Minimally invasive harvest of a quadriceps tendon graft with or without a bone block

No Clinical Advantage of Harvesting a Patellar Bone Block Compared to All Soft Tissue Graft in Primary Quadriceps Tendon Anterior Cruciate Ligament Reconstruction

PURPOSE

To compare patient-reported outcomes measurements (PROMs) and subsequent surgical interventions in patients treated with anterior cruciate ligament reconstruction (ACLR) using either quadriceps tendon autograft with a patellar bone block (bQT) or soft tissue only (sQT).

METHODS

All ACLRs performed between 01.2010 and 03.2022 were prospectively followed for 24 months and retrospectively evaluated. All primary ACLRs with full 24 months of follow-up data, without any previous surgery or any additional ligamentous interventions, were matched for major ACL risk factors, including gender, age, Tegner activity level (TAL), pivoting sports, and concomitant injuries. PROMs (Lysholm score, Visual Analog Scale (VAS) for pain, and TAL) and subsequent surgical interventions were registered after 6, 12, and 24 months postoperative. Binary logistic regression was used to assess the influence of graft type, age, preinjury TAL, gender, pivoting sports and concomitant interventions on the need to undergo subsequent surgery.

RESULTS

After matching, 246 patients were included in the final analysis. Both groups did not differ regarding any preoperative patient demographics or intraoperative details. At final follow-up, no significant difference in mean Lysholm score (sQT: 90.8±10.6, bQT: 91.8±10.6, p= .46), median TAL (sQT: 6 [1-10], bQT: 6 [1-10], p= .53) and VAS for pain (sQT: 0.7±1.1, bQT: 0.7±1.2, p= .70) was reported between both groups. 70.3% (sQT-A: 70.7%, bQT: 69.9%, p= .89) of patients returned to or exceeded their preinjury activity level. In terms of revision ACLR, there was no statistically significant difference between bQT (3.3%) and sQT (4.1%). Similarly, no difference was observed in contralateral ACLR (bQT: 7.3% sQT: 11.4%). Regression analysis indicated that none of the studied factors, including the use of a patellar bone block, influenced subsequent surgery, revision ACLR, or contralateral ACLR.

CONCLUSION

Harvesting an additional patellar bone block in quadriceps tendon ACL reconstruction does not seem to impact postoperative patient-reported outcomes, ACL revision- or contralateral ACL reconstruction rates.

LEVEL OF EVIDENCE

Level 3 - Cohort Study.

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.

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.

Technique for Harvest of Superficial Quadriceps Tendon Autograft

The idea of using quadriceps tendon autograft (QT) anterior cruciate ligament reconstruction first came into being in the 1990s; it was, however, not widely recognized and has resurfaced only in recent times. Because sufficient technological supports have not been developed to enable an optimal artificial graft, autologous grafts are still the most dependable option. The major reason for choosing QT instead of hamstring or patellar tendon to get autologous grafts is that it seems to cause the fewest donor site problems. Two commonly applied ways of using the quadriceps are partial and full thickness; another option is superficial. Our technique for harvesting the superficial part of the QT, which starts proximal to the fused point of the 3 layers, is aimed at circumventing premature cutting of the graft.

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.

Current trends in graft choice for anterior cruciate ligament reconstruction - part I: anatomy, biomechanics, graft incorporation and fixation

Graft selection in anterior cruciate ligament (ACL) reconstruction is critical, as it remains one of the most easily adjustable factors affecting graft rupture and reoperation rates. Commonly used autografts, including hamstring tendon, quadriceps tendon and bone-patellar-tendon-bone, are reported to be biomechanically equivalent or superior compared to the native ACL. Despite this, such grafts are unable to perfectly replicate the complex anatomical and histological characteristics of the native ACL. While there remains inconclusive evidence as to the superiority of one autograft in terms of graft incorporation and maturity, allografts appear to demonstrate slower incorporation and maturity compared to autografts. Graft fixation also affects graft properties and subsequent outcomes, with each technique having unique advantages and disadvantages that should be carefully considered during graft selection.

Posterior Cruciate Ligament Reconstruction Using Flat Soft-Tissue Grafts

Isolated posterior cruciate ligament (PCL) ruptures are relatively rare, but they more commonly occur in multiligament knee injuries. To date, in isolated or combined injuries with grade III step-off, surgical treatment is recommended to restore joint stability and improve knee function. Several techniques for PCL reconstruction have been described. However, recent evidence has suggested that broad, flat soft-tissue grafts may more closely mimic the native PCL ribbonlike morphology in PCL reconstruction. Furthermore, a femoral rectangular bone tunnel may more accurately re-create the native PCL attachment, allowing grafts to simulate native PCL rotation during knee flexion and potentially improving biomechanics. Therefore, we have developed a PCL reconstruction technique using flat quadriceps or hamstring grafts. This technique can be performed using 2 types of surgical instruments that allow for the creation of a rectangular femoral bone tunnel.

Harvest of All-Soft Tissue Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction With or Without Closure of Resulting Defect Has No Effect on Patellar Height

Purpose

To evaluate the radiographic effect of quadriceps tendon harvest on patellar height and to determine whether closure of a quadriceps graft harvest defect resulted in a significant change in patellar height compared to nonclosure.

Methods

We conducted a retrospective review of prospectively enrolled patients. The institutional database was queried and all patients who underwent quadriceps autograft anterior cruciate ligament reconstruction between 2015 and March 2020 were included. Graft harvest length in millimeters and final graft diameter after preparation for implantation were obtained from the operative record and demographic data were obtained from the medical record. Radiographic analysis was performed of eligible patients using standard ratios of patellar height: Insall-Salvati (IS), Blackburn-Peele (BP), and Caton-Deschamps (CD). Measurements were performed using digital calipers on a digital imaging system by 2 postgraduate fellow surgeons. Preoperative and postoperative radiographs were performed at 0° according to a standard protocol. Postoperative radiographs were performed 6 weeks postoperatively in all cases. Preoperative patellar height ratios were compared with postoperative patellar height ratios for all patients using t-tests. Subanalysis was then performed to compare the effect of closure of with nonclosure on patellar height ratios using repeated-measures analysis of variance. Interrater reliability between the 2 reviewers was assessed using an intraclass correlation coefficient calculation.

Results

In total, 70 patients met final inclusion criteria. There were no statistically significant changes from pre- to postoperative values for either reviewer for IS (reviewer 1, P = .47; reviewer 2, P = .353), BP (reviewer 1, P = .98; reviewer 2, P = .907), or CD (reviewer 1, P = .107; reviewer, 2 P = .188). The closure and nonclosure groups were adequately powered and no statistically significant demographic differences between the closure and nonclosure groups was identified for sex (P = .066), age (P = .343), weight (P = .881), height (P = .42), laterality (P = 1), meniscal repair (P = .332), graft diameter (P = .068), or graft length (P = .183). According to the repeated measures analysis of variance, closure of the quadriceps defect had no significant impact on any of the knee ratios. However, reviewer identity had a significant influence on the CD ratio. Intraclass correlation coefficient analysis revealed excellent agreement between reviewers for the IS (0.982) and BP (0.954) ratios, but only moderate-to-good agreement for the CD (0.751) ratio.

Conclusions

Harvest of quadriceps tendon graft does not result in radiographic changes in patellar height. Furthermore, closure of the quadriceps defect does not appear to result in radiographic changes in patellar height.

Level of Evidence

III, retrospective comparative trial.

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

BACKGROUND

Autograft choice in anterior cruciate ligament reconstruction (ACLR) remains controversial, with increasing interest in the usage of quadriceps tendon (QT) autograft versus traditional hamstring tendon (HT) use. The current study undertakes an in-depth review and comparison of the clinical and functional outcomes of QT and HT autografts in ACLR.

HYPOTHESIS

The QT autograft is equivalent to the HT autograft and there will be little or no significant difference in the outcomes between these 2 autografts.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

The PUBMED, EMBASE, MEDLINE, and CENTRAL databases were systematically searched from their inception until November 2020. All observational studies comparing ACLR QT and HT autografts were assessed for their methodological quality. Patient outcomes were compared according to patient-reported outcome measures (International Knee Documentation Committee [IKDC], Cincinnati, Lysholm, Tegner, and visual analog scale [VAS] measures), knee extensor and flexor torque limb symmetry indices (LSIs), hamstring to quadriceps (H/Q) ratios, functional hop capacity, knee laxity, ipsilateral graft failure, and contralateral injury.

RESULTS

A total of 20 observational studies comprising 28,621 patients (QT = 2550; HT = 26,071) were included in the quantitative meta-analysis. In comparison with patients who received an HT autograft, those who received a QT autograft had similar postoperative Lysholm (mean difference [MD], 0.67; P = .630), IKDC (MD, 0.48; P = .480), VAS pain (MD, 0.04; P = .710), and Cincinnati (MD, -0.85; P = .660) scores; LSI for knee flexor strength (MD, 6.06; P = .120); H/Q ratio (MD, 3.22; P = .160); hop test LSI (MD, -1.62; P = .230); pivot-shift test grade 0 (odds ratio [OR], 0.80; P = .180); Lachman test grade 0 (OR, 2.38; P = .320), side-to-side laxity (MD, 0.09; P = .650); incidence of graft failure (OR, 1.07; P = .830) or contralateral knee injury (OR, 1.22; P = .610); and Tegner scores (MD, 0.11; P = .060). HT autografts were associated with a higher (better) side-to-side LSI for knee extensor strength (MD, -6.31; P = .0002).

CONCLUSION

In this meta-analysis, the use of the QT autograft was equivalent to the HT autograft in ACLR, with comparable graft failure and clinical and functional outcomes observed. However, HT autografts were associated with better LSI knee extensor strength.

Quadriceps tendon autograft for anterior cruciate ligament reconstruction: state of the art

The ideal graft for anterior cruciate ligament reconstruction (ACLR) continues to be debated. Although first described in 1984, use of the quadriceps tendon (QT) autograft has only recently gained popularity. The biomechanical properties of the QT autograft are favourable compared to bone-patellar tendon-bone (BPTB) and doubled hamstring (HS) grafts with a higher load to failure and a modulus of elasticity that more closely approximates the native anterior cruciate ligament (ACL). The QT graft can be harvested with or without a bone plug, as either a full thickness or a partial thickness graft, and even through minimally invasive techniques. The surgeon must be aware of potential harvest risks including patellar fracture or a graft that is of insufficient length. Numerous short-term studies have shown comparable results when compared to BPTB or hamstring HS autografts with similar graft failure rates, patient-reported outcomes. A major advantage of QT ACLR is reduced donor site morbidity compared to BPTB. However, some persistent quadriceps weakness after QT ACLR has also been reported. The current literature shows that use of the QT autograft for ACLR provides equivalent clinical results compared to other autografts with less donor site morbidity. However, future studies with longer follow-up and higher level of evidence are needed to identify specific populations where the QT may have additional advantage.

A Minimally Invasive and Simple Technique of Superficial Quadriceps Tendon Graft Harvesting

Quadriceps tendon (QT) graft is a versatile graft for anterior and posterior cruciate ligament reconstruction. Advantages of quadriceps tendon autograft are the superior quality of graft, customization of graft size, reduced anterior knee pain, reduced risk of neurovascular injury, reduced incidence of arthrofibrosis compared to BPTB graft, preservation of ACL agonists, i.e., hamstrings, implantation of thicker graft and better patella mobility. Considering its advantages over other available autografts, its popularity is now increasing among surgeons. Conventionally, quadriceps tendon graft is harvested by an open technique, which produces an ugly scar and delays rehabilitation. In this article, we describe a minimally invasive technique of quadriceps tendon graft harvesting with a 2-2.5-cm vertical skin incision. Our technique does not require any specialized instrumentation, unlike other reported minimally invasive QT graft harvesting techniques, as we harvest the graft with a close tendon stripper.

Prediction of individual graft for anterior cruciate ligament reconstruction using anthropometric data

INTRODUCTION

Multiple options for individual anterior cruciate ligament (ACL) reconstruction exist; still, there are no guidelines for the preoperative preparation. The aim of this study was to assess the correlation between patients' anthropometric data (height, weight, and age) and measurements of potential tendons (quadriceps-, patella, hamstrings tendon) for an anterior cruciate ligament reconstruction.

MATERIAL AND METHODS

MR images of 102 patients have been analyzed. Measurements of the ACL were performed with respect to its length and angle. The diameter and length as well as width of the quadriceps and patella tendon, the cross-sectional area (CSA) and diameter of the hamstring tendons have been assessed. Patients' height, weight, BMI, sex and age have been recorded. The correlations of these measurements with the patients' anthropometric data have been calculated. Inter-rater and intra-rater reliability based on intra-class correlation (ICC) was evaluated.

RESULTS

The mean lengths of the ACL were 29.8 ± 3.5 mm, tibial insertion sites 15.8 ± 2.5 mm and femoral insertion sites 15.2 ± 3.0 mm. Thickness of the quadriceps tendons was 4.7 ± 1.1 mm and patella tendon 3.2 ± 0.7 mm. The patients' height showed significant positive correlations with the CSA of the hamstring tendon measurements, the length of the ACL, and the insertion sites of the ACL. Patients' weight showed significant positive correlations with patella tendon thickness, the CSA of the hamstring tendons, the length of the ACL, and the tibial and femoral insertion sites. Patients' age showed a significant positive correlation with patella tendon thickness. The ICCs for intra- and inter-rater reliability were 0.98 (95% CI 0.95-0.99, p < 0.001) and 0.94 (95% CI 0.88-0.99, p < 0.001).

CONCLUSION

Anthropometric data with respect to height, weight, and sex can help to predict the dimension of tendons for ACL reconstruction and do correlate with ACL tendon. Patients at risk for small graft dimensions and failure are younger than 20 years and physically active. MRIs of patients at risk for small graft dimensions should be analyzed on tendon length and cross section areas preoperatively to determine the appropriate tendon harvest and fixation technique.

Minimally Invasive Anterior Cruciate Ligament With Quadriceps Tendon Graft: A Proximal-to-Distal Harvest Technique

Recent systematic reviews have shown anterior cruciate ligament reconstruction using quadriceps tendon (QT) grafts to have superior clinical outcomes compared with traditional bone-patella tendon-bone and hamstring tendons grafts. Using minimally invasive techniques to harvest the QT graft can reduce postoperative pain and intraoperative surgical time. This technique is usually performed with a distal-to-proximal approach but often has issues of inadvertently harvesting a graft short of the desired length or causing a hematoma. As an alternative, we introduce a minimally invasive approach with a proximal-to-distal harvest technique that results in better visualization of tissue planes, more consistent graft sizes, lower risk of inadvertent arthrotomy, and reduced risk of hematoma. The minimally invasive QT graft harvest with a proximal-to-distal approach can offer unique advantages over the current standard distal-to-proximal approach.

Quadriceps tendon autograft for primary anterior cruciate ligament reconstruction show comparable clinical, functional, and patient-reported outcome measures, but lower donor-site morbidity compared with hamstring tendon autograft: A matched-pairs study with a mean follow-up of 6.5 ​years

OBJECTIVES

To compare clinical and functional outcomes of patients after primary anterior cruciate ligament reconstruction (ACLR) using quadriceps tendon- (QT-A) and hamstring tendon (HT-A) autograft with a minimum follow-up (FU) of 5 years.

METHODS

Between 2010 and 2014, all patients undergoing ACLR were recorded in a prospectively administered database. All patients with primary, isolated QT-A ACLR and without any concomitant injuries or high grade of osteoarthritis were extracted from the database and matched to patients treated with HT-A. Re-rupture rates, anterior-posterior (ap) knee laxity, single-leg hop test (SLHT) performance, distal thigh circumference (DTC) and patient-reported outcome measures (PROMs) were recorded. Between group comparisons were performed using chi-square-, independent-samples T- or Mann-Whitney-U tests.

RESULTS

45 QT-A patients were matched to 45 HT-A patients (n ​= ​90). The mean FU was 78.9 ​± ​13.6 months. 18 patients (20.0%/QT-A: N ​= ​8, 17.8%; HT-A: n ​= ​10, 22.2%; p ​= ​.60) sustained a graft rupture and 17 subjects (18.9%/QT-A: n ​= ​9, 20.0%; HT-A: n ​= ​8, 17.8%; p ​= ​.79) suffered a contralateral ACL injury. In high active patients (Tegner activity level ≥ 7) rerupture rates increased to 37.5% (HT-A) and 22.2% (QT-A; p ​= ​.32), respectively. Patients with graft failure did not differ between both groups in terms of mean age at surgery (QT-A: 26.5 ​± ​11.6 years, HT-A: 23.3 ​± ​9.5 years, p ​= ​.63) or graft thickness (mean graft square area: QT-A: 43.6 ​± ​4.7 mm², HT-A: 48.1 ​± ​7.9 mm², p ​= ​.27). No statistical between-group differences were found in ap knee laxity side-to-side (SSD) measurements (QT-A: 1.9 ​± ​1.2 ​mm, HT-A: 2.1 ​± ​1.5 ​mm; p ​= ​.60), subjective IKDC- (QT-A: 93.8 ​± ​6.8, HT-A: 91.2 ​± ​7.8, p ​= ​.17), Lysholm- (QT-A 91.9 ​± ​7.2, HT-A: 91.5 ​± ​9.7, p ​= ​.75) or any of the five subscales of the KOOS score (all p ​> ​.05). Furthermore, Tegner activity level (QT-A: 6(1.5), HT-A: 6(2), p ​= ​.62), VAS for pain (QT-A: 0.5 ​± ​0.9, HT-A: 0.6 ​± ​1.0, p ​= ​.64), Shelbourne-Trumper score (QT-A: 96.5 ​± ​5.6, HT-A: 95.2 ​± ​8.2, p ​= ​.50), Patient and Observer Scar -Assessment scale (POSAS) (QT-A: 9.4 ​± ​3.2, HT-A: 10.7 ​± ​4.9, p ​= ​.24), SSD-DTC (QT-A: 0.5 ​± ​0.5, HT.- A: 0.5 ​± ​0.6, p ​= ​.97), return to sports rates (QT-A: 82.1%, HT-A: 86.7%) and SLHT (QT -A: 95.9 ​± ​3.8%, HT-A: 93.7 ​± ​7.0%) did not differ between groups. Donor-site morbidity (HT-A n ​= ​14, 46.7%; QT-A n ​= ​3, 11.5%; p ​= ​.008) was statistically significantly lower in the QT-A group. Five patients (11.1%) of the HT-group and three patients (6.7%) in the QT-group required revision surgery (p ​= ​.29).

CONCLUSION

Patient-reported outcome measures, knee laxity, functional testing results and re-rupture rates are similar between patients treated with QT- and HT- autografts. However, patients with QT-autograft have a smaller tibial postoperative scar length and lower postoperative donor-site morbidity. There is a tendency towards higher graft rupture rates in highly active patients treated with HT autograft.

LEVEL OF EVIDENCE

II.

Estimating the adequacy of the free quadriceps tendon autograft length using anthropometric measures in anterior cruciate ligament reconstruction

OBJECTIVE

This prospective study aimed to predict the adequacy of free quadriceps tendon (QT) autograft length using simple anthropometric measures.

MATERIALS AND METHODS

One hundred and eighty-four consecutive patients who underwent knee high-resolution MRI were enrolled in this study. The QT and native anterior cruciate ligament (ACL) length were measured using the oblique sagittal section. The adequate free QT length was calculated using the native ACL length and 30 mm for femoral and tibial tunnels in each patient. A QT shorter than the calculated length was considered inadequate. Age, sex, height, weight, body mass index, thigh circumference, and activity score were used to predict the adequacy of QT length with regression analysis.

RESULTS

There were 92 men and 92 women with a mean age of 34.1 ± 8.0 years (range 18-45). The mean QT and ACL lengths were 69.0 ± 8.8 mm (range 48.1-90.3 mm) and 35.6 ± 2.5 mm (range 29.2-42.6 mm), respectively. The QT and the ACL lengths were longer in men (p < 0.001 for both). Twenty-three men and 39 women (total: 62, 33.7%) had inadequate QT length for a free QT autograft, and 6 patients (3 males, 3 females, 3.3%) had inadequate QT length with the bone block technique. There was a weak positive correlation between QT length and height (p < 0.001), weight (p < 0.001), and activity score (p = 0.007). Height was the only independent variable that predicted the QT length adequacy (r² = 0.051, p = 0.009) but ROC analysis showed that height did not have an ability to detect a subject with an inadequate QT length (AUC: 0.384, 95% CI 0.300-0.468).

CONCLUSIONS

Free QT autografts may be inadequate in one-third of the patients, while a QT autograft with a bone block is almost always sufficient. Inadequate free QT autograft is more common in women. Although QT length correlated with height, it cannot be used as an accurate diagnostic tool to identify patients with an inadequate QT autograft. Preoperative measurement of the ACL and QT lengths by MRI might be beneficial to decide whether QT is usable, especially when harvesting without a bone block.

LEVEL OF EVIDENCE

Level II, diagnostic, prospective cohort study.

Full thickness quadriceps tendon grafts with bone had similar material properties to bone-patellar tendon-bone and a four-strand semitendinosus grafts: a biomechanical study

PURPOSE

Despite increasing interest in utilizing quadriceps tendon (QT) grafts in anterior cruciate ligament reconstruction (ACLR), data on the optimal quadriceps graft thickness are limited. The purpose of this study was to characterize the mechanical properties for the quadriceps tendon, comparing full-thickness (FT) QT grafts with and without bone to a partial-thickness (PT) QT graft, and comparing the three QT grafts to four-stranded semitendinosus (4-SST) and bone-patellar tendon-bone (BTB) grafts and one experimental graft, the two-stranded rectus femoris (RF).

METHODS

Forty-eight (n = 48) young cadaveric grafts (mean age 32 ± 6 years) were utilized for testing with N = 8 specimens in each of the following groups; (1) FT QT with bone, (2) FT QT without bone, (3) PT QT without bone, (4) BTB, (5) RF, and (6) 4-SST. Each specimen was harvested and rigidly fixed in custom clamps to a dynamic tensile testing machine for biomechanical evaluation. Graft ultimate load and stiffness were recorded. Independent groups one-factor ANOVAs and Tukey's pairwise comparisons were performed for statistical analyses.

RESULTS

FT QT with bone and 4-SST grafts demonstrated similar ultimate loads to BTB grafts (both n.s), whereas PT QT demonstrate statistically significantly lower ultimate loads to BTB grafts (n.s) and 4-SST grafts (n.s). Furthermore, no statistically significant differences were observed between the ultimate loads of FT QT vs. PT QT grafts without bone (n.s) or between FT QT with vs. without bone (n.s). FT QT grafts with bone did not demonstrate statistically significantly greater ultimate loads than PT QT grafts without bone (n.s). The RF graft demonstrated statistically significantly lower ultimate loads to BTB grafts (p < 0.005) and 4-SST grafts (p < 0.014).

CONCLUSIONS

Full thickness QT grafts with bone had similar material properties to BTB and a 4-SST grafts, while Partial thickness QT graft without bone had significantly lower material properties than BTB and 4-SST, in a biomechanical setting.

Clinical Outcomes of Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Autograft Versus Hamstring Tendons Autograft: A Retrospective Analysis

AIM

 The purpose of this retrospective study was to examine the clinical outcomes of anatomic single-bundle anterior cruciate ligament (ACL) reconstruction using a free quadriceps (QUADRI) tendon or a quadrupled hamstring (HAM) autograft.

MATERIAL AND METHOD

The retrospective analysis (Level III, Therapeutic Study) included consecutive patients who underwent ACL reconstruction between April 2017 and April 2020 using either a free quadriceps tendon autograft or a hamstring tendon autograft. All patients underwent ACL reconstruction to treat isolated ACL injuries. The Tegner-Lysholm knee scoring system and the modified Cincinnati knee score were used for evaluation before surgery, and at six weeks, six months, and one-year follow-up time.

RESULTS

 In the present study, 35 people underwent quadriceps (QUADRI) grafts and 35 underwent hamstring (HAM) grafts. The demographic data for the groups were extremely comparable. The mean follow-up length for the HAM group was 11.96±0.28 months, while the QUADRI group had a mean follow-up period of 11.25±0.43 months. No significant variations in the Cincinnati score were observed between the two groups during any of the treatment's follow-up periods. Similarly, the Tegner Lysholm Score revealed no statistically significant differences between clinical outcomes in the HAM and QUADRI groups at all follow-up visits, except for the sixth week.

CONCLUSION

 Clinical outcomes are comparable in terms of stability and subjective assessments following ACL reconstruction using a free quadriceps or hamstring tendon autograft.

Graft Failure, Revision ACLR, and Reoperation Rates After ACLR With Quadriceps Tendon Versus Hamstring Tendon Autografts: A Registry Study With Review of 475 Patients

BACKGROUND

It has been indicated that anterior cruciate ligament reconstruction (ACLR) with a quadriceps tendon (QT) graft has a higher risk of revision compared with ACLR performed with a hamstring tendon (HT) graft.

PURPOSE/HYPOTHESIS

To investigate whether ACLR with QT graft had a higher risk of graft failure, revision ACLR, or reoperation compared with HT graft in a high-volume center. We hypothesized that there would be no between-group differences.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This was a registry study with review of medical records. Our study cohort consisted of patients who underwent primary ACLR with either QT or HT graft performed at Copenhagen University Hospital Hvidovre between January 2015 and December 2018. The cohort was identified from the Danish Knee Ligament Reconstruction Registry and linked to the Danish National Patient Registry to identify all hospital contacts after ACLR. The outcome variables were graft failure (rerupture or >3-mm side-to-side difference in anteroposterior [AP] laxity), revision ACLR, reoperation due to cyclops lesion, reoperation due to meniscal injury, and reoperation due to any reason. AP laxity and pivot shift were assessed at 1 year. Kaplan-Meier estimates were used to evaluate the rates of events at 2 years, and comparison was performed with Cox regression analysis.

RESULTS

A total of 475 patients (252 HT, 223 QT) were included. The rate of graft failure at 2 years was 9.4% for the QT group and 11.1% for the HT group (P = .46). For the QT and HT groups, respectively, the rate of revision ACLR was 2.3% and 1.6% (P = .60), the rate of reoperation due to cyclops lesion was 5.0% and 2.4% (P = .13), and the rate of reoperation due to meniscal injury was 4.3% and 7.1% (P = .16). The rate of reoperation due to any reason was 20.5% and 23.6% (P = .37). At 1-year follow-up, AP laxity was 1.4 mm for QT and 1.5 mm for HT (P = .51), and the proportion of patients with a positive pivot shift was 29-30% for both groups.

CONCLUSION

QT and HT grafts yielded similar rates of graft failure, revision ACLR, and reoperation at 2 years of follow-up after ACLR. Graft failure was found in 9% to 11% of patients. Patients with QT ACLR showed a non-statistically significant trend of higher risk for reoperation due to cyclops lesion, and those with HT showed a non-statistically significant trend of higher risk for reoperation due to meniscal injury.

Low surgical routine increases revision rates after quadriceps tendon autograft for anterior cruciate ligament reconstruction: results from the Danish Knee Ligament Reconstruction Registry

PURPOSE

Recent registry data have demonstrated a higher revision rate of quadriceps tendon (QT) graft compared with hamstring tendon (HT) and patellar tendon (PT) grafts. Clinic routines could be an important factor for revision outcomes. The purpose of this study is to use the Danish Knee Ligament Reconstruction Registry (DKRR) to compare revision rates in patients who have undergone ACLR with QT, HT and PT grafts related to individual clinic surgical routine.

METHODS

Data on primary ACLRs entered in the DKRR from 2012 through 2019 were analysed since QT graft usage started in 2012. Revision rates for QT, HT and PT grafts were compared according to clinic activity (0-100 and > 100 procedures). Revision rates for the three autograft cohorts are presented, as well as adjusted revision hazard rates. Instrumented knee stability and pivot-shift tests were performed at a one-year follow-up.

RESULT

QT revision rate (6.4%) for low-activity clinics was higher than for high-activity clinics (2.9%) (p = 0.003). The adjusted revision hazard ratio for low-activity clinics was 2.3 (p = 0.01). QT autograft was associated with statistically significant, increased side-to-side laxity at follow-up (1.4 mm) compared with HT and PT autografts (1.0 mm) (p < 0.01), as well as an increased positive pivot-shift rate.

CONCLUSION

QT autografts for ACLR were associated with higher revision rates in clinics with lower than 100 procedures performed from 2012 to 2019. QT graft usage is not associated with a high revision rate when routinely performed. Learning curve is an important factor when introducing QT ACLR.

LEVEL OF EVIDENCE

Level III.

Evolution in ACL Autograft Harvesting Techniques: Transition to Minimally Invasive Autograft Harvesting

Surgical techniques for anterior cruciate ligament (ACL) reconstruction continue to evolve. Harvesting techniques for commonly used ACL autografts such as bone patellar tendon bone, hamstring, and quadriceps tendon have similarly continued to progress. Traditional larger incisions for graft harvesting that were described in the 1980s have given way to smaller or more minimally invasive techniques. Advantages of these techniques are primarily anatomy based and include the following: decreased nerve complaints such as hypoesthesia or dysesthesia, improved cosmesis, decreased surgical site pain or morbidity, and, in the case of hamstring harvesting, easier tendon identification. The current literature supports reproducible minimally invasive or modified graft harvesting techniques for bone patellar tendon bone, hamstring, and quadriceps tendon autografts. Specialized instrumentation is available to simplify the harvesting process. Each of these techniques is described in detail outlining surgical steps, technical considerations, and precautions. Knowledge and review of these techniques provides the surgeon with greater flexibility and options when choosing and harvesting autograft tissue for ACL reconstruction.

Lower donor-site morbidity using QT autografts for ACL reconstruction

PURPOSE

Comparing scar cosmesis and regional hypoesthesia at the incision site between quadriceps tendon (QT), bone-patellar tendon-bone (BPTB), and hamstring tendon (HT) for anterior cruciate ligament (ACL) reconstruction.

METHODS

Ninety patients undergoing ACL reconstruction with QT, HT or BPTB were evaluated at 1-year post-op. Scar cosmesis was assessed using the patient and observer scar assessment scale (POSAS) and length of the incision. Sensory outcome was analyzed by calculating the area of hypoesthesia around the scar. The classical ACL reconstruction functional follow-up was measured using the Lysholm score and KOOS.

RESULTS

Concerning QT versus BPTB group, QT patients have a significantly lower mean POSAS (24.8 ± 6.3 vs. 39.6 ± 5.8; p < 0.0001), shorter mean incision (2.8 ± 0.4 cm vs. 6.4 ± 1.3 cm; p < 0.0001), lower extent of hypoesthesia (8.7 ± 5.1 cm² vs. 88.2 ± 57 cm²; p < 0.0001), and better Lysholm score (90.1 ± 10.1 vs. 82.6 ± 13.5; n.s.). No significant difference was seen in KOOS (90.7 ± 7.2 vs. 88.4 ± 7.0; n.s.). Concerning QT versus HT group, no significant difference was found regarding mean POSAS score (24.8 ± 6.3 vs. 31.8 ± 6.2; n.s.), mean length of the incision (2.8 ± 0.4 cm vs. 2.5 ± 0.6 cm; n.s.), KOOS (90.7 ± 7.2 vs. 89.8 ± 8.2; n.s.) and mean Lysholm score (90.1 ± 10.1 vs. 87.8 ± 0.6; n.s.). The mean measured area of hypoesthesia was significantly higher in the HT group (70.3 ± 77.1 cm² vs. 8.7 ± 5.1 cm²; p < 0.0001).

CONCLUSION

Quadriceps tendon harvesting technique has the safest incision by causing less sensory loss compared to BPTB and HT. It also has the advantage of a short incision with more cosmetic scar compared to BPTB, with no difference compared to HT. However, no significant difference in terms of functional outcome was shown between the three autografts. These findings provide surgeons evidence about their clinical practice and help with graft choice decisions.

LEVEL OF EVIDENCE

III.

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.

Anterior Cruciate Ligament Reconstructions With Quadriceps Tendon Autograft Result in Lower Graft Rupture Rates but Similar Patient-Reported Outcomes as Compared With Hamstring Tendon Autograft: A Comparison of 875 Patients

BACKGROUND

Graft rupture is a devastating outcome after anterior cruciate ligament (ACL) reconstruction (ACLR). Little is known about graft rupture rates as well as clinical and functional outcomes after ACLR with quadriceps tendon (QT) autografts.

PURPOSE

To compare QT with hamstring tendon (HT) autografts in terms of the rates of graft and contralateral ACL rupture as well as patient-reported outcome measures.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All primary ACLRs performed between 2010 and 2016 were followed prospectively for 24 months through the recording of graft ruptures and contralateral ACL injuries as well as patient-administered questionnaires.

RESULTS

A total of 875 patients were included in the study. Three factors-graft type, age group, and activity level-had a significant value in predicting the need for revision surgery. The odds of revision surgery were 5.5 times greater in children younger than 15 years than in adults older than 45 years, 3.6 times greater in patients with high activity levels than low activity levels, and 2.7 times greater in patients receiving an HT autograft as compared with a QT autograft. A significantly higher rate of ipsilateral graft ruptures versus contralateral ACL injuries was observed in the HT group (4.9% vs 2.3%; odds ratio, 2.1; P = .01) but not in the QT group (2.8% vs 2.3%). The difference in the ratios of graft and contralateral ACL ruptures was even more pronounced in highly active patients treated with HT autografts (11.1% vs 4.2%; odds ratio, 2.6; P = .01) as compared with QT autografts (5.0% vs 2.8%; P = .48). Two-year measures of Lysholm scores (mean ± SD: QT, 86.0 ± 22.3; HT, 89.4 ± 16.4) and Tegner activity scores (QT, 6.1 ± 2.0; HT, 5.7 ± 1.9) as well as visual analog scale pain (QT, 0.8 ± 1.3; HT, 0.7 ± 1.1) did not differ between grafts.

CONCLUSION

Graft choice does not influence clinical and functional outcomes 2 years after ACLR. However, 3 factors-graft type, age group, and activity level-have a significant value in predicting the need for revision surgery. Patients treated with HT autografts have a significantly higher, activity-dependent risk of revision surgery and experience more ipsilateral graft ruptures than subsequent contralateral ACL injuries when compared with patients treated with QT autografts. Young age and high activity level are significant predictors for ACL revision surgery.

Quadriceps tendon autograft for anterior cruciate ligament reconstruction is associated with high revision rates: results from the Danish Knee Ligament Registry

PURPOSE

The quadriceps tendon (QT) has recently gained interest as an anterior cruciate ligament reconstruction (ACLR) autograft. There is a paucity of data from large cohort studies on failures and revision rates after ACLR using the QT graft. The purpose of the present study is to use the Danish Knee Ligament Reconstruction Registry (DKRR) to compare revision rates, objective knee stability and subjective clinical outcomes in patients who have undergone ACLR with QT, hamstring tendon (HT), and patellar tendon (PT) as a graft for ACLR. It was hypothesized that QT autografts would result in similar objective knee stability and revision rates as HT and PT autografts.

METHODS

Data on primary ACLRs in the DKRR from 2005 through 2017 were analyzed. Knee injury and Osteoarthritis Outcome Scores (KOOS), Tegner activity scale scores, sagittal knee laxity, pivot-shift tests at 1-year follow-up and revision rates at 2-year follow-up were compared for the three autograft cohorts.

RESULTS

A total of 531 QT, 14,213 HT and 1835 PT ACLR were registered in the DKLR between 2005 and 2017. QT autograft was associated with statistically significant increased laxity (1.8 mm) compared to HT autograft (1.5 mm) (p < 0.001) and more positive pivot shift. There was a significant higher revision rate for QT (4.7%), compared to PT (1.5%) and HT (2.3%) autografts at 2-year follow-up (p < 0.002).

CONCLUSION

Quadriceps tendon autografts for ACLR was associated with higher revision rates than HT and PT grafts. QT graft was also associated with small increased objective knee laxity and more positive pivot shift than HT and PT grafts.

LEVEL OF EVIDENCE

III.

Anatomical study of quadriceps tendon for anterior cruciate ligament reconstruction

Background

The quadriceps tendon is a promising alternative graft choice for anterior cruciate ligament (ACL) reconstruction. Morphology of the graft directly affects the biomechanical properties. However, a few studies are evaluating the anatomical structures of quadriceps tendon as a graft in Asian population.

Objective

To define the anatomical structures of quadriceps tendon as a graft for ACL reconstruction.

Methods

Forty-nine quadriceps tendons were dissected and analyzed. Measurements were also done including length, width, and thickness.

Results

The maximum length of superficial quadriceps tendon was 63.2 ± 12.5 mm (range 37.6–83.4). The maximum length of tendon at the deepest part was 57.2 ± 11.5 (range 30.9–83.4). The maximum length of quadriceps tendon was located at 61.4% ± 13% (range 31.8–83.6) from medial edge of the patella insertion (approximately 5 mm lateral from the center of quadriceps tendon insertion). The width of quadriceps tendon at patella insertion was 42.4 ± 3.8 mm (range 33.8–50.5). The thickness of quadriceps tendon at its maximum length on patella insertion was 6.9 ± 2.0 mm (range 1.5–9.5). Positive correlation between the height of cadaver and the maximum length of quadriceps tendon was noted.

Conclusions

The maximum length of quadriceps tendon was located 5 mm lateral from the center of quadriceps tendon insertion. Thus, we recommend marking midline of the quadriceps tendon insertion as a medial border of the harvested graft to get maximum length of the graft. Graft length measurement using superficial anatomy should be cautioned because graft shortening might occur.

Pseudaneurysm of the superolateral genicular artery following an anterior cruciate ligament reconstruction

INTRODUCTION

Arthroscopic procedures are a safe way nowadays to do anterior cruciate ligament reconstruction. Rare complications involve injuries to popliteal vessels or one of its branches.

PRESENTATION OF CASE

We present a case of a young patient who undergone an anterior cruciate ligament reconstruction. This procedure was associated with a meniscal suture. The follow-up was marked by pseudoaneurysm of the supero-lateral genicular artery.

DISCUSSION

This is the first time a pseudoaneurysm of this branch is described in the literature as we discovered it. The treatment by an ultrasonography-guided embolization with thrombin was proceeded and suceeded.

CONCLUSION

We stress the fact with new arthroscopic procedures and techniques, new complications can occur, and we should be attentive to them and new symptoms consequently, as a painless mass on the lateral side of the knee, to ensure a fast and optimal treatment.

Anterior Cruciate Ligament Reconstruction Using a Ribbon-Like Graft With a C-Shaped Tibial Bone Tunnel

According to recent anatomic studies, the anterior cruciate ligament (ACL) appears to be a flat, "ribbon-like" structure, with a thin, oval-shaped insertion on the femur and a C-shaped tibial insertion. According to this anatomy, we describe an ACL-reconstruction technique that aims to approximate this natural anatomy. The basic principle of this technique is not to use conventional round tunnels but create tunnel shapes that resemble more closely the original ACL insertion sites. Using either a rectangular quadriceps tendon graft or a "flat" hamstring graft may not only provide a biomechanical advantage with increased rotational stability but also improve bone-tendon healing due to increased bone-tendon contact and decreased diffusion length. Creating a C-shaped tibial tunnel also avoids laceration of the anterior horn of the lateral meniscus, which is frequently harmed during conventional tibial tunnel drilling.

Predicting adequacy of free quadriceps tendon autograft, for primary and revision ACL reconstruction, from patients' physical parameters

PURPOSE

Free quadriceps tendon autograft (QTA) has gained popularity for both primary and revision ACL reconstruction. The aim of this study is to measure the dimensions of quadriceps tendon and determine its correlation with patient's height, weight and BMI. This is to provide a guide for patients and surgeons in predicting the suitability of QTA for ACL reconstructions.

METHODS

A cross-sectional study in which the length and thickness of the quadriceps tendon was measured in 51 Caucasian patients who underwent primary total knee arthroplasty. Exclusion criteria include non-Caucasians and previous tendon pathology. Patients were selected from routine elective total knee arthroplasty list. Tendon length is taken from musculotendinous junction to its insertion. Thickness was measured at midpoint and at distal insertion. Patients' height, weight and BMI were recorded. The correlation between patient physical parameters and tendon dimensions were determined.

RESULTS

Subjects' median age was 65 years (range 44-87), with 34 females and 17 males. Median length of the tendon was 9 mm (range 70-110), and median insertional thickness was 9 mm (7-10 mm). Median thickness at midpoint was 7 mm (range 4-10 mm). There was moderately positive correlation between subjects' height and tendon length (correlation coefficient 0.50), and also between weight and tendon length (correlation coefficient 0.47). There was no significant correlation between subjects' BMI and the tendon length. There was also no significant correlation between tendon thickness and subject's physical parameters.

CONCLUSION

This study has shown that most patients could provide adequate QTA for ACL reconstruction. It also points to the fact that no investigation is required to predict the adequacy of QTA. Though further studies with larger sample size are required to confirm this, clinician can rely on analysing patients' physical parameter in predicting the adequacy of QTA for ACL reconstruction.

LEVEL OF EVIDENCE

II.

Return to Sports after Anterior Cruciate Ligament Injury: a Matched-Pair Analysis of Repair with Internal Brace and Reconstruction Using Hamstring or Quadriceps Tendons

PURPOSE

 The purpose of this study was to evaluate sports activity before anterior cruciate ligament (ACL) injury and after surgical treatment of ACL rupture comparing ACL repair with an Internal Brace to ACL reconstruction using either a hamstring (HT) or quadriceps tendon (QT) autograft.

METHODS

 Between 12/2015 and 10/2016, we recruited 69 patients with a mean age of 33.4 years for a matched-pair analysis. Twenty-four patients who underwent Internal Brace reconstruction were matched according to age (± 5 years), gender, Tegner activity scale (± 1), BMI (± 1) and concomitant injuries with 25 patients who had undergone HT reconstruction and 20 patients who had undergone QT reconstruction. The minimum follow-up was 12 months.

RESULTS

 Overall, the return-to-sports rate was 91.3 %. There were no significant differences (p ≥ 0.05) in the number of sports disciplines and the time before return to sports within or among the groups. Overall and within the groups, the level of sports participation did not change significantly (p ≥ 0.05) postoperatively. The patients' sense of well-being was excellent after either ACL repair with an Internal Brace or ACL reconstruction with autologous HT or QT.

CONCLUSION

 At short-term follow-up, ACL repair using an Internal Brace enables sports activity and provides a sense of well-being similar to that of classic ACL reconstruction using hamstring or quadriceps tendon autografts in a selected patient population.

LEVEL OF EVIDENCE

Level III Retrospective comparative study.

Outcomes of Quadriceps Tendon With Patellar Bone Block Anterior Cruciate Ligament Reconstruction in Adolescent Patients With a Minimum 2-Year Follow-up

BACKGROUND

The incidence of anterior cruciate ligament (ACL) injury in the adolescent population is increasing. The quadriceps tendon-patellar bone autograft (QPA) has been established as a reliable graft choice for ACL reconstruction in the adult population.

PURPOSE

To investigate graft failure, ability to return to sport, patient-reported functional outcomes, joint laxity, and subsequent injury among adolescent patients >2 years after primary ACL reconstruction with the QPA.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Consecutive patients who underwent QPA ACL reconstruction performed by a single surgeon were identified from an existing database. Information available in the database included demographics, concomitant/subsequent injuries, surgical procedures, graft failure, return to sport, and Lachman examination collected by medical record review. Pediatric International Knee Documentation Committee (Pedi-IKDC) and Lysholm scores were collected by telephone or during a clinic visit >2 years postoperatively.

RESULTS

The final cohort included 81 of 104 consecutive adolescent patients aged 10 to 18 years (mean ± SD, 15.9 ± 1.7 years at the time of surgery) for whom follow-up information was collected at >2 years after surgery. The cumulative incidence of graft failure within the 36-month follow-up period was 1.2% (95% CI, 0.1%-11.4%). The rate of ipsilateral non-ACL injuries was similar (1.2%; 95% CI, 0.2%-7.6%). Contralateral ACL and non-ACL injuries requiring surgical intervention were documented in 9.8% (95% CI, 4.9%-19.5%). The median Pedi-IKDC score was 94 (interquartile range, 89-98). The median Lysholm score was 99.5 (interquartile range, 89.0-100.0). At 36 months after surgery, 87.9% (95% CI, 81.4%-94.9%) of individuals had returned to play.

CONCLUSION

The quadriceps tendon-patellar autograft is a novel graft that demonstrates excellent stability and favorable patient-reported outcomes. Based on these results, the QPA is a reliable choice for primary ACL reconstruction in adolescent patients.

Quadriceps tendon grafts does not cause patients to have inferior subjective outcome after anterior cruciate ligament (ACL) reconstruction than do hamstring grafts: a 2-year prospective randomised controlled trial

OBJECTIVE

We performed a randomised controlled trial (RCT) in patients undergoing ACL reconstruction (ACLR) using either quadriceps tendon graft (QT) or semitendinosus/gracilis hamstring (STG) graft. We compared subjective outcome (primary outcome) and knee stability, donor site morbidity and function (secondary outcomes).

METHODS

From 2013 to 2015, we included 99 adults with isolated ACL injuries in the RCT. Fifty patients were randomised to QT grafts and 49 to STG grafts and followed for 2 years. Patient evaluated outcomes were performed by subjective International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, Kujala and Tegner activity scores. Knee laxity was measured with a KT-1000 arthrometer. Donor site morbidity was evaluated by the 'donor site-related functional problems following ACLR score'. One-leg hop test tested limp strength symmetry.

RESULTS

At 2-year follow-up, there was no difference between the two graft groups regarding subjective patient outcome, knee stability and reoperations. Also, at 2 years, donor site symptoms were present in 27% of patients in the QT group and 50% of patients in the STG group. The donor site morbidity score was 14 and 22 for the QT and STG, respectively. Hop test demonstrated lower limp symmetry for QT graft than STG graft of 91% and 97% respectively.

CONCLUSION

QT graft for ACLR did not result in inferior subjective outcome compared with STG graft. However, QT graft was associated with lower donor site morbidity than STG grafts but resulted in more quadriceps muscle strength deficiency than hamstring grafts. Both graft types had similar knee stability outcome.

TRIAL REGISTRATION NUMBER

NCT02173483.

Magnetic resonance imaging of the quadriceps tendon autograft in anterior cruciate ligament reconstruction

BACKGROUND

Quadriceps tendon (QT) autograft is emerging as a popular technique for primary anterior cruciate ligament (ACL) reconstruction. Studies have shown that it has comparable outcomes to bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) autografts while mitigating post-operative complications associated with these grafts.

PURPOSE

To provide a literature summary of the important pre- and post-operative magnetic resonance imaging (MRI) findings of the quadriceps tendon and pertinent postoperative complications associated with the QT harvest. Radiologists should be familiar with MR findings after autologous graft harvest of the quadriceps tendon for reconstruction of the ACL.

LEVEL OF EVIDENCE

Level IV.

Soft Tissue Fixation Strategies of Human Quadriceps Tendon Grafts: A Biomechanical Study

PURPOSE

To evaluate the effects of different stitching methods and suture diameters on the graft fixation of soft tissue human quadriceps tendon grafts for anterior cruciate ligament (ACL) reconstruction.

METHODS

The Krackow locking stitch (K), whipstitch (W), and baseball stitch (B) were combined with either a 2× no. 2 (#2) or a 1× no. 5 (#5) braided composite suture for graft fixation of 36 human quadriceps tendons in 6 groups. Biomechanical testing was performed using a cyclic protocol with loads between 0 and 100 N. The maximum load until failure, cyclic elongation, and failure mode were recorded.

RESULTS

The highest mean maximum load to failure was observed in the 2 Krackow stitch groups. The K#2 group had significantly higher load to failure values compared with those of the W#2 and B#2 groups (K#2, 553 ± 82 N vs W#2, 392 ± 107 N, P = .0349; K#2 vs B#2 366 ± 118 N, P = .0129). The mean cyclic elongation was lowest in the Krackow groups (K#2, 10.59 ± 2.63 mm; K#5, 13.66 ± 2.3 mm). The regular failure mode was the rupture of the suture for the Krackow stitch (8 of 12) and suture pullout for the whipstitch (11 of 12) and baseball stitch groups (12 of 12).

CONCLUSIONS

The double Krackow stitch with no. 2 braided composite suture exhibits a high maximum load to failure combined with a low amount of elongation in a biomechanical study for human quadriceps tendon soft tissue graft fixation. Unlike the whipstitch and the baseball stitch, it can solidly prevent suture pullout.

CLINICAL RELEVANCE

A safe soft tissue graft fixation technique is especially important for quadriceps tendon grafts with their laminar anatomical structure and physiologically varying diameter. Unlike other grafts for ACL replacement, it fully relies on the soft tissue suture fixation to resist the pullout force.

Clinical outcomes after ACL reconstruction with free quadriceps tendon autograft versus hamstring tendons autograft. A retrospective study with a minimal follow-up two years

OBJECTIVE

The aim of this retrospective study was to compare the clinical outcomes of anatomic single bundle ACL reconstruction using either a free quadriceps tendon autograft or a quadrupled hamstring autograft with a minimum follow-up of 24 months.

METHODS

Consecutive patients undergoing ACL reconstruction using either a free quadriceps tendon autograft or hamstring tendon autograft from January 2013 to December 2014 were included. ACL reconstruction was done in all patients due to isolated ACL tears. Patients with associated cartilage lesions > Outerbridge III, meniscal lesions in need of meniscectomy or repair as well as patients with prior knee surgery on the affected or contralateral knee were excluded. The primary outcome evaluation was the side-to-side difference in instrumented Lachman testing. Secondary outcome evaluation consisted in the Lysholm, modified Cincinnati and SF-36 scores. Side-to-side difference in range of motion and thigh diameter was also documented.

RESULTS

After applying the inclusion/exclusion criteria, a total of 82 patients were identified and 72 (87.8%) presented to the hospital for follow-up. There were 39 patients with quadriceps graft (30.64 ± 8.71, range: 18-53 years) and 33 patients with hamstrings (28.60 ± 6.74, range: 18-46 years). No statistically significant difference between groups was detected with regard to KT-1000 measurements (p = 0.326). No significant difference was found between the mean postoperative Lysholm (p = 0.299), the modified Cincinnati (p = 0.665) and the general SF-36 scores between groups (p = 0.588). Less side-to-side thigh diameter difference was noted in the quadriceps graft group (p = 0.026).

CONCLUSION

In conclusion, similar clinical results, in terms of stability and subjective measures, can be obtained after ACL reconstruction both with a free quadriceps and a 4-strand hamstring tendons autograft.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

Quadriceps augmentation of undersized hamstrings during ACL reconstruction

BACKGROUND

Double hamstring autograft for anterior cruciate ligament (ACL) reconstruction is a well-established graft option; however, a major concern with this method arises when the prepared graft is too small. Resorting to allograft can be a solution to this problem, but some surgeons prefer to use autograft in particular situations and some patients may refuse allograft. We investigate the merits of using autogenous quadriceps tendons to augment the insufficient hamstrings and compare the autograft composite graft to a standard hamstrings graft of equal size.

METHODS

Semitendinosus, gracilis, and quadriceps tendons were harvested from 10 matched pairs of human cadaver lower extremities. Within each pair, a routine hamstring ACL graft (control) consisting of the semitendinosus and gracilis tendons, and an quadriceps augmented hamstrings graft of equal size comprised of the semitendinosus and quadriceps tendons, were prepared. A freeze-clamp mount was used to biomechanically test each graft construct. Tensile failure load, displacement, energy absorbed, and stiffness were determined and statistically compared within each pair and mode of graft failure was established.

RESULTS

No statistically significant differences were found between the quadriceps augmented hamstrings graft versus standard control grafts. Average values for peak failure load and graft displacement at the point of first failure were nearly identical. All ACL graft constructs failed at the mid-substance.

CONCLUSIONS

This study demonstrates no statistical difference in the biomechanical properties of an isolated hamstring ACL autograft versus a quadriceps augmented ACL autograft of equal size at time zero.

CLINICAL RELEVANCE

This is a potentially new and reliable method for quadriceps tendon autograft augmentation of hamstring autograft for ACL reconstruction.

Minimally Invasive Quadriceps Tendon Single-Bundle, Arthroscopic, Anatomic Anterior Cruciate Ligament Reconstruction With Rectangular Bone Tunnels

Many surgeons use quadriceps tendon (QT) graft for anterior cruciate ligament (ACL) revision surgery; however, despite excellent clinical results, the QT has not achieved universal acceptance for primary ACL reconstruction. One of the reasons for this may be that the QT is technically demanding to harvest and the scar from open harvesting techniques is less cosmetically favorable than that from hamstring tendon techniques. Recent evidence has suggested that broad flat QT grafts may more closely mimic native ACL "ribbon-like" morphology than hamstring tendon grafts. Furthermore, rectangular bone tunnels may more accurately re-create native ACL attachments, allowing grafts to simulate native ACL rotation during knee flexion and potentially improving biomechanics. Rectangular tunnels have further advantages in revision cases, in which-in comparison with round tunnels-they have reduced overlap with pre-existing transtibial tunnels, increasing the chance of bypassing primary tunnels during revision surgery. Finally, instrumentation for minimally invasive QT harvesting has reduced technical difficulty and improved cosmetic results. Hence, technical and cosmetic concerns are no longer barriers to QT use. These anatomic and biomechanical advantages and technical developments make the QT an increasingly attractive option for both primary and revision ACL reconstruction.

The Quad Link Technique for an All-Soft-Tissue Quadriceps Graft in Minimally Invasive, All-Inside Anterior Cruciate Ligament Reconstruction

The quadriceps tendon autograft has become an attractive option for anterior cruciate ligament reconstruction (ACLR) because of its robust size and versatility as a graft. Emerging literature has shown impressive biomechanical viability and promising clinical outcomes. The substantial size of a quadriceps graft and the shorter graft requirement of the all-inside approach obviate the need to harvest a bone plug for supplemental graft length and allow the use of an all-soft-tissue graft. The recent development of sophisticated harvest tools has mitigated prior issues reported with quadriceps tendon harvest. Quadriceps graft harvest is now less technically challenging, more reproducible, and can be done through a minimally invasive incision. However, an optimal technique for attachment of the adjustable loop suspensory fixation devices to an all-soft-tissue quadriceps tendon graft has yet to be established. We describe our method for quadriceps tendon harvest and present the Quad Link technique for attachment of adjustable loop suspensory fixation devices to a quadriceps graft for ACLR.

Pediatric Anterior Cruciate Ligament Reconstruction

The rate of anterior cruciate ligament (ACL) ruptures diagnosed among the pediatric and adolescent population is increasing. The rise in ACL injuries may be attributed to earlier sports specialization, year-round sports participation, increased awareness, and improved ability to diagnose the injury. Treatment options for pediatric or adolescent ACL injuries include nonoperative conservative treatment, ACL repair, or various techniques for ACL reconstruction. The best course of treatment for ACL rupture in young patients continues to be debated. Anterior cruciate ligament reconstruction with autograft is currently the gold standard and has been shown to be successful in restoring joint stability. This article reviews predisposing factors, common mechanisms, diagnostic procedures, and treatments for ACL rupture in adolescent patients, with a focus on using quadriceps patellar tendon autograft. [Orthopedics. 2018; 41(3):129-134.].

Quadriceps tendon autograft for arthroscopic knee ligament reconstruction: use it now, use it often

Traditional bone-patellar tendon-bone and hamstring tendon ACL grafts are not without limitations. A growing body of anatomic, biomechanical and clinical data has demonstrated the utility of quadriceps tendon autograft in arthroscopic knee ligament reconstruction. The quadriceps tendon autograft provides a robust volume of tissue that can be reliably harvested, mitigating the likelihood of variably sized grafts and obviating the necessity of allograft augmentation. Modern, minimally invasive harvest techniques offer the advantages of low rates of donor site morbidity and residual extensor mechanism strength deficits. New data suggest that quadriceps tendon autograft may possess superior biomechanical characteristics when compared with bone-patella tendon-bone (BPTB) autograft. However, there have been very few direct, prospective comparisons between the clinical outcomes associated with quadriceps tendon autograft and other autograft options (eg, hamstring tendon and bone-patellar tendon-bone). Nevertheless, quadriceps tendon autograft should be one of the primary options in any knee surgeon's armamentarium.

There is no difference between quadriceps- and hamstring tendon autografts in primary anterior cruciate ligament reconstruction: a 2-year patient-reported outcome study

PURPOSE

Graft choice for anterior cruciate ligament (ACL) reconstruction is crucial, however the optimal graft source remains a topic of controversy. The purpose of this study is to compare subjective and functional patient-reported outcomes (PRO) after single-bundle ACL reconstruction using quadriceps tendon (QT) or hamstring tendon (HT) autografts for single-bundle ACL reconstruction. We hypothesize that there is no difference in patient-reported functional outcomes after ACL reconstruction using either HT- or QT autograft.

METHODS

All data were extracted from a prospectively collected ACL registry. A total of 80 patients with at least 2-year follow-up were included in this study. A total of 40 patients with primary ACL reconstruction using a QT autograft harvested via a minimally invasive technique were matched by sex, age and pre-injury Tegner and Lysholm score to 40 patients who received HT autografts. Subjective and functional PRO scores including Lysholm score, Tegner activity level and visual analogue scale for pain were obtained at 6, 12 and 24 months after index surgery.

RESULTS

No significant difference between the QT and the HT group was seen at any follow-up in regard to any of the PRO scores for function or pain. 24 months post-surgery the mean Tegner activity score of the HT group was significantly (p = 0.04) lower compared to the pre-injury status. At final follow-up, 27 patients (67.5%) in the QT group and 32 patients (80.0%) in the HT returned to their pre-injury activity level (n.s.). A total of 37 patients (92.5%) of the QT cohort and 35 patients (87.5%) of the HT cohort reported "good" or "excellent" results according to the Lysholm score (n.s.). "No pain" or "slight pain" during severe exertion was reported by 33 patients (82.5%) with QT autograft and 28 patients (82.4%) with HT autograft (n.s.).

CONCLUSION

There is no significant difference between PRO 2 years post-operative using either QT or HT autografts. Both QT and HT grafts show acceptable and comparable PRO scores making the QT a reliable graft alternative to HT for primary ACL reconstruction.

LEVEL OF EVIDENCE

III.

Higher hamstring-to-quadriceps isokinetic strength ratio during the first post-operative months in patients with quadriceps tendon compared to hamstring tendon graft following ACL reconstruction

PURPOSE

The aim of this study was to compare isokinetic quadriceps and hamstring muscle strength in patients following anterior cruciate ligament (ACL) reconstruction who received either hamstring (HT) or quadriceps (QT) tendon autografts at two time intervals within the first year after surgery.

METHODS

One hundred twenty-four patients, 81 males (age 22.0 ± 6.2 years) and 43 females (age 20.9 ± 8.7 years), participated in this study. ACL reconstruction was performed with either quadriceps tendon autografts (QT; n = 61) or hamstring tendon autografts (HT; n = 63). Two isokinetic muscle strength tests (t1: 5.5 ± 1.2 months; t2: 7.6 ± 1.6 months) were performed at an angular velocity of 60°/s in both the injured and contralateral knees. An independent t test as well as a two-factor analysis of variance with repeated measurements was used. The significance level was set at p < 0.05.

RESULTS

A statistically significant lower knee extensor strength was observed in the QT group within one year after surgery (p < 0.001). Additionally, data showed a significant higher H/Q ratio in QT patients compared to the HT group at t1 (p < 0.001) and t2 (p = 0.001) as well as a significant effect over time (p < 0.001) and interaction effect of time and graft (p = 0.007). Side-to-side values for extensor muscle strength were significantly (p < 0.001) greater in HT graft patients, while QT patients showed significantly (p < 0.001) greater values for flexor muscle strength at both time points of isokinetic testing, respectively.

CONCLUSION

The results of this study indicate that graft choice has an impact on extensor strength in the first months after ACL reconstruction; however, there is no impact on flexor strength. The finding of a higher H/Q ratio in patients with QT grafts within the first months following surgery is possibly of clinical relevance. This may potentially be associated with lower stress on the maturing ACL graft. Furthermore, normal thigh strength can be restored over time.

LEVEL OF EVIDENCE

III.

Pain level after ACL reconstruction: A comparative study between free quadriceps tendon and hamstring tendons autografts

Objective

The objective of this study was to compare the pain levels and analgesic consumption after single bundle ACL reconstruction with free quadriceps tendon autograft versus hamstring tendon autograft.

Patients and methods

A total of 48 patients scheduled for anatomic single-bundle ACL reconstruction were randomized into two groups: the free quadriceps tendon autograft group (24 patients) and the hamstring tendons autograft group (24 patients). A basic multimodal analgesic postoperative program was used for all patients and rescue analgesia was provided with tramadol, at pain scores over 30 on the Visual Analog Scale. The time to the first rescue analgesic, the number of doses of tramadol and pain scores were recorded. The results within the same group were compared with the Wilcoxon signed test.

Results

Supplementary analgesic drug administration proved significantly higher in the group of subjects with hamstring grafts, with a median (interquartile range) of 1 (1.3) dose, compared to the group of subjects treated with a quadriceps graft, median = 0.5 (0.1.25) (p = 0.009). A significantly higher number of subjects with a quadriceps graft did not require any supplementary analgesic drug (50%) as compared with subjects with hamstring graft (13%; Z-statistics = 3.01, p = 0.002). The percentage of subjects who required a supplementary analgesic drug was 38% higher in the HT group compared with the FQT group.

Conclusion

The use of the free quadriceps tendon autograft for ACL reconstruction leads to less pain and analgesic consumption in the immediate postoperative period compared with the use of hamstrings autograft.

Level of Evidence

Level I Therapeutic study

Management of Anterior Cruciate Ligament Injury: What's In and What's Out?

Sports medicine physicians have a keen clinical and research interest in the anterior cruciate ligament (ACL). The biomechanical, biologic, and clinical data researchers generate, help drive injury management and prevention practices globally. The current concepts in ACL injury and surgery are being shaped by technological advances, expansion in basic science research, resurging interest in ACL preservation, and expanding efforts regarding injury prevention. As new methods are being developed in this field, the primary goal of safely improving patient outcomes will be a unifying principle. With this review, we provide an overview of topics currently in controversy or debate, and we identify paradigm shifts in the understanding, management, and prevention of ACL tears.