For years, the ACL graft conversation has centered on two mainstays: bone–patellar tendon–bone (BPTB) and hamstring tendon (HT).
Quadriceps tendon (QT) was often positioned as the capable alternative — viable, yes, but not always the default in primary reconstruction.
A new multicenter randomized controlled trial suggests that framing may be outdated.
In a Level I study published February 2026, investigators compared QT, BPTB and HT autografts in primary isolated anterior cruciate ligament reconstruction (ACLR). At two years, QT proved non-inferior to both traditional options in subjective patient-reported outcomes (PROMs) — without introducing new safety concerns.
For surgeons who have cautiously adopted QT, the data now offer something stronger than anecdote: high-level validation.
Three Grafts – One Standard
The trial randomized patients undergoing primary isolated ACLR to receive one of three autografts: QT (50 patients), BPTB (42 patients) or HT (44 patients). The cohort reflected everyday ACL practice — mean age about 26 years, roughly two-thirds male.
The primary endpoint was the International Knee Documentation Committee (IKDC) subjective score at two years, analyzed against a prespecified non-inferiority margin of –10 points.
Secondary outcomes included KOOS, ACL-QoL, Lysholm, Tegner, strength testing, hop performance, radiographic osteoarthritis and adverse events, including graft failure.
This was not a narrow PROM snapshot. It was a true head-to-head comparison of the three dominant autograft options.
Two Years Later: A Statistical Tie
At two years, the mean IKDC subjective scores were QT: 88.4, BPTB: 85.5 and HT: 89.2.
No statistically significant differences emerged.
Crucially, the lower bound of the 95% confidence interval for QT remained well within the predefined non-inferiority margin. All three groups improved significantly from baseline.
The takeaway is simple: patients reported feeling equally good, regardless of graft choice.
Failure rates were numerically higher in the BPTB group (11.9%) compared to QT (8.0%) and HT (4.6%), but these differences were not statistically significant. No signal suggested QT carried increased risk.
For surgeons weighing graft algorithms, equivalence paired with safety is powerful.
Early Strength Differences – Then Convergence
At six months, the HT group demonstrated superior quadriceps strength and triple-hop performance. By one year, those differences disappeared.
That trajectory will feel familiar to surgeons managing postoperative rehab. Harvest site morbidity can shape early strength curves. But over time, those distinctions tend to narrow.
This study reinforces that early divergence does not necessarily predict long-term separation.
Where QT Now Stands
Quadriceps tendon grafting has steadily gained ground, often favored for its substantial graft diameter, versatility in harvest technique and avoidance of some anterior knee pain concerns associated with BPTB harvest.
Still, many surgeons trained extensively in BPTB or HT techniques and have been reluctant to recalibrate without robust data.
This trial strengthens the argument that QT is not a secondary option. In terms of subjective outcomes at two years, it stands shoulder-to-shoulder with both established standards.
It does not prove superiority — but it does not need to.
In modern ACL reconstruction, graft selection is rarely one-size-fits-all. It is individualized, sport-specific and surgeon-driven. When outcomes are equivalent, flexibility becomes an advantage.
The Debate Isn’t Over – But It’s Clearer
No single trial will settle the ACL graft debate. Longer-term data on durability, osteoarthritis progression, and return-to-sport sustainability remain essential.
But within the two-year window examined here, the message is unambiguous: quadriceps tendon autograft performs at the same level as BPTB and hamstring autografts in primary isolated ACL reconstruction.
For surgeons already using QT, the evidence base just solidified. For those still evaluating it, the “alternative” label may no longer apply.
In the ACL graft heavyweight bout, quadriceps tendon just proved it belongs in the ring.
Authors: Barbara C. Boer, Reinoud W. Brouwer, Judith olde Heuvel, Astrid J. de Vries, Wybren A. van der Wal, J. Christiaan Rompen, Albert H. van Houten, Roy A. G. Hoogeslag