Full-Thickness Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction

Abstract

Background: Quadriceps tendon autograft is used increasingly worldwide for primary anterior cruciate ligament (ACL) reconstruction, but remains at the third place after patellar tendon and hamstring grafts. It has shown very good results in biomechanical and clinical studies, but most of the authors describe a partial thickness tendon graft. Indications: This presentation describes the technique for a full-thickness quadriceps tendon autograft with an original technique of fixation on the femur and provides tips and tricks to avoid pitfalls. Technique Description: Arthroscopic preparation of the tunnel is performed before graft harvesting, to obtain the exact length of the graft needed. The femoral tunnel is drilled through the anteromedial portal, 30 to 40 mm long. For the tibial tunnel, a classic drill guide system is used, set at an inclination of 40°. The total length from the tibia to the femur is measured, which allows to position the femoral fixation on the cortex without pulling it into the soft tissue. Harvesting of the graft is done using a double-bladed scalpel, using the entire thickness of the quadriceps tendon. The bone block is detached with an oscillating saw and osteotome, and the defect in the quadriceps tendon closed in 2 layers. The graft is calibrated according to the tunnel preparation and sutured on the bony end with non-absorbable sutures tied to an endobutton. Tibial fixation is achieved by tying 2 non-absorbable sutures over a cortical screw in maximum tension with a sliding type knot, to automatically adjust the tension. Final fixation is performed with a titanium interference screw. Results: In the senior author series over the last 20 years, there was only 1 intraoperative patella fracture, treated with osteosynthesis. In accordance with the literature, full-thickness quadriceps tendon graft is strong and allows back to play at the same level as before the injury, in most cases, with lower donor site morbidity than patellar tendon and hamstrings grafts, without a difference in muscle strength compared with partial thickness grafts. Discussion/Conclusion: ACL reconstruction with full-thickness quadriceps tendon has shown very good clinical outcomes, with very few complications. It can be recommended for primary and revision ACL reconstruction.