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

High rates of donor site healing using quadriceps tendon for anterior cruciate ligament reconstruction: A case series

Purpose

To investigate the healing of the quadriceps tendon donor site after partial thickness graft harvesting through ultrasound imaging at a short-term follow-up of 6-month following anterior cruciate ligament reconstruction (ACLR) and to investigate the clinical outcomes.

Methods

Between March 2019 and August 2020, 61 knees were retrospectively included in this study. Intraoperatively, the length, width and thickness of the harvested QT graft were measured. At a 6-month follow-up, patients were assessed by one of five radiologists, following the same protocol to calculate the defect volume, and patients performed a self-evaluation of pain on the Visual Analogue Scale, International Knee Documentation Committee (IKDC) and the Knee injury and Osteoarthritis Outcome Scores (KOOS).

Results

Intraoperatively, the QT grafts had a volume of 4635.4 ± 912.5 mm3. Postoperatively, ultrasound was performed at 6.5 ± 0.7 months, and the defect volume was 323.3 ± 389.2 mm3, representing a healing rate of 93% ± 9% of the donor site. At a minimum 6-month follow-up, IKDC was 61.6 ± 16 and KOOS was 70.2 ± 16.6. Age was significantly associated with the healing rate (β: -0.005; p = 0.032).

Conclusion

At 6 months follow-up, the defect size of the QT donor site had healed by 93 ± 9% leaving a mean defect volume of 323.3 mm3 according to ultrasound measurements. This suggests that the QT has a high capacity for healing after graft harvesting, with 10 patients reaching full defect closure 6 months after surgery. The clinical relevance of these findings is that the quadriceps tendon donor site has high rates of healing, but surgeons should be aware of lower healing rates in older patients.

Level of Evidence

Level IV, retrospective case series.

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.

Ipsilateral Quadriceps Tendon-Bone ACL Revision Reconstruction to Address Failed Primary Bone-Patellar Tendon-Bone ACL Reconstruction with Persistent Patellar Bone Defect

Bone-patellar tendon-bone (BPTB) autograft is a popular graft choice for anterior cruciate ligament reconstruction (ACLR) in active young adults. In case of BPTB ACLR failure, the 3 most popular autograft choices for a revision surgery include contralateral BPTB, contralateral or ipsilateral hamstrings autograft, and contralateral or ipsilateral quadriceps tendon autograft. Quadriceps tendon autograft has been gaining increasing popularity in recent years in this respect, but using quadriceps tendon-bone autograft in the setup of a previous use of ipsilateral BPTB autograft deserves special technical considerations, with emphasis on preserving patellar bone integrity. We describe a technique for performing revision ACLR after failed primary BPTB ACLR by using ipsilateral quadriceps tendon-bone autograft in the setup of persistent distal patellar bone defect. Using this autograft benefits the advantages of highly resilient graft tissue in addition to fast bone-to-bone healing on the femoral side, and it can be an excellent choice in revision reconstruction for surgeons who prefer tendon-bone autograft for highly active young adults and specifically when the patients underwent bilateral primary autologous BPTB ACLRs.

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.