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Orthop J Sports Med. 2019 Apr 24;7(4):2325967119839786. doi: 10.1177/2325967119839786. eCollection 2019 Apr.

Quadriceps Recovery After Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon Versus Patellar Tendon Autografts.

Author information

Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina, USA.
Department of Health and Human Performance, College of Charleston, Charleston, South Carolina, USA.
Department of Orthopaedics and Physical Medicine, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA.
Department of Radiology and Radiological Science, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA.



Quadriceps tendon (QT) autografts are being increasingly used for anterior cruciate ligament reconstruction (ACLR). A paucity of studies exist that compare QT autografts with alternative graft options. Additionally, concerns exist regarding quadriceps recovery after graft harvest insult to the quadriceps muscle-tendon unit.


The purpose of this study was to compare quadriceps recovery and functional outcomes in patients with QT versus bone-patellar tendon-bone (BPTB) autografts. The hypothesis was that those with QT autografts would demonstrate superior outcomes.

Study Design:

Cohort study; Level of evidence, 3.


Active patients with a history of primary, unilateral ACLR with soft tissue QT or BPTB autografts participated. Quadriceps recovery was quantified using variables of strength, muscle size, and activation. Knee extensor isometric and isokinetic strength was measured bilaterally with an isokinetic dynamometer and normalized to body weight. Quadriceps activation was measured with the superimposed burst technique. The maximal cross-sectional area of each quadriceps muscle was measured bilaterally using magnetic resonance imaging. Assessors of muscle size were blinded to the graft type and side of ACLR. Functional tests included hop tests and step length symmetry during walking, measured via spatiotemporal gait analysis. Self-reported function was determined with the International Knee Documentation Committee (IKDC) questionnaire. Neuromuscular and functional outcomes were expressed as limb symmetry indices (LSIs: [surgical limb/nonsurgical limb]*100%). Wilcoxon rank-sum tests were used to compare the LSIs and IKDC scores between groups.


There were 30 study participants (19 male, 11 female; median age, 22 years [range, 14-41 years]; median time since surgery, 8 months [range, 6-23 months]), with 15 patients in each group. There were no significant between-group differences in demographic variables or outcomes. LSIs were not significantly different between the QT versus BPTB group, respectively: knee extensor isokinetic strength at 60 deg/s (median, 70 [range, 41-120] vs 68 [range, 37-83]; P = .285), activation (median, 95 [range, 85-111] vs 92 [range, 82-105]; P = .148), cross-sectional area of the vastus medialis (median, 79 [range, 62-104] vs 77 [range, 62-95]; P = .425), single-leg hop test (median, 88 [range, 35-114] vs 77 [range, 49-100]; P = .156), and step length symmetry (median, 99 [range, 93-104] vs 98 [range, 92-103]; P = .653). The median IKDC scores between the QT and BPTB groups were also not significantly different: 82 (range, 67-94) versus 83 (range, 54-94); respectively (P = .683).


Patients with QT autografts demonstrated similar short-term quadriceps recovery and postsurgical outcomes compared with patients with BPTB autografts.


ACL reconstruction; anterior cruciate ligament; quadriceps tendon; rehabilitation

Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: This study was supported by the South Carolina Clinical & Translational Research Institute, at the Medical University of South Carolina, through National Institutes of Health grants TL1 TR001451 and UL1 TR001450. This project was also supported by the National Athletic Trainers’ Association Foundation Award (1617DGP005). S.K.W. has received educational support from Arthrex, MTF, Smith & Nephew, and Stryker; honoraria and hospitality fees from MTF; and consulting fees from MicroAire. H.S.S. has received educational support from Arthrex and Smith & Nephew and speaking fees from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

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