Poster 324: Complications following Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Pediatric Patients: A Case Series

Abstract

Objectives: The purpose of this study was to analyze the rate and type of complications and subsequent procedures encountered with soft tissue quadriceps tendon autograft (QTA) for anterior cruciate ligament reconstruction (ACLR) in pediatric patients ≤ 18 years old. Methods: After institutional review board approval, operative records of all pediatric patients ≤ 18 years old who underwent ACLR from June 2015 to December 2021 were retrospectively reviewed. A consecutive series of patients who underwent ACLR with a QTA with minimum 6 month-follow up were included in the study. Skeletally immature patients underwent an all-epiphyseal (AE) technique while patients nearing skeletal maturity or that were skeletally mature underwent a complete transphyseal (CT) procedure. All patients underwent ACLR by utilizing a full thickness soft tissue QTA without a bone plug. Additionally, patients who were determined to be at high risk of re-tear underwent a concomitant a lateral extra-articular tenodesis (LET) with a modified Lemaire technique. Preoperative demographic information, surgical details, associated diagnosis, and subsequent injuries and complications were collected. Complications associated with the quadriceps tendon harvest site and use of QTA including removal of non-absorbable sutures from the autograft donor site, quadriceps tendon rupture, and the subsequent development of a superior patellar osteochondritis dissecans lesions (OCD) were reported. Results: A total of 143 pediatric patients ≤ 18 years old underwent an ACLR with a soft tissue QTA during the study period. Of the 143 eligible patients, 137 patients had minimum 6-month follow-up and were included in the study. After 3 attempted contacts, six patients (4%) were deemed lost to follow-up and excluded from the study. The mean age was 14.8±1.6 (range 11-18 years) and 60% were male. The average follow-up time was of 2.0 ± 1.1 years (range 0.5-4.9 years). Of the 137 patients included in the study, 11 (8%) had a subsequent complication associated with the use a of a QTA. Baseline demographic characteristics of this cohort are summarized in (Table 1). Of the 11 patients with QTA related complications, 8 (6%) had a subsequent procedure to remove non- absorbable sutures used for the donor site closure. When we first began to perform QTA ACLR, non- absorbable sutures were used to close the donor site defect. We encountered a subset of patients that developed persistent donor site irritation and pain associated to the use of such sutures, and consequently changed our technique to use absorbable sutures. Interestingly, 2 (1%) patients developed OCD-like lesions in the superior aspect of the patella 1.2 ± 0.8 years on average following surgery (Fig 1). We speculate that the QTA harvest could have compromised the vasculature of the patella, thus resulting in the development of OCD and subsequent chondromalacia. Finally, 2 (1%) patients had quadriceps tendon ruptures following QTA ACLR. The first patient aged 16, slipped and fell onto a hyperflexed left knee 6 weeks after QTA ACLR and sustained a small boney avulsion injury of the superior pole of the patella. During repair, cultures were taken, and rare Staphylococcus aureus were identified. The patient was placed on Keflex for 4 weeks, however 2 weeks after finishing treatment they presented with sudden limited range of motion, increased pain, and a yellow appearing scab. An ultrasound guided aspirated was positive for Staphylococcus aureus, and the patient subsequently underwent an infection and debridement procedure. The second patient, aged 14, sustained a non-contact injury while playing football 7 months post- operatively prior to being cleared to return to sports. They sustained a complete tear of the distal quadriceps tendon, adjacent to the donor site. Of note, 1 patient underwent a concomitant removal of non-absorbable sutures and patellar chondromalacia debridement and is thus represented twice. In addition, 5 (4%) patients had a graft failure and underwent subsequent revision ACLR, 6 (4%) had a second meniscus related surgery, 8 (6%) had a subsequent lysis of adhesions procedure and 13 (9%) underwent ACLR for injuries sustained on the contralateral knee. Conclusions: In this study, we report complications encountered with soft tissue QTA for ACLR. The complication rate for quadriceps tendon graft harvest was 8%. However, given that the removal of non- absorbable sutures from the donor site was caused by the surgical technique used, the revised complication rate for quadriceps tendon graft harvest was 3%. To the authors’ knowledge, this is the first study to raise the suspicion that quadriceps tendon graft harvest could lead to the development of super patellar OCD as this occurred in two patients from this cohort. Although the use of a QTA has recently gained popularity due to its high return to sports and low graft failure rate, surgeons must be aware of the complications and risk associated with quadriceps tendon graft harvest. [Table: see text]