Quadriceps vs. Hamstring Autograft for ACL Rupture

(SQuASH Trial)

Recruiting at 8 trial locations

Overseen By Nicole Simunovic, MSc

Age: < 65

Sex: Any

Trial Phase: Academic

Sponsor: McMaster University

Disqualifiers: Osteoarthritis, Fractures, Previous knee surgery, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: Unknown

Duration: Surgery and immediate post-operative period

352 Participants Needed

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial examines two methods for repairing a torn ACL (a ligament in the knee) in children and teenagers using their own tissue. It compares using a piece of the quadriceps tendon (from the front thigh) to the hamstring tendon (from the back thigh) to determine which is more effective. The study aims to identify which option results in fewer failures, a quicker return to sports, better knee function, and improved overall quality of life. Children and teenagers who play sports and require ACL surgery might be suitable candidates for this trial. As an unphased trial, it offers participants the chance to contribute to valuable research that could enhance future ACL repair techniques for young athletes.

Do I need to stop my current medications for the trial?

The trial information does not specify whether you need to stop taking your current medications.

Is there any evidence suggesting that this trial's treatments are likely to be safe?

Research has shown that using a piece of the quadriceps tendon for ACL surgery is safe and flexible. Patients generally tolerate it well, experiencing fewer issues like knee pain or difficulty kneeling compared to other graft types.

Studies indicate that the hamstring tendon is also mostly safe but may have a slightly higher chance of requiring another surgery later on.

Both the quadriceps and hamstring tendons are successfully used in ACL repairs, each offering distinct advantages and disadvantages. The quadriceps tendon is noted for its safety and reduced discomfort post-surgery, while the hamstring tendon remains popular despite a higher risk of additional procedures. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about using quadriceps and hamstring autografts for ACL rupture because they offer personalized options based on the patient's specific needs. Unlike traditional methods that rely on patellar tendon grafts, these autografts focus on soft tissue reconstruction, potentially reducing donor site morbidity and offering better flexibility in surgical techniques. Quadriceps grafts can be particularly appealing due to their robust size and strength, while hamstring grafts are valued for their minimal impact on the knee's extensor mechanism. This approach allows surgeons to tailor the treatment to each patient's anatomy and growth potential, potentially improving recovery outcomes.

What evidence suggests that this trial's treatments could be effective for ACL rupture?

This trial will compare quadriceps tendon autografts with hamstring tendon autografts for ACL reconstruction. Earlier studies showed that using the quadriceps tendon for ACL surgery resulted in fewer graft failures and better knee stability compared to the hamstring tendon. Research suggests that the quadriceps tendon also leads to less pain and quicker recovery at the donor site. Conversely, studies on the hamstring tendon have shown about an 11.7% chance of graft tearing after an average of 4.1 years. Both methods are effective, but the quadriceps tendon appears to offer slightly better early results, making it a promising option for ACL surgeries, especially in young people. Participants in this trial will be assigned to either the quadriceps tendon or hamstring tendon treatment arm to further evaluate these outcomes. ^{6 7 8 9 10}

Who Is on the Research Team?

Darren de SA, MD

Principal Investigator

McMaster University

Are You a Good Fit for This Trial?

This trial is for boys and girls aged 10-18 who have had an ACL injury, speak the clinic's language, and can give informed consent. They must have been active in sports before their injury and be suitable for a specific type of knee surgery. Kids with very flexible joints, significant other health issues, or previous knee surgeries aren't eligible.

Inclusion Criteria

I have had ACL reconstruction with specific drilling techniques.

Patient and parent/guardian provide informed consent.

I am a candidate for a specific knee ligament surgery.

Exclusion Criteria

I have had surgery on my knee or the opposite knee before.

I may find it hard to keep up with follow-up appointments.

My knee damage is confirmed by tests to be Grade 2 or higher.

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants undergo ACL reconstruction using either soft-tissue quadriceps or hamstring autografts

Surgery and immediate post-operative period

Follow-up

Participants are monitored for safety and effectiveness after treatment, including assessments of knee function and return to sport

2 years

Long-term follow-up

Continued monitoring of knee function and re-operation rates

2 years

What Are the Treatments Tested in This Trial?

Interventions

• Quadriceps tendon autograft
• Soft tissue hamstring autograft

Trial Overview The study compares two types of tendon grafts used in knee surgery to repair the ACL in kids: one from the hamstring (the current standard) and one from the quadriceps (a newer option). The goal is to see which graft leads to better surgery outcomes like fewer re-operations and improved knee function.

How Is the Trial Designed?

Group I: Soft-tissue hamstring Active Control 1 Intervention

All patients in the study will undergo arthroscopic-assisted, single-bundle, complete transphyseal, anatomic primary ACL reconstruction at the discretion of the surgeon, considering the individual patient's age, physeal status, and anticipated years of growth remaining to skeletal maturity. Patients in this arm will undergo soft-tissue autograft reconstruction using hamstrings (i.e. semitendinosus and/or gracilis) grafts. Grafts will be secured on the femur and tibia according to surgeon preference, given literature demonstrating no clear superior method for graft fixation.

Group II: Quadriceps tendon Active Control 1 Intervention

Patients in this arm will undergo soft-tissue autograft reconstruction using all-soft-tissue quadriceps (i.e. full or partial thickness) grafts. Grafts will be secured on the femur and tibia according to surgeon preference, given literature demonstrating no clear superior method for graft fixation.

Quadriceps tendon autograft is already approved in European Union, United States for the following indications:

Approved in European Union as Quadriceps tendon autograft for:

• Anterior cruciate ligament reconstruction in skeletally immature patients

Approved in United States as Quadriceps tendon autograft for:

• Anterior cruciate ligament reconstruction in pediatric patients

Who Is Running the Clinical Trial?

McMaster University

Lead Sponsor

Trials

936

Recruited

2,630,000+

Canadian Institutes of Health Research (CIHR)

Collaborator

Trials

1,417

Recruited

26,550,000+

Canadian Orthopaedic Foundation

Collaborator

Trials

15

Recruited

1,900+

The Physicians' Services Incorporated Foundation

Collaborator

Trials

165

Recruited

31,700+

Published Research Related to This Trial

Revision anterior cruciate ligament reconstruction (ACLR) using all-soft tissue quadriceps tendon autografts showed significant improvement in knee function, with IKDC scores rising from 54.3 to 82.8 over an average follow-up of 42.2 months.

The procedure had a reasonable complication rate, with 11 graft failures out of 80 patients followed, and no significant differences in quadriceps strength were observed between patients who previously had hamstring versus patellar tendon autografts.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Revision Anterior Cruciate Ligament Reconstruction with the All-Soft Tissue Quadriceps Tendon Autograft Has Acceptable Early and Intermediate-Term Outcomes. Hunnicutt, JL., Haynes, WB., Slone, HS., et al.[2021]

Adolescents who underwent anterior cruciate ligament reconstruction (ACLR) using quadriceps tendon autograft (ACLR-Q) had significantly smaller hamstring strength deficits compared to those who received hamstring tendon autograft (ACLR-HS), indicating better preservation of hamstring function post-surgery.

While ACLR-Q patients exhibited greater quadriceps strength deficits than ACLR-HS patients, they achieved more favorable hamstring-to-quadriceps (HS:Q) ratios, suggesting a potential advantage in muscle balance that could benefit their return to sports.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Assessment of Return to Sport After ACL Reconstruction With Soft Tissue Autograft in Adolescent Athletes: Quadriceps Versus Hamstring Tendon. Kay, J., Liotta, ES., Sugimoto, D., et al.[2023]

Quadriceps tendon (QT) autograft is becoming a popular choice for anterior cruciate ligament (ACL) reconstruction due to its safety and minimal donor-site complications, showing similar outcomes and failure rates compared to traditional grafts like bone-patellar tendon-bone and hamstring tendon.

The study presents a modified technique using a partial-thickness QT graft with continuous-loop EndoButton fixation, which may enhance surgical outcomes and patient recovery in ACL reconstruction.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Anterior Cruciate Ligament Reconstruction With a Partial-Thickness Quadriceps Tendon Graft Secured With a Continuous-Loop Fixation Device. Hughes, JD., Vaswani, R., Gibbs, CM., et al.[2020]

The quadriceps tendon autograft is recommended as a superior alternative to the hamstring autograft for ACL reconstruction in pediatric patients, as it shows better preliminary outcomes and potentially lower rates of graft rupture.

Historically, 6% to 38% of pediatric patients using hamstring autografts experience graft rupture, highlighting the need for more effective graft options like the quadriceps tendon.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Open Full-Thickness Quadriceps Tendon Autograft Harvest With Repair for Anterior Cruciate Ligament Reconstruction. Aitchison, AH., Schlichte, LM., Green, DW., et al.[2020]

In a study involving 28 patients with ACL injuries, those treated with quadriceps tendon (QT) autograft experienced similar pain levels and clinical outcomes compared to those treated with hamstring tendon (HT) autograft, as measured by various scoring systems over 12 months.

Both treatment groups showed significant improvement in knee function and pain post-surgery, indicating that QT autograft is a viable alternative to HT autograft for ACL reconstruction.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Anterior cruciate ligament injuries treated with quadriceps tendon autograft versus hamstring autograft: A randomized controlled trial. Vilchez-Cavazos, F., Dávila-Martínez, A., Garza-Castro, S., et al.[2022]

In a systematic review of 15 studies involving 1154 patients, quadriceps tendon autografts (QT) showed a significantly lower rate of graft re-rupture (2.5% vs 8.7%) and donor site morbidity (17.6% vs 26.2%) compared to hamstring tendon autografts (HS) for ACL reconstruction.

While QT demonstrated a slight advantage in reducing the positive pivot shift test results, both graft types had similar functional outcomes as measured by the IKDC and Lysholm scores, indicating comparable effectiveness in overall knee function.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Quadriceps tendon has a lower re-rupture rate than hamstring tendon autograft for anterior cruciate ligament reconstruction - A meta-analysis. Hurley, ET., Mojica, ES., Kanakamedala, AC., et al.[2022]

In a study of 48 patients undergoing ACL reconstruction, those who received a free quadriceps tendon autograft experienced significantly less pain and required fewer supplementary analgesics compared to those who received a hamstring tendon autograft.

Specifically, 50% of patients with the quadriceps graft did not need any additional pain relief, while only 13% of patients with the hamstring graft had the same outcome, indicating that the quadriceps graft may be a more effective option for reducing postoperative pain.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Pain level after ACL reconstruction: A comparative study between free quadriceps tendon and hamstring tendons autografts. Buescu, CT., Onutu, AH., Lucaciu, DO., et al.[2022]

In a study of 83 patients undergoing ACL reconstruction, the soft-tissue quadriceps tendon (QT) autograft showed significantly better patient-reported outcomes at 5 years post-surgery compared to the hamstring tendon (HT) autograft, with higher IKDC and Lysholm scores.

Despite the QT autograft's superior scores, both graft types had similar rates of return to sport and postoperative complications, indicating that QT is a safe and effective alternative to HT with comparable long-term results.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Mid-Term Outcomes of the All-Soft Quadriceps Tendon Autograft Are Noninferior to Hamstring Autograft in Primary Anterior Cruciate Ligament Reconstruction: Comparison With Minimum 5-Year Follow-Up. Brinkman, JC., Tummala, SV., Hassebrock, JD., et al.[2023]

In a study of 80 patients who underwent ACL reconstruction, there were no significant differences in patient-reported outcomes (PRO) between those who received quadriceps tendon (QT) autografts and those who received hamstring tendon (HT) autografts after 2 years.

Both graft types resulted in comparable functional outcomes, with a high percentage of patients reporting good or excellent results, indicating that QT is a reliable alternative to HT for ACL reconstruction.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

There is no difference between quadriceps- and hamstring tendon autografts in primary anterior cruciate ligament reconstruction: a 2-year patient-reported outcome study. Runer, A., Wierer, G., Herbst, E., et al.[2022]

In a study of 34 patients who underwent ACL reconstruction with either quadriceps tendon (QT) or bone-patellar tendon-bone (BTB) autografts, both graft types resulted in similar isometric strength deficits one year post-surgery.

The study found no significant differences in quadriceps muscle firing patterns between the two graft types, suggesting that using QT autografts does not negatively impact muscle function compared to BTB autografts.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Comparison of Neuromuscular Firing Patterns of the Superficial Quadriceps in Soft Tissue Quadriceps Tendon Versus Bone-Patellar Tendon-Bone ACL Autografts. Letter, M., Baraga, MG., Best, TM., et al.[2022]

Citations

1. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC11295237/

Outcomes After Anterior Cruciate Ligament Reconstruction ... Quadriceps tendon autograft ACL reconstruction has less pivot shift laxity and lower failure rates than hamstring tendon autografts. Knee ...

2. pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov/19962067/

Anterior cruciate ligament reconstruction using quadriceps ... ACL reconstruction using quadriceps tendon autograft is an effective surgical option that reduces donor-site morbidity. Level of evidence: Level IV, therapeutic ...

3. sciencedirect.com sciencedirect.com/science/article/abs/pii/S0972978X23003665

Quadriceps tendon autograft is promising with lower graft ... QT autografts demonstrate encouraging outcomes, showcasing lower graft rupture rates, better functional outcomes, and comparable contralateral ACL injury rates ...

4. arthroscopytechniques.org arthroscopytechniques.org/article/S2212-6287(24)00272-X/fulltext

Quadriceps Tendon (All-Soft Tissue) Autograft Preparation ... Anterior cruciate ligament reconstruction with quadriceps tendon autograft is a reliable graft option that has recently increased in use.

5. sciencedirect.com sciencedirect.com/science/article/abs/pii/S0749806324002342

Primary All-Soft Tissue Quadriceps Tendon Autograft ... To evaluate ≥2-year patient outcomes after primary all-soft tissue quadriceps tendon autograft (ASTQ) anterior cruciate ligament reconstruction (ACLR) with ...

6. pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov/25543249/

Quadriceps Tendon Autograft for Anterior Cruciate ... Use of the quadriceps tendon autograft for ACL reconstruction is supported by current orthopaedic literature. It is a safe, reproducible, and versatile graft.

7. sciencedirect.com sciencedirect.com/science/article/pii/S2059775422000839

Quadriceps tendon autograft for primary anterior cruciate ... Quadriceps tendon autograft for primary anterior cruciate ligament reconstruction show comparable clinical, functional, and patient-reported outcome ...

8. arthroscopyjournal.org arthroscopyjournal.org/article/S0749-8063(23)00586-8/fulltext

Quadriceps Tendon Anterior Cruciate Ligament Graft ... A QT autograft is associated with less donor site morbidity, such as anterior knee pain and difficulty with kneeling, than a BPTB autograft, and short-term ...

9. arthroscopytechniques.org arthroscopytechniques.org/article/S2212-6287(24)00323-2/fulltext

All-Inside Anterior Cruciate Ligament Reconstruction Using ... We present a technique demonstrating an all-inside ACL reconstruction using a full-thickness all-soft-tissue quadriceps tendon autograft (ASTQA) ...

10. pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov/32667271/

Anterior Cruciate Ligament Reconstructions With ... Patients treated with HT autografts have a significantly higher, activity-dependent risk of revision surgery and experience more ipsilateral graft ruptures.