Is Quadriceps Tendon Autograft a Better Choice Than Hamstring Autograft for Anterior Cruciate Ligament Reconstruction? A Comparative Study With a Mean Follow-up of 3.6 Years

No difference in clinical outcome between quadriceps tendon anterior cruciate ligament reconstruction with and without bone block: Results from the Danish Knee Ligament Registry

PURPOSE

The quadriceps tendon (QT) has recently gained increasing interest as an anterior cruciate ligament reconstruction (ACLR) graft due to minimally invasive harvesting techniques and low donor site morbidity. QT grafts can be used both with a patella bone block and as complete soft tissue grafts. However, it is unknown whether the QT graft type affects clinical outcomes. This study used data from the Danish Knee Ligament Reconstruction Registry (DKRR) to compare revision rates, knee stability and subjective clinical outcomes in patients who underwent ACLR with QT graft with bone block (QT-B) or soft tissue only (QT-S).

METHODS

Patients who underwent primary ACL reconstruction with QT autografts documented in the DKRR were included and divided into the QT-B (n = 925) and QT-S (n = 659) groups. The clinical outcome was evaluated using objective-instrumented knee stability, pivot shift test, knee injury osteoarthritis outcome score (KOOS) and Tegner activity scores for the two cohorts performed at the 1-year follow-up. The overall revision rates were determined as well.

RESULTS

Revision rates at 2 years were equally low in both graft groups at 2.8%. Similarly, post-operative knee laxity was equal at 1.5 (1.4) and 1.6 (1.4) mm side-to-side laxity, respectively. However, QT-B exhibited a reduced post-operative positive pivot shift of 22% compared with 31% for QT-S. Although the subjective outcomes were equal for the KOOS and Tegner activity scale scores at the 1-year follow-up, reduced improvements in KOOS were observed for QT-B compared to QT-S.

CONCLUSION

ACL with a QT autograft harvested either with a bone block or as a soft tissue graft exhibited comparable revision rates and sagittal knee stability. Furthermore, ACL reconstruction using a QT graft with a bone block achieved better rotational stability with less pivot shift than ACL reconstruction using complete soft tissue QT grafts.

LEVEL OF EVIDENCE

Level III.

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

PURPOSE

To compare patient-reported outcomes measurements 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 January 2010 and March 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 sex, age, Tegner activity level [TAL], pivoting sports, and concomitant injuries. Patient-reported outcomes measurements (Lysholm score, visual analog scale for pain, and TAL) and subsequent surgical interventions were registered after 6, 12, and 24 months postoperatively. Binary logistic regression was used to assess the influence of graft type, age, preinjury TAL, sex, 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 differences 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 visual analog scale for pain (sQT: 0.7 ± 1.1, bQT: 0.7 ± 1.2, P = .70) were reported between both groups. A total of 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.

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, cohort study.

Incidence of Osteoarthritis Between ACL Reconstruction With Different Graft Types and Between ACL Reconstruction and Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

Variation in stiffness, fixation methods, and donor-site morbidity after anterior cruciate ligament reconstruction (ACLR) with different graft types and with anterior cruciate ligament suture repair (ACLSR) can lead to differences in dynamic knee laxity and consequent differences in posttraumatic osteoarthritis (PTOA) development.

Purpose

To compare the incidence of PTOA between different graft types used for primary ACLR and between primary ACLR and ACLSR. It was hypothesized that the incidence of PTOA would vary between ACLR with different autografts and allografts and between ACLR and ACLSR.

Study Design

Systematic review; Level of evidence, 1.

Methods

A search of the literature was performed to identify all randomized controlled trials (RCTs) comparing radiographic evidence of PTOA after ACLR between different graft types-hamstring tendon (HT) autograft, bone-patellar tendon-bone (BPTB) autograft, quadriceps tendon autograft, and allograft-and between ACLR and ACLSR. The minimum follow-up was 2 years. Study quality was assessed using the modified Coleman Methodology Score. A meta-analysis was performed to determine whether there was a difference in the incidence of PTOA between the different graft types and between ACLR and ACLSR.

Results

Eleven randomized controlled trials were included in the meta-analysis-HT: 440 patients (mean follow-up, 9.7 years); BPTB: 307 patients (mean follow-up, 11.8 years); allograft: 246 patients (mean follow-up, 5 years); ACLSR, 22 patients (5 years). No study reporting the incidence after ACLR with quadriceps tendon was included. The study quality ranged from 70 to 88. The meta-analysis indicated no significant difference in the incidence of PTOA between graft types used for ACLR and between ACLR and ACLSR (risk ratios: HT vs BPTB, 1.05; HT vs allograft, 0.81; BPTB vs allograft, 0.82; HT vs ACLSR, not estimable [P > .05 for all]). The combined number of patients with PTOA in all studies per graft type showed that patients who underwent ACLR with a BPTB autograft had the highest percentage of PTOA (HT, 23.4%; BPTB, 29.6%; allograft, 8.1%; ACLSR, 0%). However, excluding studies with a follow-up <5 years resulted in similar outcomes for patients with an HT autograft and a BPTB autograft.

Conclusion

This meta-analysis reported no difference in the incidence of PTOA between graft types used for ACLR and between ACLR and ACLSR. More research is necessary to make a reliable conclusion about which technique is associated with the lowest incidence of PTOA after ACL surgery.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Cases series; Level of evidence, 4.

METHODS

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

RESULTS

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

CONCLUSION

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

Addition of anterolateral ligament reconstruction to primary anterior cruciate ligament reconstruction could benefit recovery of functional outcomes

This study aimed to compare functional outcomes sequentially up to 1 year after combined anterior cruciate ligament reconstruction (ACLR) and anterolateral ligament reconstruction (ALLR) and isolated ACLR. Fifty patients who underwent ACLR with versus without ALLR were analyzed at four different time points (preoperatively and 3, 6, and 12 months postoperatively). For the functional outcomes, muscle strength and acceleration time (AT) were measured using an isokinetic dynamometer. Proprioception was evaluated using joint position sense and dynamic postural stability. Patient-reported outcomes were measured using the Tampa Scale for Kinesiophobia (TSK-11) scores. Functional performance was assessed using single-leg hop distance (SLHD) and Limb Symmetry Index. In the operated knees, quadriceps (at 6 months postoperatively, p = 0.003) and hamstring (at 6 and 12 months postoperatively, p < 0.001) strength were significantly higher in the combined ACLR and ALLR group than the isolated ACLR group. The TSK-11 (at 6 and 12 months postoperatively, p < 0.001) was significantly lower in the combined ACLR and ALLR group than the isolated ACLR group. SLHD was significantly higher in the combined ACLR and ALLR group than the isolated ACLR group (at 6 months, p = 0.022 and at 12 months, p = 0.024). The addition of ALLR to primary ACLR yielded better muscle performance, fear of movement, and functional performance than isolated ACLR.

Editorial Commentary: Quadriceps Tendon Is a Better Graft Than Hamstring for Anterior Cruciate Ligament Reconstruction

Over the last 12 years identification of specific risk factors (age, activity level, and laxity) for failure of anterior cruciate ligament (ACL) reconstruction have led to comparisons of the patellar tendon (PT) and hamstring (HS) tendon grafts. The PT has proved superior in most of these studies. During this same time period, there has been increased clinical/research interest in the quadriceps tendon autograft for ACL reconstruction. This has led to direct comparison to the HS and QT autografts. Again, the HS tendon appears inferior in measured outcomes to the quadriceps tendon. Increased laxity measurements seem to correlate with the decreased evidence of radiographic healing on magnetic resonance imaging. If this is the case, it may indeed be the final nail in the coffin for HS graft use in young at-risk athletic populations.

Risk of Revision and Reoperation After Quadriceps Tendon Autograft ACL Reconstruction Compared With Patellar Tendon and Hamstring Autografts in a US Cohort of 21,973 Patients

BACKGROUND

The use of quadriceps tendon (QT) autografts has increased in the past 10 years. However, there remains a dearth of large studies examining the effects of graft selection on anterior cruciate ligament reconstruction (ACLR) that includes QT grafts.

PURPOSE

To evaluate the risk of subsequent surgical outcomes, including revision and reoperation, for a large cohort of patients with primary ACLR according to autograft selection.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Data from a US health care system ACLR registry were used to conduct a cohort study. Primary isolated autograft ACLRs were identified (2012-2021). The exposure of interest was autograft type: QT, bone-patellar tendon-bone (BPTB), and hamstring tendon (HT). Multivariable Cox regression models were used to evaluate the risk of aseptic revision (defined as a subsequent surgery where removal and replacement of the original graft for noninfectious reasons was required) and risk of aseptic reoperation (defined as any subsequent surgery for noninfectious reasons where the graft was left intact) according to autograft selection.

RESULTS

The study sample comprised 21,973 ACLRs performed by 290 surgeons at 53 hospitals. QT, BPTB, and HT autografts were used in 1103 (5.0%), 9519 (43.3%), and 11,351 (51.7%) ACLRs, respectively. In adjusted models, no significant differences were observed in revision risk (hazard ratio [HR], 1.06; 95% CI, 0.60-1.89; P = .837) or reoperation risk (HR, 1.00; 95% CI, 0.70-1.43; P = .993) within 4 years of follow-up when comparing QT ACLR with BPTB ACLR. Additionally, no differences in 4-year revision (HR, 0.62; 95% CI, 0.34-1.12; P = .111) or reoperation (HR, 1.24; 95% CI, 0.85-1.80; P = .262) risks were observed when comparing QT ACLR with HT ACLR. HT ACLRs were noted to have a higher risk of revision (HR, 1.52; 95% CI, 1.25-1.84; P < .001) compared with BPTB ACLRs but a lower risk of reoperation (HR, 0.86; 95% CI, 0.75-0.98; P = .024).

CONCLUSION

In this large multicenter study using data from an ACLR registry, the authors found no difference in the risk of revision or reoperation when QT was compared with BPTB or HT autograft with the numbers available, but they did find a 1.5 times higher risk of revision when HT autograft was compared with BPTB autograft. Surgeons may use this information when choosing the appropriate graft for ACLR in their patients.

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

Purpose

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

Research question

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

Methodology

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

Results

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

Conclusion

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

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.

Strength symmetry after autograft anterior cruciate ligament reconstruction

OBJECTIVE

To compare postoperative isometric quadriceps strength indices (QI%) and hamstring strength limb symmetry indices (HI%) between partial thickness quadriceps tendon (pQT), full thickness quadriceps tendon (fQT), and bone-patellar-tendon bone (BPTB) autograft anterior cruciate ligament reconstruction (ACLR).

METHODS

Patients with primary ACLR with pQT, fQT, or BPTB autograft with the documentation of quantitative postoperative strength assessments between 2016 and 2021 were included. Isometric Biodex data, including QI% and HI% (calculated as the percentage of involved to uninvolved limb strength) were collected between 5 and 8 months and between 9 and 15 months postoperatively.

RESULTS

In total, 124 and 51 patients had 5-8- and 9-15-month follow-up strength data, respectively. No significant difference was detected between groups for sex. However, patients undergoing fQT were found to be older than those undergoing BPTB (24.6±7 vs 20.2±5; ​p = 0.01). There were no significant differences in the number of concomitant meniscus repairs between the groups (pQT vs. fQT vs. BPTB). No significant differences were detected in median (min-max) QI% between pQT, fQT, and BPTB 5-8 months [87 ​% (44%-130 ​%), 84 ​% (44%-110 ​%), 82 ​% (37%-110 ​%) or 9-15 months [89 ​% (50%-110 ​%), 89 ​% (67%-110 ​%), and 90 ​% (74%-140 ​%)] postoperatively. Similarly, no differences were detected in median HI% between the groups 5-8 months or 9-15 months postoperatively.

CONCLUSION

The study was unable to detect differences in the recovery of quadriceps strength between patients undergoing ACLR with pQT, fQT, and BPTB autografts at 5-8 months and 9-15-months postoperatively.

LEVEL OF EVIDENCE

III.

Restoring Knee Flexor Strength Symmetry Requires 2 Years After ACL Reconstruction, But Does It Matter for Second ACL Injuries? A Systematic Review and Meta-analysis

BACKGROUND

It is unknown whether knee flexor strength recovers after anterior cruciate ligament (ACL) reconstruction with a hamstring tendon (HT) autograft and whether persistent knee flexor strength asymmetry is associated to a second ACL injury.

OBJECTIVE

We aimed to systematically review (1) whether knee flexor strength recovers after ACL reconstruction with HT autografts, and (2) whether it influences the association with a second ACL injury. A third aim was to summarize the methodology used to assess knee flexor strength.

DESIGN

Systematic review and meta-analysis reported according to PRISMA.

METHODS

A systematic search was performed using the Cochrane Library, Embase, Medline, PEDRo, and AMED databases from inception to December 2021 and until completion in January 2023. Human clinical trials written in English and conducted as randomized controlled trials, longitudinal cohort, cross-sectional, and case-control studies on patients with index ACL reconstructions with HT autografts harvested from the ipsilateral side were considered. Knee flexor strength was measured isokinetically in both the reconstructed and uninjured limb to enable the calculation of the limb symmetry index (LSI). The Risk of Bias Assessment Tool for Non-Randomized Studies was used to assess risk of bias for non-randomized studies and the revised Cochrane Risk of Bias tool was used for randomized controlled trials. For the meta-analysis, the LSI (mean ± standard error) for concentric knee flexor strength at angular velocities of 60°/second (s) and 180°/s preoperatively and at 3 months, 6 months, 12 months, and 24 months were pooled as weighted means with standard errors.

RESULTS

The search yielded 64 studies with a total of 8378 patients, which were included for the assessment of recovery of knee flexor strength LSI, and a total of 610 patients from four studies that investigated the association between knee flexor strength and second ACL injuries. At 1 year after ACL reconstruction, the knee flexor strength LSI had recovered to 89.0% (95% CI 87.3; 90.7%) and 88.3% (95% CI 85.5; 91.1%) for the velocities of 60°/s and 180°/s, respectively. At 2 years, the LSI was 91.7% (95% CI 90.8; 92.6%) and 91.2% (95% CI 88.1; 94.2%), for velocities of 60°/s and 180°/s, respectively. For the association between knee flexor strength and second ACL injuries, there was insufficient and contradictory data.

CONCLUSIONS

There was low to very low certainty of evidence indicating that the recovery of knee flexor strength LSI, defined as ≥ 90% of the uninjured side, takes up to 2 years after ACL reconstruction with HT autografts. Whether knee flexor strength deficits influence the association of second ACL injuries is still uncertain. There was considerable heterogeneity in the methodology used for knee flexor strength assessment, which together with the low to very low certainty of evidence, warrants further caution in the interpretation of our results.

REGISTRATION NUMBER

CRD42022286773.

A prospective randomized controlled study of hamstring and bone-free quadriceps tendons autografts in arthroscopic ACL reconstruction

INTRODUCTION

Anterior cruciate ligament (ACL) reconstruction is one of the most common surgical procedures worldwide. However, the ideal graft source is still debatable. This study compared hamstring (HT) and bone-free quadriceps (QT) tendon autografts in terms of muscle strength and patient-reported outcomes.

METHODS

Between June 2018 and December 2019, 46 patients were enrolled in the study and randomly assigned to one of two groups for the ACL reconstruction surgery-the HT autograft group or the QT autograft group. An experienced examiner performed preoperative and postoperative examinations. The HUMAC NORM isokinetic machine (Computer Sports Medicine International-CSMI, 2004) was used to assess flexor and extensor thigh muscle strength. Both groups received the same surgical technique and fixation method. All patients were examined after three, six, nine, and 12 months. The final evaluations were performed at the 24-month follow-up. Patients' scores on the International Knee Documentation Committee (IKDC) evaluation form and the Lysholm Knee Scoring Scale were used to evaluate patient-reported outcomes. The two groups were also compared in terms of postoperative complications and activity levels.

RESULTS

The difference between preoperative and postoperative knee flexor peak torques (FPT) was lower in the QT group than in the HT group. The average difference between preoperative and postoperative knee extensor peak torque (EPT) was higher in the QT group than in the HT group. As a result, the HT group had a lower postoperative H/Q ratio (flexor strength normalized to body mass divided by extensor strength normalized to body mass) than the QT group (p < 0.001). The mean IKDC scores for the HT and QT groups were 90.13 ± 6.99 and 87.12 ± 6.61, respectively. The scores of the two groups postoperatively were close, and both groups showed significant improvement. The average graft size in the QT group was significantly greater than that in the HT group. Saphenous nerve palsy was the most common complication in the HT group (22%). Thigh hematomas were observed in two patients in the QT group and required urgent intervention (12%).

CONCLUSION

After ACL reconstruction, we found a significant decrease in strength at the donor sites in both techniques, with similar patient-reported measures and stability outcomes. The H/Q strength ratio was higher in the QT group postoperatively, which may have a protective effect on the reconstructed ligament. Level of Evidence I It is a randomized controlled trial.

Editorial Commentary: Proper Anterior Cruciate Ligament Graft Choice Mitigates Against the Need for Anterolateral Ligament Reconstruction

It is not coincidence that fervor surrounding anterolateral ligament (ALL) reconstruction increased as double-bundle anterior cruciate ligament reconstruction (ACLR) enthusiasm cooled. But perhaps we shifted our focus too soon, or perhaps we shifted our focus too much. But we must remember that the ACL is primary. Increases in ACL graft diameter by 1 or 2 mm can significantly increase graft strength and decrease revision rate. Biomechanical and clinical evidence suggests that quadriceps tendon ACLR and patellar tendon ACLR demonstrates less pivot shift phenomena than hamstring ACLR. In addition, As biologically active suture tapes become more mainstream, augmented allografts are an increasingly attractive option. Proper ACL graft choice mitigates against the need for ALL reconstruction. Risk factors for anterolateral rotatory instability may include low body mass index and lateral meniscal pathology, in addition to the well-known risks such as age, gender, activity level, and revision cases. Perhaps lateral extra-articular tenodesis should be reserved for high-risk cases.

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

Background

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

Purpose

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

Study Design

Systematic review; Level of evidence, 4.

Methods

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

Results

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

Conclusion

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

Assessment of Return to Sport After ACL Reconstruction With Soft Tissue Autograft in Adolescent Athletes: Quadriceps Versus Hamstring Tendon

Background

Quadriceps tendon soft tissue autograft represents an increasingly popular graft option for anterior cruciate ligament reconstruction (ACLR), particularly for adolescents, some of whom have an open physis, precluding use of graft options with bone plugs.

Purpose/Hypothesis

The purpose of this study was to quantify return-to-sport performance assessments in adolescents at 6 months after ACLR with all-soft tissue quadriceps tendon autograft (ACLR-Q) versus hamstring tendon autograft (ACLR-HS). It was hypothesized that ACLR-Q would be associated with improved hamstring strength and hamstring-to-quadriceps (HS:Q) ratios compared with ACLR-HS, albeit with decreased quadriceps strength.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Included were patients aged 12 to 19 years who underwent primary ACLR by a single surgeon and who completed a return-to-sport performance assessment between 5 and 9 months postoperatively. The performance assessment included manual muscle strength tests (hamstring, quadriceps, hip abductor and adductor), dynamic balance test (Y-balance), and functional hop tests (single hop, triple hop, crossover hop, 6-m timed hop). Data were converted to limb symmetry indices, and limb symmetry index deficits were compared between the ACLR-Q and ACLR-HS cohorts using the Student t test or Wilcoxon-Mann-Whitney test.

Results

An initial cohort of 90 ACLR-Q patients was compared with 54 ACLR-HS patients, with no significant differences in patient characteristics. Differences in meniscal repair rates, however, prompted use of propensity score matching on age, sex, body mass index, meniscectomy, and meniscal repair to produce comparable subcohorts. The matching resulted in 67 ACLR-Q and 52 ACLR-HS patients. Hamstring strength deficits were significantly greater in ACLR-HS versus ACLR-Q patients (-40.5% vs -5.7%; P < .001). Quadriceps strength deficits were significantly greater in ACLR-Q versus ACLR-HS patients (-12.8% vs -0.4%; P < .001). ACLR-Q patients had a significantly greater HS:Q ratio on the operative knee (P < .001) and significantly higher Y-balance composite score deficits (-2.9% vs -0.4%; P = .01) than ACLR-HS patients. There were no significant differences in hop test performance between groups.

Conclusion

Adolescent athletes who underwent ACLR-Q showed significantly greater quadriceps strength deficits but significantly smaller hamstring strength deficits than those who underwent ACLR-HS, leading to more favorable HS:Q ratios in ACLR-Q patients at 6 months postoperatively.

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

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

ACL Reconstruction With Quadriceps Soft Tissue Autograft Versus Bone-Patellar Tendon-Bone Autograft in Cutting and Pivoting Athletes: Outcomes at Minimum 2-Year Follow-up

Background

The optimal graft choice for anterior cruciate ligament (ACL) reconstruction (ACLR) in the high-level cutting and pivoting athlete remains controversial. Studies have shown similar outcomes when directly comparing bone-patellar tendon-bone (BPTB) autograft versus quadriceps soft tissue (QST) autograft in the general population. However, no studies have directly compared these 2 grafts in athletes participating in cutting and pivoting sports.

Hypothesis

It was hypothesized that, compared with BPTB autograft, the QST autograft would result in similar patient-reported outcomes and rates of retear, return to sport, and complications.

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective review was performed on athletes participating in cutting and pivoting sports (soccer, American football, lacrosse, and basketball) who underwent primary ACLR with either BPTB autograft or QST autograft chosen by the athlete between January 2015 and January 2019. The International Knee Documentation Committee (IKDC) subjective knee evaluation and Lysholm Knee Scoring Scale were used to evaluate patient-reported outcomes. Return-to-sport and complication rates were identified. Descriptive statistics were expressed using Mann-Whitney test or Student t test for continuous variables and the chi-square test for categorical variables.

Results

A total of 68 athletes (32 QST, 36 BPTB) were included for analysis. The percentage follow-up was 89% (32/36) for the QST autograft group and 86% (36/42) for the BPTB autograft group. The 2-year IKDC score (QST, 90.5 ± 6.6 vs BPTB, 89.7 ± 7.8) and 2-year Lysholm score (QST, 91.3 ± 7.5 vs BPTB, 90.5 ± 8.6) were similar between groups. The percentage of athletes able to return to sport within the follow-up period was also similar (88% vs 83%; P = .63). There were 2 retears requiring revision in the BPTB group (6%) and no retears in the QST group (P = .18). One contralateral ACL rupture occurred in the QST group (3%) and 4 in the BPTB group (11%) (P = .21).

Conclusion

The QST and BPTB autografts demonstrated similar patient-reported outcomes, return-to-sport rates, and complication rates after primary ACLR at 2-year follow-up. Both autografts appear to be reliable and consistent options for ACLR in the cutting and pivoting athlete.

Post-Operative Modified All-Inside ACL Reconstruction Technique's Clinical Outcomes and Isokinetic Strength Assessments

BACKGROUND AND OBJECTIVE

Anterior cruciate ligament (ACL) injuries are very common among the athletic population. ACL reconstruction (ACLR) performed because of these injuries is one of the procedures performed by orthopedic surgeons using different grafting methods. This study aims to compare the data related to post-operative 6-month isokinetic strength values, strength-related asymmetry rates, time parameters, and joint angle in athletes who underwent ACLR with the Modified All-inside (4ST) technique, on both the healthy knee (HK) and the ACLR-applied sides.

MATERIALS AND METHODS

A total of 20 athletes from various sports on whom the 4ST ACLR technique had been applied by the same surgeon were evaluated retrospectively. Lysholm, Tegner, and International Knee Documentation Committee (IKDC) scores of the patients were obtained pre-operative and at 6 months post-operative. Isokinetic knee extension (Ex) and flexion (Flx) strengths on the HK and ACLR sides of the patients were evaluated with a series of four different angular velocities (60, 180, 240, and 300°/s). In addition to peak torque (PT) and hamstring/quadriceps ratio (H/Q) parameters, the findings were also evaluated with additional parameters such as joint angle at peak torque (JAPT), time to peak torque (TPT), reciprocal delay (RD), and endurance ratio (ER).

RESULTS

There was a significant improvement in the mean Lysholm, Tegner, and IKDC scores after surgery compared with pre-operative levels (p < 0.05). As for PT values, there were significant differences in favor of the HK in the 60, 180, and 300°/s Ex phases (p < 0.05). In terms of the H/Q and (hamstring/hamstring)/(quadriceps/quadriceps) (HH/QQ) ratios, there were significant differences at 300°/s (p < 0.05). In terms of JAPT, there were significant differences in the 300°/s Ex and 180°/s Flx phases (p < 0.05). In terms of TPT, there were significant differences in the 300°/s Ex phase (p < 0.05). In terms of RD and ER, no significant difference was observed between the HK and ACLR sides at any angular velocity.

CONCLUSIONS

Although differences were observed in PT values, particularly in the Ex phase, this did not cause a significant change in H/Q ratios. Similar results were observed for additional parameters such as JAPT, TPT, RD, and ER. The results show that this ACLR technique can be used in athletes in view of strength gain and a return to sports.

New Considerations in ACL Surgery: When Is Anatomic Reconstruction Not Enough?

➤ Clinicians should be careful to assess for associated injuries including anterolateral complex and medial meniscal ramp lesions or lateral meniscal posterior root tears.➤ Consideration of lateral extra-articular augmentation should be given for patients with >12° of posterior tibial slope.➤ Patients with preoperative knee hyperextension (>5°) or other nonmodifiable risk factors, including high-risk osseous geometry, may benefit from a concomitant anterolateral augmentation procedure to improve rotational stability.➤ Meniscal lesions should be addressed at the time of anterior cruciate ligament reconstruction with meniscal root or ramp repair.

Current trends in graft choice for primary anterior cruciate ligament reconstruction - part II: In-vivo kinematics, patient reported outcomes, re-rupture rates, strength recovery, return to sports and complications

Postoperative patient satisfaction after anterior cruciate ligament reconstruction (ACL-R) is influenced mainly by the degree of pain, the need for reoperation, and functional performance in daily activities and sports. Graft choice has shown to have an influence on postoperative outcomes after ACL-R. While patient reported outcomes measurements do not differ between graft options, evidence shows that normal knee kinematics is not fully restored after ACL-R with an increase in postoperative anterior tibial translation (ATT). Postoperative graft rupture rates seem to favor bone-patella-tendon-bone (BPTB) and quadriceps tendon (QT) autografts over HT or allografts. While return to sports rates seem comparable between different graft types, postoperative extensor strength is reduced in patients with BPTB and QT whereas flexion strength is weakened in patients with HT. Postoperative donor site morbidity is highest in BPTB but comparable between HT and QT. With all graft options having advantages and drawbacks, graft choice must be individualized and chosen in accordance with the patient.

Mid-Term Outcomes of the All-Soft Quadriceps Tendon Autograft Are Noninferior to Hamstring Autograft in Primary Anterior Cruciate Ligament Reconstruction: Comparison With Minimum 5-Year Follow-Up

PURPOSE

To compare the 5-year clinical and functional outcomes of the soft-tissue quadriceps tendon (QT) with those of the hamstring tendon (HT) autograft.

METHODS

A retrospective review of patients undergoing anterior cruciate ligament reconstruction using either soft-tissue QT or double-tendon HT autograft with at least 5 years of follow-up was conducted. Surgical technique included anteromedial portal creation for the femoral tunnel and transtibial technique for the tibia. Graft fixation was achieved with interference composite screws for the QT and combination of interference composite screw and suture button for the HT cohort. The 2 groups were compared for differences in outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, return to sport, and complications.

RESULTS

A total of 37 patients with QT autograft and 46 HT autografts were included in the study, with a mean follow up of 69.9 months and 70.9 months, respectively. The QT group demonstrated a larger graft size on average (9.64 mm vs 7.90 mm, P < .001). The IKDC and Lysholm scores were similar between the 2 groups at 2-years' postoperatively. At 5 years' postoperatively, the QT group demonstrated significantly greater IKDC (P = .018) and Lysholm (P = .007) scores. The cohorts demonstrated similar rates of achieving minimal clinically important difference thresholds at both 2 and 5 years' postoperatively. The 2 groups also demonstrated comparable rates of return to sport, time to return, and postoperative complications.

CONCLUSIONS

Although the QT autograft demonstrated increased patient-reported outcome scores when compared with the HT at 5 years' postoperatively, there was no clinically significant difference between the cohorts at 2 or 5 years' postoperatively. The QT autograft is an effective alternative to HT autograft with noninferior results to the HT autograft at mid-term follow-up.

LEVEL OF EVIDENCE

III, retrospective comparison study.

No difference in patient reported outcomes, laxity, and failure rate after revision ACL reconstruction with quadriceps tendon compared to hamstring tendon graft: a systematic review and meta-analysis

PURPOSE

The purpose of this study was to synthesize and quantitatively assess the outcomes of ACL Revision using a quadriceps tendon (QT) graft and to compare them with those of ACL Revisions performed with hamstring tendons (HT) graft.

METHODS

A comprehensive search based on the PRISMA protocol was performed across PubMed, Scopus, Embase, and Cochrane Library from inception until February 2022. Clinical studies reporting the outcomes of ACL Revision with QT autograft were included. Subjective and Objective IKDC, Tegner activity level, Lysholm knee score, KOOS score, VAS for pain, knee laxity (KT-1000/2000 arthrometer, Lachman test, and pivot-shift test), and graft failure were assessed. A systematic review and meta-analysis were performed and a quality assessment of the included studies was carried out with the MINORS score.

RESULTS

Seven studies met the selection criteria and were included in the systematic review for the qualitative synthesis of data. A pooled mean of all the variables was provided for the 7 studies, while 3 studies included a control group of ACL Revision with HT and were included in a meta-analysis. A total of 420 participants with a mean age of 28.9 ± 10.5 years and a mean postoperative follow-up of 39.3 ± 16.4 months were assessed. Of these, 277 patients underwent ACL Revision with QT and 143 patients underwent ACL Revision with HT. In the QT group, average graft failure was 9.8% compared to 17.4% in the HT group. KOOS Sport and pivot-shift test showed better postoperative outcomes in QT than HT, although it was not statistically significant (p = 0.052).

CONCLUSION

The QT autograft was associated with an improved trend of rotatory laxity, PROMs and failure rate compared to HT autograft after revision ACL reconstruction. The QT autograft for revision ACL reconstruction is supported by the current literature. It is a viable graft that should be considered for both primary and revision ACL reconstruction.

LEVEL OF EVIDENCE

Level IV.

Quadriceps tendon autograft is comparable to hamstring tendon and bone-patella-tendon-bone up to 2 years after isolated primary anterior cruciate ligament reconstruction

PURPOSE

To evaluate the functional and graft survivorship outcomes of the three most common autograft options for primary anterior cruciate ligament reconstruction (ACLR)-hamstring tendon (HT), bone-patella-tendon-bone (BPTB), and quadriceps tendon (QT).

METHODS

Patients captured by the New Zealand ACL registry who underwent a primary ACLR from 2014 to 2020 were considered for the study. Patients with associated knee injury (including meniscus, chondral, osseous, and additional ligamentous injury) and previous knee surgery were excluded. Comparison was made between HT, BPTB, and QT autografts with respect to Marx and KOOS (Knee Osteoarthritis Outcome Score) scores at minimum 2 years follow-up. In addition, graft survivorship was evaluated by comparing all-cause revision per 100 graft years and revision-free proportion at 2 years post-surgery.

RESULTS

2,582 patients (1,921 HT, 558 BPTB, 107 QT) were included in the study. Differences in adjusted functional outcomes between HT and BPTB were found at 12 months (mean Marx; HT 6.2; BPTB 7.1; P < 0.001) (mean KOOS Sport and Recreation; HT 75.1; BPTB 70.5; n.s.) and 24 months (mean KOOS Sports and Recreation; HT 79.2; BPTB 73.9; P < 0.001). QT was comparable to HT and BPTB in all functional scores at 12 months and 2 years. No statistically significant differences were found in revision rate between all three autograft groups up to 2 years post-surgery (revision rate per 100 graft years; HT 1.05; BPTB 0.80; QT 1.68; n.s. HT vs. BPTB; n.s. HT vs. QT; n.s. QT vs. BPTB).

CONCLUSIONS

QT was found to be comparable to both HT and BPTB in all functional scores and revision rates up to 2 years post-surgery.

LEVEL OF EVIDENCE

Level III.

The Associations Between Quadriceps Tendon Graft Thickness and Isokinetic Performance

BACKGROUND

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

HYPOTHESIS/PURPOSE

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

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV.

REGISTRATION

This study was preregistered under PROSPERO with preregistration code CRD42022302078.

Anatomic anterior cruciate ligament reconstruction: Freddie Fu's paradigm

Anterior cruciate ligament (ACL) reconstruction techniques have evolved over the past four decades. There is evidence that non-anatomic reconstruction techniques, such as traditional transtibial drilling, fail to recreate the native anatomy of the ACL, which can lead to increased rotatory knee instability, revision risk, and post-traumatic osteoarthritis. Anatomic ACL reconstruction has emerged as the gold standard, with the goal of restoring the patient's native anatomy and knee kinematics. This review will summarise the relevant anatomy, modern anatomic ACL reconstruction techniques, and literature supporting anatomic ACL reconstruction as the new paradigm. LEVEL OF EVIDENCE: Level V, review article.

Quadriceps tendon autograft with or without bone block have comparable clinical outcomes, complications and revision rate for ACL reconstruction: a systematic review

PURPOSE

The purpose of this systematic review is to report complications, graft failure, fixation methods, rehabilitation protocol, clinical and patient-reported outcomes, and return to sports with the use of quadriceps tendon graft with the bone block (QT-B) and without bone block (QT-S).

METHODS

According to the PRISMA guidelines a comprehensive search was performed across PubMed/MEDLINE, Scopus, EMBASE, and Cochrane Library databases from inception until April 2022. Only prospective studies using quadriceps tendon autograft with a minimum of 20 patients were considered for inclusion. The outcome measures extracted from the studies were the KT-1000, Lysholm score, Subjective and Objective IKDC, Tegner, Marx Score, complications, failures and/or revision surgery, and rate of return to sports. Cochrane risk of bias and MINORS tool were used for the risk of bias assessment of all included studies.

RESULTS

A total of 13 studies were included, consisting of 5 randomized controlled trials, 6 cohort studies, 1 case-control and 1 case series. A total of 484 patients received QT-S in 6 studies of which 224 (46.2%) were males and 212 (43.8%) females with a mean age of 21.5 ± 7.5 (range 14-58). While 243 patients received QT-B in 7 studies of which 167 (68.7%) were males and 76 (31.3%) females with a mean age of 28.9 ± 4.5 (range: 18-49). The studies analyzed had a mean MINORS score of 14.6 (range, 12-19). Both QT-B and QT-S for ACL reconstruction reported satisfactory results in terms of patient-reported outcome measures. Although, a slightly higher anterior laxity was found with the QT-S than with the QT-B.

CONCLUSION

Quadriceps tendon with a bone block (QT-B) or without bone block (QT-S) for ACL reconstruction is supported by current literature. Both grafts are safe and viable options for ACL reconstruction with comparable clinical outcomes, complications and revision rates.

LEVEL OF EVIDENCE

Level IV.

REGISTRATION

PROSPERO-CRD42022347134; https://www.crd.york.ac.uk/prospero/.

GRAFTS FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: SYSTEMATIC REVIEW AND META-ANALYSIS

Objective

This study proposes to systematically review the literature and compare data on (1) function, (2) pain, (3) return to sport, and (4) complications after anterior cruciate ligament (ACL) reconstruction with quadriceps tendon autograft (QT) and hamstring tendon autograft (HT).

Methods

In June 2021, a systematic review of the EMBASE, MEDLINE/PubMed, Cochrane Central Register of Controlled Trials, and LILACS databases was performed, based on PRISMA guidelines. The search strategy included the keywords: "Previous Cruciate Ligament Reconstruction," "ACL reconstruction," "quadriceps tendon autograft," "quadriceps graft," "Hamstring-Tendon Autografts." Meta-analyses were performed using Review Manager software (RevMan Web).

Results

There were no significant differences between the two groups regarding function according to Lysholm score (MD 3.01; CI-0.30, 6.33, p = 0.08), the presence of pain (RR 0.89; CI-0.57, 1.39, p = 0.60), and re-rupture (RR 0.60; IC-0.19, 1.88, p = 0.38).

Conclusion

QT and HT autografts show comparatively good results in ACL reconstruction without significant differences regarding function, pain, and rupture after surgical intervention. Level of Evidence II, Systematic Review of Level II Studies.

All-Soft Tissue Quadriceps Tendon Autograft in Revision Anterior Cruciate Ligament Reconstruction in Athletes: Comparison to Bone-Patellar Tendon-Bone Autograft With at Least a 2-Year Follow-up

BACKGROUND

Revision anterior cruciate ligament (ACL) reconstruction is being performed at an increasing rate. Previous literature has suggested that autograft ACL reconstruction is a better option than allograft in revision surgery, although the optimal autograft choice remains unknown. The all-soft tissue quadriceps tendon (ASTQT) autograft has been found to be an effective option for primary ACL reconstruction. However, few studies have evaluated ASTQT autograft in revision ACL reconstruction.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate the ASTQT autograft in revision ACL reconstruction in athletes compared with bone-patellar tendon-bone (BTB) autograft. We hypothesized that the ASTQT autograft would lead to similar return to play, time to return to play, retear rate, and patient-reported outcomes compared with BTB autograft.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective study was performed on all athletes undergoing revision ACL reconstruction between August 2013 and December 2019 at a single institution. Patients participating in high school or college athletics undergoing first-time revision with either ASTQT or BTB autograft with ≥2 years of follow-up were included. Demographic variables, complications, return to sports, and outcome scores including the International Knee Documentation Committee (IKDC) and Lysholm were collected and compared between the 2 cohorts.

RESULTS

A total of 58 revision ACL reconstructions were included, with 32 in the ASTQT cohort and 26 in the BTB cohort. Return to sports at the same level occurred in 62.5% of the ASTQT group and 53.8% of the BTB group. The ASTQT group returned to sports significantly faster than the BTB group (8.9 vs 10.3 months; P = .020). There was no difference in retear rates (3.1%, ASTQT; 7.7%, BTB) or other complications between the 2 groups. The IKDC scores were significantly higher at the 6- and 12-month follow-up for the ASTQT autograft group compared with the BTB group (6 months: ASTQT, 71.3; BTB, 61.7, P = .001; 12 months: ASTQT, 82.7; BTB, 78.6; P = .021). Lysholm scores were also greater in the ASTQT cohort at these time points (6 months: ASTQT, 75.1; BTB, 63.6; P < .001; 12 months: ASTQT, 82.0; BTB, 74.5; P < .001). However, IKDC and Lysholm scores were similar between both groups at final follow-up (IKDC: ASTQT, 82.9; BTB, 81.7; P = .344; Lysholm: ASTQT, 83.0; BTB, 81.0; P = .104) There was no significant clinical difference in the absolute difference in scores or rate of achieving clinical thresholds between the 2 cohorts.

CONCLUSION

ASTQT autograft for revision ACL in athletes has similar outcomes compared with BTB autograft. However, the ASTQT may possibly afford quicker return to sports and better early improvements in patient-reported outcomes that normalize by 1 year. The soft tissue quadriceps autograft should be considered a viable graft option in revision ACL reconstruction in athletes.

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.

Functional Outcome of All-Soft-Tissue Quadriceps Tendon Autograft in ACL Reconstruction in Young and Athletic Patients at a Minimum Follow-Up of 1 Year

To investigate the functional outcome in young and athletic patients with ACL injuries, treated with an all-soft-tissue quadriceps tendon autograft at a minimum follow-up of 12 months. Methods: Patients who received a QT autograft ACL reconstruction between August 2018 and December 2020 were included in this study. Range of motion in the operated knee was described at 6 and 18 weeks after surgery and the functional outcome parameters (Lysholm score, IKDC score and Tegner activity scale) were calculated at 6 and ≥ 12 months after surgery. Results: Forty patients were included in this study, of which 29 identified as male and 11 as female. The average age was 31.3 years (range 16 to 57 years) and the mean follow-up time was 16.8 months (range 12 to 30 months). All functional outcome scores showed improvement over the course of the follow-up: Lysholm score 94.2 to 95.5 (n.s.), IKDC score 90.1 to 93.9 (n.s.), Tegner activity scale 3.7 to 5.0 (p > 0.001), all at six months and ≥12 months. No reruptures happened during the time of the follow-up. Conclusions: This study shows that the all-soft-tissue quadriceps tendon autograft technique can improve functional outcome in young and athletic patients with an ACL injury at short to intermediate follow-up.

Functional and clinical outcome of anterior cruciate ligament reconstruction with peroneus longus autograft and correlation with MRI after 3 years

Introduction

Autograft options for anterior cruciate ligament reconstruction over the years have gone from bone-patellar tendon-bone to hamstring to peroneus longus tendon. Considering the drawbacks of other autografts, we analyse peroneus longus autograft holistically as a viable alternative.

Materials and methods

This was a prospective study of 113 patients undergoing anterior cruciate ligament reconstruction with peroneus longus autograft between January 2017 and November 2018 for isolated, full-thickness ACL tears. Functional analysis was done using the Tegner-Lysholm score pre-operatively, at 6 months, 1 year, 2 years, and 3 years postoperatively. At terminal follow-up, stability was checked clinically by Lachman test, residual morbidity of donor site was assessed using foot and ankle disability index, and radiographic correlation was done with magnetic resonance imaging.

Results

The mean diameter of the graft after tripling was 9 ± 0.71 mm and the average length before tripling was found to be 27.07 ± 2.76 cms. At terminal follow-up, 101 patients showed excellent, while 12 patients showed good outcomes. The mean foot and ankle disability index was 94.8 ± 3. 90.27% of patients had no laxity on clinical examination, and magnetic resonance imaging of all the patients at terminal follow-up showed good graft uptake.

Conclusions

Peroneus longus autograft shows intraoperative consistency and gives excellent functional outcome, clinical stability, and no donor site morbidity even three years postoperatively.

Quadriceps tendon autograft for pediatric anterior cruciate ligament reconstruction results in promising postoperative function and rates of return to sports: A systematic review

PURPOSE

To assess the performance of the quadriceps tendon (QT) autograft in pediatric anterior cruciate ligament reconstruction (ACLR).

METHODS

A systematic search of MEDLINE, PubMed, and EMBASE was conducted on March 1, 2021. Studies of all levels of evidence reporting outcomes and/or complications after QT autograft ACLR in pediatric patients (≤ 18 years old) were eligible for inclusion. Study demographics, patient demographics, reported outcomes, and complications were abstracted. Screening and data abstraction were designed in accordance with PRISMA and R-AMSTAR guidelines. Descriptive statistics were presented when applicable, with data for heterogeneous outcomes presented in narrative summary fashion.

RESULTS

A total of 14 studies examining 596 patients (46.3% female), mean age 15.4 years, were included in this systematic review. Mean postoperative Lysholm scores ranged from 94.0 to 99.5. Mean postoperative IKDC subjective scores ranged from 75.9 to 94.0. Limb symmetry index ranged from 96.8 ± 10.4 to 100.4 ± 7.6% across multiple hop tests. Return to sports (RTS) rates ranged from 88.9 to 91.7%. Eleven studies reported postoperative complications, whereby 16 patients (4.8%) experienced contralateral complications and injuries. Forty-six patients (9.4%) experienced ipsilateral complications, including ten graft failures (2.5%) and two growth disturbances (0.6%).

CONCLUSIONS

QT autograft ACLR in the pediatric population retains the potential of regaining a preinjury level of knee stability, and yields promising postoperative function and rates of RTS, yielding comparable outcomes relative to HT autograft and the reference-standard BPTB ACLR that have previously been described in the literature. Moreover, use of the QT autograft is associated with low rates of postoperative complications, including graft failure and growth disturbances in this active and high-risk patient population in observational studies to date. Therefore, clinical equipoise exists to further appraise the influence of QT autograft on postoperative outcomes compared to aforementioned autograft options in a randomized control trial fashion.

LEVEL OF EVIDENCE

IV.

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.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Clinical Relevance

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

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

BACKGROUND

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

HYPOTHESIS

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

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

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

RESULTS

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

CONCLUSION

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

Traditional and Additional Isokinetic Knee Strength Assessments of Athletes; Post-Operative Results of Hamstring Autograft ACL Reconstruction

Background and Objectives: Anterior cruciate ligament (ACL) injuries are common injuries in athletes, and, accordingly, ACL reconstruction (ACLR) is one of the most common orthopedic surgical procedures performed on athletes. This study aims to compare the 6-month post-operative isokinetic knee strength evaluations of the semitendinous/gracilis (ST/G) ACLR technique performed on healthy (HK) and ACLR knees of athletes. Materials and Methods: A retrospective cohort of 29 athletes from various sports branches who underwent ST/G ACLR technique by the same surgeon were evaluated. The isokinetic knee extension (Ex) and flexion (Flx) strength of the patients on the HK and ACLR sides were evaluated with a series consisting of three different angular velocities (60, 180, and 240°/s). In addition to the traditional evaluations of peak torque (PT) and hamstring/quadriceps (H/Q) parameters, the findings were also evaluated with additional parameters such as the joint angle at peak torque (JAPT), time to peak torque (TPT), and reciprocal delay (RD). Results: There was a significant improvement in the mean Lysholm, Tegner, and IKDC scores after surgery compared with preoperative levels (p < 0.05). As for the isokinetic PT values, there were significant differences in favor of HK in the 60°/s Flx, 180°, and 240°/s Ex phases (p < 0.05). In addition, there was a significant difference in the 60° and 180°/s Flx phases in RD (p < 0.05). In H/Q ratio, TPT, and JAPT values, no significant difference was observed between HK and ACLR at all angular velocities. Conclusions: The findings showed that the ST/G 6-month post-operative isokinetic knee strength in athletes produced high results in HK, and, when evaluated in terms of returning to sports, the H/Q ratios on the ACLR side were sufficient to make the decision to return to sports. It was found that the ACLR side was slower than the HK side in the reciprocal transitions, particularly in the Flx phase. We believe that this results from the deformation of the hamstring muscle after reconstruction of the ST/G ACLR side.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Clinical Relevance

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

Optimal Graft Choice in Athletic Patients with Anterior Cruciate Ligament Injuries: Review and Clinical Insights

Anterior cruciate ligament (ACL) rupture is a common sporting-related knee injury with a potentially detrimental impact on the athlete’s career, yet there is no formal consensus on the optimal graft choice for reconstructing the ruptured ACL in this specific population. Options for reconstruction include autograft, allograft, and artificial grafts. However, each has associated failure risk and donor site morbidity. Our operational definition of the athlete is a skeletally mature individual participating in high level activity with the expectation to return to pre-injury level of activity. The athlete has unique injury characteristics, post-operative expectations, and graft demands that differ to the general population. Long-term outcomes are of particular importance given on-going mechanical demands on the reconstructed knee. Therefore, the purpose of this review is to consolidate current literature on the various ACL reconstruction graft options, with a focus on the optimal graft for returning the athlete to activity with the lowest rate of re-injury.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

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

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

Quadriceps tendon vs hamstring autograft in primary ACL reconstruction – a comparative study with minimum two-year follow-up

Recently there has been growing interest in the quadriceps tendon (QUAD) as a valid option for reconstruction of the anterior cruciate ligament (ACLR). The aims of the study is to compare the out- comes achieved in anatomic ACLR involving QUAD vs. Hamstring (HT) autografts. A total of 52 consecutive patients underwent an ACLR, 25 patients with QUAD graft and 27 with HT graft. The same surgical technique, fixation method and postoperative protocol were used in both groups. The following parameters were evaluated: functional status (Lysholm, Tegner, subjective IKDC scores), joint stability (Lachman and pivot shift tests), surgical reoperation rate, complications, degree of satisfaction and return to previous level of activity. Descriptive statistics were analysed using the Student’s t-test. Forty four patients were evaluated (20 QUAD, 24 HT), with a mean follow-up of 27.4 months. Two patients were re-operated in the QUAD group (including one ACL revision), and one patient in the HT group required an ACL revision. There were no significant differences between the two groups in postoperative scores: Lysholm (96.05 vs. 96.05), IKDC (86.2 vs. 91.2) and Tegner (6 vs. 5) scales. The percentage of negative Lachman and pivot shift tests was similar in the two groups (45% vs. 50% and 40% vs. 45.8%, respectively). There were no significant differences between the groups in the degree of satisfaction (95.8% vs. 80%, p = .16) or in the percentage who returned to their previous level of activity (62.5% vs. 45%, p = .17). The use of a QUAD graft in ACL reconstruction leads to similar clinical and functional outcomes to those obtained with HT.

Is contralateral autogenous patellar tendon graft a better choice than ipsilateral for anterior cruciate ligament reconstruction in young sportsmen? A randomized controlled trial

AIM

The aim of this study was to compare the peak extensor torque (primary outcome), sensory-motor capacity and Lysholm questionnaire score up to the fourth postoperative month post-primary anterior cruciate ligament reconstruction (ACLR) with bone-patellar-tendon-bone (BPTB) graft using either ipsilateral or contralateral technique in young sportsmen.

METHODS

We performed a randomized controlled trial from 2018 to 2019. The same preoperative protocol, surgical technique and postoperative protocol were used in both groups. Eighty-eight young adult male patients were randomized, and 44 of each group completed the trial.

RESULTS

After the follow up analysis, the contralateral receptor and donor limb demonstrated a statistically significant increase in peak extension torque compared with the ipsilateral operated limb (effect size (ES) = 0.99, power = 0.99, P < 0.0001; ES = 0.46, power = 0.56, P < 0.04). The symmetry between limbs was compared between groups. In the contralateral group, there was a significant decrease in the recipient limb (after surgery), compared with the donor limb (before surgery) (ES = 0.87, power = 0.99, P < 0.0001). In the ipsilateral group, the operated limb demonstrated a significant decrease in peak extension torque compared with the non-operated limb after surgery (ES = 1.88, power = 0.99, P < 0.0001). The comparison between groups in sensory-motor capacity and Lysholm score demonstrated a non-significant group effect postoperatively.

CONCLUSION

The use of contralateral BPTB is more effective in increasing peak extension torque when compared with ipsilateral technique in young sportsmen. Furthermore, patients achieved greater symmetry (side to side) in quadriceps muscle performance after the 4-month follow up with a contralateral graft.

Quadriceps Tendon Anterior Cruciate Ligament Reconstruction: A Systematic Review of Postoperative Rehabilitation and Complication Profiles

PURPOSE

The purposes of this study are to explore current elements for postoperative rehabilitation protocol after quadriceps tendon-anterior cruciate ligament reconstruction (QT-ACLR), outline general timelines for progression of those elements, and explore their associated complication rates and profiles.

METHODS

In accordance with PRISMA guidelines, 5 online databases (EMBASE, MEDLINE, CINAHL, Cochrane, and PubMed) were searched and screened in duplicate using predetermined criteria for studies on the aforementioned patient population. Descriptive statistics are presented.

RESULTS

A total of 56 studies were included, with 31 studies using quadriceps tendon with bone block (B-QT) and 26 studies using all-soft tissue quadriceps tendon (S-QT). The majority of studies permitted full weightbearing and range of motion (ROM) within the first 12 postoperative weeks, and motion-controlled braces within 6 weeks. Isometric exercises were initiated within 1 week after surgery, closed-chain exercises within 12 weeks, and open-chain and sports-specific exercises within 36 weeks. Complication profiles were similar between graft types and included graft failure (1.2%-1.6%), cyclops syndrome (0.4%-0.7%), and persistent stiffness (0.9%).

CONCLUSIONS

Current postoperative rehabilitation strategies in ACLR with QT offer a complication profile comparable to those reported with other graft types. Based on the included rehabilitation regimen, these protocols should focus on early ROM, specifically on achieving full extension, alongside isometric quadriceps strengthening. Progression to closed- and open-chain exercises should follow in a progressive manner, similar to existing protocols in ACLR. Adjuncts such as motion-controlled bracing and continuous passive motion machines may be used if graft protection is prioritized. This review highlights the need for comparison of defined protocols against one another in the setting of QT-ACLR.

LEVEL OF EVIDENCE

IV, systematic review of Level I-IV studies.

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.

Quadriceps Strength following Anterior Cruciate Ligament Reconstruction: Normative Values based on Sex, Graft Type and Meniscal Status at 3, 6 & 9 Months

Background

Higher postoperative quadriceps function has been positively associated with surgical outcomes after anterior cruciate ligament reconstruction (ACLR). However, the impact of autograft harvest and/or a concomitant meniscal procedure on the recovery of quadriceps strength is not well defined.

Purpose

To describe postoperative recovery of quadriceps strength following ACLR related to autograft selection, meniscal status, and sex.

Study Design

Retrospective Cohort.

Methods

One hundred and twenty-five participants who underwent ACLR with either a hamstring tendon (HT), bone-patellar tendon-bone (BPTB) or quadriceps tendon (QT) autograft were included. At postoperative months 3, 6 and 9, each participant completed an isometric quadriceps strength testing protocol at 90-degrees of knee flexion. Participants' quadriceps average peak torque (Q-AvgPKT), average peak torque relative to body weight (Q-RPKT), and calculated limb symmetry index (Q-LSI) were collected and used for data analysis. Patients were placed in groups based on sex, graft type, and whether they had a concomitant meniscal procedure at the time of ACLR. At each time point, One-way ANOVAs, independent samples t-test and chi-square analyses were used to test for any between-group differences in strength outcomes.

Results

At three months after ACLR, Q-RPKT was significantly higher in those with the HT compared to the QT. At all time points, males had significantly greater Q-RPKT than females and HT Q-LSI was significantly higher than BPTB and QT. A concomitant meniscal procedure at the time of ACLR did not significantly affect Q-LSI or Q-RPKT at any testing point.

Conclusion

This study provides outcomes that are procedure specific as well as highlights the objective progression of quadriceps strength after ACLR. This information may help better-define the normal recovery of function, as well as guide rehabilitation strategies after ACLR.

Level of Evidence

3.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

III, retrospective cohort study.

Prediction of quadriceps tendon-patellar bone autograft diameter in adolescents with 2-dimensional magnetic resonance imaging and anthropometric measures

OBJECTIVES

This study evaluates the correlation between the bone end and soft tissue end of the quadriceps tendon-patellar bone autograft (QPA) size and pre-operative MRI measurements of the quadriceps tendon along sections to be included in the graft harvest in adolescents. We also assessed association between graft diameter and anthropometric measures (height, weight, and BMI), age, and sex.

METHODS

Patients (10-18 years) who underwent QPA ACL reconstruction and had a pre-operative MRI were considered for inclusion. Age, height, and weight, tibial and femoral side graft diameter, and patellar bone block dimensions were collected. Using a pre-operative 2D sagittal plane MRI, we measured the quadriceps at 10-mm increments above the patella, up to 40 mm. We assessed correlation between the bone-end graft diameter and the AP measure at 10 mm above the patella, and correlation between the soft-tissue end graft diameter and the most proximal AP measure.

RESULTS

A total of 103 patients were included. A significant correlation between the soft-tissue side graft diameter and most proximal AP measurement was observed (r_s = 0.51; p < 0.001). However, measurements significantly underestimated the soft-tissue end graft diameter (9.6 ± 0.8 vs. 7.4 ± 1.1; p < 0.001). There was no correlation between the bone-end graft diameter and AP measurement 10 mm above the patella. Anthropometric measures were not associated with graft size. Skeletal maturity was associated with smaller graft size (p = 0.08).

CONCLUSION

Soft-tissue end graft diameter is associated with the AP measure of the quadriceps at 20-40 mm above the superior pole of the patella.

A Comparison of Two-Year Anterior Cruciate Ligament Reconstruction Clinical Outcomes Using All-Soft Tissue Quadriceps Tendon Autograft With Femoral/Tibial Cortical Suspensory Fixation Versus Tibial Interference Screw Fixation

PURPOSE

To contribute to future quadriceps tendon harvest and fixation guidelines in the setting of anterior cruciate ligament reconstruction by comparing 2-year patient-reported subjective knee outcome scores and incidence of graft-related complications between the shorter harvest all-inside tibial-femoral suspensory fixation (TFSF) approach versus the longer harvest standard tibial interference screw fixation technique.

METHODS

Patients who underwent primary anterior cruciate ligament reconstruction with all soft tissue quadriceps tendon autograft from January 2017 to May 2019 were identified for inclusion. Patients were matched into 2 cohorts of 62 based on reconstruction technique. All patients completed baseline and minimum 2-year International Knee Documentation Committee, Tegner Activity Level, and Lysholm questionnaires and were queried regarding subsequent procedures and complications to the operative knee.

RESULTS

Average graft length for the all-inside TFSF was 69.55 (95% confidence interval 68.99-70.19) mm versus 79.27 (95% confidence interval 77.21-81.34) mm in the tibial screw fixation cohort (P = .00001). Two-year Lysholm scores were greater in the TFSF cohort (P = .04) but were not clinically significant. There was no difference in 2-year International Knee Documentation Committee (P = .09) or Tegner (P = .69) scores between cohorts, but more patients in the TFSF cohort returned to or exceeded their baseline activity level compared with the tibial screw fixation cohort (73% vs 61%, P = .25). Seven patients in the TFSF cohort versus 13 in the tibial screw fixation cohort reported anterior knee pain or kneeling difficulty (P = .22). There were no differences in reported complications.

CONCLUSIONS

All-inside soft-tissue quadriceps tendon autograft with TFSF resulted in clinically comparable subjective outcome scores at 2 years to tibial screw fixation. There were also no differences in complications or reports of anterior knee pain or kneeling difficulty. All-inside TFSF can be a viable alternative to tibial screw fixation for all-soft tissue quadriceps autograft.

LEVEL OF EVIDENCE

III, comparative therapeutic trial.