Anterior cruciate ligament reconstruction using quadriceps tendon autograft: intermediate-term outcome

Anatomical evaluation of the rectus femoris tendon and its related structures

PURPOSE

The purpose of this study was to evaluate the anatomical structure of the quadriceps tendon in detail for use as an anterior cruciate ligament (ACL) graft tendon.

MATERIALS AND METHODS

Sixteen cadaveric knees with an average age of 78.8 were used. After careful dissection of skin and fascia, the muscle structure of each quadriceps was evaluated. In particular, the rectus femoris (RF) tendon was measured at its widest and narrowest width, the distance between widest or narrowest point and the proximal end of the patella, and the length.

RESULTS

The quadriceps tendon consisted of three layers. At the surface layer, the RF tendon existed mostly independently. The middle layer consisted of the vastus lateralis (VL) and medialis (VM) tendons. The deep layer consisted of the vastus intermedius (VI) tendon. The VL and VI tendons overlapped and were firmly connected, constituting the strength and size of the quadriceps. The narrowest width of the RF was 15.3 mm, and the narrowest point existed 4.8 mm proximal to the upper end of the patella. The average length of the RF was 27.3 cm.

CONCLUSION

If the RF tendon only is used as an ACL graft, surgeons should be cautious of the fact that the narrowest point of the RF tendon is located close to the patella. The entire quadriceps tendon is big enough to be used as an ACL graft. However, since the direction of the VL and VI tendons is different, the suitability of the quadriceps tendon as an ACL graft is questionable.

Anatomic anterior cruciate ligament reconstruction with quadriceps tendon autograft

A multitude of graft options exist including both allograft and autograft sources for reconstruction of the anterior cruciate ligament. With recent concerns regarding the early graft failure and cost-effectiveness of allograft sources, more attention has been directed toward autograft options. However, autograft harvest has been associated with specific morbidity that can result in suboptimal outcomes. The quadriceps tendon is an excellent biomechanical and biologic option.

Anterior cruciate ligament graft choices

CONTEXT

Reconstruction of the anterior cruciate ligament (ACL) is a common surgical procedure; however, there is no consensus to what the best graft option is to replace the injured ACL. The main options available consist of allografts and autografts, which include patellar tendon, hamstring tendon, and quadriceps tendon autografts.

EVIDENCE ACQUISITION

The PubMed database was searched in August 2010 for English-language articles pertaining to ACL grafts.

RESULTS

Postoperative outcome variables were analyzed to determine similarities and differences among the different graft options. These variables include stability, strength, function, return to sports, patient satisfaction, complications, and cost.

CONCLUSIONS

Both allografts and the 3 main options for autografts can provide excellent results in ACL reconstruction and lead to a high percentage of satisfied patients. However, differences exist among the graft choices. Both the similarities and the differences are important to discuss with a patient who will be undergoing ACL reconstruction so that he or she has the best information available when making a choice of graft.

Anterior cruciate ligament (ACL) reconstruction with quadriceps tendon autograft and press-fit fixation using an anteromedial portal technique

Background

This article describes an arthroscopic anterior cruciate ligament (ACL) reconstruction technique with a quadriceps tendon autograft using an anteromedial portal technique.

Methods

A 5 cm quadriceps tendon graft is harvested with an adjacent 2 cm bone block. The femoral tunnel is created through a low anteromedial portal in its anatomical position. The tibial tunnel is created with a hollow burr, thus acquiring a free cylindrical bone block. The graft is then passed through the tibial tunnel and the bone block, customized at its tip, is tapped into the femoral tunnel through the anteromedial portal to provide press-fit fixation. The graft is tensioned distally and sutures are tied over a bone bridge at the distal end of the tibial tunnel. From the cylindrical bone block harvested from the tibia the proximal end is customized and gently tapped next to the graft tissue into the tibial tunnel to assure press fitting of the graft in the tibial tunnel. The distal part of the tibial tunnel is filled up with the remaining bone.

All patients were observed in a prospective fashion with subjective and objective evaluation after 6 weeks, 6 and 12 months.

Results

Thirty patients have been evaluated at a 12 months follow-up. The technique achieved in 96.7% normal or nearly normal results for the objective IKDC. The mean subjective IKDC score was 86.1 ± 15.8. In 96.7% the Tegner score was the same as before injury or decreased one category. A negative or 1+ Lachman test was achieved in all cases. Pivot-shift test was negative or (+) glide in 86.7%. The mean side-to-side difference elevated by instrumental laxity measurement was 1.6 ± 1.1 mm. Full ROM has been achieved in 92.3%. The mean single one-leg-hop index was 91.9 ± 8.0 at the follow-up.

Conclusions

Potential advantages include minimum bone loss specifically on the femoral side and graft fixation without implants.

Anatomic guidelines for harvesting a quadriceps free tendon autograft for anterior cruciate ligament reconstruction

PURPOSE

The purpose of this study was to review the anatomy of the quadriceps tendon and provide guidelines for harvesting the quadriceps tendon for anterior cruciate ligament (ACL) reconstruction.

METHODS

Eleven cadaveric knees were dissected, and the quadriceps tendon was analyzed. Multiple measurements of length, depth, and width were taken in a standardized manner for each cadaver and recorded.

RESULTS

The quadriceps tendon superficial morphology showed 2 distinct peaks, with the maximum length correlating with the lateral peak. The mean tendon peak length was 88.3 ± 8.4 mm (range, 78.3 to 99.7 mm). The mean width of the quadriceps tendon at its insertion onto the patella was 43.3 ± 5.8 mm (range, 34.3 to 54.1 mm). The quadriceps tendon was noted to be asymmetric, with the maximum tendon length located at 61.6% ± 4.1% of the width from the medial border of the quadriceps tendon insertion. This point was also the maximum tendon depth at insertion.

CONCLUSIONS

Quadriceps free tendon graft harvesting should begin by locating the apex (maximum length) of the quadriceps tendon (61% of the distance from the patella's medial edge). The surgeon should then harvest a 10-mm-wide graft centered about 2 mm medial to this point, using the depth of a No. 10 scalpel blade (7 mm) as a guide to thickness to harvest an optimal quadriceps free tendon graft for ACL reconstruction.

CLINICAL RELEVANCE

This anatomic study identifies the site of harvest of a quadriceps free tendon autograft (without a patellar bone block) to maximize the length and bulk of the graft for its use in ACL reconstruction.

Anatomic single- and double-bundle anterior cruciate ligament reconstruction, part 2: clinical application of surgical technique

The anterior cruciate ligament has been and is of great interest to scientists and orthopaedic surgeons worldwide. Anterior cruciate ligament reconstruction was initially performed using an open approach. When the approach changed from open to arthroscopic reconstruction, a 2- and, later, 1-incision technique was applied. With time, researchers found that traditional arthroscopic single-bundle reconstruction did not fully restore rotational stability of the knee joint and a more anatomic approach to reconstruct the anterior cruciate ligament has been proposed. Anatomic anterior cruciate ligament reconstruction intends to replicate normal anatomy, restore normal kinematics, and protect long-term knee health. Although double-bundle anterior cruciate ligament reconstruction has been shown to result in better rotational stability in both biomechanical and clinical studies, it is vital to differentiate between anatomic and double-bundle anterior cruciate ligament reconstruction. The latter is merely a step closer to reproducing the native anatomy of the anterior cruciate ligament; however, it can still be done nonanatomically. To evaluate the potential benefits of reconstructing the anterior cruciate ligament in an anatomic fashion, accurate, precise, and reliable outcome measures are needed. These include, for example, T2 magnetic resonance imaging mapping of cartilage and quantification of graft healing on magnetic resonance imaging. Furthermore, there is a need for a consensus on which patient-reported outcome measures should be used to facilitate homogeneous reporting of outcomes.

Current concepts in anatomic single- and double-bundle anterior cruciate ligament reconstruction

An anterior cruciate ligament (ACL) tear is one of the most common orthopedic sport injuries. The ACL consists of 2 functional bundles-the anteromedial and posterolateral-which are named for the position of their insertion sites on the tibia. Anatomic ACL reconstruction can be defined as the restoration of the ACL to its native dimensions, collagen orientation, and insertion sites. Some biomechanical studies have demonstrated that anatomic ACL reconstruction can restore knee motion significantly similar to that of the normal knee, as compared with traditional, nonanatomic single-bundle procedures. In vivo kinematic studies have also shown that nonanatomic single-bundle reconstruction fails to restore normal dynamic knee stability in all cases. Accurate restoration of knee kinematics with anatomic ACL reconstruction is critical to protect against the possibility that nonatomic surgical technique could result in early osteoarthritis, which is common in patients who sustain ACL tears. Surgical techniques for ACL reconstruction vary, and if different aspects of the surgery are compared for superiority (eg, single- vs double-bundle techniques), it is necessary that both procedures meet criteria to be designated as "anatomic." By emphasizing the importance of restoring the native anatomy of the knee, surgeons can give their patients the best chance at restoration of joint function and preservation of long-term knee health.

Autografts commonly used in anterior cruciate ligament reconstruction

Anterior cruciate ligament reconstruction is among the most common orthopaedic procedures in the United States, with >200,000 performed annually. Much has been published regarding the use of autograft versus allograft. Bone-patellar tendon-bone is the most frequently used autograft, but hamstring and quadriceps tendon grafts are common alternatives. Each graft has distinct advantages and disadvantages, and selection is individualized. Fixation methods vary by graft type. Fixation resulting in a construct that is too rigid may restrict knee range of motion. Donor site morbidity must be considered, as well. Autograft harvest may result in anterior knee pain, kneeling pain, anterior knee numbness, muscle weakness, and patellar fracture. Appropriate graft selection is essential to optimize outcomes.

[Anterior cruciate ligament reconstruction using quadriceps tendon autograft and press-fit fixation]

BACKGROUND

Reconstruction of the anterior cruciate ligament (ACL) is a widely used procedure, but up to now no results have been published on an implant-free technique using a quadriceps tendon autograft and press-fit fixation.

METHODS

A total of 112 patients with primary rupture of the anterior cruciate ligament were included in a prospective case control study and 106 patients could be evaluated postoperatively after a mean of 12.4 months (range 12-14 months).

RESULTS

The patients showed good to excellent results according to the Lysholm score in 81% and the International Knee Documentation Committee (IKDC) score in 86% of cases. Furthermore the anterior-posterior translation was less than 3 mm in 83% of the patients by testing with the KT-1000 arthrometer. Neither tunnel widening nor an increase of radiological joint degeneration was recorded by radiological examination.

CONCLUSION

Reconstruction of the ACL with an autologous quadriceps tendon and an implant-free technique yielded good results compared to established operative methods in the short-term and should be consistently followed-up for long-term confirmation.

Simultaneous reconstruction of ruptured anterior cruciate ligament and medial patellofemoral ligament with ipsilateral quadriceps grafts

Rupture of the anterior cruciate ligament is a well-known entity and causes anteroposterior and rotational instability of an injured knee. Rupture of the medial patellofemoral ligament is less frequent, and its insufficiency causes patellar instability. Several techniques have been described for the reconstruction of each ligament. The 2 lesions and following instabilities can coexist, and both ligaments can be reconstructed simultaneously. We report on 2 cases, 1 recreational sportswoman and 1 high-level sportswoman, with coexisting lesions treated surgically by a single-step procedure using ipsilateral graft of the quadriceps tendon for reconstruction of medial patellofemoral ligament and anterior cruciate ligament. The advantage of this procedure is that there is only 1 donor site, and thus lower donor-site morbidity, while the strength of either neoligament is not sacrificed. The technique is described here.