Comparison of Bone-Patella Tendon-Bone (BTB) and Quadriceps Autograft for ACL Reconstruction

OBJECTIVES: Graft choice for anterior cruciate ligament (ACL) reconstruction remains controversial. Quadriceps autograft has emerged as an alternative graft choice. However, there remains a paucity of comparative outcomes. Our purpose is to compare subjective outcomes and complications of ACL reconstruction using either BTB or quadriceps autograft. Our hypothesis is that there will be no difference in subjective outcome or complications between groups. METHODS: Following IRB approval, retrospective review of prospectively collected data identified consecutive cohorts of patients undergoing ACL reconstruction with either BTB or quadriceps autograft. Surgery was performed by a single sports fellowship trained surgeon between 2011-2019. Patients undergoing concomitant osteotomies, cartilage restoration, and other ligament reconstruction procedures were excluded. Pre- and post-surgical patient reported outcomes (PROs) including IKDC, KOOS, PROMIS, SANE, Tegner, and Marx were compared between groups. Complications requiring re-operation (infection, stiffness, reconstruction failure) were recorded. Results were analyzed statistically. RESULTS: 141 patients met inclusion criteria. There were 72 BTB and 69 quadriceps autografts. Mean age was 20.5 years in the BTB group and 20.7 years in the quadriceps group (p=0.9). 28 of 69 (40.6%) BTB and 34 of 72 (47.2%) quadriceps were female. Pre-operative KOOS Pain (64.5, 78.0, p=0.0007), KOOS QOL (29.6, 37.7, p=0.05), IKDC (44.5, 52.6, p=0.05), and PROMIS Physical Function (39.0, 42.7 p=0.04) scores were significantly higher in the BTB cohort. There were no differences in other baseline PROs. At minimum 6-month follow-up (range 6 - 57 months), patients in both quadriceps and BTB autograft cohorts reported statistically significant improvements in all KOOS domains, Tegner (76.4%, p=0.0002; 94.0%, p=0.000000003), IKDC (67.3%, p=0.0000009; 54.0%, p=0.000000009), SANE (69.4%, p=0.0000001; 70.7%, p=0.000000002), PROMIS Mobility T-Score (30.6%, p=0.0000003; 24.6%, p=0.000002), PROMIS Global Physical Health (15.3%, p=0.00002; 14.3%, p=0.00004), PROMIS Physical Function (33.2%, p=0.0000000008; 29.6%, p=0.00000002), PROMIS Pain Interference (-17.9%, p=0.00000002; -20.8%, p=0.00000000007). Post-operative Tegner (4.7, 6.0, p=0.04) and Global Mental Health (55.7, 60.1, p=0.008) scores were significantly higher in the BTB cohort. Complications were low and not significant between groups. Both quadriceps and BTB autograft cohorts required post-operative re-operations (4.4% and 6.9%, p=0.5). Quadriceps had 2 ligament reconstructions (2.9%) and 1 surgery for stiffness (1.4%). BTB group had 3 ligament reconstructions (4.2%) and 2 surgeries for stiffness (2.8%). CONCLUSION: Patients undergoing either BTB and quadriceps autograft ACL reconstruction demonstrated significant subjective improvements and low rates of complications requiring re-operation. At mid-term follow-up, the BTB cohort had higher activity and mental health scores.