Regarding “ Editorial Commentary : Quadrupled Semitendinosus Autograft Is a Suitable Graft Choice for Anterior Cruciate Reconstruction, Regardless of Diameter, in Patients With Lower Risk for Rerupture”

We read with great interest the editorial commentary titled “Quadrupled Semitendinosus Autograft Is a Suitable Graft Choice for Anterior Cruciate Reconstruction, Regardless of Diameter, in Patients With Lower Risk for Rerupture,”1 which addresses our study “Diameter of Quadrupled Semitendinosus Autograft in Primary Anterior Cruciate Ligament Reconstruction Did Not Impact Early Revision Rate or Functional Outcome in a Large Cohort of Patients.”2 While we appreciate the recognition of our work, we would like to provide several clarifications regarding the interpretation of our findings. The primary aim of our study was to assess the impact of graft diameter in quadrupled semitendinosus tendon (ST) autografts—rather than hamstring tendon (HT) autografts in general—on risk for early revision anterior cruciate ligament reconstruction (ACLR), postoperative knee laxity, and patient-reported outcomes. Quadrupled ST grafts differ biomechanically from traditional HT grafts, constructed using both ST and gracilis tendon, and we believe quadrupled ST grafts warrant evaluation as a separate graft choice. At our institution, this is standard graft used for primary ACLR. The editorial commentary rightfully points out the lower revision rate (2.6%) in our study compared to other publications. Although this may in part reflect a lower-risk population included in our cohort, our data indicate that patient-related factors and particularly young age and high preinjury activity level are more strongly associated with early revision than graft diameter. Among the 4519 patients included, the subgroup who underwent revision ACLR within 2 years (n = 117) had a mean age of 18 ± 3 years. The mean preinjury Tegner activity level was 7 which indicates a high preinjury activity level and the mean graft diameter was 8.25 ± 0.7 mm, i.e., well above the frequently cited 8 mm threshold.3, 4 These findings, supported by multivariate analysis, suggest that the increased rate of revision ACLR observed in young patients with high-activity level is largely attributable to demographic and functional factors rather than graft diameter, indicating that its clinical relevance may be limited. Additionally, in our cohort, ST graft diameter was not associated with postoperative knee laxity. Grafts smaller than 8 mm were only associated to slightly lower Knee injury and Osteoarthritis Outcome Score in the Sport and Recreation subscale at 2-year follow-up with no significant differences across the other Knee injury and Osteoarthritis Outcome Score subscales. The commentary recommends considering alternative graft options in younger athletes such as bone–patellar tendon–bone autografts or adding stabilizing procedures (e.g., anterolateral ligament reconstruction or lateral extra-articular tenodesis) in younger athletes. While we acknowledge that several studies have showed potential benefits of such techniques in high-risk populations, our dataset does not permit evaluation of these strategies. Further research is warranted to determine the most effective graft type and adjunct procedures for young, high-demand patients undergoing ACLR. In this regard, our ongoing randomized controlled trial (SEQUAR study),5 is designed to address this question directly, comparing quadrupled ST autografts to quadriceps tendon autografts in high-demand athletes (preinjury Tegner activity level ≥7). Until such data are available, we caution against overextending recommendations about graft choice beyond the scope of the current findings. In conclusion, our data do not support an association between graft diameter and early revision surgery after primary ACLR using a quadrupled ST autograft and the commonly used threshold of 8 mm—originally proposed for HT grafts—did not appear to be relevant in the context of this graft configuration. Our results underscore the need to consider a broader set of patient- and surgery-related variables, beyond graft diameter, when assessing revision risk after ACLR. We agree that further high-level studies, including RCTs comparing graft types and adjunct procedures, are needed to guide graft type selection in high-risk populations. The author (R.C.) declares the following financial interests/personal relationships which may be considered as potential competing interests: R.C. reports was provided by Karolinska Institutet. The other authors (V.S., G.E., A.S.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.