity, long-term graft survival, knee stability, and complication rates—when evaluated against hamstring tendon (HT) and bone–patellar tendon–bone (BPTB) autografts. High-level evidence restricted to randomized controlled trials directly comparing QT with HT or BPTB remains limited. To compare clinical outcomes, graft failure, donor-site morbidity, and knee stability among QT, HT, and BPTB autografts for primary ACLR using level-I and level-II randomized controlled trials (RCTs). Methods The MEDLINE (PubMed), Embase (Elsevier), and Cochrane Library databases were searched on 1 September 2025, and repeated 2 weeks later. Only level-I or -II RCTs comparing QT to HT or BPTB in primary ACLR were included. Random-effects meta-analyses were performed for International Knee Documentation Committee (IKDC) and Lysholm scores, instrumented laxity, graft failure, donor-site morbidity, and reoperation. Risk of bias was assessed with RoB 2.0, and small-study effects with funnel and doi plots. Results Eleven RCTs (mean follow-up, 2–10 years) were included. Pooled IKDC scores averaged 84.8 (95% CI 81.9–87.9) and Lysholm scores averaged 93.1 (95% CI 91.6–94.6), with no significant differences between QT and either comparator ( P > 0.05). Side-to-side anterior tibial translation averaged 1.2 mm (95% CI 0.99–1.54 mm) across all grafts, also without significant differences ( P > 0.05). Pooled graft failure and ipsilateral reoperation rates were 0.7% (95% CI 0.0–1.9%) and 2.3% (95% CI 0.6–4.7%), respectively, again with no between-graft differences ( P > 0.05). Donor-site morbidity did not differ significantly between QT and HT (mean 13.83 95% CI 9.6–19.83; P > 0.05). Conclusion This meta-analysis of level-I/II randomized controlled trials found no statistically significant differences among quadriceps tendon, hamstring tendon, and bone–patellar tendon–bone autografts in patient-reported outcomes, knee stability, graft re-rupture, or additional knee surgery. Donor-site morbidity comparisons were limited by incomplete reporting, particularly for BPTB. These findings suggest that contemporary surgical techniques and rehabilitation protocols may minimize graft-specific differences in mid-term outcomes, although interpretation should consider the limited number of direct comparative trials across all three graft types. Level of evidence Systematic review and meta-analysis; level of evidence, 1 and 2.
D’Ambrosi et al. (Thu,) studied this question.