Patellar Fractures After the Harvest of a Quadriceps Tendon Autograft With a Bone Block: A Case Series

Complications in Anterior Cruciate Ligament Surgery and How to Avoid Them

Complications following anterior cruciate ligament (ACL) reconstruction can be detrimental to a patient's recovery and limit their ability to successfully return to sport. Arthrofibrosis, graft failure, and infection are a few examples of complications that can arise. Therefore, it is important for surgeons to recognize that each step during perioperative surgical decision making can impact patients' risk for such complications. The purpose of this paper is to discuss common complications following ACL reconstruction and how surgeons can avoid or reduce the risk of complications.

Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: 3-Year Clinical and Patient-Reported Outcomes

BACKGROUND

The rate of anterior cruciate ligament (ACL) rupture in active, skeletally immature patients is increasing. Although hamstring tendon autograft (HTA) was previously deemed the gold standard, recent studies have shown HTA to have a high failure rate in this high-risk population of young competitive athletes, and quadriceps tendon autograft (QTA) has yielded excellent preliminary outcomes in some studies examining this population.

PURPOSE

To evaluate 3-year clinical and patient-reported functional outcomes of primary ACL reconstruction (ACLR) with soft tissue QTA in skeletally immature patients.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Skeletally immature patients who underwent ACLR with a full-thickness soft tissue QTA were included. Preoperative patient and surgical data were collected. The ACLR technique was selected predicated upon skeletal age and included all-epiphyseal and complete transphyseal techniques. Patients were followed for a minimum of 2 years with successive clinical visits or were contacted via telephone. Patients who did not have minimum 2-year follow-up after 3 contact attempts via telephone were excluded. Information regarding return to sports (RTS) and concomitant or subsequent surgical procedures was collected. Pediatric International Knee Documentation Committee (Pedi-IKDC), Hospital for Special Surgery Functional Activity Brief Scale (HSS Pedi-FABS), and Single Assessment Numeric Evaluation (SANE) scores were collected.

RESULTS

Of 85 adolescent patients aged 11.1 to 17.6 years (mean age, 14.1 ± 1.2 years), 2 patients were determined to be lost to follow-up after 3 failed contact attempts. Of the patients included in this study (N = 83), 26 patients (31%) underwent all-epiphyseal and 57 patients (69%) underwent complete transphyseal ACLR. Additionally, 48 patients (58%) underwent concomitant lateral extra-articular tenodesis using the iliotibial band with a modified Lemaire technique. The mean follow-up time was 3.7 ± 1.2 years (range, 2-7 years). Twenty (24%) patients had subsequent surgical procedures, of which 3 (4%) were due to graft failures. At a mean 3-year follow-up, the mean Pedi-IKDC, HSS Pedi-FABS, and SANE scores were 90, 23, and 94 respectively; the RTS rate was 100%; and the rate of RTS at the previous level of performance was 93%.

CONCLUSION

Use of a soft tissue QTA for ALCR in a high-risk skeletally immature population of athletes resulted in excellent postoperative outcomes with low rates of graft failure and high return to sport rates.

A Comparative Analysis of Quadriceps Tendon, Patellar Tendon Bone Allograft, and Cadaver Graft in Anterior Cruciate Ligament (ACL) Repair and Reconstructive Surgery

Anterior cruciate ligament (ACL) injuries are a common occurrence among athletes and active individuals, often necessitating surgical intervention for optimal recovery. The choice of graft material for ACL reconstruction remains a topic of debate, with various options available, including quadriceps tendon (QT), patellar tendon bone allograft (PTBA), and cadaver graft (CG). This paper aims to provide an extensive review and comparison of the efficacy, outcomes, and complications associated with these graft types based on recent research. A systematic literature search following PRISMA guidelines was conducted to identify relevant studies published in the past six years. The findings suggest that while each graft type has its advantages and limitations, there is no definitive superior choice. Factors such as patient age, activity level, comorbidities, and surgeon preference should be considered when selecting the most appropriate graft for ACL repair surgery. QT grafts are associated with lower donor-site morbidity compared to patellar tendon grafts. However, QT grafts may have a higher risk of graft rupture and decreased knee flexion strength. PTBA grafts, compared to QT grafts, have a higher risk of donor-site morbidity but a lower risk of graft rupture and improved knee stability. CG grafts have lower donor-site morbidity compared to PTBA grafts but may have a higher risk of graft rupture and decreased knee flexion strength compared to PTBA grafts. In conclusion, the choice of graft material for ACL reconstruction is a complex decision that requires careful consideration of various factors, including patient age, activity level, comorbidities, and surgeon preference. While each graft type has its advantages and limitations, there is no definitive superior choice. Therefore, it is essential to carefully weigh the risks and benefits of each graft type to ensure optimal outcomes for patients undergoing ACL repair surgery.

Minimally Invasive Quadriceps Tendon Anterior Cruciate Ligament Reconstruction Using the Quadriceps Tendon Harvest Guide System

Anterior cruciate ligament (ACL) reconstruction using the quadriceps tendon (QT) autograft is an increasingly utilized technique that confers less donor site morbidity and comparable outcomes to other historically used graft options. The graft harvest and implantation process present vast variability-particularly regarding the achievement of adequate graft site visualization, consistently attaining a uniform and appropriately sized graft, and subsequent reconstruction of the ACL with the all-soft tissue graft. The purpose of this Technical Note and video is to describe and demonstrate minimally invasive quadriceps tendon autograft harvesting using the Quadriceps Tendon Harvest Guide System (QUADTRAC), and its subsequent implantation within a single-bundle ACL reconstruction with suspensory fixation.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Clinical Relevance

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

Minimally Invasive Quadriceps Tendon Harvest for Anterior Cruciate Ligament Reconstruction Using the Quadriceps Tendon Harvest Guide (QUADTRAC) System and Repair Augmentation With a Bioinductive Implant

Quadriceps tendon autografts are an increasingly popular choice for anterior cruciate ligament (ACL) reconstruction, with decreased donor-site morbidity alongside good patient outcomes. Although harvesting of the tendon can be done in a minimally invasive fashion, this introduces some difficulty with visualization and consistency of graft sizing. The purpose of this Technical Note and video is to provide a method of quadriceps tendon autograft harvesting using the Quadriceps Tendon Harvest Guide System (QUADTRAC) in a single-bundle ACL reconstruction.

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.

A Comprehensive Physiotherapeutic Rehabilitation Protocol for Malunited Post-operative Patellar Fractures: A Case Report

A patellar fracture is a fracture of the kneecap. The patella is a shield that plays a vital function in the biomechanics of the knee joint. Traumatic knee injuries produced by direct trauma or quick quadriceps contraction with the knee bent can result in the loss of the extensor mechanism. A 69-year-old female patient presented with pain in her right knee following a slip at her home, which resulted in an injury to her knee. Subsequently, a radiological investigation suggests a patellar fracture. The purpose of this case report is to investigate the rehabilitation techniques and concrete the result. This report emphasizes the value of a comprehensive rehabilitation program designed to assist people with this type of fracture pattern in reaching their peak operational capacity. The patient underwent a comprehensive rehabilitation regimen that included cryotherapy, range of motion exercises, strengthening exercises, gait training, balance and proprioception training. The functional outcomes were assessed using a visual analogue scale, goniometry, manual muscle testing, Berg balance scale and lower extremity functional scale. The patient exhibited significant improvement and a positive response to the therapeutic techniques and outcome assessments. This underscores the necessity for a well-rounded treatment approach to manage patellar fractures and optimize patient outcomes effectively.

Harvest location has a minimal impact on differences in cross-sectional area of quadriceps tendon in anterior cruciate ligament reconstruction

PURPOSE

Anterior cruciate ligament (ACL) reconstruction with quadriceps tendon (QT) has been gaining popularity. However, it is unknown how differences in harvest location of the QT affect its thickness and cross-sectional area (CSA). The present study aimed to clarify the differences in thickness and CSA of the QT based on location of tendon harvesting.

METHODS

Patients scheduled for, or who underwent, ACL reconstruction were prospectively included in the study. The short-axis images on ultrasound were used to assess the CSA of the QT at 30 and 60 mm proximal to the superior pole of the patella. QT autografts with CSAs greater than or equal to 10 mm of width were included and measured at three different locations, namely the center, medial one-third, and lateral one-third at the widest diameter of the QT. Patients with less than 10-mm width of the QT at 60 mm proximal to the superior pole of the patella were excluded. The thickness and CSA were compared based on the location of tendon harvest.

RESULTS

Thirty-seven patients were recruited for the study. The mean thickness and CSA were larger in the center of the QT compared to the lateral one-third at 30 mm proximal to the superior pole of the patella (thickness, 6.7 ± 1.3 mm vs. 5.9 ± 1.3 mm; P = 0.009; CSA, 65.6 ± 11.4 mm2 vs. 58.8 ± 11.9 mm2; P = 0.036). There were no significant differences in thickness and CSA of the QT among the three assessment locations at 60 mm proximal to the superior pole of the patella (n.s.).

CONCLUSION

The thickness and CSA of QT was greater in the center compared to the lateral one-third at 30 mm proximal to the QT insertion point. However, the difference in value was clinically non-significant, and therefore, harvest location of the QT autograft may not meaningfully impact intraoperative graft diameter. As a result, surgeons may choose the harvest location without concern for resultant graft diameter as long as the enough length of QT is secured.

LEVEL OF EVIDENCE

III.

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.

Knee Extensor Mechanism Complications After Autograft Harvest in ACL Reconstruction: A Systematic Review and Meta-analysis

Background

Existing systematic reviews have sought to characterize the relative donor-site morbidity of bone-patellar tendon-bone (BTB) and quadriceps tendon (QT) grafts after anterior cruciate ligament reconstruction (ACLR). However, no studies have reported the pooled proportions of patellar fractures and donor tendon ruptures across the body of literature.

Purpose

To estimate the proportion of patellar fractures, patellar tendon ruptures, and QT ruptures associated with BTB or QT autograft harvest during ACLR using published data.

Study Design

Systematic review; Level of evidence, 4.

Methods

A meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using 3 online databases (PubMed, Scopus, and Web of Science). A total of 800 manuscripts were included in the initial research of peer-reviewed articles in English that reported extensor mechanism complications associated with graft harvest in patients after ACLR. Pooled proportions of patellar fractures, patellar tendon ruptures, and QT ruptures were calculated for each graft type (BTB, QT) using a random-effects model for meta-analysis.

Results

A total of 28 studies were analyzed. The pooled proportion of patellar fractures was 0.57% (95% CI, 0.34%-0.91%) for the BTB harvest and 2.03% (95% CI, 0.78%-3.89%) for the QT harvest. The proportion of patellar tendon ruptures was 0.22% (95% CI, 0.14%-0.33%) after the BTB harvest, and the proportion of QT ruptures was 0.52% (95% CI, 0.06%-1.91%) after the QT harvest. The majority of included studies (16/28 [57.1%]) had an evidence level of 4.

Conclusion

Based on the current literature, the proportion of extensor mechanism complications after ACLR using either a BTB or a QT autograft is low, indicating that the extensor mechanism harvest remains a safe option. A higher proportion of patellar fractures was noted for QT grafts and a higher proportion of donor tendon ruptures was noted for QT grafts compared with BTB grafts.

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.

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.

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/.

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level II, diagnostic, prospective cohort study.

Lateral Harvest of an Osseous-Based Quadriceps Tendon Autograft Results in Thinner Remaining Patellar Bone

Background:

Patellar fracture after quadriceps tendon (QT) autograft harvest for anterior cruciate ligament reconstruction (ACLR) has been reported in up to 8.8% of patients.

Purpose:

To determine the thickness of the remaining patellar bone across the QT graft harvest location while providing clinical guidance for safely harvesting a patellar bone block when using a QT graft in ACLR.

Study Design:

Descriptive laboratory study.

Methods:

Medial and lateral QT graft boundaries were marked using a bone saw on 13 cadaveric patellae, and 3-dimensional computed tomography models were created. After the harvest of a virtual bone block with a maximum depth of 10 mm, the thickness of the remaining bone was measured across the graft harvest location in 9 zones. The thickness of the remaining bone was analyzed according to zone, graft harvest location, and patellar facet length. Risk zones were defined as <50% total patellar depth remaining.

Results:

We observed substantial variability in QT bone block harvest location, in which the distance between the lateral boundary of the harvest location and the lateral patellar cortex was from 21.2% to 49.2% of the axial patellar width. There was significantly less bone remaining in the lateral columns (mean ± SD, 7.56 ± 2.19 mm) compared with the medial columns (9.83 ± 2.10 mm) of the graft harvest location (P = .028). The number of risk zones was significantly associated with distance to the lateral cortical edge, with an increase in 0.59 zones with every 1-mm decrease in distance to the lateral cortex edge (b = -0.585; R² = 0.620; P = .001). With every 1-mm increase in the distance of the lateral cortex to the lateral graft boundary, the thickness of bone remaining in the lateral column increased by 0.412 mm (P < .001). No risk zones were encountered when the lateral boundary of the harvest location was created 18.9 mm from the lateral edge of the patella or 43% of the total patellar width from the lateral edge.

Conclusion:

Harvest of a more laterally based QT autograft bone block resulted in thinner remaining patellar thickness, increasing the potential of encountering a risk zone for fracture.

Clinical Relevance:

Care should be taken to avoid harvesting the patellar bone block too laterally during ACLR.

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.

Morphological Evaluation of the Quadriceps Tendon Using Preoperative Ultrasound in Anterior Cruciate Ligament Reconstruction

BACKGROUND

An evaluation of quadriceps tendon (QT) morphology preoperatively is an important step when selecting an individually appropriate autograft for anterior cruciate ligament (ACL) reconstruction. However, to our knowledge, there are no studies that have assessed the morphology of the entire QT in an ACL-injured knee preoperatively using ultrasound.

PURPOSE

We aimed to investigate the morphological characteristics of the QT using preoperative ultrasound in ACL-injured knees.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 33 patients (mean age, 26.0 ± 11.5 years) with a diagnosed ACL tear undergoing primary ACL reconstruction were prospectively included. Using ultrasound, short-axis images of the QT were acquired in 10-mm increments from 30 to 100 mm proximal to the superior pole of the patella. The length of the QT was determined by 2 contiguous images that did and did not contain the rectus femoris muscle belly. The width of the superficial and narrowest parts of the QT, the thickness of the central and thickest parts of the QT, and the cross-sectional area at the central 10 mm of the superficial QT width were measured at each assessment location. The estimated intraoperative diameter of the QT autograft was calculated using a formula provided in a previous study.

RESULTS

There were no significant relationships between QT morphology and any of the demographic data collected. The length of the QT was less than 70 mm in 45.5% of patients (15/33). The width, thickness, cross-sectional area, and estimated intraoperative diameter of the QT autograft were significantly greater at 30 mm than at 70 mm proximal to the superior pole of the patella.

CONCLUSION

Preoperative ultrasound may identify a QT that is too small for an all-soft tissue autograft in ACL reconstruction. Furthermore, harvesting a QT with a fixed width may result in autografts that are smaller proximally than they are distally. Assessing the morphology of the QT preoperatively using ultrasound may help surgeons to adequately reconstruct the native length and diameter of the ACL with a QT autograft.

Double-Layered Quadriceps Tendon Autografts Provide Lower Failure Rates and Improved Clinical Results Compared With Hamstring Tendon Grafts in Revision ACL Reconstruction

Background:

We developed a quadriceps-tendon graft technique using a double-layered, partial-thickness, soft tissue quadriceps tendon graft (dlQUAD) for anterior cruciate ligament reconstruction (ACLR). This technique allows simple femoral loop button fixation and a limited harvest depth of the quadriceps tendon.

Purpose:

To evaluate the outcome of patients undergoing revision ACLR using the dlQUAD technique compared with a hamstring tendon graft (HT).

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 114 patients who underwent revision ACLR between 2017 and 2018 were included in this retrospective case series. At a mean follow-up of 26.9 ± 3.7 months (range, 24-36), 89 patients (dlQUAD: n = 43, HT: n = 46) were clinically examined. In addition, patients completed the Lysholm score, Tegner activity scale, subjective International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score, and visual analog scale (VAS) for pain. Postoperative failure of the revision ACLR was defined as a side-to-side difference (SSD) in Rolimeter testing ≥5 mm or a pivot-shift grade of 2 or 3.

Results:

Nine patients (10.1%) were identified with a failed revision ACLR. There was a significantly lower failure rate with dlQUAD versus the HT group (2.3% vs 17.4%; P = .031). The mean postoperative SSD was significantly less in the dlQUAD group (1.3 ± 1.3 mm [range, 0-5] vs 1.8 ± 2.2 mm [range, 0-9]; P = .043). At the latest follow-up, Tegner and IKDC scores significantly improved in the dlQUAD group compared with the HT group (Tegner: 5.8 ± 1.8 vs 5.6 ± 1.5; P = .043; IKDC: 83.8 ± 12.2 vs 78.6 ± 16.8; P = .037). The pain VAS score was also significantly reduced in the dlQUAD group compared with the HT group (0.9 ± 1.1 vs 1.6 ± 2.0; P = .014).

Conclusion:

The dlQUAD and HT techniques both demonstrated significant improvement of preoperative knee laxity and satisfactory patient-reported outcome measures after revision ACLR. Compared with the HT grafts, the dlQUAD technique showed lower failure rates and small increases in Tegner and IKDC scores.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Descriptive laboratory study.

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

Current and future of anterior cruciate ligament reconstruction techniques

In recent years, anterior cruciate ligament (ACL) reconstruction has generally yielded favorable outcomes. However, ACL reconstruction has not provided satisfactory results in terms of the rate of returning to sports and prevention of osteoarthritis (OA) progression. In this paper, we outline current techniques for ACL reconstruction such as graft materials, double-bundle or single-bundle reconstruction, femoral tunnel drilling, all-inside technique, graft fixation, preservation of remnant, anterolateral ligament reconstruction, ACL repair, revision surgery, treatment for ACL injury with OA and problems, and discuss expected future trends. To enable many more orthopedic surgeons to achieve excellent ACL reconstruction outcomes with less invasive surgery, further studies aimed at improving surgical techniques are warranted. Further development of biological augmentation and robotic surgery technologies for ACL reconstruction is also required.

Qualitative and Quantitative Anatomy of the Human Quadriceps Tendon in Young Cadaveric Specimens

Background:

A detailed understanding of the anatomy of the quadriceps tendon (QT) is clinically relevant, owing to its increased use as a graft in anterior cruciate ligament reconstruction.

Purpose:

To qualitatively and quantitatively describe the anatomy of the QT in younger adult specimens.

Study Design:

Descriptive laboratory study.

Methods:

A total of 18 nonpaired cadaveric knees with a mean age of 30.1 years (range, 18-38 years) were utilized for this study. A 3-dimensional coordinate measuring system was used to assess the structural relationships between the different layers of the QT and their attachments to the patella, and QT thickness was measured medially, centrally, and laterally at 2-cm intervals from the patellar eminence line (PEL; defined as a straight line between the medial and lateral patellar eminences) and proximally.

Results:

In all specimens, 3 distinct layers formed the QT. The first (superficial) layer was formed by the rectus femoris, which was fused to the second layer with an unclearly defined direct attachment to the patella. The median length of the QT was 86.9 mm (range, 68.4-98.9 mm). The second (middle) layer consisted of the vastus medialis and vastus lateralis and was found to have fibers running in an oblique direction that attached on the patella. A “fuse point,” where the proximal part of the rectus femoris started to merge to the second layer, was identified at a median of 48.7 mm (range, 27.9-62.6 mm) from the PEL. The third (deep) layer consisted of the vastus intermedius. The median thickness of the graft centrally at 20, 40, 60, 80, and 100 mm from the PEL was 8.5, 7.2, 7.5, 6.5, and 5.4 mm, respectively.

Conclusion:

Overall, 3 different layers of the QT were consistently found in all specimens. The first layer was fused with the second layer, and the direction of the fibers of the second layer or the vastus medialis and vastus lateralis was oblique. The median length of the QT was 86.9 mm, and the thickness of the tendon diminished proximally.

Clinical Relevance:

This study allows for a better understanding of QT anatomy when harvesting the tendon as a graft for ligamentous reconstruction.

Long-term Outcomes of Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon-Patellar Bone Autograft

Background:

To date, there have been few studies on the outcomes of anterior cruciate ligament reconstruction (ACLR) using quadriceps tendon–patellar bone (QTPB) autograft.

Purpose:

To evaluate the long-term clinical outcomes of ACLR using QTPB autograft.

Study Design:

Case series; Level of evidence, 4.

Methods:

We retrospectively reviewed 139 patients who underwent primary ACLR with QTPB autografts and had at least 7 years of postoperative follow-up data. Instability, clinical scores, donor-site morbidity, radiographic progression of osteoarthritis, and any associated complications were assessed.

Results:

The proportion of knees classified as grade >1 on the anterior drawer, Lachman, and pivot-shift tests decreased significantly postsurgically (from 47.4% to 5.0%, 48.9% to 4.3%, and 53.3% to 5.0%, respectively; P < .001 for all). The mean clinical scores at the final follow-up were 89.8, 81.0, and 4.4 for the Lysholm, International Knee Documentation Committee, and Tegner Activity Scale, respectively. The results of the Cybex II dynamometer isokinetic test showed decreases in flexion and extension strength at both 60° and 180° per second, which persisted until the final follow-up visit. About one-fifth (19.4%) of the patients had osteoarthritis (Kellgren-Lawrence grade ≥1) before surgery, which increased to 33.8% at the final follow-up. The overall complication rate was 23.2%, and about one-third of the patients who experienced complications underwent revision surgery as a result of graft rupture and residual instability.

Conclusion:

In the current study, ACLR using QTPB autograft provided satisfactory long-term clinical results, with acceptable rates of complication and donor-site morbidity.

Bone Versus All Soft Tissue Quadriceps Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

To examine existing literature on objective and patient-reported outcomes and complications after anterior cruciate ligament reconstruction (ACLR) with bone-quadriceps-tendon (B-QT) or soft tissue-quadriceps tendon (S-QT) to further clarify the role of graft type in primary ACLR.

METHODS

In accordance with PRISMA guidelines, PubMed, Embase, and Medline were searched in October 2019 for English-language, human studies of all evidence levels on patients undergoing primary ACLR with B-QT or S-QT autograft.

RESULTS

24 of 1,381 studies satisfied criteria, with 20 using B-QT (1,534 patients, mean age 29.6 years [range 14 to 59], mean follow-up 41.2 months [range 12 to 120]) and 5 using S-QT (181 patients, mean age 32.4 years [range 15 to 58), mean follow-up 25.5 months [range 12 to 46]). International Knee Documentation Committee (IKDC) scores were 67.3 to 89.5 with B-QT and 80.4 to 81.6 with S-QT. Lysholm scores were 85.7 to 97.4 with B-QT and 81.6 to 89.2 with S-QT. More B-QT patients demonstrated rotatory laxity on pivot shift compared with S-QT (0% to 39% versus 0%, respectively). The most common complication was graft rupture, and no differences were observed between graft choices (B-QT 0% to 9% versus S-QT 0% to 3.8%).

CONCLUSIONS

The main findings from this review report that more B-QT patients demonstrated postoperative rotatory instability than S-QT patients, and that there are no differences in graft rupture between the 2 graft choices. Although statistical conclusions may not be drawn because of heterogeneity in reporting, it appears that the B-QT group featured much wider major and minor complication profiles.

LEVEL OF EVIDENCE

IV, systematic review of level I-IV studies.

ACL reconstruction in the professional or elite athlete: state of the art

Anterior cruciate ligament (ACL) injuries are on the rise at all levels of sport, including elite athletics. ACL injury can have implications on the athlete's sport longevity, as well as other long-term consequences, such as the development of future knee osteoarthritis. In the elite athlete, ACL injury can also have ramifications in terms of contract/scholastic obligations, sponsorships and revenue-generating potential. Although the goal of anterior cruciate ligament reconstruction (ACLR) is to return any athlete to the same preinjury level of sport, management of ACL injuries in the elite athlete come with the additional challenge of returning him or her to an extremely high level of physical performance. Despite outcome studies after ACLR in elite athletes showing a high return-to-sport rate, these studies also show that very few athletes are able to return to sport at the same level of performance. They also show that those athletes who undergo ACLR have careers that are more short-lived in comparison to those without injury. Thus, returning an elite athlete to 'near peak' performance may not be good enough for the athletic demands of elite-level sports. A possible explanation for the variability in outcomes is the great diversity seen in the management of ACL injuries in the elite athlete in terms of rehabilitation, graft choices, portal drilling and reconstruction techniques. Recently, the advent of anatomical, individualised ACLR has shown improved results in ACLR outcomes. However, larger-scale studies with long-term follow-ups are needed to better understand the outcomes of modern ACLR techniques-particularly with the rise of quadriceps tendon as an autograft choice and the addition of lateral extra-articular tenodesis procedures. The purpose of this article was thus to provide an up-to-date state-of-the-art review in the management of ACL injuries in the elite athlete.

Anatomic single vs. double-bundle ACL reconstruction: a randomized clinical trial-Part 1: clinical outcomes

PURPOSE

Compare clinical outcomes of anatomic single-bundle (SB) to anatomic double-bundle (DB) anterior cruciate ligament reconstruction (ACLR). It was hypothesized that anatomic DB ACLR would result in better International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) scores and reduced anterior and rotatory laxity compared to SB ACLR.

METHODS

Active individuals between 14 and 50 years of age that presented within 12 months of injury were eligible to participate. Individuals with prior injury or surgery of either knee, greater than a grade 1 concomitant knee ligament injury, or ACL insertion sites less than 14 mm or greater than 18 mm were excluded. Subjects were randomized to undergo SB or DB ACLR with a 10 mm-wide quadriceps tendon autograft harvested with a patellar bone block and were followed for 24 months. The primary outcome measures included the IKDC-SKF and KT-1000 (side to side difference) and pivot shift tests. Other secondary outcomes included measures of sports activity and participation, range of motion (ROM) and re-injury.

RESULTS

Enrollment in the study was suspended due to patellar fractures related to harvest of the patellar bone plug. At that time, 57 subjects had been randomized (29 DB) and two-year follow-up was attained from 51 (89.5%). At 24-month follow-up there were no between-group differences detected for the primary outcomes. Twenty-one (77.8%) DB's and 20 (83.3%) SB's reported returning to pre-injury sports 2 years after surgery (n.s) Three subjects (2 DB's, 5.3% of total) sustained a graft rupture and 5 individuals (4 SB's, 8.8% of total) had a subsequent meniscus injury.

CONCLUSIONS

Due to the early termination of the study, there were no detectable differences in clinical outcome between anatomic SB and DB ACLR when performed with a quadriceps tendon autograft with a bone block in individuals with ACL insertion sites that range from 14 to 18 mm.

LEVEL OF EVIDENCE

Level 2.

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

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

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

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

Quadriceps tendon anterior cruciate ligament reconstruction

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

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

Background:

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

Hypothesis:

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

Study Design:

Cohort study; Level of evidence, 3.

Methods:

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

Results:

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

Conclusion:

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

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

BACKGROUND

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

PURPOSE

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

LEVEL OF EVIDENCE

Level IV.