Risk of Revision and Reoperation After ACL Reconstruction: Comparison of Quadriceps Tendon,Patellar Tendon,and Hamstring Autografts Stratified by Patient Sex and Age: A Cohort Study of 27,715 Patients From 2012 to 2023

Abstract

Background:

Many different graft choices exist for anterior cruciate ligament reconstruction (ACLR) with potential for variable outcomes based on graft type.

Purpose:

To evaluate risk for subsequent surgical outcomes after primary ACLR according to autograft selection, stratified by patient sex and age.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data from the Kaiser Permanente ACLR Registry was used to conduct a cohort study. A total of 27,715 patients with primary isolated autograft ACLR were identified (2012-2023). The exposure of interest was autograft type: quadriceps tendon (QT), patellar tendon (PT), or hamstring tendon (HT). Multivariable Cox proportional hazards regression models were used to evaluate the risk for revision and risk for ipsilateral reoperation according to autograft selection with adjustment for confounders.

Results:

No differences were found in revision or reoperation risks across sex and age groups for QT versus PT ACLR. For QT compared to HT ACLR, QT was associated with a lower revision risk in females <22 years (hazard ratio [HR], 0.45; 95% CI, 0.22-0.92). A higher risk of reoperation for stiffness (HR, 3.12; 95% CI, 1.00-9.72) and cartilage (HR, 3.65; 95% CI, 1.28-10.44) was observed with QT versus HT ACLR in males <22 years, while a higher overall reoperation risk (HR, 1.59; 95% CI, 1.06-2.40) was observed in males ≥22 years. When comparing PT to HT ACLR, PT had a lower risk of revision (HR, 0.57; 95% CI, 0.43-0.75) but a higher stiffness reoperation risk (HR, 1.58; 95% CI, 1.11-2.25) in females <22 years. PT versus HT was associated with higher overall reoperation (HR, 1.39; 95% CI, 1.12-1.73) and stiffness reoperation (HR, 1.56; 95% CI, 1.10-2.21) risks in males ≥22 years.

Conclusion:

In young female patients, HT ACLR was associated with a 2.3 and 1.8 times higher revision risk when compared to QT and PT ACLR, respectively. No differences in risk of revision were noted between QT and PT ACLR. The risk for ipsilateral reoperation varied across patient age and sex, with higher risks observed for specific reoperation reasons with QT and PT compared to HT ACLR. Surgeons should consider these data when discussing risks and benefits of the different graft options for ACLR, especially with their female patients.