[Other] Comparison of Autograft Types in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Bayesian Network Meta-Analysis of Randomized Clinical Trials Copy

Background: The literature regarding optimal autograft choice for anterior cruciate ligament (ACL) reconstruction (ACLR) remains inconclusive. This network meta-analysis (NMA) compares common autografts for primary ACLR.

Methods: PubMed, Scopus, Web of Science, and Embase were searched up to May 3, 2025, for randomized clinical trials (RCTs) on primary ACLR in adults that compared ≥2 of the following tendon autografts: 4-strand semitendinosus (4SST), 4-strand semitendinosus-gracilis (4SSTG), its 5-strand variant (5SSTG), bone-patellar tendon-bone (BPTB), quadriceps tendon with bone (QTB), and free quadriceps tendon (FQT). Outcomes analyzed in the NMA were the International Knee Documentation Committee (IKDC) subjective score, Lysholm score, Tegner Activity Scale, anteroposterior (instrumented) and rotational (pivot-shift) stability, and rerupture or revision ACLR rate. Autografts were ranked using surface under the cumulative ranking (SUCRA) values.

Results: A total of 44 RCTs with 3,491 patients were included in the NMA. With respect to the IKDC, QTB was statistically superior to BPTB (mean difference = 3.46, 95% credible interval [CrI]: 0.29 to 6.77), although the difference was likely not clinically meaningful. QTB ranked highest for the IKDC (SUCRA = 90.1%) and Tegner (SUCRA = 85.3%), while BPTB ranked lowest for the IKDC and Lysholm. With respect to knee laxity, QTB ranked second in anteroposterior and first in rotational stability, and it carried a significantly lower risk of a 2+ or higher pivot-shift than 4SST (risk ratio = 0.26, 95% CrI: 0.07 to 0.85). QTB was associated with a decreased risk of rerupture/revision compared with other autografts (SUCRA = 83.3%).

Conclusions: Based on the autograft rankings, QTB was found to lead to improved functional, activity-related, and stability outcomes overall, while also reducing the risk of graft failure.

Level of evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.