Free Bone Plug Quadriceps Tendon Harvest and Suspensory Button Attachment for Anterior Cruciate Ligament Reconstruction

Estimation Failure Risk by 0.5-mm Differences in Autologous Hamstring Graft Diameter in Anterior Cruciate Ligament Reconstruction: A Meta-analysis

BACKGROUND

Because grafts are made in 0.5-mm increments clinically for anterior cruciate ligament (ACL) reconstruction, it is important to clarify how the failure rate decreases as the diameter increases. Moreover, it is important to know whether even a slight increase in the graft diameter decreases the risk of failure.

HYPOTHESIS

The risk of failure decreases significantly with each 0.5-mm increase in hamstring graft diameter.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

The systematic review and meta-analysis have estimated the diameter-specific failure risk for each 0.5-mm increase in ACL reconstruction using autologous hamstring grafts. We searched for studies describing the relationship between graft diameter and failure rate published before December 1, 2021, in leading databases, such as PubMed, EMBASE, Cochrane Library, and Web of Science, according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We included studies using single-bundle autologous hamstring grafts to investigate the relationship between failure rate and graft diameter of 0.5-mm intervals with >1-year follow-up. Then, we calculated the failure risk caused by 0.5-mm differences in autologous hamstring graft diameter. Assuming Poisson distribution for the statistical model, we employed an extended linear mixed-effects model in the meta-analyses.

RESULTS

Five studies containing 19,333 cases were eligible. The meta-analysis revealed that the estimated value of the coefficient of diameter in the Poisson model was -0.2357 with a 95% CI of -0.2743 to -0.1971 (P < .0001). With every 1.0-mm increase in diameter, the failure rate decreased by 0.79 (0.76-0.82) times. In contrast, the failure rate increased by 1.27 (1.22-1.32) times for each 1.0-mm decrease in diameter. The failure rate significantly decreased with each 0.5-mm increase in graft diameter in the range of <7.0 to >9.0 mm from 3.63% to 1.79%.

CONCLUSION

The risk of failure decreased correspondingly with each 0.5-mm increase in graft diameter in the range of <7.0 to >9.0 mm. Failure is multifactorial; however, increasing the graft diameter as much as possible to match each patient's anatomic space without overstuffing is an effective precaution that surgeons can take to reduce failures.

Revision anterior cruciate ligament reconstruction using the ipsilateral Quadriceps tendon autograft: a modular reconstructive option

PURPOSE

Failed ACL reconstruction is a common occurrence nowadays due to the increased incidence of ACL surgeries and return to full activities following the surgery. Several challenges might stand in the face of this revision surgery particularly the graft harvest and its suitability to the situation with possible widening of the tunnel and the avoidance of additional morbidity at the contralateral side or anterior knee pain as in patellar tendon harvest. The aim of this study is to evaluate the ipsilateral quadriceps tendon as a source of autograft in revision ACL surgery which constitutes a viable option that can potentially decrease the morbidity of the procedure, and meanwhile provide a graft substitute that can be tailored to suit the dilated tunnels commonly encountered in revision surgery, thus giving the patients a good potential for better functional outcome.

METHODS

Revision anterior cruciate ligament reconstruction was done in 30 patients using the ipsilateral quad tendon as a pure soft tissue or with a bony fragment.

RESULTS

The mean subjective international Knee Documentation Committee score (IKDC score) at two years follow-up was 65.83 ± 7.20. There is statistically significant improvement of the objective as well as the subjective IKDC scores at the end of follow-up when compared to the preoperative as well as the 6-month evaluation figures. The KT1000 arthrometer recorded a mean of 4.50 ± 1.07. Significant improvement of the limb symmetry index was at two years duration.

CONCLUSIONS

The quadriceps tendon can be a solution for several challenges that might appear during the revision ACL surgery with comparable results to other tendons and with minimal morbidity on the function of the harvested muscle tendon.

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.

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.

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.

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.

Continuous-Loop Tape Technique Has Greater Stiffness and Less Elongation Compared With Tied-Suture Fixation of Full-Thickness All-Soft Tissue Quadriceps Tendon Autografts

Background

Many graft fixation techniques are utilized for full-thickness soft tissue quadriceps tendon autografts during anterior cruciate ligament reconstruction (ACLR).

Purpose

To determine the tensile properties of all-soft tissue quadriceps tendon graft fixation using a tied-suture versus continuous-loop tape technique. It was hypothesized that the continuous-loop tape technique would have less cyclic elongation and greater ultimate load to failure and stiffness compared with a commonly used tied-suture technique.

Study Design

Controlled laboratory study.

Methods

Sixteen fresh-frozen human knee specimens were used to harvest a full-thickness all-soft tissue quadriceps tendon graft; half were secured using a Krackow suture technique with 2 braided sutures, and half were secured using a continuous-loop tape suspensory fixation button with a rip-stop stitch. Cyclic and permanent elongation, toe- and linear-region stiffness, and ultimate load were determined. Statistical analysis was performed at P <.05.

Results

The tied-suture fixation group demonstrated significantly higher permanent elongation (11.7 ± 3.6 vs 4.2 ± 1.0 mm, P < .001) and cyclic elongation (5.9 ± 1.3 vs 2.0 ± 0.4 mm, P < .001) compared with the continuous-loop tape fixation group. There was a significantly higher linear-region stiffness with continuous-loop tape fixation compared with tied-suture fixation (98.8 ± 12.7 vs 85.5 ± 7.5 N/mm, P = .022). No significant difference in ultimate load between groups (517.1 ± 149.2 vs 465.6 ± 64.6 N) was found. The mode of failure was tendon pull-through for the continuous-loop tape group and suture breakage in the tied-suture group (P < .001).

Conclusion

Continuous-loop tape fixation is superior to tied-suture fixation in regard to elongation and stiffness for all-soft tissue quadriceps tendon grafts, but there was no significant difference in ultimate load.

Clinical Relevance

Continuous-loop tape fixation of all-soft tissue quadriceps tendon grafts for ACLR is a valid technique with superior tensile properties.

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.

Patient-Reported Knee Outcome Scores With Soft Tissue Quadriceps Tendon Autograft Are Similar to Bone-Patellar Tendon-Bone Autograft at Minimum 2-Year Follow-up: A Retrospective Single-Center Cohort Study in Primary Anterior Cruciate Ligament Reconstruction Surgery

Background:

Quadriceps tendon (QT)–bone autografts used during anterior cruciate ligament (ACL) reconstruction have provided comparable outcomes and decreased donor-site morbidity when compared with bone–patellar tendon–bone (BPTB) autografts. No study has directly compared the outcomes of the all–soft tissue QT autograft with that of the BPTB autograft.

Hypothesis:

Patient-reported knee outcome scores and rates of postoperative complication after primary ACL reconstruction with QT autografts are no different from BPTB autografts at a minimum 2-year follow-up.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 75 patients who underwent primary autograft ACL reconstruction with QT or BPTB autografts between January 1, 2015, and March 31, 2016, at a single hospital center were contacted by telephone and asked to complete the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation, Tegner activity level scale, and Lysholm knee scoring scale. Information about the subsequent surgeries performed on the operative knee was also collected. Statistical analysis was performed using the Kruskal-Wallis test and the Fisher exact test for categorical data.

Results:

Fifty patients (28 QT, 22 BPTB) completed the surveys at a mean follow-up of 33.04 months (range, 24-44 months). For the QT versus the BPTB group respectively, the median IKDC scores were 94.83 (interquartile range [IQR], 7.61) versus 94.83 (IQR, 10.92) (P = .47), the median Tegner scores were 6 (IQR, 2.5) versus 6 (IQR, 2.75) (P = .48), and the median Lysholm scores were 95 (IQR, 9) versus 95 (IQR, 13) (P = .27). Additionally, 2 QT patients and 3 BPTB patients required follow-up arthroscopy for arthrolysis (P = .64). There was 1 graft failure in the QT group requiring revision surgery.

Conclusion:

There was no statistical difference in patient-reported knee outcomes or graft complication rates between the QT and BPTB autograft groups at a minimum 2-year follow-up after primary ACL reconstruction. This study highlights that the all–soft tissue QT autograft may be a suitable graft choice for primary ACL reconstruction.

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.

Graft Diameter as a Predictor for Revision Anterior Cruciate Ligament Reconstruction and KOOS and EQ-5D Values: A Cohort Study From the Swedish National Knee Ligament Register Based on 2240 Patients

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction (ACLR) using a hamstring tendon (HT) autograft is an effective and widespread method. Recent studies have identified a relationship between the graft diameter and revision ACLR.

PURPOSE

To evaluate the influence of the graft diameter on revision ACLR and patient-reported outcomes in patients undergoing primary ACLR using HT autografts.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A prospective cohort study was conducted using the Swedish National Knee Ligament Register (SNKLR) involving all patients undergoing primary ACLR using HT autografts. Patients with graft failure who needed revision surgery (cases) were compared with patients not undergoing revision surgery (controls). The control group was matched for sex, age, and graft fixation method in a 3:1 ratio. Conditional logistic regression was performed to produce odds ratios and 95% CIs. Univariate linear regression analyses were performed for patient-related outcomes. The Knee injury and Osteoarthritis Outcome Score (KOOS) and EuroQol 5 dimensions questionnaire (EQ-5D) values were obtained.

RESULTS

A total of 2240 patients were included in which there were 560 cases and 1680 controls. No significant differences between the cases and controls were found for sex (52.9% male), mean age (21.7 years), and femoral and tibial fixation. The mean graft diameter for the cases was 8.0 ± 0.74 mm and for the controls was 8.1 ± 0.76 mm. In the present cohort, the likelihood of revision surgery for every 0.5-mm increase in the HT autograft diameter between 7.0 and 10.0 mm was 0.86 (95% CI, 0.75-0.99; P = .03). Univariate linear regression analysis found no significant regression coefficient for the change in KOOS or EQ-5D values.

CONCLUSION

In a large cohort of patients after primary ACLR with HT autografts, an increase in the graft diameter between 7.0 and 10.0 mm resulted in a 0.86 times lower likelihood of revision surgery with every 0.5-mm increase. This study provides further evidence of the importance of the HT autograft size in intraoperative decision making.

Autograft Options for ACL Reconstruction. Which is Best?

Anterior cruciate ligament (ACL) tears are commonly seen in orthopedic practice, and usually restoration is recommended to re-establish normal knee function. Autografts and allografts are viable options. Among autografts the main sources are the patellar tendon, the hamstrings and the quadriceps tendon, each having advantages and drawbacks. Many factors should be taken into consideration when deciding on a graft source for ACL restoration; however, clinical data may aid the surgeon in choosing the right graft for every specific patient in an individualized manner. This short review is intended to highlight the main characteristics and clinical data for each type of autograft.

Primary Anterior Cruciate Ligament Reconstruction. How Do We Do It?

Anterior cruciate ligament (ACL) tears are frequently seen in current practice mostly affecting the young, active subjects, and usually require ligament reconstruction in order to restore normal knee kinematics. As worldwide interest in anatomic reconstruction grew over the last decade, we have also refined our technique in order to restore the anatomical function as near to the normal as possible. This anatomical restoration concept is believed to prevent the onset of osteoarthritis, which the non-anatomic reconstructions fail to attain. The knowledge gained from the ACL anatomy, function and kinematics has helped in developing the current anatomic methods of reconstruction, which take into account patient anatomy, the rupture pattern, as well as the comorbidities. We present our approach to anatomical single- and double-bundle ACL reconstruction.