2025 ISAKOS Congress in Munich, Germany

2025 ISAKOS Biennial Congress Paper


Risk of Revision and Re-Operation After ACL Reconstruction. Comparison of Quadriceps Tendon, Patellar Tendon, and Hamstring Autografts Stratified by Patient Gender and Age: A Cohort Study of 27,715 Patients

Gregory B. Maletis, MD, Baldwin Park, CA UNITED STATES
Heather Prentice, PhD, San Diego, CA UNITED STATES
Chelsea Reyes UNITED STATES
Christopher Lehman, S San Fran, CA UNITED STATES
Colin Mansfield, MD, Walnut Creek, CA UNITED STATES
Justin S. Yang, MD, Los Angeles, CA UNITED STATES

Kaiser Permanente, San Diego, CA, UNITED STATES

FDA Status Not Applicable

Summary

In females, HT ACLR had a 1.8X higher risk of revision compared to PT, and a 2.4X higher risk of revision compared to QT. In males, HT had a 1.3 X higher risk of revision compared to PT. No differences were noted when QT was compared to PT. Surgeons should consider this data when discussing risks and benefits of the different graft options for ACLR, especially with their female patients.

Abstract

The purpose of this study was to evaluate the risk of revision and reoperation, for a cohort of primary anterior cruciate ligament reconstruction (ACLR) patients according to autograft selection stratified by patient gender and age.

Methods

Data from a US healthcare system’s ACLR registry was used to conduct a cohort study. 27,715 primary isolated autograft ACLR patients were identified (2012-2023); those with prior procedures in the same knee were excluded. The exposure of interest autograft type: quadriceps tendon (QT), bone-patellar tendon-bone (PT), and hamstring tendons (HT). Multivariable Cox proportional hazard regression models were used to evaluate the risk for revision and reoperation according to autograft selection. Age, body mass index, gender, race/ethnicity, ASA classification, activity at the time of injury, prior contralateral ACLR, cartilage and meniscal injury, tunnel drilling technique, and operative time, were considered as covariates in regression analysis; models also included a cluster term for operating surgeon to account for correlation of ACLR performed by the same surgeon. Hazard ratios (HR) and 95% confidence intervals are reported, a p<0.05 the threshold for statistical significance. Secondary analysis restricted to patients <22 years at the time of their ACLR.

Results

The study sample comprised 27,715 ACLR. There were 10,955 females and 16,760 males who underwent primary isolated ACLR; procedures were performed by 319 surgeons at 58 hospitals.
In the female cohort, QT, PT, and HT autograft were used in 874 (8.0%), 4597 (42.0%), and 5484 (50.1%) ACLR, respectively. In adjusted models, no significant differences were observed in revision risk (HR=0.72, 95% CI=0.35-1.49, p=0.375) or reoperation risk (HR=0.84, 95% CI=0.58-1.21, p=0.344) when comparing QT to PT. However, QT had a lower revision risk (HR=0.41, 95% CI=0.22-0.77, p=0.006) compared to HT; no differences were observed for reoperation (HR=0.95, 95% CI=0.65-1.38, p=0.787). HT were noted to have a higher risk of revision (HR=1.76, 95% CI=1.36-2.29, p<0.001) compared to PT and no difference in reoperation risk (HR=0.89, 95% CI=0.75-1.05, p=0.167). Similar findings were observed when restricting to patients aged <22 years.
There were 1297 (7.7%) QT, 7560 (45.1%) PT, and 7903 (47.2%) HT ACLR performed in male patients. No differences in revision or reoperation risk were observed when comparing QT to PT (revision: HR=0.98, 95% CI=0.60-1.60, p=0.936; reoperation: HR=1.15, 95% CI=0.74-1.78, p=0.526) or HT (revision: HR=0.70, 95% CI=0.47-1.04, p=0.074; reoperation: HR=1.34, 95% CI=0.92-1.93, p=0.123). While HT associated with a higher revision risk compared to PT (HR=1.32, 95% CI=1.08-1.61, p=0.008), no difference was observed in reoperation risk (HR=0.88, 95% CI=0.74-1.04, p=0.132). Similar findings were observed when restricting to patients aged <22 years.

Conclusion

In females, a 1.8X higher risk of revision was identified when HT was compared to PT, and a 2.4X higher risk of revision when HT was compared to QT. In males, a 1.3 X higher risk of revision was identified when HT was compared to PT. No differences in risk of revision were noted when QT was compared to PT. Surgeons should consider this data when discussing risks and benefits of the different graft options for ACLR, especially with their female patients.