Quadriceps Tendon Autograft in Anterior Cruciate Ligament Reconstruction: A Systematic Review

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.

A novel surgical technique for revision anterior cruciate ligament reconstruction using an isolated rectus femoris tendon autograft

INTRODUCTION

Only a few anatomic studies have described an isolated rectus femoris tendon autograft for anterior cruciate ligament (ACL) reconstruction. This study aims to demonstrate a new surgical technique utilising the rectus femoris tendon for ACL reconstruction. This study hypothesises that the rectus tendon autograft will yield satisfying postoperative outcomes in terms of stability, with minimal complications at the harvest site.

METHODS

This retrospective study investigated the outcomes of 28 revision ACL reconstructions using a rectus tendon autograft with a mean follow-up of 41.7 (range, 24.0-64.8) months. A 3 cm longitudinal incision was used to harvest the rectus tendon with an open tendon stripper. Intraoperative collected data included the length of the tendon and thickness of a 4-fold graft. Further outcome parameters include anterior cruciate ligament stability and range of motion. Additionally, postoperative complications, especially donor site morbidity, were documented in type and frequency.

RESULTS

The mean tendon length measured 32.4 cm (range, 30-35 cm). After preparing a 4-fold graft, the mean diameter was 9.2 mm (range, 8.0-10 mm) at the tibial and 9.0 mm (range, 7.5-10 mm) at the femoral end. Stability evaluated by the Lachman test improved significantly from 2 (Interquartile range (IQR), 2-3) preoperatively to 0 (IQR, 0-1) postoperatively (p < .001). Rerupture of the anterior cruciate ligament graft was observed in 2 patients (7.1%). Four patients showed a persistent extension deficit of about 5 degrees postoperatively. Two of them underwent revision surgery due to a Cyclops lesion. Only one patient complained of prolonged pain at the harvest site (3.6%).

CONCLUSION

The 4-fold rectus tendon represents a novel autograft technique in revision ACL reconstruction. This study provides evidence of appropriate graft dimensions and satisfying postoperative outcomes regarding stability. The technique is associated with a low complication rate at the harvest site.

STUDY DESIGN

Case series; Level of evidence, IV.

The Use of a Simple Vaginal Speculum to Harvest Quadriceps Tendon Autografts for Anterior Cruciate Ligament Reconstruction and Avoid Any Potential Pitfalls during Harvesting Procedure: Technical note

This technical note aimed to present a straigthforward method for harvesting quadriceps tendon autografts with the use of a simple vaginal speculum and direct visualisation of a scope. Anterior cruciate ligament reconstruction with quadriceps tendon autografts has gained popularity in recent years, with many harvesting techniques that use different harvesting systems available on the market. These techniques vary from transverse to longitudinal skin incisions and from open to minimally invasive approaches and have a learning curve, as with the majority of surgical procedures. The technique proposed in this technical note is minimally invasive, can be easily reproduced by any surgeon irrespective of their experience, has a short learning curve, requires no additional cost or technical support during the procedure and creates a stable working space that allows for freedom of manipulation of surgical instruments and the arthroscope.

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.

Quadriceps Tendon With Bone Autograft Has Better Stability and Magnetic Resonance Imaging Maturation Than Hamstring Tendon Autograft After Anterior Cruciate Ligament Reconstruction in Patients With Knee Hyperextension

PURPOSE

To compare the clinical outcomes of anterior cruciate ligament (ACL) reconstruction between methods using quadriceps tendon with bone (QTB) and hamstring tendon (HT) in patients with hyperextension of the knee.

METHODS

The medical records of patients with knee hyperextension greater than 8° who underwent arthroscopic ACL reconstruction between October 2010 and October 2020 with follow-up for at least 2 years (median, 3 years; interquartile range [IQR], 2.0-4.6 years) were retrospectively reviewed. Side-to-side difference in anterior translation, pivot-shift test grade, Lysholm score, and graft intensity using the Howell grade on magnetic resonance imaging at final follow-up were compared between the QTB and HT groups.

RESULTS

The HT and QTB groups consisted of 42 patients and 21 patients, respectively. The overall mean age was 21.5 years (range, 14-48 years), and the median Tegner Activity Scale score was 6 (range, 3-9). Postoperatively, the median side-to-side difference in anterior translation was 1.75 mm (IQR, 1-3 mm) in the HT group and 1.0 mm (IQR, 0-1.75 mm) in the QTB group (P = .01). Pivot-shift testing showed grade 0 in 74.7%, grade 1 in 18.7%, and grade 2 in 6.6% of patients in the HT group and grade 0 in 85.7% and grade 1 in 14.3% of those in the QTB group (P = .03). The median postoperative Lysholm score was 99 in both groups. Graft signal intensity showed a significant between-group difference: grade I in 52%, grade II in 36%, and grade III in 12% of patients in the HT group versus grade I in 85.7%, grade II in 9.5%, and grade III in 4.8% of those in the QTB group (P = .03).

CONCLUSIONS

In patients who underwent ACL reconstruction for hyperextension of the knee, QTB yielded better clinical outcomes than HT with respect to anterior stability, rotational stability, and graft signal intensity on median 2-year follow-up magnetic resonance imaging.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Evaluating the quality of systematic reviews of comparative studies in autograft-based anterior cruciate ligament reconstruction using the AMSTAR-2 tool: A systematic umbrella review

PURPOSE

There remains a lack of consensus around autograft selection in anterior cruciate ligament reconstruction (ACLR), though there is a large body of overlapping systematic reviews and meta-analyses. Systematic reviews and their methodological quality were aimed to be further assessed, using a validated tool known as assessing the methodological quality of systematic reviews (AMSTAR-2).

METHODS

MEDLINE, Embase and CENTRAL were searched from inception to 23 April 2023 for systematic reviews (with/without meta-analysis) comparing primary ACLR autografts. A final quality rating from AMSTAR-2 was provided for each study ('critically low', 'low', 'moderate' or 'high' quality). Correlational analyses were conducted for ratings in relation to study characteristics.

RESULTS

Two thousand five hundred and ninety-eight studies were screened, and 50 studies were ultimately included. Twenty-four studies (48%) were rated as 'critically low', 17 (34%) as 'low', seven (14%) as 'moderate' and two (4%) as 'high' quality. The least followed domains were reporting on sources of funding (1/50 studies), the impact of risk of bias on results of meta-analyses (11/36 studies) and publication bias (17/36 studies). There was a significant increase in the frequency of studies graded as 'moderate' compared to 'low' or 'critically low' quality over time (p = 0.020).

CONCLUSION

The methodological quality of systematic reviews comparing autografts in ACLR is low, with many studies being rated lower due to commonly absent aspects of systematic review methodology such as investigating sources of funding and publication bias. More recent studies were generally more likely to be of higher quality. Authors are advised to consult AMSTAR-2 prior to conducting systematic reviews in ACLR.

LEVEL OF EVIDENCE

Level IV.

A Prospective Randomized Controlled Trial Investigating Quadriceps Versus Hamstring Tendon Autograft in Anterior Cruciate Ligament Reconstruction

BACKGROUND

Numerous graft options are available when undertaking anterior cruciate ligament (ACL) reconstruction (ACLR), although a lack of high-quality evidence exists comparing quadriceps (QT) and hamstring (HT) autografts.

PURPOSE

To investigate patient outcomes in patients undergoing HT versus QT ACLR.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

After recruitment and randomization, 112 patients (HT = 55; QT = 57) underwent ACLR. Patients were assessed pre- and postoperatively (6 weeks and 3, 6, 12, and 24 months), with a range of patient-reported outcome measures (PROMs), graft laxity (KT-1000 arthrometer; primary outcome variable), active knee flexion and extension range of motion (ROM), peak isokinetic knee extensor and flexor strength, and a 6-hop performance battery. Limb symmetry indices (LSIs) were calculated for strength and hop measures. Secondary procedures, ACL retears, and contralateral ACL tears were reported.

RESULTS

All PROMs and knee ROM measures significantly improved (P < .0001), and no other group differences (P > .05) were observed-apart from the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) score, which was significantly better in the HT group at 3 (P = .008), 6 (P = .010), and 12 (P = .014) months. No significant changes were observed in side-to-side laxity from 6 to 24 months (P = .105), and no group differences were observed (P = .487) at 6 (HT mean, 1.2; QT mean, 1.3), 12 (HT mean, 1.1; QT mean, 1.3), and 24 (HT mean, 1.1; QT mean, 1.2) months. While the HT group demonstrated significantly greater (P < .05) quadriceps strength LSIs at 6 and 12 months, the QT group showed significantly greater (P < .05) hamstring strength LSIs at 6, 12, and 24 months. The HT group showed significantly greater (P < .05) LSIs for the single horizontal (6 months), lateral (6 and 12 months), and medial (6 months) hop tests for distance. Up until 24 months, 1 patient (QT at 22 months) had a retear, with 2 contralateral ACL tears (QT at 19 months; HT at 23 months). Secondary procedures included 5 in the HT group (manipulation under anesthesia, notch debridement, meniscal repair, and knee arthroscopy for scar tissue) and 6 in the QT group (notch debridement, meniscal repair, knee arthroscopy for scar tissue, tibial tubercle transfer, and osteochondral autologous transplantation).

CONCLUSION

Apart from the ACL-RSI, the 2 autograft groups compared well for PROMs, knee ROM, and laxity. However, greater hamstring strength LSIs were observed for the QT cohort, with greater quadriceps strength (and hop test) LSIs in the HT cohort. The longer-term review will continue to evaluate return to sports and later-stage reinjury between the 2 graft constructs.

REGISTRATION

ACTRN12618001520224p (Australian New Zealand Clinical Trials Registry).

Primary Versus Revision ACL Reconstruction Using Quadriceps Autograft: A Matched-Control Cohort Study

Background

The incidence of anterior cruciate ligament (ACL) reconstruction is increasing, and quadriceps tendon (QT) autograft is gaining popularity for both primary and revision ACL reconstruction.

Purpose

To evaluate the differences in the patient-reported functional outcomes, concomitant injuries, and graft failure in primary versus revision ACL surgery using QT autograft.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 376 patients with primary ACL reconstruction and 138 patients with revision ACL reconstruction were retrospectively retrieved from a prospectively collected ACL registry. A minimally invasive technique was used for QT autograft harvesting. The surgical procedure and rehabilitation protocol were identical in both groups. To maintain a homogeneous cohort for the study, the groups were matched by age, sex, and preinjury outcome scores (Lysholm knee score, Tegner activity level, and visual analog scale [VAS] for pain). Initial baseline assessments of outcome scores were compared with scores collected at the 2-year postoperative mark.

Results

The mean age of the primary group and revision group was 32.9 ± 10.2 years (range, 18-55 years) and 32.3 ± 9.9 years (range, 19-55 years) respectively. Significant preinjury to postoperative improvements were noted in Lysholm (88.2 ± 16.4 vs 83.5 ± 15.0; P = .007) and VAS pain (0.9 ± 1.3 vs 1.5 ± 1.6; P = .001) scores after primary ACL reconstruction compared with revision reconstruction. However, no significant difference was found in Tegner activity level (6.7 ± 1.8 vs 5.9 ± 1.8; P > .430). Primary ACL injury was associated with significantly higher concomitant medial collateral ligament injuries (P = .019), while the revision group was associated with significantly higher concomitant cartilage (P = .001) and meniscal (P = .003) injuries. A significantly higher graft failure rate was noted in the revision group compared with the primary ACL reconstruction group (13.0% vs 5.6%; P = .005).

Conclusion

Both primary and revision ACL reconstruction with QT autograft had acceptable functional outcomes. The primary group had better outcomes than the revision group, possibly due to the lower prevalence of meniscal and cartilage injuries in the primary group compared with the revision group. The revision group was associated with higher graft failure than the primary group. QT autograft is a viable graft choice for both primary and revision ACL reconstruction.

Patellar Fracture Forces Are Not Affected by Proximal Versus Distal Bone Block Anterior Cruciate Ligament Reconstruction Harvest Sites in a Cadaveric Model

Purpose

To quantify the maximum load to fracture in patellae from which bone-patellar tendon-bone (BPTB) and bone-quadriceps tendon (BQT) autografts have been harvested for anterior cruciate ligament reconstruction in a cadaveric model.

Methods

Forty-six fresh-frozen patellae were isolated and divided into the BPTB harvest and BQT harvest groups with matching based on donor age and sex. Computed tomography scans were obtained to calculate bone mineral density (BMD) and patellar height, width, and thickness. BPTB and BQT grafts were harvested from the inferior patella and superior patella, respectively, and then ramped to failure in a 3-point bend test configuration to simulate a postoperative fracture produced by a direct impact after a fall. The presence of fracture, fracture pattern, and maximum load to fracture were recorded. Donor demographic characteristics; patellar height, width, and thickness; and maximum load were compared by the Student t test. Pearson correlations were used to determine whether maximum load was affected by BMD or patellar morphology. The level of significance was set at P < .05.

Results

Maximum load to fracture was not significantly different (P = .91) between the BPTB (5.0 ± 2.3 kN) and BQT (5.1 ± 2.6 kN) groups. Maximum load to fracture in the BPTB group did not correlate with BMD (P = .57) or patellar measurements (P = .57 for thickness, P = .43 for width, and P = .45 for height). Maximum load to fracture in the BQT group positively correlated with BMD and negatively correlated with patellar height. Maximum load to fracture in the BQT group did not correlate with patellar thickness or width. Fracture through the harvest site was observed in 87% of BPTB specimens and 78% of BQT specimens.

Conclusions

The location of the BPTB or BQT autograft harvest site did not significantly affect patellar load to fracture in a cadaveric model.

Clinical Relevance

It is important to understand patellar morphology and the effect of BPTB and BQT graft harvest-site locations on the biomechanical strength of the patella after anterior cruciate ligament reconstruction.

Quadriceps tendon autograft has similar clinical outcomes when compared to hamstring tendon and bone-patellar tendon-bone autografts for revision ACL reconstruction: a systematic review and meta-analysis

PURPOSE

Research regarding revision anterior cruciate ligament reconstruction (RACLR) with quadriceps tendon (QT) autografts is lacking. The purpose of this study was to perform a systematic review and meta-analysis of RACLR with QT and compare its patient outcomes to RACLR with hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts.

METHODS

Adhering to PRISMA guidelines, a search for studies using QT in RACLR was performed within PubMed, Scopus, and CINAHL from database date of inception through December 26, 2022. Primary outcomes sought included: failure rate, Lysholm scores, International Knee Documentation Committee (IKDC) scores, IKDC grades, arthrometric knee side-to-side differences (STSD), pivot shift grade, donor site morbidity, return to sport, visual analog scale (VAS) pain scores.

RESULTS

Nine studies were included consisting of 606 RACLR: 349 QT, 169 HT, and 88 BTB. Overall failure rates were 7.6% QT, 13.3% HT, and 8.7% BTB. Mean weighted Lysholm scores were 85.8 ± 3.8 QT, 82.5 ± 3.8 HT and 86.6 ± 4.5 BTB. IKDC average scores were 82.3 ± 1.6 QT, 80.1 ± 1.7 HT, and 81.7 ± 5.5BTB. Combined rates of IKDC A/B grades were 88.4% and 80.0% for QT and HT, respectively. VAS average scores were 0.9 ± 1.1 QT, 1.4 ± 0.2 HT, and 0.7 ± 0.8 for BTB. Side-to-side difference was reported for QT and HT with average values of 1.7 ± 0.6 mm and 2.1 ± 0.5 mm, respectively. Grade 0 or 1 pivot shifts were reported in 96.2% of QT patients and 91.3% of HT. Donor site morbidity, only reported for QT and HT, was 14.6 ± 9.7% and 23.6 ± 14.1%, respectively. QT resulted in a mean Tegner score of 5.9 ± 1.5 versus HT 5.7 ± 1.5. Rate of return to pivoting sports was 38.0% QT, 48.6% HT, and 76.9% BTB. Across all outcomes, there was no significant difference when comparing QT to HT, QT to BTB, and QT compared to HT and BTB combined.

CONCLUSIONS

RACLR with QT yields satisfactory patient reported outcomes, satisfactory improvement in knee laxity, expected return to sport rates, and has an overall 7.6% failure rate. Outcomes are comparative to those of HT and BTB making it an acceptable graft choice for RACLR. Surgeons should consider using QT autograft for RACLR, especially when other autografts are unavailable.

LEVEL OF EVIDENCE

IV.

Role of Quadriceps Tendon Autograft in Primary and Revision Anterior Cruciate Ligament Reconstruction

» The quadriceps tendon (QT) autograft is becoming increasingly popular in both primary and revision anterior cruciate ligament reconstruction (ACLR).» The biomechanical properties of the QT are similar to those of the native ACL, the hamstring tendon (HT), and bone-patellar tendon-bone (BTB) autografts.» QT autograft allows surgeons to be flexible with their graft size and reconstruction technique.» The QT autograft performs in a similar fashion to the BTB and HT autografts, with excellent patient-reported outcomes, consistent postoperative knee stability, and low rates of postoperative complications including graft failure and donor site morbidity.» There are emerging data that the QT autograft is a viable option in revision ACLR.

Morphology of the quadriceps tendon and its patella insertion site on three-dimensional computed tomography and magnetic resonance imaging: A cadaveric study

AIM

This study was conducted to clarify the morphological properties of the quadriceps tendon (QT) and its patella insertion site using three-dimensional computed tomography and magnetic resonance imaging.

METHODS

Twenty-one right knees from human cadavers were evaluated using three-dimensional computed tomography and magnetic resonance imaging. The morphologies of the QT and its patella insertion site were evaluated, along with intra-tendon differences in length, width, and thickness.

RESULTS

The QT insertion site on the patella was dome-shaped without characteristic bony features. The mean surface area of the insertion site was 502.5 ± 68.5 mm2 (range, 336.0-610.7). The QT was longest 2.0 mm lateral to the central width of the insertion and gradually became shorter toward both edges (mean length, 59.7 ± 8.3 mm). The QT was widest at the insertion site (mean width, 39.1 ± 5.3 mm) and gradually became narrower toward the proximal side. The QT was thickest 2.0 mm medial to the center (mean thickness, 11.4 ± 1.9 mm).

CONCLUSION

The morphological properties of the QT and its insertion site were consistent. The characteristics of the QT graft depend on the harvested region.

Spin in the Abstracts of Meta-analyses and Systematic Reviews: Quadriceps Tendon Graft for Anterior Cruciate Ligament Reconstruction

BACKGROUND

Spin is a reporting bias that misrepresents research. Ultimately it can affect surgeon decision making and patient care. Anterior cruciate ligament (ACL) reconstruction is common, but debate continues over optimal treatment modalities.

PURPOSE

To identify the prevalence of spin in meta-analysis and systematic review abstracts regarding the treatment of ACL injuries with quadriceps tendon graft.

STUDY DESIGN

Cross-sectional study.

METHODS

Electronic libraries (MEDLINE, Embase, Web of Science, Google Scholar) were searched for meta-analyses and systematic reviews regarding the treatment of ACL tears with quadriceps tendon graft. The 9 most severe types of spin commonly found in abstracts were used as an evaluation tool to assess the articles. Two reviewers each performed a blinded assessment of each article for spin. A third reviewer helped after review was done to address any discrepancies between the original reviewers. Further evaluation included year of publication, number of citations, journal impact factor, and A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR-2) score.

RESULTS

The electronic database search resulted in 986 articles, of which 13 met our inclusion criteria. After review, we found that 53.8% (7/13) of the included articles contained 1 of the 9 most severe forms of spin. Of the 13 articles, 15.4% (n = 2) contained 2 types of spin, and 38.5% (n = 5) contained 1 type of spin. No studies contained ≥3 types of spin. Of the types of spin evaluated, the most prevalent (n = 4; 30.8%) was type 3 ("selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention"). All studies, regardless of the presence of spin, were found to be low or critically low quality according to the AMSTAR-2 assessment.

CONCLUSION

This study demonstrated the presence of spin in 53.8% of meta-analysis and systematic review abstracts pertaining to quadriceps tendon graft for ACL reconstruction. Orthopaedic surgeons should learn to recognize spin as they review articles when deciding the treatment course for ACL injuries. Additionally, strict criteria should be considered to reduce the prevalence of spin in orthopaedic literature.

Biomechanical Evaluation of TensionLoc Versus the Double Spike Plate for ACL Graft Tibial Fixation

Background

The optimal tibial fixation of anterior cruciate ligament (ACL) reconstruction (ACLR) grafts remains controversial.

Purpose/Hypothesis

The purpose of this study was to compare the biomechanical characteristics of the TensionLoc (TL) cortical fixation device with the Double Spike Plate (DSP) fixation device for ACL tibial fixation using both bone-patellar tendon-bone (BTB) and quadriceps grafts. It was hypothesized that there would be no differences in biomechanical characteristics between the fixation devices regardless of graft type.

Study Design

Controlled laboratory study.

Methods

ACLR was performed on 14 matched-pair cadaveric knee specimens-7 pairs using quadriceps grafts (n = 3 male cadaveric knee specimens; n = 4 female cadaveric knee specimens; age, 51 ± 8 years) and 7 pairs using BTB grafts (n = 3 male cadaveric knee specimens; n = 4 female cadaveric knee specimens; age, 50 ± 7 years). One side of each pair was randomized to receive DSP fixation, and the contralateral side received TL fixation. Specimens underwent cyclic ramp loading (10 cycles each at 50-100 N, 50-250 N, and 50-400 N), followed by load-to-failure testing, with the tensile force in line with the tibial tunnel. Results between the 2 fixation types were compared with a paired t test.

Results

For the quadriceps graft, there were no significant differences in cyclic loading or load-to-failure characteristics between fixation types (P≥ .092 for all parameters). For the BTB graft, TL fixation resulted in higher stiffness than DSP at all cyclic testing cycles except for cycle 1 during 100-N loading and had lower displacement at 250-N loading (3.4 ± 0.1 vs 5.4 ± 0.3 mm; P = .045). For load to failure, TL fixation resulted in higher stiffness than DSP fixation (232 ± 3.1 vs 188.4 ± 6.4 N/mm; P = .046); however, all other load-to-failure parameters were not statistically different (P≥ .135 for all parameters).

Conclusion

With the quadriceps tendon graft, there were no significant differences in biomechanical characteristics between TL and DSP ACL tibial fixations; however, with BTB grafts, the TL tibial fixation demonstrated greater biomechanical integrity than the DSP tibial fixation.

Clinical Relevance

The TL fixation device may provide an alternative ACL tibial fixation option for BTB and soft tissue grafts.

Smaller diameter femoral tunnel biocomposite interference screws provide adequate fixation strength in anterior cruciate ligament reconstruction

PURPOSE

The purpose of this study was to evaluate the effect of bioabsorbable interference screw diameter on the pullout strength and failure mode for femoral tunnel fixation in primary anterior cruciate ligament reconstruction (ACLR) at time zero fixation using bone-patellar tendon-bone (BTB) autograft in a cadaveric model.

METHODS

Twenty-four fresh-frozen cadaveric knees were obtained from 17 different donors. Specimens were allocated to three different treatment groups (n = 8 per group) based on interference screw diameter: 6 mm, 7 mm, or 8 mm biocomposite interference screw. All specimens underwent dual energy X-ray absorptiometry (DEXA) scanning prior to allocation to ensure no difference in bone mineral density among groups (n.s.). All specimens underwent femoral-sided ACLR with BTB autograft. Specimens subsequently underwent mechanical testing under monotonic loading conditions to failure. The load to failure and failure mechanism were recorded.

RESULTS

The mean pullout force (N) at time zero for each group was 309 ± 213 N, 518 ± 313 N, and 541 ± 267 N for 6 mm, 7 mm, and 8 mm biocomposite interference screw diameter, respectively (n.s.). One specimen in the 6 mm group, two specimens in the 7 mm group, and one specimen in the 8 mm group failed by screw pullout. The remainder in each group failed by graft failure (n.s.).

CONCLUSION

Biocomposite interference screw diameter did not have a significant influence on fixation pullout strength or failure mode following femoral tunnel fixation using BTB autograft at time zero. A 6 mm interference screw can improve preservation of native bone stock, increase potential for biologic healing, and decrease the risk of damage to the graft during insertion without significantly compromising fixation strength. This study supports the use of smaller 6 mm interference screw diameter options for femoral tunnel fixation in ACLR.

Is anterior knee pain following anterior cruciate ligament reconstruction a consideration for graft choice, and the influence of COVID: a qualitative analysis in recreational athletes

BACKGROUND

We set out to investigate whether anterior knee pain following anterior cruciate ligament reconstruction has a significant effect on patients, and whether it should influence graft choice.

METHODS

This was a qualitative analysis of a set of recreational athletes treated at a university hospital at about 1 year following anterior cruciate ligament reconstruction surgery. Participants were interviewed by an orthopaedic fellow and resident using structured, open-ended questions. Inductive theme analysis was used to code the data.

RESULTS

There were 4 major themes: (1) Our hypothesis was that patients would be given adequate information to make an appropriate graft choice. This hypothesis was rejected. Discussion took place, but with little details or rationale for the graft choice. The predominant theme was that the surgeon made the decision, and there was a lack of reliable information for the patient to make a choice. (2) The overall theme was that most patients had no anterior knee pain, and it did not interfere with activities of daily living. (3) One theme was that patients were able to resume all sports without restriction, but in some, the anterior knee pain interfered with the more demanding activities such as impact, cutting, and pivoting. A separate theme was that fear was a major impediment to return to sports and was not related to the anterior knee pain. (4) The overriding theme was that the generalized closures associated with the COVID-19 pandemic slowed the rehabilitation process. Although virtual care was available in general, it was not particularly satisfactory. Patients indicated that they had not been able to return to the gym or to their sporting activities as a result.

CONCLUSIONS

Amongst non-competitive athletes, anterior knee pain post-anterior cruciate ligament reconstruction surgery does not significantly affect activities of daily living. Although there is a minor effect on sporting activities, the inability to return to sports is related to factors such as the COVID-19 pandemic, fear, or insufficient rehabilitation, rather than anterior knee pain. Overall, anterior knee pain is not a significant factor that plays a role in determining graft choice.

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.

Surgeon's experience, sports participation and a concomitant MCL injury increase the use of patellar and quadriceps tendon grafts in primary ACL reconstruction: a nationwide registry study of 39,964 surgeries

PURPOSE

To investigate the influence of surgeon-related factors and clinic routines on autograft choice in primary anterior cruciate ligament reconstruction (ACLR).

METHODS

Data from the Swedish National Knee Ligament Registry (SNKLR), 2008-2019, were used to study autograft choice (hamstring; HT, patellar; PT, or quadriceps tendon; QT) in primary ACLR. Patient/injury characteristics (sex, age at surgery, activity at time of injury and associated injuries) and surgeon-/clinic-related factors (operating volume, caseload and graft type use) were analyzed. Surgeon/clinic volume was divided into tertiles (low-, mid- and high-volume categories). Multivariable logistic regression was performed to assess variables influencing autograft choice in 2015-2019, presented as the odds ratio (OR) with a 95% confidence interval (CI).

RESULTS

39,964 primary ACLRs performed by 299 knee surgeons in 91 clinics were included. Most patients received HT (93.7%), followed by PT (4.2%) and QT (2.1%) grafts. Patients were mostly operated on by high-volume (> 28 ACLRs/year) surgeons (68.1%), surgeons with a caseload of ≥ 50 ACLRs (85.1%) and surgeons with the ability to use ≥ two autograft types (85.9%) (all p < 0.001). Most patients underwent ACLR at high-volume (> 55 ACLRs/year) clinics (72.2%) and at clinics capable of using ≥ two autograft types (93.1%) (both p < 0.001). Significantly increased odds of receiving PT/QT autografts were found for ACLR by surgeons with a caseload of ≥ 50 ACLRs (OR 1.41, 95% CI 1.11-1.79), but also for injury during handball (OR 1.31, 95% CI 1.02-1.67), various other pivoting sports (basketball, hockey, rugby and American football) (OR 1.59, 95% CI 1.24-2.03) and a concomitant medial collateral ligament (MCL) injury (OR 4.93, 95% CI 4.18-5.80). In contrast, female sex (OR 0.87, 95% CI 0.77-0.97), injury during floorball (OR 0.71, 95% CI 0.55-0.91) and ACLR by mid-volume relative to high-volume surgeons (OR 0.62, 95% CI 0.53-0.73) had significantly reduced odds of receiving PT/QT autografts.

CONCLUSION

An HT autograft was used in the vast majority of cases, but PT/QT autografts were used more frequently by experienced surgeons. Prior research has demonstrated significant differences in autograft characteristics. For this reason, patients might benefit if surgery is performed by more experienced surgeons.

LEVEL OF EVIDENCE

Level III.

Anterior cruciate ligament reconstruction with all-soft tissue quadriceps tendon versus quadriceps tendon with bone block

PURPOSE

The purpose of this study was to evaluate whether there was a difference in clinical outcomes between patients who underwent primary ACL reconstruction (ACLR) with all-soft tissue quadriceps tendon (sQT) autograft versus QT with bone block (bQT).

METHODS

A retrospective cohort study of 708 patients who underwent QT ACLR was conducted. Primary ACLR patients with at least 1 year of follow-up were identified and those who received sQT were compared to those who received bQT. Data collection entailed patient demographics, surgical variables, patient reported outcomes (PROs), knee stability testing, and complications. The primary outcome of interest was International Knee Documentation Committee (IKDC) score, reported as mean score, pre- and postoperative difference, and number who met minimum clinically important difference (MCID). Secondary outcomes included Lachman and pivot shift grade, other patient reported outcomes (PROs), complication rates, and return to sport (RTS).

RESULTS

A total of 195 patients (147 sQT, 48 bQT) who underwent primary QT ACLR met criteria for analysis, with mean follow-up of 17.0 ± 7.9 months. No difference was detected between cohorts with respect to postoperative IKDC score (sQT: n = 120, 81.0 ± 18.9, bQT: n = 10, 80.9 ± 20.4, n.s.), proportion of patients who met MCID (sQT: 68/78 [87%], bQT: 6/7 [86%], n.s.), or results of stability testing. In the sQT cohort, 86% (106/123) of athletes achieved full RTS, compared to 85% (34/40) in the bQT cohort (n.s.). Time to RTS was less than a year in both cohorts (sQT: 10.5 ± 3.8 months [n = 106], bQT: 11.1 ± 3.9 months [n = 31], n.s.). Graft rupture occurred in 7 (5%) sQT patients and 3 (6%) bQT patients (n.s.), and all clinical failures were due to graft rupture (n.s.). No differences were detected for rates of postoperative complications.

CONCLUSION

No differences in clinical outcomes were detected between patients who underwent primary ACLR with sQT autograft versus bQT autograft. Currently, the decision to employ sQT or bQT is largely determined by surgeon preference. This study demonstrates excellent outcomes with both preparations and supports the use of either graft type at the discretion of the treating surgeon.

LEVEL OF EVIDENCE

III.

Harvesting a second graft from the extensor mechanism for revision ACL reconstruction does not delay return of quadriceps function

PURPOSE

The purpose of this study was to evaluate whether harvesting a second graft from the ipsilateral extensor mechanism adversely affects clinical outcomes in revision anterior cruciate ligament (ACL) reconstruction.

METHODS

A retrospective review of 34 patients undergoing revision anterior cruciate ligament (ACL) reconstruction with either quadriceps tendon (QT) autograft or bone-tendon-bone (BTB) autograft was conducted. Patients with two grafts (BTB+QT) from the extensor mechanism were matched based on age, laterality, and sex to patients who had primary reconstruction with hamstring (HS) autograft followed by revision with either BTB or QT autograft (HS+QT/BTB). Return of quadriceps function was assessed with time to return to jogging in a standardized rehab protocol or time to regain 80% quadriceps strength. Secondary outcomes included International Knee Documentation Committee (IKDC) and Marx scores at 12-month follow-up and return to sport.

RESULTS

There were no significant differences in return to jogging or 80% quadriceps strength (HS 149.5 ± 38.2 days, BTB+QT 131.7 ± 40.1 days, n.s.), number able to return to sport (HS 62%, BTB+QT 93%, n.s.), months to return to sport (HS 10.6 ± 1.4, BTB+QT 10.5 ± 2.3, n.s.), return to pre-injury level of competition (HS 62%, BTB+QT 73%, n.s.), or IKDC (HS 77.2 ± 16.4, BTB+QT 74.8 ± 23.9, n.s.) and Marx scores (HS 9.2 ± 5.3, BTB+QT 8.0 ± 3.7, n.s.) at one-year follow-up.

CONCLUSION

The main finding of the present study was that outcomes for patients who underwent revision ACL reconstruction with a second extensor mechanism autograft were comparable to those seen for patients who underwent revision ACL reconstruction with extensor mechanism autograft after primary ACL reconstruction with hamstring autograft. By better understanding the consequences of harvesting a second graft from the extensor mechanism, surgeons can better decide what graft to use in revision ACL reconstruction.

LEVEL OF EVIDENCE

Level III.

Classic and Current Opinions in Human Organ and Tissue Transplantation

Graft tolerance is a pathophysiological condition heavily reliant on the dynamic interaction of the innate and adaptive immune systems. Genetic polymorphism determines immune responses to tissue/organ transplantation, and intricate humoral and cell-mediated mechanisms control these responses. In transplantation, the clinician's goal is to achieve a delicate equilibrium between the allogeneic immune response, undesired effects of the immunosuppressive drugs, and the existing morbidities that are potentially life-threatening. Transplant immunopathology involves sensitization, effector, and apoptosis phases which recruit and engages immunological cells like natural killer cells, lymphocytes, neutrophils, and monocytes. Similarly, these cells are involved in the transfer of normal or genetically engineered T cells. Advances in tissue transplantation would involve a profound knowledge of the molecular mechanisms that underpin the respective immunopathology involved and the design of precision medicines that are safe and effective.

A Partial-Thickness Quadriceps Autograft Reliably Augments the Size of the Hamstring Graft During Anterior Cruciate Ligament Reconstruction

Purpose

To measure the increase in diameter resulting from the augmentation of a hamstring autograft with a partial width rectus femoris tendon band in anterior cruciate ligament reconstruction.

Methods

Thirty-three cadaveric knees were dissected to harvest semitendinosus and gracilis tendons (4S) along with a 6-mm wide tendon band from the rectus femoris. Harvesting was done according to the usual surgical techniques of both harvests. Measures of length and diameter in 4S and 4S augmented with the rectus femoris band (4S +Q) configurations were performed separately by 3 evaluators.

Results

The quadriceps augmentation led to an average increase of 1.49 mm (95% confidence interval 1.03-1.95 mm) in diameter of the 4-strand hamstring grafts. The previously demonstrated threshold diameter of 8.5 mm was attained in only 30% of 4S grafts within this population in comparison with 88% when augmented with a quadriceps band.

Conclusions

In conclusion, supplementing doubled hamstring graft (4S) with quadricipital tendon in anterior cruciate ligament reconstruction (ACLR) increases the graft diameter by an average of 1.49 mm. It has the physical potential to reliably augment hamstring grafts that measure 7.5 mm in diameter or more in order to obtain an 8.5 mm when necessitated.

Clinical Relevance

Increased graft diameter is associated with a decreased risk of graft failure after ACLR. Because of this, it is important to identify methods to increase the size of grafts. This study investigates the use of a partial-width rectus femoris tendon band as an option to reliably augment graft sizes during ACLR.

Quadriceps Tendon Autograft Versus Bone-Patellar Tendon-Bone and Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

The best type of autograft for anterior cruciate ligament (ACL) reconstruction remains debatable.

HYPOTHESIS

Compared with bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) autografts, the quadriceps tendon (QT) autograft has comparable graft survival as well as clinical function and pain outcomes.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

A systematic literature search was conducted in PubMed, Embase, Scopus, and the Cochrane Library to July 2020. Randomized controlled trials (RCTs) and observational studies reporting comparisons of QT versus BPTB or HT autografts for ACL reconstruction were included. All analyses were stratified according to study design: RCTs or observational studies.

RESULTS

A total of 24 studies were included: 7 RCTs and 17 observational studies. The 7 RCTs included 388 patients, and the 17 observational studies included 19,196 patients. No significant differences in graft failure (P = .36), the International Knee Documentation Committee (IKDC) subjective score (P = .39), or the side-to-side difference in stability (P = .60) were noted between QT and BPTB autografts. However, a significant reduction in donor site morbidity was noted in the QT group compared with the BPTB group (risk ratio [RR], 0.17 [95% CI, 0.09-0.33]; P < .001). No significant differences in graft failure (P = .57), the IKDC subjective score (P = .25), or the side-to-side stability difference (P = .98) were noted between QT and HT autografts. However, the QT autograft was associated with a significantly lower rate of donor site morbidity than the HT autograft (RR, 0.60 [95% CI, 0.39-0.93]; P = .02). A similar graft failure rate between the QT and control groups was observed after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. However, a significantly lower rate of donor site morbidity was observed in the QT group compared with the control group after both early and late full weightbearing, after early and late full range of motion, and after using the QT autograft with a bone plug and all soft tissue QT grafts. No difference in effect estimates was seen between RCTs and observational studies.

CONCLUSION

The QT autograft had comparable graft survival, functional outcomes, and stability outcomes compared with BPTB and HT autografts. However, donor site morbidity was significantly lower with the QT autograft than with BPTB and HT autografts.

Postoperative Anterior Cruciate Ligament Reconstruction Quadricep and Patella Tendon Rupture, Infection, and Lysis of Adhesions Decreased Despite Changing Graft Trends Over the Past Decade

Purpose

To investigate recent trends in postoperative complications following anterior cruciate ligament (ACL) reconstruction.

Methods

Patients who underwent ACL reconstruction surgery were identified in a national insurance database and separated into 2 cohorts based on the date of their initial surgery comprising the years 2010 to 2012 and 2016 to 2018, respectively. Patients were matched 1:1 based on comorbidities and Elixhauser Comorbidity Index. All patients were assessed for postoperative complications within 18 months of surgery. Rate of complication was compared between cohorts.

Results

Overall, the all-cause complication rate was 2%. There were significantly more quadriceps tendon rupture, patella tendon rupture, lysis of adhesion, and infection in the early cohort. There were significantly more instances of deep vein thrombosis in the late cohort. We found no significant difference in manipulations under anesthesia between the 2 cohorts.

Conclusions

Patients who underwent surgery in the late cohort had lower rates of postoperative complications, except for deep vein thrombosis. The rate of postoperative quadriceps tendon rupture decreased despite considerable increase in the use of quadriceps tendon autograft.

Clinical Relevance

As there has been an increased use of quadriceps tendon autografts, but little is known about the postoperative complications after ACL reconstruction with these grafts. This information has the potential to improve patient outcomes.

Direct suturing quadriceps tendon to a continuous loop with a suspensory button provides biomechanically superior fixation in ACL reconstruction

PURPOSE

To compare the biomechanical strength of different fixation configurations using suspensory buttons in a soft-tissue quadriceps tendon (QT) grafts in anterior cruciate ligament (ACL) reconstruction.

METHODS

Forty bovine QTs, 6-cm long and 10-mm wide, were allocated into four groups with different suture configurations using suspensory buttons (n = 10 in each group): Group A, a baseball suture with a knot tied to the continuous loop with a suspensory button; Group B, same configuration as in Group A but with the knot tied at the opposite end of the baseball suture; Group C, a continuous loop with a suspensory button stitched directly to the QT with simple sutures, and Group D, a baseball suture tied directly to a suspensory button. Biomechanical testing was performed by preloading followed by cyclic loading for 500 cycles between 10 and 100 N. The length of elongation (mm) and maximum load to failure (N) were recorded, and compared among the four groups.

RESULTS

Group C showed significantly smaller elongation (4.1 mm [95% CI 3.1-5.2]) than Group A (8.2 mm [95% CI 7.0-9.4]), Group B (10.5 mm [95% CI 7.7-13.3]), and Group D (8.5 mm [95% CI 7.0-9.9]) (A-C; P = 0.004, B-C; P = 0.0001, C-D; P = 0.0018). The maximum load to failure in Group C (386 N [95%CI 306-466]) was significantly higher than that in Group A (196 N [95% CI 141-251]), Group B (226 N [95% CI 164-289]), and Group D (212 N [95%CI 171-253]) (A-C; P = 0.0001, B-C; P = 0.0009, C-D; P = 0.0002). No significant differences were observed between Group A, B, and D in terms of elongation and maximum load to failure.

CONCLUSION

The soft-tissue QT graft fixation configuration stitched directly to a continuous loop with suspensory button using simple sutures exhibits small elongation and high maximum load to failure among the four configurations. Regarding clinical relevance, direct suturing of the soft-tissue QT to a continuous loop with a suspensory button may be advantageous for femoral fixation in ACL reconstruction from a biomechanical perspective, and warrant future development of a novel fixation device using this principle.

Anterior cruciate ligament reconstruction using quadriceps tendon autograft is a viable option for small-statured female patients

PURPOSE

The choice of graft for anterior cruciate ligament (ACL) reconstruction remains controversial. The quadriceps tendon (QT) autograft is a good alternative for ACL reconstruction. However, concerns regarding its use in short-statured patients, related to donor site morbidity, anterior knee pain, or loss of muscle strength remain. This study aimed to compare muscle strength and morbidity between patients with short and normal statures following ACL reconstruction with a QT autograft.

METHODS

A total of 73 female patients (mean age, 33.8 ± 11.5 years) who underwent primary ACL reconstruction between 2016 and 2019 were included. Patients were categorized into two groups: group S, with a height ≤ 163 cm, and group L, with a height > 163 cm. Muscle strength, harvesting site morbidity, and ACL-return to sport after injury scale (ACL-RSI) were evaluated, with a mean timing of the follow-up of 9.0 ± 2.3 months.

RESULTS

The mean quadriceps strength for the isokinetic measurements at 60° and 240° was 65.0% and 74.0% in group S, respectively, and 70.0% and 75.7% in group L, respectively. There was no significant difference in the postoperative muscle strength or mean ACL-RSI (group S, 70.0; group L, 65.9) between the groups. No donor site morbidity was observed in either group.

CONCLUSION

Muscle strength recovery, morbidity, and readiness to return to sports were similar in both groups, which supports the possibility of QT autografts for patients with a small stature. The results of this study may provide useful information for surgeons who are hesitant to perform QT autografts because of patient physique.

LEVEL OF EVIDENCE

IV.

Quantification and comparison of tenocyte distribution and collagen content in the commonly used autografts for anterior cruciate ligament reconstruction

Anterior cruciate ligament is a commonly damaged ligament of the knee. Reconstruction of this ligament usually entails the use of graft harvested from the same subject (i.e., autografts). Several tendons, for example quadriceps, patellar or semitendinosus tendon can be used as an autograft. The composition of the tendons is similar to the anterior cruciate ligament but there is no data that directly compares the compositions of the quadriceps, patellar and semitendinosus tendons. This study quantified and compared the tenocyte distribution and collagen content of these tendons from cadavers of South Africans of European Ancestry. The tenocyte distribution and collagen content were assessed using the ImageJ software. The results showed similarities in the collagen content across the tendons in both sexes (P>0.05). The tenocyte distribution was significantly higher in the quadriceps (P=0.019) or semitendinosus (P=0.016) tendon than in the patellar tendon in the female but no difference was seen in the male (P=0.872). This shows that a large harvestable area may not be directly associated with a more abundant collagen content or tenocyte distribution in the tendon. However, sex-specific tenocyte distribution is an important observation that underpins the possible influence of underlying biological factors on the composition of each tendon and this requires further investigations. In all, this study will contribute to knowledge and assist orthopaedic surgeons in making an informed decision on the choice of graft.

A Systematic Review and Meta-Analysis of Strength Recovery Measured by Isokinetic Dynamometer Technology after Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Autografts vs. Hamstring Tendon Autografts or Patellar Tendon Autografts

Background: This systematic review and meta-analysis compared the isokinetic strength of the muscular knee joint between quadriceps tendon autografts (QTAs) and hamstring tendon autografts (HTAs) or patellar tendon autografts (PTAs) after anterior cruciate ligament (ACL) reconstruction by determining the isokinetic angular velocity and follow-up time points. The functional outcomes and knee stability at the same time points were also compared using isokinetic technology. Methods: Two independent reviewers searched the Medline (via PubMed search engine), Scopus, Web of Science and Cochrane Library databases to include full text comparative studies that assessed isokinetic strength test following ACL reconstruction. The DerSimonian and Laird method was used. Results: In total, ten studies were included; seven compared studies QTAs vs. HTAs, and three compared QTAs vs. PTAs. Five studies were included in the meta-analysis. Isokinetic strength data were reported 3, 6, 12 and 24 months after ACL reconstruction. Conclusions: The QTAs showed better and significant results with knee flexion compared with HTAs, similar results to PTAs at 6 and 12 months. While HTAs showed better and significant results with knee extension at 6 months and similar results at 12 months compared to QTAs. Furthermore, a standardized isokinetic strength test must be followed to achieve a more specific conclusion and better clinical comparison among participants.

No Difference in Complication Rates or Patient-Reported Outcomes Between Bone–Patella Tendon–Bone and Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction

Purpose

To compare subjective outcomes and complications of anterior cruciate ligament reconstruction (ACLR) using either bone–patellar tendon–bone (BPTB) or quadriceps tendon (QT) autograft.

Methods

A retrospective analysis of prospectively collected data identified consecutive cohorts of patients undergoing ACLR with either BPTB or QT autograft. Patients with less than 12-month follow-up and those undergoing concomitant osteotomies, cartilage restoration, and/or other ligament reconstruction procedures were excluded. Pre- and postsurgical patient-reported outcomes including International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, Patient-Reported Outcomes Measurement Information System (PROMIS), Single Assessment Numeric Evaluation, Tegner, and Marx were compared between groups. Complications requiring reoperation were recorded.

Results

One hundred nineteen patients met inclusion criteria, including 39 QT autografts and 80 BPTB autografts. Demographic information was comparable between groups. Mean follow-up was comparable between groups (QT 22.4 ± 10.6 months vs BPTB 28.5 ± 18.5 months, P = .06). At minimum 12-month follow-up (range 12.0-100.8 months), patients in both groups demonstrated statistically significant improvements in International Knee Documentation Committee (QT 60.0%, P < .0001; BPTB 57.7%, P < .0001), all Knee Injury and Osteoarthritis Outcome Score domains, PROMIS Mobility T-Score (QT 27.2%, P = .0001; BPTB 23.2%, P < .0001), PROMIS Global Physical Health (QT 14.4%, P = .002; BPTB 13.4%, P = .001), PROMIS Physical Function (QT 29.6%, P < .0001; BPTB 37.1%, P < .0001), PROMIS Pain Interference (QT –16.5%, P < .0001; BPTB –20.8%, P < .0001), Single Assessment Numeric Evaluation, (QT 76.9%, P < .0001; BPTB 73.3%, P < .0001), Tegner (QT 92.9%, P = .0002; BPTB 101.4%, P < .0001), and Marx (QT –26.6%, P = .02; BPTB –32.0%, P = .0002) with no statistically significant differences between the 2 groups. Overall postoperative reoperation rate did not differ between groups (QT 12.8% vs BPTB 23.8%, P = .2). Revision ACL reconstruction rate did not differ between groups (QT 5.1% vs BPTB 7.5%, P = .6).

Conclusions

Patients undergoing autograft ACLR with either BPTB or QT demonstrated significant subjective improvements in patient-reported outcomes from preoperative values and no statistically significant differences in outcomes between the groups. Complication and revision ACLR rates were similar between the 2 groups.

Level of Evidence

III, retrospective cohort study.

Knee strength deficits following anterior cruciate ligament reconstruction differ between quadriceps and hamstring tendon autografts

PURPOSE

To compare patient reported outcomes and functional knee recovery following anterior cruciate ligament (ACL) reconstruction using either a quadriceps tendon (QT) or hamstring tendon (HT) autograft.

METHODS

Thirty-five QT patients (age 20; range 15-34 years) participated in this study and were matched for gender, age and pre-injury activity level to 70 HT (age 20; range 15-32 years) patients. The following assessments were performed at 6 and 12 months post-operatively; standardized patient-reported outcome measures (IKDC, KOOS-QOL, ACL-RSI, Marx activity, anterior knee pain), knee range of motion (passive and active), anterior knee laxity, hop tests (single and triple crossover hop for distance), and isokinetic strength of the knee extensors and flexors. All dependent variables were analysed using a two-way mixed ANOVA model, with within (Time; 6 and 12 months) and between-subject (Graft; QT and HT) factors.

RESULTS

Patient reported outcome measures and hop performance improved between 6 and 12 months (p < 0.001), however no significant differences in either patient-reported outcomes or hop performance were found between the two grafts. Isokinetic strength testing showed both groups improved their peak knee extensor strength in the operated limb between 6 and 12 months (p < 0.001), but the QT group had significantly lower knee extensor strength symmetry at both time points compared to HT at 60 deg/s (p < 0.001) and 180 deg/s (p < 0.01). In contrast, the QT group had significantly greater knee flexor strength symmetry at both time points compared to HT at 60 deg/s (p < 0.01) and 180 deg/s (p = 0.01), but knee flexor strength limb symmetry did not significantly improve over time in either group.

CONCLUSION

Recovery of knee function following either QT or HT ACL reconstruction continues between 6 and 12 months after surgery. However, knee extensor strength deficits in the QT group and knee flexor strength deficits in the HT persisted at 12 months. This may have implications for decisions regarding return to sport.

LEVEL OF EVIDENCE

III.

Patellar Size Variation at the Quadriceps Tendon-Bone Block Harvest Site: A Magnetic Resonance Imaging Study to Evaluate the Safe Zone for Harvesting a Sufficient Bone Block

BACKGROUND

Quadriceps tendon (QT) autografts with and without a bone block are the least studied and least used options for anterior cruciate ligament reconstruction surgery. In particular, there is a lack of literature describing patellar anatomy. Until now, guidelines for patellar bone block harvesting have been based solely on personal experience. In this study, we intended to derive recommendations from physical regularities and objective criteria.

PURPOSE

To determine the maximal, individual-related length and depth of the bone block that can be safely harvested and to provide guidelines to help surgeons make decisions on graft choice.

STUDY DESIGN

Descriptive laboratory study.

METHODS

The study group consisted of 50 male participants and 50 female participants (mean age, 29.4 ± 7.9 years) who underwent 3.0-T magnetic resonance imaging of their knee. Patellar height was determined at the center of the middle third of the QT insertion on the patella and the medial and lateral endpoints; the depth was measured at the midpoints of the respective heights.

RESULTS

The mean width of the QT and the mean thickness were 49.0 ± 7.6 and 7.3 ± 1.0 mm, respectively. The mean patellar thickness in reference to the medial endpoint, the center, and the lateral endpoint was 18.3 ± 2.4, 17.9 ± 2.3, and 15.1 ± 2.3 mm, respectively, whereas the mean patellar height was 35.1 ± 4.1, 36.7 ± 4.2, and 35.1 ± 3.9 mm. In general, the tendon and patellar dimensions were significantly larger in male participants than in female participants (P = .016).

CONCLUSION

Bone block harvesting, with its depth not exceeding 50% of the patellar thickness and its length accounting for <50% of the patellar height, poses the least risk for a patellar fracture when located medial to midline. If the bone block is excised from the medial half of the central area (the latter is defined by the middle third of the QT insertion), with the outer edge of the saw positioned at the medial border of the central area, a graft of 15 mm length, 10 mm width, and 8 mm depth can be safely harvested in all White male participants and almost all female participants taller than 165 cm, according to our findings.

CLINICAL RELEVANCE

This is the first study presenting recommendations for patellar bone block harvesting at the quadriceps tendon insertionbased on physical regularities and objective criteria and not on personal experience.

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

PURPOSE OF REVIEW

The purpose of this review is to provide an up-to-date summary on the most recent literature examining techniques and outcomes in anterior cruciate ligament (ACL) reconstruction using quadriceps tendon (QT) which will enable surgeons to make well informed evidence-based decisions when choosing a particular graft option and technique in ACL reconstruction.

RECENT FINDINGS

Several RCTs and systematic reviews have been published recently on this topic, and overall, there were no differences found between the QT, HT, and BPTB groups in patient-reported outcomes, stability testing, or graft re-rupture rates. In terms of strength testing, the QT group did have inferior knee extensor strength on isokinetic testing when compared to the HT group, whereas the HT group had inferior knee flexor strength compared to the QT group. No differences were found on strength testing between the QT and BPTB groups. Currently, two large RCTs, the Stability2 and SQuASH trials, are ongoing examining the effectiveness of the QT vs BPTB with or without LET and QT vs HT in the pediatric population which will help shed further light on the effectiveness of the QT as a graft choice in ACL reconstruction. The findings of this scoping review demonstrate that the QT is an excellent graft option in ACL reconstruction both in the primary and revision settings, among adult and pediatric populations. This review provides surgeons with further assurance when selecting QT autograft in ACL reconstruction.

Knee muscle strength after quadriceps tendon autograft anterior cruciate ligament reconstruction: systematic review and meta-analysis

PURPOSE

Restoration of knee muscle strength is associated with better outcomes following anterior cruciate ligament (ACL) reconstruction, but little is known about the outcome of strength following quadriceps tendon autograft (QT) ACL reconstruction in relation to other graft types. The aim of this review was to evaluate strength outcomes of the knee extensors and knee flexors following QT ACL reconstruction compared to (1) the non-reconstructed contralateral limb and (2) alternative ACL graft types.

METHODS

Four electronic databases were searched up until 21st February 2020. Summary meta-analyses were performed comparing knee strength outcomes following QT ACL reconstruction to the contralateral limb by way of limb symmetry index (LSI). Comparative meta-analyses were performed comparing QT ACL reconstruction to alternative ACL grafts for the two most frequently reported strength outcome measures which were peak knee extensor torque LSI, and peak knee flexor torque LSI at the following post-operative periods: 3, 5-8, 9-15, 24, 36-60 months.

RESULTS

In total, 18 studies met the inclusion criteria. Knee strength outcomes of 952 QT ACL reconstructions were included and compared to either the contralateral limb or 1 of 4 alternative ACL graft types; 245 hamstring tendon autograft (HT), 143 patellar tendon autograft (PT), 45 quadriceps tendon allograft, and 21 tibialis anterior allograft. Knee extensor strength LSI following QT ACL reconstruction did not reach 90% even at 24 months post-operatively. Conversely, knee flexor strength LSI following QT ACL reconstruction exceeded 90% at the 9-15 months post-operative period. Knee extensor strength at 5-8 months following QT ACL reconstruction appears similar to PT but weaker than HT ACL reconstruction. In addition, peak knee flexor LSI was significantly greater at 5-8 months in QT ACL reconstruction patients compared to HT patients.

CONCLUSION

The decision to utilize a QT graft for ACL reconstruction should include consideration of strength outcomes. Knee extensor strength recovery following QT ACL reconstruction appears not to be restored before 24 months.

LEVEL OF EVIDENCE

Level IV.

Revision Anterior Cruciate Ligament Reconstruction with the All-Soft Tissue Quadriceps Tendon Autograft Has Acceptable Early and Intermediate-Term Outcomes

PURPOSE

The purposes were to (1) examine early to intermediate-term clinical outcomes and complications of revision anterior cruciate ligament reconstruction (ACLR) using all-soft tissue quadriceps tendon (QT) autografts, and (2) compare quadriceps strength between patients who had hamstring versus patella tendon autografts in their previous reconstruction.

METHODS

One hundred patients (52 males/48 females; 22.6 ± 8.0 years) undergoing revision ACLR with all-soft tissue QT autografts were prospectively followed. All revision procedures were performed by a single surgeon, using a minimally invasive graft harvest technique and suspensory fixation. Subjective assessment of knee function was obtained before and after surgery with the International Knee Documentation Committee (IKDC) survey. Postoperative knee laxity and isokinetic quadriceps strength were collected at regular intervals. Strength was reported as limb symmetry index (LSI; surgical side divided by nonsurgical side). Complications including hematomas, postoperative loss of knee extension, and graft failures were recorded. To determine clinical significance (P ≤ .05), outcomes were compared using analysis of variance or paired samples t-tests.

RESULTS

The mean IKDC scores significantly improved (54.3 ± 13.0 vs 82.8 ± 13.8), with an average follow-up of 42.2 ± 21.2 months. There were no significant changes in knee laxity side-to-side differences: 6 weeks (1.2 ± 1.5 mm), 3 months (1.2 ± 1.8 mm), 6 months (1.4 ± 1.6 mm). Quadriceps LSIs significantly improved from 71.6% ± 19.3% at 6 months to 81.5% ± 19.3% at 12 months for 60°/s isokinetic testing and 76.6% ± 16.4% at 6 months to 83.9% ± 16.9% at 12 months for 180°/s testing. Graft harvest site hematomas developed in 2 patients, postoperative loss of knee extension in 4 patients, and graft failure in 11 patients. No significant differences in quadriceps or hamstrings LSIs were noted between patients with previous hamstring versus patella tendon autografts (P > .050).

CONCLUSION

Revision ACLR with all-soft tissue QT autografts has acceptable early and intermediate-term outcomes with reasonable complication rates (11/80 patients with follow-up). Secondary insult to the extensor mechanism via QT autograft harvest does not adversely affect strength after prior patellar tendon versus hamstring autograft.

LEVEL OF EVIDENCE

Level IV, cases series subgroup analysis.

Comparison of knee extensor strength after anterior cruciate ligament reconstruction using either quadriceps tendon or hamstring tendon autografts

PURPOSE

The aim was to assess the consequences of quadriceps tendon (QT) harvest on knee extensor strength after anterior cruciate ligament reconstruction (ACL-R) compared to hamstring tendon (HT) autograft. Secondary objectives were to evaluate flexor strength recovery and search for correlation between strength status and functional outcome.

METHODS

This a retrospective cohort of 44 patients who underwent ACL-R using either QT (25) or HT (19). Median age was 31.1 years. We assessed thigh muscle strength thanks to concentric iso kinetic evaluation (peak torque) at 60°.s^-1, 180°.s^-1, 240°.s^-1 and eccentric at 30°.s^-1, 7 months on average after surgery. Muscle strength values were compared to the uninjured leg in order to calculate a percentage of deficit as well as unilateral hamstring/quadriceps (H/Q) ratios. KOOS score was obtained at a mean follow-up of 18 months.

RESULTS

Extensor strength deficit (concentric 60°.s^-1) was one average 33.1% in the QT group and 28.2% in the HT group (p = 0.42). Difference of flexor strength deficit (concentric 60°.s^-1) was close to be significant with 5% and 12% of deficit in the QT and HT group, respectively (p = 0.1), and statistically significant for high angular velocity (14% versus 3% at 240°.s^-1, p = 0.04). H/Q ratios were comparable in both groups ranging from 0.62 to 0.78. Quadriceps muscle strength deficit was negatively correlated with the KOOS score (Pearson coefficient = -0.4; p = 0.005).

CONCLUSION

QT autograft harvest does not yield significant quadriceps muscle weakness after ACL-R, which appear to be a pejorative factor for functional outcome.

LEVEL OF EVIDENCE

IV, Retrospective study.

Patients with a quadriceps tendon shorter than 60 mm require a patellar bone plug autograft in anterior cruciate ligament reconstruction

PURPOSE

To assess the length and thickness of the quadriceps tendon (QT) and anterior cruciate ligament (ACL) to predict the required QT length for individual ACL reconstruction.

METHODS

Thirty patients (9 females, 21 males; mean age 24.5 years; mean height 169.3 cm) who underwent ACL reconstruction using the QT with a bone plug autograft were enrolled. The length and thickness of the QT on preoperative magnetic resonance imaging (MRI) were compared with those measured under direct visualization. The ACL length was measured on preoperative MRI and three-dimensional computed tomography after ACL reconstruction. The QT length on MRI was compared with the required graft length, and the factors related to an adequate QT length were assessed.

RESULTS

The mean QT length on MRI was 60.8 ± 1.3 mm and was significantly positively correlated with the QT length under direct visualization (P < 0.01). On MRI, the mean ACL length was 30.8 ± 1.2 mm and the mean QT thickness was 6.3 ± 0.2 mm. Although the mean QT was 0.1 mm longer than the mean required graft length, the QT on MRI was shorter than the required graft length in 37% of patients (11/30). Adequate QT length was related to a QT length of more than 60 mm, but not to age, sex, height, or ACL length.

CONCLUSION

Although preoperative MRI predicted the required QT length for ACL reconstruction, 37% of patients lacked an adequate QT length, and a QT shorter than 60 mm required the addition of patellar bone.

LEVEL OF EVIDENCE

III.

Anterior Cruciate Ligament Reconstruction Graft Preference Most Dependent on Patient Age: A Survey of United States Surgeons

PURPOSE

The purpose of this study was to define the anterior cruciate ligament (ACL) reconstruction (ACLR) graft preference of surgeons and to explore factors associated with their predilection.

METHODS

A 15-question survey regarding ACLR graft preference in various situations was completed by 514 American Orthopaedic Society for Sports Medicine and Arthroscopy Association of North America surgeons. Surgeon and practice demographics, along with various patient factors, were evaluated with bivariate and multivariable models for association with surgeon preference. Surgeons were also queried about their preference for their own ACLR. For surgeons who personally sustained an ACL, an additional 6 questions inquired about their experience.

RESULTS

Surgeons reported the 5 most important factors in patient graft choice, in order: patient age, graft failure in literature and practice, pivot sport, and patient preference. Autograft patellar and quadriceps tendon were strongly preferred for younger, pivoting athletes (P < .001), among those with fellowship training (47% vs 33%, P = .006), in academic practices (52% vs 44%, P = .003), and in more sports medicine-specific practices, with a higher number of ACLRs performed per year (P < .001). Northeast, Southeast, Midwest, and Southwest surgeons had lower hamstring autograft preference (P < .001). Non-fellowship-trained surgeons preferred hamstring autograft (P = .010). Allograft was preferred for older patients (P < .001). Nonsignificant predictors included highest level of athlete for whom an ACLR had been performed, level of athlete serving as team physician, and years in practice. No factors were associated with surgeon preference for their own ACLR despite deeming these factors important for patients. ACL tears were reported by 13% of respondents, with 86% stating it influenced their decision to enter orthopaedics.

CONCLUSIONS

Patient age was the most important factor in graft choice, with patellar and quadriceps tendon autograft the preferred graft for ACLR for younger, pivoting athletes. Fellowship training and practice demographics were also correlated with graft choice for patients.

CLINICAL RELEVANCE

Graft preference for ACLR varies among surgeons and is associated with surgeon experience and patient characteristics, including patient age, type of sport, and patient preference.

Physeal-Sparing Anterior Cruciate Ligament Reconstruction for Skeletally Immature Patients: All-Epiphyseal Technique Using Quadricep Tendon Autograft

The anterior cruciate ligament (ACL) is a major stabilizing structure of the knee and one of the most common injured structures. The true incidence of ACL injury in children and adolescents is unknown, but recent studies suggest increased ACL injury rates, especially in the sports-participating population. The mechanism of injury, clinical examination, and diagnosis of ACL injury in children is the same as in adults. The main concerns in the management of pediatric ACL injuries are the open physes and the eventual long-term consequences of the ACL deficient knee. The ideal treatment strategy of pediatric ACL injuries is still controversial, because there is still no universal consensus for techniques, graft choices, and postoperative rehabilitation. We present a case of a 12-year-old male patient who underwent ACL reconstruction using an all-inside, physeal-sparing technique with a quadriceps tendon autograft and discuss the current treatment strategies.

Posterior cruciate ligament reconstruction with peroneus longus tendon versus hamstring tendon: a comparison of functional outcome and donor site morbidity

PURPOSE

This study aimed to evaluate the differences in clinical outcome and donor site morbidity between the Peroneus Longus Tendon (PLT) and Hamstring Tendon (HT) in single-bundle Posterior Cruciate Ligament (PCL) reconstruction.

METHODS

Patients with an isolated PCL injury underwent single-bundle PCL reconstruction using consecutive sampling. Patients were allocated into two groups (PLT and HT) and prospectively observed. The tendon graft diameter was measured intraoperatively. Functional scores (IKDC, Lysholm, and modified Cincinnati scores) were recorded preoperatively and 2 years postoperatively. The thigh circumference and functional score according to the Foot and Ankle Disability Index (FADI) and American Orthopedic Foot and Ankle Society (AOFAS) were recorded to evaluate the morbidities in the ankle.

RESULTS

Fifty-five patients (hamstring n = 27, peroneus n = 28) met the inclusion criteria. The diameter of the PLT graft (8.2 ± 0.6 mm) was comparable to that of the HT graft (8.3 ± 0.5 mm). Both groups had excellent postoperative knee functional outcome scores. The mean AOFAS and FADI scores were excellent, with no difference in thigh circumference between the groups.

CONCLUSION

PLT is a good choice as a graft in PCL reconstruction at the 2-year follow-up, with minimal donor site morbidity.

LEVEL OF EVIDENCE

II.

Quadriceps tendon autograft is an effective alternative graft for posterior cruciate ligament reconstruction in isolated or multiligament injuries: a systematic review

IMPORTANCE

High-grade posterior cruciate ligament (PCL) tears can be a significant cause of patient morbidity and knee instability. The graft of choice for operative repair remains controversial, although recently there has been increased interest in quadriceps tendon (QT) as an autologous graft option.

OBJECTIVE

The purpose of this study was to perform a systematic review to assess reported clinical outcomes of PCL reconstructions using QT autografts.

EVIDENCE REVIEW

A comprehensive review of clinical studies was performed evaluating PCL reconstruction with QT autograft including a systematic search of PubMed, Scopus, Cochrane and Google Scholar databases, and reference lists of relevant papers. Clinical results, stability results, functional outcomes, range-of-motion outcomes, complications and morbidity, and the conclusions of each study were evaluated.

FINDINGS

Seven studies were included in the review of clinical results, including 145 subjects undergoing PCL reconstructions with QT autograft. All studies evaluated quadriceps tendon bone (QT-B) grafts. Among these seven studies, two included isolated PCL reconstruction while five included multiligamentous knee injury reconstruction. These studies suggest that QT-B autograft offers a viable graft option for primary PCL reconstruction with generally favourable patient-reported outcomes, knee stability and range of motion reported along with relatively low complication rates.

CONCLUSIONS AND RELEVANCE

Use of the QT-B autograft may be a reasonable graft option for PCL reconstruction. However, high-quality prospective studies are required to evaluate the long-term safety, efficacy and functional outcomes.

LEVEL OF EVIDENCE

Level IV (Systematic review of Level IV studies).

Implications for Early Postoperative Care After Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction: A Technical Note

The quadriceps tendon (QT) has become increasingly used by orthopaedic surgeons as an alternative autograft choice in anterior cruciate ligament reconstruction. As its use increases, athletic trainers and other rehabilitation clinicians will treat a greater number of patients with this autograft type. The recently developed, minimally invasive technique for harvest of the all-soft tissue autograft has many benefits, including versatility, decreased donor-site morbidity, and enhanced cosmesis. Early clinical trials revealed that the QT autograft resulted in decreased anterior knee pain and similar strength and functional outcomes to those of more common autograft types. From a rehabilitation perspective, many characteristics should be considered, such as the importance of early knee extension and quadriceps activation. Therefore, the purpose of this technical note is to expose athletic trainers to the QT autograft so that they may provide the best care for patients after anterior cruciate ligament reconstruction.

Strength deficits and flexion range of motion following primary anterior cruciate ligament reconstruction differ between quadriceps and hamstring autografts

OBJECTIVE

To determine if anterior cruciate ligament (ACL) reconstruction with a quadriceps tendon (QT) could achieve faster postoperative recovery compared with hamstring tendon (HT) ACL reconstruction.

METHODS

Thirty-seven QT patients were matched for gender, age and preinjury activity level with 74 HT patients. A 6-month postoperative assessment included standardised reported outcome measures: patient-reported outcome measures (PROMs) (International Knee Documentation Committee-subjective knee evaluation form, Knee injury and Osteoarthritis Outcome Score-knee related quality of life subscale, ACL-Return to Sport after Injury scale, Marx activity scale, anterior knee pain), range of motion (active, standing and passive), anterior knee laxity testing, hop tests (single and triple crossover hop for distance) and isokinetic strength testing of the knee extensors and flexors. T-tests or Mann Whitney U tests were used to compare data between groups.

RESULTS

There were no significant differences between the two groups for any of the PROMs. The HT group had reduced active and standing knee flexion range compared with the QT group (p<0.001). Isokinetic strength testing showed significant deficits in limb symmetry indices for both concentric hamstring peak torque at 60°/s (p<0.001) and 180°/s (p=0.01) in the HT group. There were significantly greater deficits in limb symmetry indices for concentric quadriceps peak torque at 60°/s (p<0.001) and 180°/s (p=0.001) in the QT group.

CONCLUSION

The QT graft does not appear to offer a more rapid recovery in terms of knee symptoms or function which could have allowed for faster progression to the dynamic phases of rehabilitation.

LEVEL OF EVIDENCE

Level III.

Open Full-Thickness Quadriceps Tendon Autograft Harvest With Repair for Anterior Cruciate Ligament Reconstruction

Historically, one of the most common graft choices for anterior cruciate ligament (ACL) reconstruction in the pediatric population has been the hamstring autograft. Although pediatric ACL reconstructions with a hamstring autograft have allowed a majority of children and adolescents to return to athletics, it has been reported that anywhere between 6% and 38% of these patients will go on to experience subsequent graft rupture. The quadriceps tendon autograft is an alternative to the hamstring tendon autograft that demonstrates superior preliminary outcomes, and we currently recommend it for skeletally immature patients undergoing primary and revision ACL reconstruction. This paper aims to describe our technique for an open full-thickness quadriceps tendon harvest with repair.

Quadriceps tendon anterior cruciate ligament reconstruction

Quadriceps tendon is a promising alternative graft option for anterior cruciate ligament (ACL) reconstruction, which can be harvested with or without a bone block as well as a full or partial thickness graft. Therefore, quadriceps tendon graft could be used in primary and revision ACL reconstruction based on the requirements (tunnel size, tunnel position, etc.). The all soft tissue, partial thickness quadriceps tendon graft in detail and pitfalls of the harvest are described in the present review. After quadriceps tendon harvest, especially in soccer players, who need a strong quadriceps to strike a ball with power, the postoperative rehabilitation may need to be adapted. LEVEL OF EVIDENCE: V.

All inside full thickness quadriceps tendon ACL reconstruction: Long term follow up results

Purpose

The aim of this study is to evaluate results of anterior cruciate ligament reconstruction (ACL) using an All-Inside Full Thickness Quadriceps Reconstruction technique at 5 years follow up.

Methods

This is a Retrospective cohort study of patients undergoing ACL reconstruction. Inclusion criteria for this report were isolated primary ACL reconstructions without chondral lesions (Grade III/IV Outerbridge), using autologous full-thickness quadriceps tendon (FQT) graft with bone block, with an “all-inside” technique. Functional scales of Lysholm, IKDC, Tegner and objective results of side to side difference (KT1000) were used for this evaluation. Additionally, complications and comorbidities were also analyzed.

Results

Two hundred and ninety-one ACL reconstructions were retrospectively reviewed at 5 years postoperatively; 268 (92.1%) were men and 23 (7.90%) women. Lysholm Score improved from 64 (SD = 6.09) to 91 (SD = 6.05) points average. IKDC showed 59.79%, excellent and 3.4% good results. Arthrometric analysis showed that 259 knees (89%) had a difference of less than 3 mm. Median pre-injury Tegner score was 9 (Range 4–10), while final median Tegner activity level at 5 years was 8 (Range 4–10). Among comorbidities, 5.15% of the patients presented anterior knee pain. No visualization difficulties or significant hematomas were found.

Conclusion

Use of all inside FQT for ACL reconstruction in a young, high demand sports population, present at 5 years, good to excellent results, functionally and objectively, with low rates of complications and comorbidities.

Femoral Interference Screw Fixation in ACL Reconstruction Using Bone-Patellar Tendon-Bone Grafts

» Anterior cruciate ligament (ACL) reconstruction is a commonly performed orthopaedic procedure with numerous reconstructive graft and fixation options. Interference screws have become one of the most commonly utilized methods of securing ACL grafts such as bone-patellar tendon-bone (BPTB) autografts. » The composition of interference screws has undergone substantial evolution over the past several decades, and numerous advantages and disadvantages are associated with each design. » The composition, geometry, and insertional torque of interference screws have important implications for screw biomechanics and may ultimately influence the strength, stability of graft fixation, and biologic healing in ACL reconstruction. » This article reviews the development and biomechanical properties of interference screws while examining outcomes, complications, and gaps in knowledge that are associated with the use of femoral interference screws during BPTB ACL reconstruction.

Quadriceps Tendon Autograft in Anterior Cruciate Ligament Reconstruction

Quadriceps tendon (QT) autograft in anterior cruciate ligament reconstruction has received increased attention, as more studies compare clinical outcomes between QT, bone-patellar tendon-bone (BPTB), and hamstring tendon (HT) autografts. Biomechanically, QT has similar properties to BPTB and to HT. QT has shown equivalent stability, patient-reported outcome measures, strength and graft failure rates, and decreased donor site morbidity compared with BPTB and HT. All three autografts have excellent clinical outcomes. Ultimately, anterior cruciate ligament graft selection should be a discussion between a physician and their patient while considering a patient's age, activity level, and occupation.