Anterior Cruciate Ligament Reconstruction with Use of Autologous Quadriceps Tendon Graft

Anterior cruciate ligament grafts display differential maturation patterns on magnetic resonance imaging following reconstruction: a systematic review

PURPOSE

The appearance of anterior cruciate ligament (ACL) grafts on magnetic resonance imaging (MRI) is related to graft maturity and mechanical strength after ACL reconstruction (ACLR). Accordingly, the purpose of this review was to quantitatively analyze reports of serial MRI of the ACL graft during the first year following ACLR; the hypothesis tested was that normalized MRI signal intensity would differ significantly by ACL graft type, graft source, and postoperative time.

METHODS

PubMed, Scopus, and CINAHL were searched for all studies published prior to June 2018 reporting MRI signal intensity of the ACL graft at multiple time points during the first postoperative year after ACLR. Signal intensity values at 6 and 12 months post-ACLR were normalized to initial measurements and analyzed using a least-squares regression model to study the independent variables of postoperative time, graft type, and graft source on the normalized MRI signal intensity.

RESULTS

An effect of graft type (P = 0.001) with interactions of graft type * time (P = 0.012) and graft source * time (P = 0.001) were observed. Post hoc analyses revealed greater predicted normalized MRI signal intensity of patellar tendon autografts than both hamstring (P = 0.008) and hamstring with remnant preservation (P = 0.001) autografts at postoperative month 12.

CONCLUSION

MRI signal varies with graft type, graft source, and time after ACLR. Enhanced graft maturity during the first postoperative year was associated with hamstring autografts, with and without remnant preservation. Serial MRI imaging during the first postoperative year may be clinically useful to identify biologically or mechanically deficient ACL grafts at risk for failure.

LEVEL OF EVIDENCE

IV.

All inside full thickness quadriceps tendon ACL reconstruction: Long term follow up results

Purpose

The aim of this study is to evaluate results of anterior cruciate ligament reconstruction (ACL) using an All-Inside Full Thickness Quadriceps Reconstruction technique at 5 years follow up.

Methods

This is a Retrospective cohort study of patients undergoing ACL reconstruction. Inclusion criteria for this report were isolated primary ACL reconstructions without chondral lesions (Grade III/IV Outerbridge), using autologous full-thickness quadriceps tendon (FQT) graft with bone block, with an “all-inside” technique. Functional scales of Lysholm, IKDC, Tegner and objective results of side to side difference (KT1000) were used for this evaluation. Additionally, complications and comorbidities were also analyzed.

Results

Two hundred and ninety-one ACL reconstructions were retrospectively reviewed at 5 years postoperatively; 268 (92.1%) were men and 23 (7.90%) women. Lysholm Score improved from 64 (SD = 6.09) to 91 (SD = 6.05) points average. IKDC showed 59.79%, excellent and 3.4% good results. Arthrometric analysis showed that 259 knees (89%) had a difference of less than 3 mm. Median pre-injury Tegner score was 9 (Range 4–10), while final median Tegner activity level at 5 years was 8 (Range 4–10). Among comorbidities, 5.15% of the patients presented anterior knee pain. No visualization difficulties or significant hematomas were found.

Conclusion

Use of all inside FQT for ACL reconstruction in a young, high demand sports population, present at 5 years, good to excellent results, functionally and objectively, with low rates of complications and comorbidities.

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.

No difference between full thickness and partial thickness quadriceps tendon autografts in anterior cruciate ligament reconstruction: a systematic review

PURPOSE

The purpose of this review was to compare outcomes and complication profiles of anterior cruciate ligament reconstruction (ACL-R) between full thickness (FT-Q) and partial thickness (PT-Q) quadriceps tendon (QT) autografts.

METHODS

As per PRISMA guidelines, PubMed, EMBASE, and MEDLINE were searched in September 2017 for English language, human studies of all levels of evidence on patients undergoing primary ACL-R with FT-Q or PT-Q. This search was repeated in March 2018 to capture additional articles. Data regarding postoperative outcomes and complications were abstracted. Due to heterogeneous reporting, data were not combined in meta-analysis and were summarized descriptively.

RESULTS

Upon screening 3670 titles, 18 studies satisfied inclusion/exclusion criteria. The second search identified an additional two studies for a total of 20 studies (50% case-control, 50% case series). These studies examined 1212 patients (1219 knees) of mean age 29.8 years (range 15-59) followed a mean of 42.2 months (range 12-120). FT-Q and PT-Q autografts were used in eight studies (50.5% of knees), and thirteen studies (49.5% of knees), respectively. Only one study directly compared FT-Q to PT-Q. Instrumented laxity was less than 3 mm in 74.8 and 72.4% of the FT-Q and PT-Q groups, respectively. Postoperative IKDC Subjective Knee Form scores were similar between the FT-Q (82.5) and PT-Q (82.1) groups. Postoperative quadriceps strength, measured as a percentage of the contralateral side, were similar in the FT-Q (89.5%) and PT-Q (85.1%) groups. Graft failure rates for the FT-Q and PT-Q groups were 3.7 and 3.0%, respectively.

CONCLUSION

Across the 20 studies included in this review, there appeared to be no difference in outcomes or complications between either FT-Q or PT-Q in primary ACL-R. Moreover, primary ACL-R using QT autografts appears to have successful outcomes with a low rate of graft failure, irrespective of tendon thickness. While further comparative studies are needed to better delineate the optimal thickness of quadriceps tendon for primary ACL-R, these data suggest that, in primary ACL-R, either FT-Q or PT-Q is efficacious and, in the clinical setting, surgeons may be justified in using either graft thickness.

LEVEL OF EVIDENCE

IV, Systematic Review of Level III and IV studies.

Predicted quadriceps vs. quadrupled hamstring tendon graft size using 3-dimensional MRI

BACKGROUND

The objective of this study is to (1) compare the predicted cross-sectional area and diameter between quadriceps tendon and quadrupled hamstring autografts, and (2) assess the predicted size of the quadriceps tendon graft in patients with hamstrings that are insufficient for use in ACL reconstruction.

METHODS

A retrospective review of 54 knee 3D MRIs was conducted. Quadriceps tendon graft area was defined as a one-centimeter wide area of quadriceps tendon, measured three centimeters above the patella perpendicular to tendon axis. Quadrupled hamstring graft area was defined as double the combined areas of the gracilis and semitendinosus tendon, measured three centimeters above the joint line perpendicular to tendon axis. Pearson correlation was used to compare the quadriceps tendon and quadrupled hamstring grafts.

RESULTS

Mean cross-sectional area of quadrupled hamstring and quadriceps tendon grafts were 47.2 mm² and 84.4 mm² respectively. A statistically significant positive correlation exists between quadrupled hamstring graft and quadriceps tendon graft cross-sectional area (r = 0.41; p = 0.002). Nine of the 54 patients had predicted quadrupled hamstring grafts deemed insufficient for use in ACL reconstruction (<8 mm diameter). All of these patients had predicted quadriceps tendon graft diameters >8 mm.

CONCLUSION

There is a positive correlation between predicted quadriceps tendon and quadrupled hamstring grafts. While 17% of patients in this series had predicted insufficient quadrupled hamstring grafts, all of the patients had predicted quadriceps tendon grafts of sufficient size for ACL reconstruction. Quadriceps tendon grafts are a viable alternative in patients at-risk for insufficient quadrupled hamstring grafts.

LEVEL OF EVIDENCE

IV.

The rotating stretched curved planar reconstruction of 3D-FIESTA MR imaging for evaluating the anterior cruciate ligament of the knee joint

PURPOSE

To determine the feasibility of the rotating stretched curved planar reconstruction (CPR) of three-dimensional fast imaging with steady-state acquisition magnetic resonance imaging (3D-FIESTA MRI) for evaluating the anterior cruciate ligament of the knee joint.

MATERIALS AND METHODS

MRI of 40 knee joints in healthy volunteers was performed on a 3.0-T MR scanner and a phased-array extremity coil. The protocol consisted of oblique sagittal spin echo (SE) T1WI, coronal FS-PDWI, axial FS-FSE-T2WI, and 3D-FIESTA sequences. The rotating stretched curved planar reconstructions (CPR) of the ACL at angles of 0°, 30°, 60°, 90°, 120°, 150°, and 180° were generated from images of 3D-FIESTA sequences. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of the 3D-FIESTA were compared with those of the oblique sagittal SE T1WI sequence. The presence of the tibial attachment, midportion, femoral attachment, and double bundles of the ACL on the oblique sagittal SE T1WI and CPR of 3D-FIESTA MR imaging were divided into two categories: visible and not visible.

RESULTS

The ACL SNR efficiency of 3D-FIESTA sequences was significantly higher than that of oblique sagittal SE T1WI sequence (P < 0.05). The 3D-FIESTA sequences produced images with a significantly higher CNR between ACL and synovial fluid than did the oblique sagittal SE T1WI sequence (P < 0.05). CPR of 3D-FIESTA MRI generated an excellent visualization of the ACL. The CPR of 3D-FIESTA MRI was rated superior to oblique sagittal SE T1WI sequence in 60% and 65% of cases with regard to the tibial attachment and midportion of ACL, respectively (P < 0.05). CPR of 3D-FIESTA MR imaging was rated superior to oblique sagittal SE T1WI sequence in 80% and 85% of cases with regard to femoral attachment and double bundles of ACL, respectively (P < 0.05).

CONCLUSION

The rotating stretched curved planar reconstruction of 3D-FIESTA sequences is significantly better than that of conventional 2D-MRI in evaluating the native ACL and its components, AM bundle and PL bundle, in healthy volunteers.

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

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

Quadriceps Tendon-Bone or Patellar Tendon-Bone Autografts When Reconstructing the Anterior Cruciate Ligament: A Meta-analysis

OBJECTIVE

We aimed to quantitatively assess the outcomes of studies, comparing the use of Bone-patellar tendon-bone (BPTB) and the quadriceps tendon-bone (QTB) autografts when reconstructing the anterior cruciate ligament (ACL).

DATA SOURCES

MEDLINE, Embase, and CINAHL databases were searched for relevant articles published between January 1980 and January 2015 for the purpose of identifying studies comparing BPTB and QTB autografts for ACL reconstruction. Included studies were assessed regarding their methodological quality before analysis. Outcomes analyzed were graft failure rates, objective and subjective stability assessments, as well as the presence and severity of donor site morbidity.

MAIN RESULTS

Five studies contributed to the quantitative analysis of 806 patients with 452 patients included in the BPTB group and 354 patients in the QTB group. Graft failure rates were similar between the 2 groups [odds ratio (OR) = 0.61; confidence interval (CI) = 0.17-2.15; Z = 0.78, P = 0.44]. There were no significant differences between the 2 groups when testing anteroposterior stability using an arthrometer (standardized mean difference = 0.07; CI = -0.12-0.25; Z = 0.70, P = 0.48). At 1 year postoperatively, there was no difference in the percentage of patients with a positive pivot shift test between the 2 groups (OR = 1.0; CI = 0.85-1.18; Z = 0.01, P = 0.99). However, significantly less patients had graft site pain 1 year after surgery in the QTB group (OR = 0.10; CI = 0.02-0.43; Z = 3.12, P = 0.002). Similarly, fewer patients reported moderate to severe pain while kneeling, in the QTB group (OR = 0.16; CI = 0.07-0.37; Z = 4.26, P < 0.001).

CONCLUSIONS

This study demonstrates comparable survival rates and joint stability when BPTB and QTB grafts are used. However, fewer adverse donor site symptoms are evident with QTB grafts.

LEVEL OF EVIDENCE

III.

Anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone allograft: matched case control study

Background

Quadriceps tendon-patellar bone (QTPB) autograft is an excellent graft option with good clinical outcome. Use of QTPB autografts have increased because they minimize donor-site morbidity including anterior knee pain, while providing adequate mechanical strength. Although, there were many clinical results about allografts that used in anterior cruciate ligament (ACL) reconstruction, it have never been reported about the clinical outcome of ACL reconstruction with QTPB allograft.

The purpose of this study is to evaluate the clinical outcome of ACL reconstruction with QTPB allograft and to compare with QTPB autograft. We hypothesized that ACL reconstruction with QTPB allograft had good functional outcomes and stability and no significant difference compared to the ACL reconstruction with QTPB autograft.

Methods

From February 2009 to January 2014, 213 cases who received ACL reconstruction with QTPB grafts were included. Forty-five patients who received ACL reconstruction with QTPB allograft were individually matched in age, sex, direction of the injured knee and body mass index (BMI) to a control group of 45 patients who received QTPB autograft. Clinical results were evaluated using International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner scale, Knee injury and Osteoarthritis Outcome Score (KOOS) and ligament laxity. An average follow-up time was 31.2 months.

Results

The functional scores and ligament laxity improved from initial to the last visit in those with ACL reconstruction with QTPB allograft (p < 0.05). No significant statistical difference was found in clinical outcomes and complications including re-rupture between the QTPB allograft and autograft groups (p > 0.05). Laxity using anterior drawer test, Lachman test and KT-2000 showed no significant difference. No significant difference was found between the two groups in quadriceps peak extension torque, except at 60° per second at 6 months.

Conclusion

QTPB allograft achieved good clinical outcome with no difference compared with QTPB autograft. QTPB allograft for ACL reconstruction is promising alternative to selected and compliant patients. Long-term follow-up needs to further evaluate the clinical outcomes and complications including re-rupture rate.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III.

Primary anterior cruciate ligament reconstruction: perioperative considerations and complications

Anterior cruciate ligament (ACL) injuries are among the most commonly studied orthopaedic injuries. Despite having an excellent prognosis, complications do occur. The timely recognition and management of complications is imperative to ensure the success of reconstruction. Avoiding such complications requires thorough preoperative planning, proficient technical skills to properly manage intraoperative complications, and an extensive knowledge of possible postoperative complications.

Quadriceps tendon autograft for anterior cruciate ligament reconstruction: a comprehensive review of current literature and systematic review of clinical results

PURPOSE

The autograft of choice for anterior cruciate ligament (ACL) reconstruction remains controversial. Recently, there has been an increase in interest in the quadriceps tendon as an autologous graft option for ACL reconstruction. The purposes of this study were to provide an in-depth review of quadriceps tendon anatomy, histology, and biomechanics and to synthesize reported clinical outcomes of ACL reconstructions using quadriceps tendon autografts. We hypothesize that (1) published studies on the anatomic, histologic, and biomechanical data regarding the quadriceps tendon support its use as a graft option for ACL reconstruction and (2) clinical outcomes of ACL reconstruction using quadriceps tendon autograft have similar clinical outcomes to bone-patellar tendon-bone autografts with less donor-site morbidity.

METHODS

We performed a comprehensive review of the literature regarding the anatomy, histology, and biomechanical studies of the quadriceps tendon, as well as a systematic review of clinical studies (Level of Evidence I-III) evaluating outcomes after ACL reconstruction using quadriceps tendon autograft. Stability outcomes, functional outcomes, range of motion, patient satisfaction, morbidity, and complications were comprised.

RESULTS

Fourteen studies were included in the review of clinical results, including 1,154 ACL reconstructions with quadriceps tendon autograft. Six studies directly compared quadriceps tendon autografts (n = 383) with bone-patellar tendon-bone autografts (n = 484). Stability outcomes (Lachman, pivot-shift, and instrumented laxity testing), functional outcomes (International Knee Documentation Committee and Lysholm scores), overall patient satisfaction, range of motion, and complications were similar between quadriceps tendon and other graft options. Less donor-site morbidity was seen in patients who underwent quadriceps tendon ACL reconstructions.

CONCLUSIONS

Use of the quadriceps tendon autograft for ACL reconstruction is supported by current orthopaedic literature. It is a safe, reproducible, and versatile graft that should be considered in future studies of ACL reconstruction.

LEVEL OF EVIDENCE

Level III, systematic review of Level I, II, and III studies.

Anterior Cruciate Ligament Reconstruction with Quadriceps Tendon Autograft: A Minimally Invasive Harvest Technique

Introduction

We describe a minimally invasive surgical technique for harvest of a quadriceps tendon autograft that reliably produces a graft suitable for anterior cruciate ligament (ACL) reconstruction while minimizing morbidity and complications classically associated with alternative autograft choices.

Step 1 Positioning

Position the patient supine on the operating room table.

Step 2 Marking of Landmarks

Palpate and mark soft-tissue and osseous landmarks on the involved extremity.

Step 3 Subcutaneous Dissection

Perform the incision and subcutaneous dissection.

Step 4 Graft Harvest

Harvest the graft.

Step 5 Graft Preparation

Prepare the graft.

Step 6 Closure

If a partial-thickness graft is harvested, no deep closure is needed.

Results

Since September of 2011, the quadriceps tendon has been our autograft of choice for ACL reconstruction.IndicationsContraindicationsPitfalls & Challenges.

Modified Transtibial Technique for Anterior Cruciate Ligament Reconstruction with Quadriceps Tendon Autograft

Introduction

The modified transtibial technique with quadriceps tendon autograft allows anatomic anterior cruciate ligament (ACL) reconstruction without tunnel widening and results in a stable and functional knee with a satisfactory clinical outcome.

Step 1 Prepare the Patient

Prepare the patient under spinal anesthesia with the usual arthroscopic setting.

Step 2 Arthroscopic Examination

Perform arthroscopic examination to confirm the ACL rupture and other intra-articular lesions.

Step 3 Harvest the Quadriceps Tendon

Harvest the central one-third of the quadriceps tendon strip with a proximal patellar bone block.

Step 4 Prepare the Quadriceps Tendon Graft

Prepare the quadriceps tendon graft to pass smoothly through the tunnels.

Step 5 Set the Tibial Tunnel Entry Point

Make a 3-cm longitudinal skin incision at the anteromedial aspect of the proximal part of the tibia.

Step 6 Create the Tibial Tunnel

Drill a 10-mm tibial tunnel.

Step 7 Target the Femoral Tunnel Starting Point

Aim the guide at the lateral bifurcate ridge on the medial wall of the lateral femoral condyle with the modified transtibial technique.

Step 8 Create the Femoral Tunnel

Drill a 10-mm femoral tunnel.

Step 9 Fix the Graft

Fix the graft with adequate tension.

Step 10 Postoperative Rehabilitation

Rehabilitate the patient step by step.

Results

In a study that compared fifty-two patients managed with a modified transtibial technique and another fifty-two patients managed with an anteromedial transportal technique, there were no significant differences in the clinical results in terms of manual laxity, arthrometric analysis, and subjective outcome.IndicationsContraindicationsPitfalls & Challenges.

"Central" quadriceps tendon harvest with patellar bone plug: surgical technique revisited

The objective of this article is to review the surgical technique for quadriceps tendon graft harvest while highlighting an additional technical note that has not been previously emphasized. The quadriceps tendon typically inserts eccentrically on the superior pole of the patella. By shifting the soft-tissue harvest to a location just off the medial edge of the tendon, the adjoining patellar bone plug will be centered on the superior pole of the patella, reducing the risk of an iatrogenic patellar fracture.