Translate this page into:
Comparative functional outcome study of superficial quadriceps tendon versus hamstring tendon autograft in arthroscopic anterior cruciate ligament reconstruction
*Corresponding author: Varrdhaman H. Dhariwal, Department of Orthopaedics, Stanley Medical College, Chennai, Tamil Nadu, India. varrdh@gmail.com
-
Received: ,
Accepted: ,
How to cite this article: Dhariwal VH, Rajamanickam P, Kannaiyan M, Iyyappan A. Comparative functional outcome study of superficial quadriceps tendon versus hamstring tendon autograft in arthroscopic anterior cruciate ligament reconstruction. J Arthrosc Surg Sports Med. 2026;7:51-5. doi: 10.25259/JASSM_29_2025
Abstract
Objectives:
The aim of this study was to evaluate the functional outcomes of arthroscopic anterior cruciate ligament (ACL) reconstruction using a quadriceps tendon graft and a hamstring tendon. Functional outcomes are measured using the Tegner Lysholm (TL) score and the International Knee Documentation Committee (IKDC) score, which provide a comprehensive evaluation of knee function and patient recovery.
Materials and Methods:
Patients aged 18 and above with Grade 3 anterior tibial translation were included in the study. Radiological confirmation was obtained through magnetic resonance imaging to support the diagnosis. Arthroscopic ACL reconstruction was then performed using a quadriceps tendon or hamstring autograft. Postoperatively, all patients were monitored, and functional knee assessment scores were recorded and compared with pre-operative values. Postoperatively, radiographs were done at 6 months, 1 year, and 2 years.
Results:
In our study, 80 patients underwent the procedure. Both the quadriceps and hamstring groups that underwent arthroscopic primary ACL reconstruction have similar outcomes in terms of IKDC and TL functional scores, with both having a P-value greater than 0.05.
Conclusion:
The quadriceps tendon autograft and the hamstring tendon autograft are equally effective for providing good functional scores to the knee joint.
Keywords
Anterior cruciate ligament
Hamstring tendon
International Knee Documentation Committee
Superficial quadriceps tendon
Tegner Lysholm
INTRODUCTION
The anterior cruciate ligament (ACL) is one of the important ligaments. The rising incidence of ACL injuries can be attributed to increased participation in sports and the growing number of road traffic accidents, especially involving two-wheelers. Early ACL reconstruction plays a crucial role in restoring knee stability and facilitating a return to activity, potentially reducing long-term complications such as chondral and meniscal damage in unstable knees.[1] Over the years, experts have introduced and refined multiple graft options to enhance outcomes in ACL reconstruction. Assessing the functional results of these techniques with a suitable graft is crucial to keeping pace with advancements in the field. This study main objective is to determine quadriceps tendon graft or the hamstring tendon graft which is providing better functional outcome.
MATERIALS AND METHODS
Study design
This prospective cohort study was conducted at our institute by a single surgeon, involving 90 patients (40 in each cohort) with ACL tears who underwent arthroscopic ACL reconstruction using a quadriceps tendon or hamstring tendon autograft. There were 5 lost-to-follow-up cases in each group. Simple random sampling was used for patient selection. The study included patients aged 18–45 years of either sex with ACL tears. Follow-up evaluations were performed at 6 months, 1 year, and 2 years post-surgery. Pre-operative Tegner Lysholm (TL) and International Knee Documentation Committee (IKDC) scores were recorded. The differences between preoperative and postoperative scores were analyzed using the unpaired t-test.
Surgical procedure
Under aseptic precautions and appropriate anesthesia, the patient was positioned supine with the knee flexed to 90°. An anterolateral portal was established, and diagnostic arthroscopy was performed to assess intra-articular structures, confirming ACL rupture. If a quadriceps tendon graft was planned, it was harvested using the Rajeev Raman technique[2] through a 3 cm incision made superior to the patella at the junction of the medial two-thirds and lateral one-third. An 8 mm graft was obtained using a closed tendon stripper [Figure 1a], and the donor site was closed in layers with Vicryl to achieve a watertight seal. If a hamstring graft was preferred, a curved medial parapatellar incision was made approximately three fingerbreadths below the joint line and one fingerbreadth medial to the tibial tuberosity. The semitendinosus and gracilis tendons were identified at the posteromedial pes anserinus, isolated, and harvested using sharp or blunt dissection or a tendon stripper after releasing fascial attachments [Figure 1b]. Graft thickness was standardized at 8 mm (tripled, quadrupled, or five-stranded), and donor tendons were repaired. The graft was then coated with 1 g of powdered vancomycin. With the knee flexed to 120°, the femoral tunnel was created at the posterolateral aspect of the femoral condyle using a guide wire and reamer, followed by tibial tunnel creation at 55° using a tibial jig. The graft was passed through both tunnels and secured with femoral fixation and with the tibial screw inserted at 15° of knee flexion and posterior translation of the tibia. Graft integrity and range of motion were assessed arthroscopically to confirm proper placement and tension.
- (a) Superficial quadriceps tendon Harvest. (b) Hamstring tendon Harvest.
Participants
Inclusion criteria
Age between 18–45 years and all cases with ACL injuries (grade 3 Lachmann test), irrespective of the mode of injury/duration/mechanism of injury/associated injuries of menisci were included in our study.
Exclusion criteria
Age below 18 years and above 45 years, lateral compartment osteoarthritis, ligament laxity, and infection are excluded from our study. Patients who met the inclusion criteria were selected and proceeded with the selection of grafts in a randomized manner. The presence of collateral ligament injury is excluded from the study.
Patients are selected in a randomized control manner by simple random sampling.
Study size
n = 80.
Statistical methods
In this cohort study, there were no confounding factors as mentioned in the exclusion criteria. We used an independent sample t-test to analyze the data that we obtained.
RESULTS
Participants
Forty patients in each group were recruited in our study and followed it up for 2 years.
Descriptive data
In this study, the mean age for the hamstring group is 28.3 (±5.24) and for the quadriceps group it is 26.75 (±3.90) with the sex distribution of 37 males and three females in the hamstring group and 36 males and four females in the quadriceps group. Among the hamstring group, 13 are manual workers, 16 are professionals, and 11 are semi-manual workers; with the quadriceps group, 12 are manual workers with 15 are professionals, and 13 are semi-manual workers.
Outcome data
In our study, the functional outcome in terms of IKDC and TL was analyzed statistically between both the groups using an independent sample t-test. In the Hamstring group, the mean preoperative IKDC score is 54.03 with the standard deviation (SD) of 2.93, improved to a value of mean 87.4 with SD 2.60 at 2-year follow-ups. Similarly, in the quadriceps group, the mean pre-operative IKDC score is 55.89 with a SD of 5.50, which improved to postoperative values of a mean 86.65 with SD at 2-year follow-up. The functional outcome in terms of TL was analyzed. For the hamstring group, the pre-operative mean of 52.40 with SD 5.07, and for the quadriceps group, it is 54.18 with SD of 2.01, which improved to a mean of 91.2 and SD of 2.18 in the hamstring group and with mean of 90.30 with SD of 3.99 in the quadriceps group. The results are plotted in the form of a graph for both the scoring system and found to have equivocal results [Figures 2-4].
- Tegner Lysholm (TL) score using hamstring tendon graft and quadriceps tendon graft showing similar scores in pre-operative and post-operative follow-up of 2 years.
- International Knee Documentation Committee (IKDC) scores using hamstring tendon graft and quadriceps tendon graft showing similar scores in pre-operative and post-operative follow-up of 2 years.
- International Knee Documentation Committee and Tegner Lysholm score with follow-up and no statistical difference with both the groups. Independent sample t-test, P < 0.05 and in this it is insignificant here. SD: Standard deviation
Main results
On comparing the two groups in terms of IKDC and TL scores using an independent sample t-test, the P-value is found to be insignificant (P > 0.05) at the end of the 2-year follow-up; for IKDC comparison, P = 0.164, and for TL, it is 0.176, respectively.
Presentation
TL score using hamstring tendon graft and quadriceps tendon graft showing similar scores in pre-operative and post-operative follow-up of 2 years.
IKDC scores using hamstring tendon graft and quadriceps tendon graft showing similar scores in pre-operative and post-operative follow-up of 2 years.
Post-operative clinical pictures of operated cases
Hamstring group
Post-operative clinical picture of the Hamstring tendon group.
Quadriceps group
Post-operative clinical picture of the quadriceps tendon group.
Results of the IKDC and TL scores, compared preoperatively and postoperatively over 2 years, show no statistical difference between the hamstring tendon and quadriceps tendon groups.
DISCUSSION
When surgeons started to do ACL reconstruction arthroscopically, the patellar tendon was used. Later, there was a shift toward soft-tissue graft such as the hamstring. During the later period of evolution, a superficial quadriceps graft was used as the graft. As the Raman et al. technique of harvesting the quadriceps graft came recently,[2] we want to compare the functional outcome of this graft with the hamstring tendon graft, especially in a low-resource center like us.
Appropriate graft selection is also important in making the procedure successful in terms of functional outcome [Figures 5 and 6]. Studies have shown that there is better acceptance of quadriceps among patients who require more hamstring strength, such as those involved in skiing, even in the elderly whose occupation is technically demanding.[3] In our study, we have excluded the patients who are elderly due to complications such as osteoarthritis and developing early stiffness, which is difficult to be identified due to surgery or pre-existing arthritis. In the elderly also, there are evidences which showed good clinical results in both the hamstring and quadriceps tendon groups.[4]
- Post-operative clinical picture of hamstring tendon group.
- Post-operative clinical picture of quadriceps tendon group.
There are a few patients in our study which they showed there is extension lag during the initial post-operative period which can be improved during with physiotherapy is possible to have a decreased in the hamstring and the quadriceps strength in terms of flexion and extension[5] which cannot be cured completely as we alter the physiological action to the muscle. Muscle strength can be improved by increasing the remaining muscle bulk through active quadriceps exercises and physiotherapy. The functional scores and the clinical post-operative range of movement for the hamstring and the quadriceps groups show no significant difference. A systemic review and meta-analysis study conducted in 2004 showed similar results in terms of patient-reported outcome measures,[6] graft ruptures, and the overall complications were also comparable in both groups. In our study, both groups had no significant donor site morbidity, which contradicts the meta-analysis done previously. Our center, though a low-resource center, has similar comparable results to other international studies[6], which makes this study unique.
There are studies that showed the quadriceps tendon have better donor site morbidity than the hamstring tendon.[7] In our study, we have selected the site of harvesting the quadriceps tendon at the central part in all the patients within the group. By this, we are able to get the adequate size of the graft and avoid the graft thinning out while harvesting the quadriceps tendon graft. In our study, both the hamstring and the quadriceps groups are fixed with the interference screws in both the quadriceps and the hamstring tendon groups.
There is no difference in fixation technique done in our study. As per the previous articles, the different fixation techniques do not provide any difference in clinical and stability outcomes.[8] In patients with knee instability which causes hyperextension, the integrity of posterior cruciate ligament is checked by magnetic resonant imaging and then proceeded with arthroscopic reconstruction. In such cases, we preferred to use the quadriceps graft.[9]
Key results
On comparing both the study groups, both show comparatively good results. No significant difference in their functional results observed in terms of IKDC and TL scores.
Limitations and strength
In our study, we had an adequate sample with a sufficient follow-up duration of 2 years. There are no complications noted in terms of surgical site infection and graft rupture during our follow-up. There was minimal absence during the follow-up. Since our study is a single surgeon and done in a single center, the outcome results will be more comparable when we approach in a multicentric manner. Even though fewer articles showed that doing a lateral extra-articular tenodesis may increase the stability of the knee,[10] we have not included it under the study.
CONCLUSION
This is a prospective study comparing the quadriceps and the hamstring tendon autograft with the quadriceps tendon harvested using a mini incision technique, using functional IKDC and TL score in arthroscopic ACL reconstruction, which showed equally good clinical results in terms of stability of the knee joint and provided good functional range of motion of the knee joint.
Author contributions:
HVD: Study design, analysis, reviewing manuscript; RP: Ideas and reviewing manuscript; KMK: Ideas and reviewing manuscript; AI - Manuscript preparation and statistics.
Ethical approval:
The research/study approved by the Institutional Review Board at Stanley Medical College, number 02022022004, dated February 02, 2022.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
References
- Safety and early return to sports for early ACL reconstruction in young athletes: A retrospective study. Medicina (Kaunas). 2024;60:1229.
- [CrossRef] [PubMed] [Google Scholar]
- A minimally invasive and simple technique of superficial quadriceps tendon graft harvesting. Arthrosc Tech. 2022;11:e2347-55.
- [CrossRef] [PubMed] [Google Scholar]
- Editorial commentary: Anterior cruciate ligament graft selection is best tailored to individual patient sport and activity level. Arthroscopy. 2025;41:1521-2.
- [CrossRef] [PubMed] [Google Scholar]
- Both hamstring and quadriceps tendon autografts offer similar functional outcomes after arthroscopic anterior cruciate ligament reconstruction in patients aged 50 years or older. Arthroscopy. 2024;41:1512-20.
- [CrossRef] [PubMed] [Google Scholar]
- A prospective randomized controlled study of hamstring and bone-free quadriceps tendons autograft in arthroscopic ACL reconstruction. Eur J Orthop Surg Traumatol. 2024;34:293-301.
- [CrossRef] [PubMed] [Google Scholar]
- Quadriceps tendon versus hamstring tendon graft for primary anterior cruciate ligament reconstruction: A systematic review and meta-analysis of randomised trials. Knee. 2024;49:226-40.
- [CrossRef] [PubMed] [Google Scholar]
- Quadriceps tendon autograft for primary anterior cruciate ligament reconstruction in comparison to hamstring tendon autografts. Egypt Orthop J. 2024;59:176-83.
- [CrossRef] [Google Scholar]
- ACL reconstruction using quadrupled semitendinosus versus double-stranded semitendinosus and gracilis autograft: 2 year results from a prospective randomized controlled study. Am J Sports Med. 2024;52:1927-36.
- [CrossRef] [PubMed] [Google Scholar]
- Quadriceps tendon with bone autograft has better stability and magnetic resonance imaging maturation than hamstring tendon autograft after anterior cruciate ligament reconstruction in patients with knee hyperextension. Arthroscopy. 2024;40:1234-44.
- [CrossRef] [PubMed] [Google Scholar]
- Anterior cruciate ligament reconstruction using hamstring autograft plus lateral extra-articular tenodesis and all-soft tissue quadriceps alone have lower retear rate and pivot-shift grade but similar outcome to hamstring autograft alone in high-risk patients. Arthroscopy 2025:749-8063.
- [CrossRef] [PubMed] [Google Scholar]