Quadricep ACL Reconstruction Techniques and Outcomes: an Updated Scoping Review of the Quadricep Tendon

Anterior Cruciate Ligament Reconstruction in Young Athletes: A Comprehensive Review of Lateral Extra-Articular Tenodesis and Anterolateral Ligament Reconstruction Techniques

Anterior cruciate ligament (ACL) injuries are prevalent among young athletes and pose significant challenges due to their impact on immediate and long-term knee function. Traditional ACL reconstruction techniques, while effective, may not always meet the unique needs of this population, particularly given their high physical demands and the risk of future complications. This review evaluates two advanced surgical techniques - lateral extra-articular tenodesis (LEAT) and anterolateral ligament (ALL) reconstruction - as potential enhancements to conventional ACL reconstruction. LEAT involves augmenting knee stability by addressing lateral compartment issues, while ALL reconstruction focuses on reconstructing the ALL to improve overall knee function. The review compares these techniques regarding surgical procedures, clinical outcomes, biomechanical effectiveness, and complications. LEAT and ALL reconstruction are examined for their impact on recovery, return-to-sport rates, and long-term knee health, highlighting their advantages and limitations. Findings suggest that both techniques offer promising benefits, with the potential for improved outcomes compared to traditional methods. However, the effectiveness of each technique can vary based on individual factors and the specific demands of different sports. Further research is needed to fully understand the long-term implications and refine these approaches. This review aims to guide clinical decision-making and optimize treatment strategies for young athletes with ACL injuries, enhancing their prospects for a successful return to athletic activity.

Quadriceps tendon versus hamstring tendon graft for primary anterior cruciate ligament reconstruction: A systematic review and meta-analysis of randomised trials

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) is most commonly performed with hamstring tendon (HT) or bone-patellar tendon-bone (BTB) autografts, although the quadriceps tendon (QT) autograft has recently increased in popularity. This systematic review and meta-analysis review compares QT and HT autografts for primary ACLR with a sole focus on randomised controlled trials (RCTs).

METHODS

A prospective protocol was registered on PROSPERO (CRD42023427339). The search included MEDLINE, Embase and Web of Science until February 2024. Only comparative RCTs were included. The primary outcome was the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form score. Secondary outcomes included: other validated patient-reported outcome measures (PROMs), objective strength scores, complications, and return to sport and work.

RESULTS

From 2,609 articles identified, seven were included (n = 474 patients). This meta-analysis did not identify a significant difference in post-operative IKDC scores (5 articles; p = 0.73), Lysholm scores (3 studies; p = 0.80) or Tegner activity scales (2 studies; p = 0.98). There were no differences in graft failure rates (4 studies; p = 0.92) or in overall adverse events (4 studies; p = 0.83) at 24 months post-ACLR as per meta-analysis. Donor site morbidity scores were significantly lower in the QT group (MD -4.67, 95% CI -9.29 to -0.05; 2 studies, 211 patients; p = 0.05, I2 = 34%).

CONCLUSION

There were no differences between QT and HT in PROMs, graft failure rates or overall complications based on low- to moderate-quality evidence. There may possibly be lower donor site morbidity with the QT autograft, however, the evidence is not sufficient to draw definitive conclusions.

Surgical Techniques in Primary ACL Reconstruction: Getting It Right the First Time

The ideal anterior cruciate ligament reconstruction (ACLR) is an individualized anatomic approach aimed at restoring the native structure and function of the knee. Surgeons are tasked with difficult decisions during operative planning, including the optimal graft choice for the patient and appropriate anatomic tunnel placement. Special considerations should additionally be given for skeletally immature patients and those at high-risk for failure, including younger, active patients participating in pivoting sports. The purpose of this review is to provide an overview of the individualized approach to ACLR, including the necessary preoperative and operative considerations to optimize patient outcomes.

Following Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Autograft, the Incidence of Anterior Knee Pain Ranges From 5.4% to 48.4% and the Incidence of Kneeling Pain Ranges From 4.0% to 75.6%: A Systematic Review of Level I Studies

Purpose

To (1) perform a systematic review of level I randomized controlled trials (RCTs) detailing the incidence of anterior knee pain and kneeling pain following anterior cruciate ligament reconstruction (ACLR) with bone-patellar tendon-bone (BPTB) autograft and (2) investigate the effect of bone grafting the patellar harvest site on anterior knee and kneeling pain.

Methods

A systematic review of level I studies from 1980 to 2023 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome evaluated was the presence of donor site morbidity in the form of anterior knee pain or kneeling pain. A secondary subanalysis was performed to assess for differences in the incidence of postoperative pain between patient groups undergoing ACLR with BPTB receiving harvest site bone grafting and those in whom the defect was left untreated.

Results

Following full-text review, 15 studies reporting on a total of 696 patients met final inclusion criteria. Patients were followed for an average of 4.78 years (range, 2.0-15.3), and the mean age ranged from 21.7 to 38 years old. The incidence of anterior knee pain, calculated from 354 patients across 10 studies, ranged from 5.4% to 48.4%. The incidence of postoperative pain with kneeling was determined to range from 4.0% to 75.6% in 490 patients from 9 studies. Patients treated with bone grafting of the BPTB harvest site had no significant difference in incidence of any knee pain compared with those who were not grafted, with incidences of 43.3% and 40.2%, respectively.

Conclusions

Based on the current level I RCT data, the incidences of anterior knee pain and kneeling pain following ACLR with BPTB autograft range from 5.4% to 48.4% and 4.0% to 75.6%, respectively.

Level of Evidence

Level I, systematic review of RCTs.

Tape-Reinforced Graft Suturing and Retensioning of Adjustable-Loop Cortical Buttons Improve Quadriceps Tendon Autograft Biomechanics in Anterior Cruciate Ligament Reconstruction: A Cadaveric Study

PURPOSE

To investigate the biomechanical effects of tape-reinforced graft suturing and graft retensioning for all-soft tissue quadriceps tendon (ASTQT) anterior cruciate ligament reconstruction (ACLR) in a full-construct human cadaveric model.

METHODS

Harvested cadaveric ASTQT grafts were assigned to either (1) double-suspensory adjustable-loop cortical button device (ALD) fixation in which both graft ends were fixed with a suspensory fixation device with (n = 5) or without (n = 5) tape-reinforced suturing or (2) single-suspensory distal tendon fixation in which only the patellar end was fixed with an ALD (n = 5) or fixed-loop cortical button device (FLD) (n = 5). All specimens were prepared using a No. 2 whipstitch technique, and tape-reinforced specimens had an integrated braided tape implant. Graft preparation time was recorded for double-suspensory constructs. Samples were tested on an electromechanical testing machine using a previously published protocol simulating rehabilitative kinematics and loading.

RESULTS

Tape-reinforced graft suturing resulted in greater graft load retention after cycling (11.9% difference, P = .021), less total elongation (mean [95% confidence interval (CI)], 5.57 mm [3.50-7.65 mm] vs 32.14 mm [25.38-38.90 mm]; P < .001), greater ultimate failure stiffness (mean [95% CI], 171.9 N/mm [158.8-185.0 N/mm] vs 119.4 N/mm [108.7-130.0 N/mm]; P < .001), and less graft preparation time (36.4% difference, P < .001) when compared with unreinforced specimens. Retensioned ALD constructs had less cyclic elongation compared with FLD constructs (mean total elongation [95% CI], 7.04 mm [5.47-8.61 mm] vs 12.96 mm [8.67-17.26 mm]; P = .004).

CONCLUSIONS

Tape-reinforced graft suturing improves time-zero ASTQT ACLR construct biomechanics in a cadaveric model with 83% less total elongation, 44% greater stiffness, and reduced preparation time compared with a whipstitched graft without tape reinforcement. ALD fixation improves construct mechanics when compared with FLD fixation as evidenced by 46% less total elongation.

CLINICAL RELEVANCE

Tape-reinforced implants and graft retensioning using ALDs improve time-zero ACLR graft construct biomechanics in a time-zero biomechanical model. Clinical studies will be necessary to determine whether these implants improve clinical outcomes including knee laxity and the incidence of graft rupture.

Editorial Commentary: Quadriceps Tendon Anterior Cruciate Ligament Graft Shows Advantages and Disadvantages

A quadriceps tendon autograft is becoming an increasingly popular graft option for both primary and revision ACL reconstruction. The biomechanical properties of a QT autograft are favorable compared to a bone-patellar tendon-bone (BPTB) or a doubled hamstring (HS) autograft. 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 studies have shown comparable clinical results when compared to a BPTB or a HS autograft. However, if harvested with a bone block, a QT autograft carries a higher risk of patellar fracture than a BPTB autograft. Other potential disadvantages include persistent quadriceps weakness, and registry data have shown a higher revision rate compared to a BPTB or HS ACL reconstruction, which is thought to be due to a high learning curve, leading to higher revision rates in low volume centers. Finally, a graft-fixation construct with good time 0 biomechanical characteristics may only be successful in the long term if the graft heals effectively. Time will tell.

Approximately half of pediatric or adolescent patients undergoing revision anterior cruciate ligament reconstruction return to the same level of sport or higher: A systematic review

PURPOSE

To summarise the surgical techniques and clinical outcomes in paediatric and adolescent patients undergoing revision anterior cruciate ligament reconstruction (r-ACLR).

METHODS

Three databases (MEDLINE, PubMed and EMBASE) were searched from inception to 29 July 2023. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, surgical details, patient-reported outcome measures (PROMs), rates of instability, rupture and return to sport (RTS) were extracted.

RESULTS

Eight studies comprising 706 (711 knees) patients were included (48.7% female). The mean age at r-ACLR was 17.1 years (range: 16.5-18.0). Autografts (67.5%) were more common than allografts (32.2%) in revision, with bone-patellar tendon-bone (BPTB) being the most prevalent autograft source (59.6%). Bone grafts were used in seven patients (4.8% of 146 patients). The most common femoral and tibial fixation techniques were interference screws (37.6% and 38.1%, of 244 patients, respectively). The most common tunnelling strategy was anatomic (69.1% of 236 patients), and meniscus repairs were performed in 39.7% of 256 patients. The re-rupture rate was 13.0% in 293 patients. RTS at the same level or higher was 51.6% in 219 patients. The mean (SD) Lysholm score was 88.1 (12.9) in 78 patients, the mean (SD) Tegner score was 6.0 (1.6) in 78 patients, and the mean (SD) IKDC score was 82.6 (16.0) in 126 patients.

CONCLUSION

R-ACLR in paediatric and adolescent patients predominantly uses BPTB autografts and interference screw femoral and tibial fixation with concomitant meniscal procedures. Rates of re-rupture and RTS at the same level or higher were 13.0% and 51.6%, respectively. Information from this review can provide orthopaedic surgeons with a comprehensive understanding of the most commonly used operative techniques and their outcomes for revision ACLR in this population.

LEVEL OF EVIDENCE

Level IV.

Minimally Invasive Harvesting of Triple-Fold Superficial Layer Quadriceps Autograft for Knee Ligament Reconstruction

Graft selection plays a critical role in anterior cruciate ligament reconstruction. Autograft options, including hamstrings, bone-patellar tendon-bone, and quadriceps, offer distinct advantages and disadvantages. Soft tissue quadriceps tendon autografts are increasingly favored due to their strength, size compatibility, and potential for enhanced graft healing. This technique offers minimal skin incision, a longer graft, and reduced morbidity, as it specifically targets the superficial band of the quadriceps tendon.

Graft-Specific Surgical and Rehabilitation Considerations for Anterior Cruciate Ligament Reconstruction with the Quadriceps Tendon Autograft

Anterior cruciate ligament reconstruction (ACLR) with a bone-patellar tendon-bone (BPTB) or hamstring tendon (HT) autograft has traditionally been the preferred surgical treatment for patients returning to Level 1 sports. More recently, international utilization of the quadriceps tendon (QT) autograft for primary and revision ACLR has increased in popularity. Recent literature suggests that ACLR with the QT may yield less donor site morbidity than the BPTB and better patient-reported outcomes than the HT. Additionally, anatomic and biomechanical studies have highlighted the robust properties of the QT itself, with superior levels of collagen density, length, size, and load-to-failure strength compared to the BPTB. Although previous literature has described rehabilitation considerations for the BPTB and HT autografts, there is less published with respect to the QT. Given the known impact of the various ACLR surgical techniques on postoperative rehabilitation, the purpose of this clinical commentary is to present the procedure-specific surgical and rehabilitation considerations for ACLR with the QT, as well as further highlight the need for procedure-specific rehabilitation strategies after ACLR by comparing the QT to the BPTB and HT autografts.

Level of Evidence

Level 5.

The Associations Between Quadriceps Tendon Graft Thickness and Isokinetic Performance

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) using the quadriceps tendon is an increasingly popular technique. Both partial-thickness quadriceps tendon (PT-Q) and full-thickness quadriceps tendon (FT-Q) graft depths are employed.

HYPOTHESIS/PURPOSE

This study was designed to assess isokinetic peak torque, average power, and total work during knee extension in patients with FT-Q or PT-Q grafts for ACLR. We hypothesized that both groups would show lower isokinetic values for the operated side, with greater deficits in the FT-Q group than in the PT-Q group.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 26 patients who underwent ACLR with either an FT-Q or PT-Q graft were recruited between June 2021 and November 2021. Patients underwent isokinetic knee extension testing at > 1 year after surgery. Mixed repeated-measures analysis of covariance with least square difference post hoc testing was used to determine significant differences or interactions for all variables.

RESULTS

Peak torque was significantly lower for the operated limb than the nonoperated limb in the FT-Q group (mean difference [MD] ± standard error [SE], -38.6 ± 8.3 Nċm [95% CI, -55.7 to -21.5 Nċm]; P < .001; d = 0.90) but not in the PT-Q group (MD ± SE, -7.3 ± 7.7 Nċm [95% CI, -23.2 to 8.5 Nċm]; P = .348; d = 0.20). Similarly, average power for the operated limb was lower than that for the nonoperated limb in the FT-Q group (MD ± SE, -53.6 ± 13.4 W [95% CI, -81.3 to -26.9 W]; P < .001; d = 0.88) but not in the PT-Q group (MD ± SE, -4.1 ± 12.4 W [95% CI, -29.8 to 21.5 W]; P = .742; d = 0.07), and total work was lower for the operated limb compared with the nonoperated limb in the FT-Q group (MD ± SE, -118.2 ± 27.1 J [95% CI, -174.3 to -62.2 J]; P < .001; d = 0.96) but not in the PT-Q group (MD ± SE, -18.3 ± 25.1 J [95% CI, -70.2 to 33.6 J]; P = .472; d = 0.15).

CONCLUSION

The FT-Q group showed significant deficits in the operated limb compared with the nonoperated limb for all isokinetic variables. In contrast, no significant differences were found between the nonoperated and operated limbs for the PT-Q group.