The outcomes of quadriceps tendon autograft for anterior cruciate ligament reconstruction in adolescent athletes: a retrospective case series

Bone-patellar tendon-bone, hamstring, and quadriceps tendon autografts for anterior cruciate ligament reconstruction in skeletally immature patients: a systematic review

INTRODUCTION

Historically, anterior cruciate ligament (ACL) ruptures in the paediatric age group were managed conservatively with bracing, casting, activity modification, and physical therapy. However, most of these patients had to reduce their sports activities, and secondary damages to the affected knee were prevalent.

SOURCE OF DATA

Published scientific literature in Embase, Web of Science, PubMed, and Google Scholar databases.

AREAS OF AGREEMENT

ACL reconstruction in children with open physes patients is debated. Any damage to the physes around the knee could lead to growth abnormalities and axial deviation of the knee.

AREAS OF CONTROVERSY

Different grafts are available and suitable for ACL reconstruction in skeletally immature patients; however, which graft performs better remains unclear.

GROWING POINTS

This systematic review compared bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and quadriceps tendon (QT) autografts for ACL reconstruction in skeletally immature patients. The joint laxity, Patient-reported outcome measures (PROMs), return to sport, and complications were compared.

AREAS TIMELY FOR DEVELOPING RESEARCH

In skeletally immature patients, HT, BPTB, and QT autografts for ACL reconstruction yielded good outcomes. Comparative studies are strongly required to establish the most suitable autograft.

Sex-Specific Outcomes After Anterior Cruciate Ligament Reconstruction Using an All-Soft Tissue Quadriceps Tendon Autograft in a Young Active Population

BACKGROUND

The ideal graft for anterior cruciate ligament (ACL) reconstruction (ACLR) in young athletes has a high return-to-sport (RTS) rate and a low reinjury rate. Quadriceps tendon autografts are being used with increasing frequency for ACLR in this population, despite a paucity of evidence to support their use.

PURPOSE

To report the RTS rate, ipsilateral reinjury rate, and contralateral ACL injury rate in a young athletic population undergoing primary ACLR using an all-soft tissue quadriceps tendon (ASTQT) autograft.

STUDY DESIGN

Cases series; Level of evidence, 4.

METHODS

Patients aged 14 to 22 years who underwent primary ACLR using an ASTQT autograft by a single surgeon between January 1, 2005, and April 30, 2020, were identified via electronic medical records and contacted ≥24 months after ACLR to complete a survey regarding subsequent ipsilateral or contralateral ACL injuries and RTS. Patients who had undergone previous ACLR (ipsilateral or contralateral) were excluded.

RESULTS

A total of 656 patients (330 male, 326 female; mean age, 17.9 years) were identified, and 395 patients completed the survey (60.2%; 174 male, 221 female; mean age, 17.8 years) with a mean follow-up of 73 ± 29 months (range, 24-139 months). The RTS rate was high (male: 87.7%; female: 82.8%; P = .19). Male and female patients had similar rates of revision ACLR (male: 12.6%; female: 10.0%; P = .40) and contralateral ACL injuries (male: 13.8%; female: 11.3%; P = .46).

CONCLUSION

A high RTS rate and similar rates of ipsilateral and contralateral ACL injuries were found for male and female patients in a young athletic population undergoing primary ACLR using an ASTQT autograft. These results help one to better understand the utility of ASTQT grafts to support successful ACLR in young athletic populations, for which ASTQT grafts appear to yield favorable outcomes.

Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: 3-Year Clinical and Patient-Reported Outcomes

BACKGROUND

The rate of anterior cruciate ligament (ACL) rupture in active, skeletally immature patients is increasing. Although hamstring tendon autograft (HTA) was previously deemed the gold standard, recent studies have shown HTA to have a high failure rate in this high-risk population of young competitive athletes, and quadriceps tendon autograft (QTA) has yielded excellent preliminary outcomes in some studies examining this population.

PURPOSE

To evaluate 3-year clinical and patient-reported functional outcomes of primary ACL reconstruction (ACLR) with soft tissue QTA in skeletally immature patients.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Skeletally immature patients who underwent ACLR with a full-thickness soft tissue QTA were included. Preoperative patient and surgical data were collected. The ACLR technique was selected predicated upon skeletal age and included all-epiphyseal and complete transphyseal techniques. Patients were followed for a minimum of 2 years with successive clinical visits or were contacted via telephone. Patients who did not have minimum 2-year follow-up after 3 contact attempts via telephone were excluded. Information regarding return to sports (RTS) and concomitant or subsequent surgical procedures was collected. Pediatric International Knee Documentation Committee (Pedi-IKDC), Hospital for Special Surgery Functional Activity Brief Scale (HSS Pedi-FABS), and Single Assessment Numeric Evaluation (SANE) scores were collected.

RESULTS

Of 85 adolescent patients aged 11.1 to 17.6 years (mean age, 14.1 ± 1.2 years), 2 patients were determined to be lost to follow-up after 3 failed contact attempts. Of the patients included in this study (N = 83), 26 patients (31%) underwent all-epiphyseal and 57 patients (69%) underwent complete transphyseal ACLR. Additionally, 48 patients (58%) underwent concomitant lateral extra-articular tenodesis using the iliotibial band with a modified Lemaire technique. The mean follow-up time was 3.7 ± 1.2 years (range, 2-7 years). Twenty (24%) patients had subsequent surgical procedures, of which 3 (4%) were due to graft failures. At a mean 3-year follow-up, the mean Pedi-IKDC, HSS Pedi-FABS, and SANE scores were 90, 23, and 94 respectively; the RTS rate was 100%; and the rate of RTS at the previous level of performance was 93%.

CONCLUSION

Use of a soft tissue QTA for ALCR in a high-risk skeletally immature population of athletes resulted in excellent postoperative outcomes with low rates of graft failure and high return to sport rates.

Quadriceps tendon autograft is promising with lower graft rupture rates and better functional Lysholm scores than hamstring tendon autograft in pediatric ACL reconstruction. A systematic review and meta-analysis

Purpose

Graft rupture is the most prevalent complication following pediatric anterior cruciate ligament reconstruction (ACLR). The hamstring tendon (HT) autograft is frequently employed, while the quadriceps tendon (QT) autograft has garnered increased attention recently. This study aims to perform a systematic review to assess the complication rates and functional outcomes associated with these two widely used autografts in skeletally immature patients - comparing HT versus QT autografts.

Research question

Is QT autograft better than HT autograft for ACLR in skeletally immature cohorts?

Methodology

Three electronic databases (PubMed/Medline, Scopus, and Ovid) were comprehensively searched to identify pertinent articles reporting the outcomes of HT and QT autografts in pediatric ACLR with a minimum 2-year follow-up. Data on the outcome parameters, such as graft rupture rates, contralateral ACL injury rates, functional outcomes, and growth disturbances rates, were extracted. Meta-analysis was performed using OpenMeta Analyst software.

Results

Twelve studies were included for meta-analysis (pooled analysis) with 659 patients (QT: 205; HT: 454). The analysis showed that QT autografts had a significantly lesser graft rupture rate than HT autografts (3.5 % [95 % CI 0.2, 6.8] and 12.4 % [95 % CI 6.1, 18.7] respectively, p < 0.001). The graft rupture rates between QT with bone and without bone block showed no statistically significant difference (4.6 % [95 % CI 0.8, 1.0] and 3.5 % [95 % CI 2.0, 8.9] respectively, p = 0.181). The overall contralateral ACL injury rate was 10.2 %, and the subgroup analysis revealed no statistically significant difference between the QT and HT groups (p = 0.7). Regarding functional outcome scores at the final follow-up, the mean Lysholm score demonstrated a significant increase in the QT group compared to the HT group (p < 0.001). There were no significant differences between the two groups concerning growth disturbances at the final follow-up. Return to sports (RTS) varied between 6 and 13.5 months after surgery.

Conclusion

QT autografts demonstrate encouraging outcomes, showcasing lower graft rupture rates, better functional outcomes, and comparable contralateral ACL injury rates and growth disturbances relative to the commonly used HT autograft in skeletally immature patients undergoing ACLR.

Plastic and elastic biomechanical properties of anterior cruciate ligament autografts

BACKGROUND

Anterior cruciate ligament (ACL) rupture is a common orthopedic injury, occurring in roughly 68.6 per 100,000 persons annually, with the primary treatment option being ACL reconstruction. However, debate remains about the appropriate graft type for restoring the native biomechanical properties of the knee. Furthermore, plastic graft elongation may promote increased knee laxity and instability without rupture. This study aims to investigate the plastic properties of common ACL-R graft options.

METHODS

Patellar tendon (PT), hamstring tendon (HT), and quadriceps tendon (QT) grafts were harvested from 11 cadaveric knees (6 male and 5 female) with a mean age of 71(range 55-81). All grafts were mechanically tested under uniaxial tension until failure to determine each graft's elastic and plastic biomechanical properties.

RESULTS

Mechanically, the QT graft was the weakest, exhibiting the lowest failure force and the lowest failure stress (QT < HT, p = 0.032). The PT was the stiffest of the grafts, having a significantly higher stiffness (PT > QT, p = 0.0002) and Young's modulus (PT > QT, p = 0.001; PT > HT, p = 0.041). The HT graft had the highest plastic elongation at 4.01 ± 1.32 mm (HT > PT, p = 0.002). The post-yield behavior of the HT tendon shows increased energy storage capabilities with the highest plastic energy storage (HT > QT, p = 0.012) and the highest toughness (HT > QT, p = 0.032).

CONCLUSION

Our study agrees with prior studies indicating that the failure load of all grafts is above the requirements for everyday activities. However, grafts may be susceptible to yielding before failure during daily activities. This may result in the eventual loss of functionality for the neo-ACL, resulting in increased knee laxity and instability.

Outcomes of bone-patellar tendon-bone autograft and quadriceps tendon autograft for ACL reconstruction in an all-female soccer player cohort with mean 4.8-year follow up

OBJECTIVE

The purpose is to compare functional outcomes, return to soccer rates, and revision rates in an all-female soccer player cohort undergoing quadriceps tendon (QT) autograft ACLR versus bone-patellar tendon-bone (BPTB) autograft ACLR.

METHODS

Female soccer players who sustained an ACL rupture and underwent primary anatomic, single-bundle ACLR with BPTB autograft or QT autograft were included. Demographic and surgical characteristics were collected. Outcomes of interest included Tegner score, International Knee Documentation Committee (IKDC) score, Marx score, return to soccer rates, and failure rates.

RESULTS

Data on 23 patients undergoing BPTB autograft ACLR and 14 undergoing QT autograft ACLR was available. Average age was 18.7 years, and average follow up was 4.8 years. Overall, 76 ​% (28/37) returned to soccer and 5.4 ​% (2/37) underwent revision ACLR. No major significant differences were found in demographic or surgical characteristics. No differences were found in postoperative IKDC scores, preoperative, postoperative, or change from pre-to postoperative Marx activity scores, or pre-and postoperative Tegner scores between the groups. QT autograft ACLR patients had significantly less change in Tegner scores pre-to postoperatively compared to the BTPB autograft ACLR group (0.6 ​± ​1.2 versus 2.1 ​± ​1.8; p ​= ​0.02). Both groups had similar rates of return to soccer [78 ​% (18/23) BPTB autograft ACLR versus 71 ​% (10/14) QT autograft ACLR; p ​= ​0.64] and rates of revision (8.7 % (2/23) BPTB autograft ACLR; 0 % (0/14) QT autograft ACLR.

CONCLUSION

Results of this study suggest that BPTB autograft ACLR and QT autograft ACLR produce comparable, successful functional and return to soccer outcomes in this all-female soccer player cohort study. Larger, prospective studies are needed to improve the strength of conclusions and provide more information on the optimal graft choice for female soccer players. Surgeons can use the results of this study to counsel female soccer players on expected outcomes after ACLR.

LEVEL OF EVIDENCE

III.

Adverse Events and Complications After Primary ACL Reconstruction With Quadriceps Tendon Autograft: A Systematic Review

Background

Anterior cruciate ligament reconstruction (ACLR) surgery with quadriceps tendon (QT) grafts, both with and without a patellar bone plug, have gained popularity in recent years in the primary and revision settings. Postoperative complications occur with the use of QT autografts.

Purpose

To systematically review the incidence of postoperative complications after primary ACLR QT autograft and compare complication rates in patients undergoing all-soft tissue QT grafts versus QT grafts with a patellar bone plug (QTPB).

Study Design

Systematic review; Level of evidence, 4.

Methods

A literature search using the 2020 PRISMA guidelines was performed by querying PubMed, Embase, and Scopus databases from database inception through August 2022. Included were evidence level 1 to 4 human clinical studies in English that reported complications after primary ACLR with QT autograft. The incidence of complications within the included studies was extracted. Differences in the incidence of postoperative complications between ACLR with QT with and without a patellar bone plug were calculated.

Results

A total of 20 studies from 2004 to 2022, comprised of 2381 patients (2389 knees; 68.3% male) with a mean age of 27 years (range, 12-58 years), were identified. The mean follow-up was 28.5 months (range, 6-47 months). The total incidence of complications was 10.3%, with persistent postoperative knee pain being the most common (10.8%). Patients who underwent ACLR with all-soft tissue QT grafts had a 2.7-times increased incidence of anterior knee pain (23.3% vs 8.6%) and reoperations (5.9% vs 3.2%) when compared with QTPB grafts (P < .01 for both). There was no appreciable difference in total complications, graft failures, ACLR revisions, cyclops lesions, or range of motion deficit (P > .05 for all). Patellar fractures occurred exclusively after QTPB (2.2%).

Conclusion

Complications after primary ACLR using QT autograft were recorded in 10.5% of knees, with anterior knee pain being the most common. No difference was reported in the overall incidence of complications with the use of the QT versus QTPB grafts; however, anterior knee pain was 2.7 times greater with use of a soft tissue quadriceps graft.

Reconsideration of Return-to-Sport Decision-Making After Pediatric ACL Injury: A Scoping Review

CONTEXT

Up to 90% of pediatric athletes return to sport (RTS) after anterior cruciate ligament reconstruction (ACL-R); however, <50% RTS at the same level and second ACL injury rates are up to 32%.

OBJECTIVES

(1) Determine which physical and patient-reported outcome measures guide clinical decision-making on RTS in pediatric athletes after ACL-R and (2) present a framework with insights from cognitive and neurophysiological domains to enhance rehabilitation outcomes.

DATA SOURCES

PubMed, CINAHL, Embrase, and Cochrane library databases and gray literature.

STUDY SELECTION

Data on pediatric (<18 years) ACL-R patients, RTS, tests, and decision-making were reported in 1214 studies. Two authors independently reviewed titles and abstract, excluding 962 studies. Gray literature and cross-reference checking resulted in 7 extra studies for full-text screening of 259 studies. Final data extraction was from 63 eligible studies.

STUDY DESIGN

Scoping review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Details on study population, aims, methodology, intervention, outcome measures, and important results were collected in a data chart.

RESULTS

Studies included 4456 patients (mean age, 14 years). Quadriceps and hamstring strength (n = 25), knee ligament arthrometer (n = 24), and hop tests (n = 22) were the most-reported physical outcome measures guiding RTS in <30% of studies with cutoff scores of limb symmetry index (LSI) ≥85% or arthrometer difference <3 mm. There were 19 different patient-reported outcome measures, most often reporting the International Knee Documentation Committee (IKDC) (n = 24), Lysholm (n = 23), and Tegner (n = 15) scales. Only for the IKDC was a cutoff value of 85% reported.

CONCLUSION

RTS clearance in pediatric ACL-R patients is not based on clear criteria. If RTS tests were performed, outcomes did not influence time of RTS. Postoperative LSI thresholds likely overestimate knee function since biomechanics are impaired despite achieving RTS criteria. RTS should be considered a continuum, and biomechanical parameters and contextual rehab should be pursued with attention to the individual, task, and environment. There is a need for psychological monitoring of the ACL-R pediatric population.

Less than 1% risk of donor-site quadriceps tendon rupture post-ACL reconstruction with quadriceps tendon autograft: a systematic review

PURPOSE

The purpose of this study is to develop a comprehensive complications profile for quadriceps tendon-autograft anterior cruciate ligament reconstruction (QT ACL-R).

METHODS

A traditional and grey literature search was conducted in accordance with PRISMA and R-AMSTAR guidelines. PubMed, EMBASE, MEDLINE, CINAHL, Cochrane, Web of Science, and many grey literature sources were searched from inception to May 29, 2022. All studies were searched and screened in duplicate with included studies being of all levels of evidence, reporting complications, and with patients of all ages undergoing primary ACL reconstruction with quadriceps tendon autograft in the last 15 years. Studies were excluded if they had cadaveric or animal subjects or were reviews. Risk of bias assessment was conducted using MINORS criteria for non-randomised studies and Cochrane's RoB 2.0 for randomised studies. Data were summarised with weighted event rates generated under a random-effects model.

RESULTS

A total of 55 studies (5315 reconstructions) were included: 32 used quadriceps tendon with bone block (B-QT), 19 used all-soft tissue quadriceps tendon (S-QT), and four did not report the QT graft subtype used. Included patients had an age range of 6.2-58 years and an average reported follow-up time of 28.1 months (range, 6-90 months) for non-randomised studies and 34.3 months (range, 0.233-120 months) for randomised studies. Pooled incidence rates for clinically relevant major complications included contralateral ACL injury at 6.0%, postoperative meniscal issues at 5.4%, cyclops lesions at 4.8%, graft failure at 4.1%, patellar fracture at 2.2%, hardware removal at 1.7%, infection at 1.5%, and donor-site quadriceps tendon rupture at 0.7%. Pooled incidence rates for clinically relevant minor complications included anterior knee pain at 9.7%, kneeling pain at 9.5%, sensation deficits at 4.4%, loss of extension at 4.2%, donor-site tendinopathy at 3.9%, cosmetic issues at 1.8%, and hematoma at 1.5%.

CONCLUSIONS

QT ACL-R resembles other graft types in its rates and types of postoperative complications. In this exploratory systematic review, no complications of QT ACL-R were found to be disproportionately represented in the literature. This graft type should remain an option with comparable complication rates to other graft choices.

LEVEL OF EVIDENCE

Level IV.

REGISTRATION

This study was preregistered under PROSPERO with preregistration code CRD42022302078.

The patellar ligament: A comprehensive review

The patellar ligament (PL) is an epiphyseal ligament and is part of the extensor complex of the knee. The ligament has gained attention due to its clinical relevance to autograft and tendinopathy. A variety of anatomical variations of the PL such as aplasia, numerical variations, and vascularity are being reported recently by clinicians and anatomists. The aim of this literature was to review the available literature to provide a consensus regarding anatomic variations of the PL, neurovasculature surrounding the PL, histology of the PL, and various aspects of PL measurements with relevance to the surgical considerations and sex and age-related differences. A narrative review of the patellar ligament was performed by conducting a detailed literature search and review of relevant articles. A total of 90 articles on the patellar ligament were included and were categorized into studies based on anatomical variations, neurovasculature, morphometrics, microanatomy, sex and age-related difference, and ACL reconstruction. The anatomical variations and morphometrics of the PL were found to correlate with the frequency of strain injuries, tendinopathy, and efficacy of the PL autograft in anterior cruciate ligament reconstruction. The sex differences in PL measurements and the effect of estrogen on collagen synthesis explained a higher incidence of patellar tendinopathy in women. An awareness of its variations enables careful selection of surgical incisions, thereby avoiding complications related to nerve injury. Accurate knowledge of the PL microanatomy assists in understanding the mechanism of ligament degeneration, rupture, autograft harvesting, and ligamentization results.