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
Restricted accessResearch articleFirst published online April, 2026
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
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.
BokshanSLMehtaSDeFrodaSFOwensBD.What are the primary cost drivers of anterior cruciate ligament reconstruction in the United States? A cost-minimization analysis of 14,713 patients. Arthroscopy. 2019;35(5):1576-1581.
2.
Castellanos DolkDHedevikH, et al. Nationwide incidence of anterior cruciate ligament reconstruction in higher-level athletes in Sweden: a cohort study from the Swedish National Knee Ligament Registry linked to six sports organisations. Br J Sports Med. 2025;59(7):470-479.
3.
CavaignacECoulinBTschollPNik Mohd FatmyNDuthonVMenetreyJ. Is quadriceps tendon autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? A comparative study with a mean follow-up of 3.6 years. Am J Sports Med. 2017;45(6):1326-1332.
4.
ChildersJEngELackB, et al. Reported anterior cruciate ligament injury incidence in adolescent athletes is greatest in female soccer players and athletes participating in club sports: a systematic review and meta-analysis. Arthroscopy. 2025;41(3):774-784.e772.
5.
ChivotMPiogerCCognaultJ, et al. Every layer of quadriceps tendon's central and medial portion offers similar tensile properties than hamstrings or ilio-tibial band grafts. J Exp Orthop. 2020;7(1):50.
6.
ConnorsJPCusanoASaleetJ, et al. Return to sport and graft failure rates after primary Anterior cruciate ligament reconstruction with a bone-patellar tendon-bone versus hamstring tendon autograft: a systematic review and meta-analysis. Am J Sports Med. 2025;53(8):1996-2006.
7.
CrawfordSNWatermanBRLubowitzJH.Long-term failure of anterior cruciate ligament reconstruction. Arthroscopy. 2013;29(9):1566-1571.
8.
CristianiRForssbladMEdmanGErikssonKStålmanA.Age, time from injury to surgery and quadriceps strength affect the risk of revision surgery after primary ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2021;29(12):4154-4162.
9.
DaiWLengXWangJChengJHuXAoY.Quadriceps tendon autograft versus bone-patellar tendon-bone and hamstring tendon autografts for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med. 2022;50(12):3425-3439.
10.
DavisACVoelkelJLRemmersCLAdamsJLMcGlynnEA.Comparing Kaiser Permanente members to the general population: implications for generalizability of research. Perm J. 2023;27(2):87-98.
11.
DingDYPrenticeHAReyesCPaxtonEWChenFMaletisGB.Patient and operative risk factors for subsequent knee arthroplasty after primary anterior cruciate ligament reconstruction: a cohort study of 52,222 patients. Am J Sports Med. 2025;53(10):2370-2378.
12.
EkelandAEngebretsenLFenstadAMHeirS.Similar risk of ACL graft revision for alpine skiers, football and handball players: the graft revision rate is influenced by age and graft choice. Br J Sports Med. 2020;54(1):33-37.
13.
GarciaMMomenzadahKShariyateMJ, et al. Plastic and elastic biomechanical properties of anterior cruciate ligament autografts. BMC Musculoskelet Disord. 2024;25(1):157.
14.
GetgoodAMJBryantDMLitchfieldR, et al. Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the STABILITY Study randomized clinical trial. Am J Sports Med. 2020;48(2):285-297.
15.
GifstadTFossOAEngebretsenL, et al. Lower risk of revision with patellar tendon autografts compared with hamstring autografts: a registry study based on 45,998 primary ACL reconstructions in Scandinavia. Am J Sports Med. 2014;42(10):2319-2328.
16.
GopinatthVTartibiSSmithMVMatavaMJBrophyRHKnapikDM.Long-term results of bone-patellar tendon-bone versus hamstring tendon autograft for primary anterior cruciate ligament reconstruction: a meta-analysis of randomized controlled trials. Orthop J Sports Med. 2025;13(4):23259671251330307.
17.
HaleyRMLamplotJDMyerGD, et al. Localized anterior arthrofibrosis after soft-tissue Quadriceps tendon anterior cruciate ligament reconstruction is more common in patients who are female, undergo meniscal repair, and have grafts of larger diameter. Arthroscopy. 2023;39(6):1472-1479.
18.
HuletCSonnery-CottetBStevensonC, et al. The use of allograft tendons in primary ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019;27(6):1754-1770.
19.
IrelandML.The female athlete: entitled to compete, predetermined to tear her anterior cruciate ligament?Curr Sports Med Rep. 2005;4(2):57-60.
20.
JacksonGRLeeJTuthillT, et al. Higher rates of residual postoperative instability after anterior cruciate ligament reconstruction in female patients: a systematic review of level II studies. Arthrosc Sports Med Rehabil. 2023;5(5):100772.
21.
KaedingCCArosBPedrozaA, et al. Allograft versus autograft anterior cruciate ligament reconstruction: predictors of failure from a MOON prospective longitudinal cohort. Sports Health. 2011;3(1):73-81.
22.
KaedingCCPedrozaADReinkeEKHustonLJSpindlerKP.Risk factors and predictors of subsequent ACL injury in either knee after ACL reconstruction: prospective analysis of 2488 primary ACL reconstructions from the MOON cohort. Am J Sports Med. 2015;43(7):1583-1590.
LindMMenhertFPedersenAB.Incidence and outcome after revision anterior cruciate ligament reconstruction: results from the Danish registry for knee ligament reconstructions. Am J Sports Med. 2012;40(7):1551-1557.
25.
LindMStraussMJNielsenTEngebretsenL.Low surgical routine increases revision rates after quadriceps tendon autograft for anterior cruciate ligament reconstruction: results from the Danish Knee Ligament Reconstruction Registry. Knee Surg Sports Traumatol Arthrosc. 2021;29(6):1880-1886.
26.
LundBNielsenTFaunøPChristiansenSELindM.Is quadriceps tendon a better graft choice than patellar tendon? A prospective randomized study. Arthroscopy. 2014;30(5):593-598.
27.
MagnussenRALawrenceJTWestRLTothAPTaylorDCGarrettWE.Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthroscopy. 2012;28(4):526-531.
28.
MagnussenRAMeschbachNTKaedingCCWrightRWSpindlerKP.ACL graft and contralateral ACL tear risk within ten years following reconstruction: a systematic review. JBJS Rev. 2015;3(1):e3.
29.
MagnussenRATrojaniCGrananLP, et al. Patient demographics and surgical characteristics in ACL revision: a comparison of French, Norwegian, and North American cohorts. Knee Surg Sports Traumatol Arthrosc. 2015;23(8):2339-2348.
30.
MaletisGBChenJInacioMCFunahashiTT.Age-related risk factors for revision anterior cruciate ligament reconstruction: a cohort study of 21,304 patients from the Kaiser Permanente Anterior Cruciate Ligament Registry. Am J Sports Med. 2016;44(2):331-336.
31.
MaletisGBInacioMCDesmondJLFunahashiTT.Reconstruction of the anterior cruciate ligament: association of graft choice with increased risk of early revision. Bone Joint J. 2013;95-B(5):623-628.
32.
MaletisGBInacioMCFunahashiTT.Analysis of 16,192 anterior cruciate ligament reconstructions from a community-based registry. Am J Sports Med. 2013;41(9):2090-2098.
33.
MariscalcoMWFlaniganDCMitchellJ, et al. The influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Arthroscopy. 2013;29(12):1948-1953.
34.
MokACFancherAJVopatML, et al. Sex-specific outcomes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Orthop J Sports Med. 2022;10(2):23259671221076883.
35.
MontalvoAMSchneiderDKWebsterKE, et al. Anterior cruciate ligament injury risk in sport: a systematic review and meta-analysis of injury incidence by sex and sport classification. J Athl Train. 2019;54(5):472-482.
36.
MouarbesDMenetreyJMarotVCourtotLBerardECavaignacE. Anterior cruciate ligament reconstruction: a systematic review and meta-analysis of outcomes for quadriceps tendon autograft versus bone-patellar tendon-bone and hamstring-tendon autografts. Am J Sports Med. 2019;47(14):3531-3540.
37.
NylandJCollisPHuffstutlerA, et al. Quadriceps tendon autograft ACL reconstruction has less pivot shift laxity and lower failure rates than hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc. 2020;28(2):509-518.
38.
PaternoMVRauhMJSchmittLCFordKRHewettTE.Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. Am J Sports Med. 2014;42(7):1567-1573.
39.
PaudelYRSommerfeldtMVoaklanderD.Incidence and risk factors for revision and contralateral anterior cruciate ligament reconstruction: a population-based retrospective cohort study. Medicine (Baltimore). 2023;102(20):e33669.
40.
PaxtonEWKileyMLLoveRBarberTCFunahashiTTInacioMC.Kaiser Permanente implant registries benefit patient safety, quality improvement, cost-effectiveness. Jt Comm J Qual Patient Saf. 2013;39(6):246-252.
41.
PerssonAFjeldsgaardKGjertsenJE, et al. Increased risk of revision with hamstring tendon grafts compared with patellar tendon grafts after anterior cruciate ligament reconstruction: a study of 12,643 patients from the Norwegian Cruciate Ligament Registry, 2004-2012. Am J Sports Med. 2014;42(2):285-291.
42.
PrenticeHAChanPHPaxtonEWFelsonDTFunahashiTTMaletisGB.Patient and operative risk factors for osteoarthritis after primary anterior cruciate ligament reconstruction: a cohort study of 41,976 patients. Am J Sports Med. 2024;52(10):2482-2492.
43.
PrenticeHALindMMoutonC, et al. Patient demographic and surgical characteristics in anterior cruciate ligament reconstruction: a description of registries from six countries. Br J Sports Med. 2018;52(11):716-722.
44.
RahardjaRZhuMLoveHClatworthyMGMonkAPYoungSW.Effect of graft choice on revision and contralateral anterior cruciate ligament reconstruction: results from the New Zealand ACL Registry. Am J Sports Med. 2020;48(1):63-69.
45.
Rahr-WagnerLThillemannTMPedersenABLindM.Comparison of hamstring tendon and patellar tendon grafts in anterior cruciate ligament reconstruction in a nationwide population-based cohort study: results from the Danish registry of knee ligament reconstruction. Am J Sports Med. 2014;42(2):278-284.
46.
RuedlGWebhoferMLinortnerI, et al. ACL injury mechanisms and related factors in male and female carving skiers: a retrospective study. Int J Sports Med. 2011;32(10):801-806.
47.
RunerAWiererGHerbstE, et al. There is no difference between quadriceps- and hamstring tendon autografts in primary anterior cruciate ligament reconstruction: a 2-year patient-reported outcome study. Knee Surg Sports Traumatol Arthrosc. 2018;26(2):605-614.
48.
SandersTLPareekAHewettTE, et al. Long-term rate of graft failure after ACL reconstruction: a geographic population cohort analysis. Knee Surg Sports Traumatol Arthrosc. 2017;25(1):222-228.
49.
SchmückerMHaraszukJHölmichPBarfodKW.Graft failure, revision ACLR, and reoperation rates after ACLR with quadriceps tendon versus hamstring tendon autografts: a registry study with review of 475 patients. Am J Sports Med. 2021;49(8):2136-2143.
SnaebjörnssonTSvantessonESundemoD, et al. Young age and high BMI are predictors of early revision surgery after primary anterior cruciate ligament reconstruction: a cohort study from the Swedish and Norwegian knee ligament registries based on 30,747 patients. Knee Surg Sports Traumatol Arthrosc. 2019;27(11):3583-3591.
52.
SpindlerKPHustonLJZajichekA, et al. Anterior cruciate ligament reconstruction in high school and college-aged athletes: does autograft choice influence anterior cruciate ligament revision rates?Am J Sports Med. 2020;48(2):298-309.
53.
SpraggLChenJMirzayanRLoveRMaletisG.The effect of autologous hamstring graft diameter on the likelihood for revision of anterior cruciate ligament reconstruction. Am J Sports Med. 2016;44(6):1475-1481.
54.
SutherlandKClatworthyMChangKRahardjaRYoungSW.Risk factors for revision anterior cruciate ligament reconstruction and frequency with which patients change surgeons. Orthop J Sports Med. 2019;7(11):2325967119880487.
55.
TanTKSubramaniamAGEbertJRRadicR.Quadriceps tendon versus hamstring tendon autografts for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med. 2022;50(14):3974-3986.
56.
UrchekRKarasS.Biomechanical comparison of quadriceps and 6-strand hamstring tendon grafts in anterior cruciate ligament reconstruction. Orthop J Sports Med. 2019;7(10):2325967119879113.
57.
VaishyaRMisraSSinghLP, et al. Surgical training and learning curves in orthopedic surgery—a review. J Orthop Rep. 2025;4(2 suppl):100584.
58.
VisnesHGifstadTPerssonA, et al. ACL reconstruction patients have increased risk of knee arthroplasty at 15 years of follow-up: data from the Norwegian Knee Ligament Register and the Norwegian Arthroplasty Register from 2004 to 2020. JB JS Open Access. 2022;7(2):e22.00023.
59.
WebsterKEFellerJA.Return to level I sports after anterior cruciate ligament reconstruction: evaluation of age, sex, and readiness to return criteria. Orthop J Sports Med. 2018;6(8):2325967118788045.
60.
WigginsAJGrandhiRKSchneiderDKStanfieldDWebsterKEMyerGD.Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Am J Sports Med. 2016;44(7):1861-1876.
61.
YangJSPrenticeHAReyesCELehmanCRMaletisGB.Risk of revision and reoperation after quadriceps tendon autograft ACL reconstruction compared with patellar tendon and hamstring autografts in a US cohort of 21,973 patients. Am J Sports Med. 2024;52(3):670-681.
62.
ZhangZAmbrogiFBokovAFGuHde BeursEEskafK.Estimate risk difference and number needed to treat in survival analysis. Ann Transl Med. 2018;6(7):120.
