Rectus femoris tendon autograft yields comparable early outcomes to hamstring tendon autograft, but evidence remains limited: A systematic review

PURPOSE: To compare clinical outcomes, strength, donor-site morbidity, complications and graft failure after primary or revision anterior cruciate ligament reconstruction (ACLR) using rectus femoris tendon (RT) versus hamstring tendon (HT) autografts. METHODS: A systematic review was conducted in accordance with preferred reporting items for systematic reviews and meta-analyses 2020. Comparative clinical studies of RT and HT autografts in primary or revision ACLR were included. Outcomes were synthesised narratively because of the small number of studies and clinical and methodological heterogeneity. RESULTS: Four comparative studies enrolled 324 patients, of whom 299 were available for final comparative analysis (RT, n = 142; HT, n = 157). Two studies evaluated primary and two evaluated revision ACLR. Three studies reported patient-reported outcomes. One revision study found higher International Knee Documentation Committee scores (83.8 ± 12.2 vs. 78.6 ± 16.8; p = 0.037) and Tegner scores (5.8 ± 1.8 vs. 5.6 ± 1.5; p = 0.043) with RT; however, the absolute differences were small, and attainment of a minimal clinically important difference was not reported. The other two studies found no significant between-group differences. At approximately 6 months, quadriceps peak torque did not differ between RT and HT (173.0 ± 62.0 vs. 167.7 ± 45.7 Nm; p = 0.689). Failure rates were 2.3% versus 17.4% (p = 0.031) in one revision study and 7.1% versus 7.4% in another. Donor-site morbidity was reported quantitatively in one study and did not differ significantly (4.7% vs. 13.0%; p = 0.268). CONCLUSION: RT autografts produced early clinical outcomes broadly comparable to HT autografts, but the evidence base comprises only four heterogeneous comparative studies with short and unequal follow-up. RT may be considered when established autografts are unavailable, particularly in revision ACLR; routine use in primary ACLR cannot yet be recommended. LEVEL OF EVIDENCE: Level IV.