The quiet revolution in anterior cruciate ligament grafting: An international survey of current global practices in quadriceps tendon use.

Abstract

To evaluate the current practices, techniques, and opinions regarding the use of the quadriceps tendon (QT) in anterior cruciate ligament reconstruction (ACLR) among knee surgeons worldwide. A 25-question web-based, anonymous survey was conducted between July 1 and August 15, 2025, and distributed electronically to members of the ACL Study Group, Herodicus Society, and Magellan Society. The questionnaire explored demographics, graft choice, surgical technique, fixation methods, postoperative management, and perceived complications related to QT use. Data were analyzed descriptively. A total of 137 surgeons completed the survey (response rate: 16%), representing more than 30 countries. Respondents had a mean age of 55 ± 11 years (range: 36-88) and reported performing an average of 160 ± 170 ACL reconstructions per year (range: 0-1500). The QT was reported to be used in 27% of primary ACL reconstructions, with an average usage of 42% in revision cases. Over the past five years, QT use increased by approximately 15%. The most commonly reported reasons for selecting QT included its use in revision settings, reduced donor site morbidity, and limitations related to prior grafts. Partial-thickness harvest was preferred by 62% of respondents, and 63% used a soft-tissue-only graft. Adjustable buttons and interference screws were the most frequent methods for femoral and tibial fixation, respectively. Most surgeons (83%) did not alter rehabilitation protocols when using QT, and 71% did not perceive an increased risk of cyclops lesions. This international survey provides valuable insights into current practices and evolving approaches regarding quadriceps tendon use in ACL reconstruction among knee surgeons. While QT usage has increased and is commonly employed in revision settings, there remains variability in harvesting technique, fixation strategy, and perceived indications. These findings underscore the need for further comparative clinical studies and efforts toward standardization of QT-based ACL reconstruction techniques. International Survey, Level IV.