Nick Smith presented at 2026 in Glasgow, one of the UK’s leading meetings focused on knee surgery, sports injuries and joint preservation.

The meeting brought together national and international experts to discuss the latest developments in ligament reconstruction, arthroplasty, cartilage restoration, osteotomy and knee preservation surgery. A major theme throughout the conference was how surgical techniques continue to evolve towards more personalised, biomechanically informed treatment strategies designed to improve patient outcomes and reduce re-injury risk.

Quadriceps Tendon ACL Reconstruction – Where Are We Now?

Mr Smith’s presentation focused on the rapidly increasing use of quadriceps tendon grafts in ACL reconstruction and the current evidence surrounding outcomes, biomechanics and graft selection.

Quadriceps tendon grafts have become one of the fastest-growing graft choices worldwide, particularly in younger athletic patients, revision surgery and complex ligament reconstruction.

Historically, hamstring tendon and bone-patellar tendon-bone (BTB) grafts have dominated ACL reconstruction. However, both grafts have recognised limitations:

  • Hamstring grafts may lead to hamstring weakness and variable graft size
  • BTB grafts are associated with anterior knee pain and kneeling discomfort

The quadriceps tendon has increasingly emerged as an attractive alternative, offering:

  • A large and reliable graft diameter
  • Strong biomechanical properties
  • Lower donor-site morbidity than BTB in many studies
  • Flexibility for use with or without a bone plug

Biomechanics and Graft Characteristics

The presentation reviewed the evolving biomechanical evidence surrounding quadriceps tendon grafts and how they compare with both hamstring and BTB grafts.

A key discussion point was that while hamstring grafts may demonstrate very high load-to-failure values in laboratory testing, quadriceps tendon grafts are structurally and biomechanically more similar to BTB grafts. Multi-strand hamstring constructs may also undergo elongation due to strand settling and interstitial motion.

The talk highlighted how quadriceps tendon grafts combine several of the advantages traditionally associated with both hamstring and BTB grafts, leading some surgeons to describe them as a potential “unicorn graft”.

Clinical Outcomes and Current Evidence

The presentation reviewed contemporary evidence comparing quadriceps tendon grafts with both hamstring and BTB grafts.

Current studies suggest:

  • Similar stability and functional outcomes compared with BTB grafts
  • Lower rates of anterior knee pain and kneeling discomfort compared with BTB
  • Similar or potentially lower failure rates compared with hamstring grafts
  • Larger and more reliable graft diameter

Mr Smith also discussed findings from randomised controlled trial meta-analysis data, which demonstrated no major differences in patient-reported outcomes, knee laxity or re-rupture rates compared with hamstring grafts, whilst potentially offering lower donor-site morbidity.

Challenges and Learning Curve

The presentation also addressed several important considerations surrounding quadriceps tendon ACL reconstruction, including:

  • Learning curve issues
  • Early quadriceps weakness
  • Graft preparation complexity
  • Rare complications such as patellar fracture when using bone-plug harvest techniques

Particular emphasis was placed on the importance of surgeon experience and volume. Registry data discussed during the presentation suggested higher failure rates in low-volume centres, reinforcing the need for careful adoption and appropriate rehabilitation protocols.

Where Does the Quad Graft Fit in Modern ACL Surgery?

A major discussion point was where quadriceps tendon grafts currently fit within modern ACL reconstruction practice.

The presentation suggested that quadriceps tendon grafts may be particularly useful:

  • As an alternative to hamstring grafts
  • In revision ACL reconstruction
  • In multi-ligament knee injuries
  • Where reliable graft size is important

However, discussion also focused on the need for longer-term high-quality data before completely replacing BTB grafts in the very highest-risk patients, where minimising re-rupture risk remains the overriding priority.

Innovation and the Future of ACL Surgery

The meeting also featured extensive discussion around:

  • AI and data-driven surgical planning
  • Individualised graft selection
  • Biological augmentation
  • Return-to-sport decision making
  • Rehabilitation optimisation
  • Prevention of ACL graft failure

The continued evolution of ACL surgery towards increasingly personalised and evidence-based treatment pathways was a recurring theme throughout the conference.

A Valuable National Meeting

BASK 2026 once again highlighted the strength of knee surgery research and innovation within the UK and internationally.

Mr Smith’s presentation contributed to excellent discussion surrounding modern ACL graft choice and the growing role of quadriceps tendon grafts within contemporary ligament reconstruction surgery.

 

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