Quadriceps Tendon: The Forgotten Graft

Author's Reply

Both Quadriceps and Bone–Patellar Tendon–Bone Autografts Improve Postoperative Stability and Functional Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review

Objectives:The quadriceps tendon (QT) autograft has been successfully utilized for anterior cruciate ligament (ACL) reconstruction for decades. While many studies have shown QT autografts are an effective graft choice, few have prospectively examined short and intermediate-term clinical outcomes following revision procedures. This study examines prospectively collected intermediate-term clinical outcomes, including complication rates, following primary ACL reconstruction with all soft tissue QT autograft.Methods:353 patients undergoing primary ACL reconstruction with an all soft tissue QT autograft were prospectively followed. All procedures were performed by a single surgeon, utilizing a minimally invasive graft harvest technique and suspensory fixation. All patients received aggressive rehabilitation without functional bracing post-operatively. Subjective assessment of knee function was obtained using pre-operative and post-operative IKDC scores, with a minimum of 1-year follow-up. Postoperative KT-1000 arthrometer and isokinetic strength testing measurements were collected at regular intervals. The incidence of graft harvest site hematoma, arthrofibrosis, and graft failure were recorded.Results:The mean age of the study population was 20.4 ± 6.4 (mean ± SD) years, with an average follow up of 2.53 ± 1.04 years. Primary ACL reconstruction was performed in 353 patients. The patient population was approximately evenly split by gender with 27 male (56%) and 21 female (44%). and the preoperative mean IKDC score was 44.9 ± 15.5, and postoperative mean IKDC score was 85.2 ± 14.3, (p<0.0001). The percentage of patients with ≤3 mm side-to-side difference on KT-1000 arthrometer testing at 6-weeks, 3-months, and 6-months was found to be 97%, 96%, and 93%, respectively. No significant increase (p>0.05) in side-to-side measurements was found between the 6-week to 3-month or the 3-month to 6-month intervals. Isokinetic strength testing at 6 months post-operatively showed the mean extension torque at 60°/s and 180°/s was 75.2% and 80.3% respectively. These values increased significantly at 1 year to 86.1% (p<.0006) and 87.5% (p = .018). Graft harvest site hematoma developed in 11 patients (2.7%) and arthrofibrosis occurred in 30 (7.5%). Graft failure requiring revision occurred in 17 (4.2%) patients, with a mean time to revision procedure of 542 ± 210 days post-operatively.Conclusion:ACL reconstruction with an all soft tissue QT autograft using a minimally invasive harvest technique and suspensory fixation has acceptable short and intermediate-term clinical outcomes. No evidence of early graft failure or lengthening was discovered, confirming suspensory fixation is sufficient for aggressive rehabilitation in a young, athletic patient population. The low complication and failure rates in patients that received QT autograft for ACL reconstruction compare favorably to published data on alternate autograft options. The results of this study support the use of all soft tissue QT autograft in ACL reconstruction.

Objectives:Bone-patellar tendon-bone (BTB) autograft has historically been regarded as the gold standard for anterior cruciate ligament reconstruction (ACLR). Despite widespread utilization of BTB autografts, multiple complications following BTB harvest have been reported, including anterior knee pain, difficulty kneeling, patellar tendon rupture, patella fracture, tendon contracture, and numbness. The quadriceps tendon (QT) autograft has been proposed as an alternative graft in young, high demand patients to achieve comparable clinical outcomes while avoiding complications associated with BTB autograft. Recently, a novel 10-question donor site morbidity (DSM) instrument was developed by Hacken et al that was used to evaluate DSM following BTB ACLR. However, to date, the instrument has not been used to evaluate DSM following QT harvest. Therefore, a retrospective evaluation of DSM following ACLR with QT versus BTB autograft was performed.Methods:All patients who underwent ACLR with QT autograft between January 2018 and February 2020 were identified in a single institution registry and matched to a control group of patients who underwent BTB autograft ACLR on the basis of age and sex. DSM was assessed using a 10-question DSM instrument and scores were compared to traditional patient reported outcome measures including the IKDC, Marx Activity Scale, and SANE scores. Post-operative complications including quadriceps tendon rupture, patella fractures, and graft failure were assessed via registry query. Multivariate analysis was conducted to investigate factors associated with DSM.Results:Thirty-two QT patients (15M,17F) with a mean age of 23.0 years (range 13-45) were compared to 61 BTB patients (32M,29F) with a mean age of 22.2 (range 13-45) who responded at a minimum 24- months after surgery. DSM scores were rated good or excellent in 26/31 QT patients(81%) versus 44/61 BTB patients(72%) (P=0.45). Significant differences were noted between graft types with respect to presence of numbness, with 37/61 BTB patients(61%) versus 10/32 QT patients(31%) reporting mild, moderate, or diminished sensation to light touch(P=0.02). Differences were also noted in kneeling pain, with 30/61 BTB patients(49%) versus 6/32 QT patients(19%) reporting either mild pain with kneeling or inability to kneel on hard surfaces (P=0.01). Finally, differences were reported in patient-reported presence of quadriceps wasting, with 20/32 QT patients(38%) reporting atrophy versus 15/61 BTB patients(25%) (P=0.01). However, no differences were noted in pain at donor site, size of numbness, difficulty with stairs or prolonged sitting, anterior knee pain, or incision cosmesis(P>0.05). Multivariate analysis demonstrated that graft type, sex, body mass index (BMI), operative age, and meniscus integrity were not associated with DSM scores(P>0.05). Correlations between PROMS and DSM showed correlations with IKDC, Marx, and SANE(P<0.01). There were no instances of quad tendon rupture, patella fracture, or ACL graft failure in either group.Conclusions:DSM following ACLR with QT and BTB autograft demonstrated good to excellent results in the majority of patients. Significantly more BTB patients experienced numbness at the harvest site and pain with kneeling compared to QT patients. However, more patients reported quadriceps atrophy following QT compared to BTB autograft. PROMS correlated with DSM scores, suggesting that these instruments may be impacted by DSM following ACLR.

Background: Comprehensive studies evaluating quadriceps tendon (QT) autograft for anterior cruciate ligament (ACL) reconstruction are lacking. The optimal choice of graft between bone–patellar tendon–bone (BPTB), hamstring tendon (HT), and QT is still debatable. Hypothesis: The current literature supports the use of QT as a strong autograft with good outcomes when used in ACL reconstruction. Study Design: Meta-analysis; Level of evidence, 2. Methods: A systematic search of the literature was performed in PubMed, MEDLINE, Cochrane, and Ovid databases to identify published articles on clinical studies relevant to ACL reconstruction with QT autograft and studies comparing QT autograft versus BPTB and HT autografts. The results of the eligible studies were analyzed in terms of instrumented laxity measurements, Lachman test, pivot-shift test, Lysholm score, objective and subjective International Knee Documentation committee (IKDC) scores, donor-site pain, and graft failure. Results: Twenty-seven clinical studies including 2856 patients with ACL reconstruction met the inclusion criteria. Comparison of 581 QT versus 514 BPTB autografts showed no significant differences in terms of instrumented mean side-to-side difference (P = .45), Lachman test (P = .76), pivot-shift test grade 0 (P = .23), pivot-shift test grade 0 or 1 (P = .85), mean Lysholm score (P = .1), mean subjective IKDC score (P = .36), or graft failure (P = .50). However, outcomes in favor of QT were found in terms of less donor-site pain (risk ratio for QT vs BPTB groups, 0.25; 95% CI, 0.18-0.36; P < .00001). Comparison of 181 QT versus 176 HT autografts showed no significant differences in terms of instrumented mean side-to-side difference (P = .75), Lachman test (P = .41), pivot-shift test grade 0 (P = .53), Lysholm score less than 84 (P = .53), mean subjective IKDC score (P = .13), donor-site pain (P = .40), or graft failure (P = .46). However, outcomes in favor of QT were found in terms of mean Lysholm score (mean difference between QT and HT groups, 3.81; 95% CI, 0.45-7.17; P = .03). Conclusion: QT autograft had comparable clinical and functional outcomes and graft survival rate compared with BPTB and HT autografts. However, QT autograft showed significantly less harvest site pain compared with BPTB autograft and better functional outcome scores compared with HT autograft.

Unnecessary Complication?

What's New in Sports Medicine.

Saphenous nerve injury after anterior cruciate ligament reconstruction: Reduced numbness area after ligamentoplasty using quadriceps tendon compared with hamstring tendon

The purpose of our study was to analyze the graft contact stress at the tunnel after transtibial single-bundle (SB) and transportal double-bundle (DB) anterior cruciate ligament (ACL) reconstruction. After transtibial SB (20 cases) and transportal DB (29 cases) ACL reconstruction, the three-dimensional image of each patient made by postoperative computed tomography was adjusted to the validation model of a normal knee and simulated SB and DB ACL reconstructions were created based on the average tunnel position and direction of each group. We also measured graft and contact stresses at the tunnel after a 134 N anterior load from 0° to 90° flexion. The graft and contact stresses became the greatest at 30° and 0° flexion, respectively. The total graft and contact stresses after DB ACL reconstruction were greater than those after SB ACL reconstruction from 0° to 30° and 0° to 90° knee flexion, respectively. However, the graft and contact stresses of each graft after DB ACL reconstruction were less than those after SB ACL reconstruction. In conclusion, the total graft and total contact stresses after DB ACL reconstruction are higher than those after SB ACL reconstruction from 0° to 30° and 0° to 90° knee flexion, respectively. However, the stresses of each graft after DB ACL reconstruction are about half of those after SB ACL reconstruction.

Level 5.

Double-bundle (DB) anterior cruciate ligament (ACL) reconstruction is becoming increasingly common. However, no definitive data on the superiority of DB reconstruction have been shown when compared with single-bundle (SB) ACL reconstruction. We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL and Embase databases using various combinations of keywords such as 'ACL', 'reconstruction', 'DB' and 'SB'. Only articles published in peer-reviewed journals were included in this systematic review. Several new techniques are available for ACL reconstruction. DB ACL reconstruction could provide better outcome for patients in terms of closer restoration of normal knee biomechanics and improving the rotatory laxity of the knee. Data are lacking to allow definitive conclusions on the use of DB reconstruction techniques for routine management of patients with ACL tear. Given the limitations of the current studies, it is not possible to recommend systematic use of DB ACL reconstruction. Even though biomechanical results are encouraging, subjective patient evaluation is similar for SB and DB reconstruction. Studies of higher levels of evidence, for instances large adequately powered randomized trials, should be conducted to bring new insight in this field. With the current evidence available, a simple SB ACL reconstruction is a suitable technique, and it should be not abandoned until stronger scientific evidence in favour of DB ACL reconstruction will be produced.

Background: The effects of notchplasty on the clinical outcome after anatomic double-bundle anterior cruciate ligament (ACL) reconstruction remain unclear. Hypothesis: Anatomic ACL reconstruction with notchplasty would result in less risk of loss of extension and would provide adequate space for better graft healing, leading to better knee stability compared with anatomic ACL reconstruction without notchplasty. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 137 patients who underwent anatomic double-bundle ACL reconstruction were included. Seventy-three patients without notchplasty were classified as the control group, and 64 patients with 2-mm notchplasty were classified as the notchplasty group. The following evaluation methods were used: loss of extension, patient’s subjective feeling of limited extension and pain at passive full extension, muscle strength, manual laxity tests, KT-1000 arthrometer measurement, patellofemoral joint findings, Tegner score, Lysholm score, subjective scores, and time to return to sports. Tearing of the reconstructed ACL and additional synovectomy were recorded. Both tibial and femoral tunnel positions were measured using 2-view radiographs: a Rosenberg and a lateral view. Results: Loss of extension was larger in the notchplasty group compared with controls (at 6 months: 0.8° vs 1.4°, P = .012; at 2 years: 0.4° vs 0.9°, P = .0053). The number of patients with a feeling of limited extension was also larger in the notchplasty group (at 6 months: 13 patients graded 1+ [somewhat limited] and 2 patients graded 2+ [very limited] vs 18 graded 1+ and 6 graded 2+, P = .015; at 2 years: 2 graded 1+ and 0 graded 2+ vs 4 graded 1+ and 5 graded 2+, P = .011). Six patients in the notchplasty group required additional synovectomy because of the prolonged loss of extension, whereas no patient in the control group required additional synovectomy. There were no differences between groups regarding muscle strength, patellofemoral findings, Lysholm score, Tegner score, subjective scores, or time to return to sports. The KT-1000 arthrometer measurement was better in the notchplasty group (1.2 vs 0.4 mm, P = .0017). However, 6 patients in the notchplasty group showed an overconstrained knee (KT-1000 measurement ≤–2 mm), compared with only 1 patient in the control group. There were no differences between groups in the other manual laxity tests or the tunnel positions. Conclusion: In anatomic double-bundle ACL reconstruction, anterior stability was improved and there were no harmful effects on patellofemoral joint findings by 2-mm notchplasty; however, notchplasty likely caused overconstrained knee, leading to a need for additional synovectomy in some patients. In contrast, anatomic double-bundle ACL reconstruction without notchplasty did not increase the incidence of loss of extension or of graft failure.

Introduction: Anterior cruciate ligament reconstruction (ACLR) is among the most common knee procedures in the United States, particularly in athletes who participate in cutting and pivoting sports. While bone-patellar tendon-bone (BTB) autografts have long been considered the gold standard for this group, drawbacks such as anterior knee pain and difficulty kneeling have prompted interest in quadriceps tendon autografts. With a larger cross-sectional area and higher load-to-failure, the quadriceps autograft is a promising alternative. This study reported return-to-play timelines and re-rupture rates in 44 cutting and pivoting athletes who underwent ACLR using quadriceps tendon autograft with internal brace augmentation (QAIB), offering early insight into its potential as an alternative to BTB autografts.Methods: A retrospective chart review was performed on cutting and pivoting athletes who underwent ACLR using QAIB. Athletes were included if they participated in organized sports or sustained their injury while engaging in a cutting and pivoting sport. Five sports were classified as cutting and pivoting: football, soccer, basketball, lacrosse, and rugby. Patients were excluded if postoperative care was transferred to outside providers. Through chart review, time to return and re-rupture rates were collected. Time to return was defined by either direct documentation of the return date or the earliest documented clearance for return. Patients lacking this data were excluded from the time-to-return analysis. One patient was omitted due to a postoperative infection requiring graft removal and revision with a non-quadriceps autograft. Patients undergoing additional ligamentous reconstructions, such as posterolateral corner repairs, were also excluded from time-to-return calculations due to prolonged expected recovery.Results: A total of 44 athletes were included, with an average age of 20.3 years. Of these, 29 (65.9%) were male and 15 (34.1%) were female. Eleven (25%) were Division I athletes. The most common sports were football (n=15) and basketball (n=15), followed by soccer (n=11), lacrosse (n=2), and rugby (n=1). Concomitant meniscal surgery was performed in 22 patients (50%). Time-to-return data was available for 36 athletes (81.8%). Seven lacked sufficient documentation, and one patient was excluded from the study entirely due to postoperative infection requiring graft revision. Two patients were excluded from the time-to-return analysis due to concurrent posterolateral corner reconstructions. The average time to return was 240.5 days (range: 166-312). Among Division I athletes (9/11, 81.8%), the average time to return was 255.0 days (range: 181-312), compared to 234.6 days (range: 166-309) for non-Division I athletes (27/33, 81.8%). No re-ruptures occurred. Four athletes (9.1%) developed arthrofibrosis requiring manipulation under anesthesia: one female athlete (basketball) and three male athletes (two football, one basketball)Conclusion: QAIB ACLR in cutting and pivoting athletes demonstrated a 0% re-rupture rate and return-to-play timelines comparable to existing standards. While early results are promising, limitations in data capture, particularly return-to-play documentation and patient-reported outcomes, highlight the need for more robust, prospective studies to better assess long-term efficacy and safety.

Background Anatomic double-bundle reconstruction has been thought to better simulate the anterior cruciate ligament anatomy. It is, however, a technically challenging procedure, associated with longer operation time and higher cost. Hypothesis Double-bundle anterior cruciate ligament reconstruction using a single femoral and tibial tunnel can closely reproduce intact knee kinematics. Study Design Controlled laboratory study. Methods Eight fresh-frozen human cadaveric knee specimens were tested using a robotic testing system to investigate the kinematic response of the knee joint under an anterior tibial load (130 N), simulated quadriceps load (400 N), and combined torques (5 N·m valgus and 5 N·m internal tibial torques) at 0°, 15°, 30°, 60°, and 90° of flexion. Each knee was tested sequentially under 4 conditions: (1) anterior cruciate ligament intact, (2) anterior cruciate ligament deficient, (3) single-bundle anterior cruciate ligament reconstruction using quadrupled hamstring tendon, and (4) single-tunnel—double-bundle anterior cruciate ligament reconstruction using the same tunnels and quadrupled hamstring tendon graft as in the single-bundle anterior cruciate ligament reconstruction. Results Single-tunnel—double-bundle anterior cruciate ligament reconstruction more closely restored the intact knee kinematics than single-bundle anterior cruciate ligament reconstruction at low flexion angles (≤30°) under the anterior tibial load and simulated muscle load (P < .05). However, single-tunnel—double-bundle anterior cruciate ligament reconstruction overconstrained the knee joint at high flexion angles (≥60°) under the anterior tibial load and at 0° and 30° of flexion under combined torques. Conclusion This double-bundle anterior cruciate ligament reconstruction using a single tunnel can better restore anterior tibial translations to the intact level compared with single-bundle anterior cruciate ligament reconstruction at low flexion angles, but it overconstrained the knee joint at high flexion angles. Clinical Relevance This technique could be an alternative for both single-bundle and double-tunnel—double-bundle anterior cruciate ligament reconstructions to reproduce intact knee kinematics and native anterior cruciate ligament anatomy.

To determine whether anatomic double-bundle anterior cruciate ligament (ACL) reconstruction compared to anatomic single-bundle ACL reconstruction more effectively restored antero-posterior (A-P) laxity, rotatory laxity and reduced frequency of graft rupture. Our hypothesis was that anatomic double-bundle ACL reconstruction results in superior rotational knee laxity and fewer graft ruptures due to its double-bundle tension pattern, compared with anatomic single-bundle ACL reconstruction. An electronic search was performed using the PubMed, EMBASE and Cochrane Library databases. All therapeutic trials written in English reporting knee kinematic outcomes and graft rupture rates of primary anatomic double- versus single-bundle ACL reconstruction were included. Only clinical studies of levels I-II evidence were included. Data regarding kinematic tests were extracted and included pivot-shift test, Lachman test, anterior drawer test, KT-1000 measurements, A-P laxity measures using navigation and total internal-external (IRER) laxity measured using navigation, as well as graft failure frequency. A total of 7,154 studies were identified of which 15 papers (8 randomized controlled trials and 7 prospective cohort studies, n = 970 patients) met the eligibility criteria. Anatomic ACL double-bundle reconstruction demonstrated less anterior laxity using KT-1000 arthrometer with a standard mean difference (SMD) = 0.36 (95% CI 0.214-0.513, p < 0.001) and less A-P laxity measured with navigation (SMD = 0.29 95% CI 0.01-0.565, p = 0.042). Anatomic double-bundle ACL reconstruction did not lead to significant improvements in pivot-shift test, Lachman test, anterior drawer test, total IRER or graft failure rates compared to anatomic single-bundle ACL reconstruction. Anatomic double-bundle ACL reconstruction is superior to anatomic single-bundle reconstruction in terms of restoration of knee kinematics, primarily A-P laxity. Whether these improvements of laxity result in long-term improvement of clinical meaningful outcomes remains uncertain. II.