Quadriceps Tendon Autograft Research Articles

Postoperative Strength Differences at Short-Term Follow-Up Vary Based on Autograft Harvest Site After Adolescent Transphyseal Anterior Cruciate Ligament Reconstruction

PurposeThe purpose of this study was to compare the clinical and patient-reported outcomes of adolescent patients who underwent anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) versus hamstrings tendon (HT) autograft. MethodsThis was a retrospective cohort study of adolescent patients ≤18 years treated at a single tertiary care children’s hospital who underwent primary transphyseal ACLR using QT or HT between January 2018-December 2019. All patients had minimum 6-month follow-up. Outcomes included isokinetic strength testing, postoperative PROMIS and IKDC scores, and complications. These were compared between QT and HT cohorts. ResultsA total of 84 patients were included (44 HT, 40 QT). The QT cohort had a higher proportion of male patients (62.5% vs 34.1%, p=0.01). At 3 months, those with HT had lower Hamstrings/Quadriceps (H/Q) strength ratios (60.7±11.0 vs 79.5±18.6, p<0.01) and flexion-limb symmetry index (LSI) (85.6±16.1 vs 95.5±15.7, p=0.01), while patients with QT had lower extension-LSI (67.3±9.5 vs 77.4±10.7, p<0.01). The H/Q ratio was lower at 6 months for patients with HT (59.4±11.5 vs 66.2±7.5, p<0.01). PROMIS/IKDC scores were not different at 3 months or latest follow-up. Patients with QT had more wound issues (20.0% vs 2.3%, p=0.01). Those receiving HT autograft had more ipsilateral knee injuries (18.2% vs 2.5%, p=0.03), but there was no difference in graft failure for HT and QT ACLR (9.1% vs 2.5%, p=0.36). ConclusionThere were no differences in PROM between patients receiving QT and HT autografts. QT grafts had more post-operative wound issues but a lower rate of ipsilateral knee complications (graft failure or meniscus tear). Differences in quadriceps and hamstrings strength post-operatively compared to the contralateral limb were observed for adolescent ACLR patients receiving QT and HT autografts, respectively. This contributed to higher H/Q ratios seen at 3 and 6 months postoperatively for patients receiving QT autografts. Level of EvidenceLevel III, retrospective comparative therapeutic study

Investigating the effect of autograft diameter for quadriceps and patellar tendons use in anterior cruciate ligament reconstruction: a biomechanical analysis using a simulated Lachman test.

Current clinical practice suggests using patellar and quadriceps tendon autografts with a 10 mm diameter for ACL reconstruction. This can be problematic for patients with smaller body frames. Our study objective was to determine the minimum diameter required for these grafts. We hypothesize that given the strength and stiffness of these respective tissues, they can withstand a significant decrease in diameter before demonstrating mechanical strength unviable for recreating the knee's stability. We created a finite element model of the human knee with boundary conditions characteristic of the Lachman test, a passive accessory movement test of the knee performed to identify the integrity of the anterior cruciate ligament (ACL). The Mechanical properties of the model's grafts were directly obtained from cadaveric testing and the literature. Our model estimated the forces required to displace the tibia from the femur with varying graft diameters. The 7 mm diameter patellar and quadriceps tendon grafts could withstand 55-60 N of force before induced tibial displacement. However, grafts of 5.34- and 3.76-mm diameters could only withstand upwards of 47 N and 40 N, respectively. Additionally, at a graft diameter of 3.76 mm, the patellar tendon experienced 234% greater stiffness than the quadriceps tendon, with similar excesses of stiffness demonstrated for the 5.34- and 7-mm diameter grafts. The patellar tendon provided a stronger graft for knee reconstruction at all diameter sizes. Additionally, it experienced higher maximum stress, meaning it dissociates force better across the graft than the quadriceps tendon. Significantly lower amounts of force were required to displace the tibia for the patellar and quadriceps tendon grafts at 3.76- and 5.34-mm graft diameters. Based on this point, we conclude that grafts below the 7 mm diameter have a higher chance of failure regardless of graft selection.

A Minimally Invasive Technique for Harvesting Quadriceps Tendon Autograft With a Bone Plug for Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) was first described decades ago. Recent studies have demonstrated superior graft characteristics (diameter, strength, and stiffness) and reduced postoperative morbidity. However, limited instrumentation options currently available to surgeons allow for minimally invasive QT harvest with a bone plug. As an alternative to traditional QT harvest techniques, we describe a surgical technique allowing for minimally invasive QT autograft harvest with a bone plug (QuadVantage Technologies, Inc). This approach can offer technical advantages, including efficiency of graft harvest, reproducibility of procedure, and more consistent graft sizes.

Quadriceps tendon autograft has similar clinical outcomes when compared to hamstring tendon and bone-patellar tendon-bone autografts for revision ACL reconstruction: a systematic review and meta-analysis.

Research regarding revision anterior cruciate ligament reconstruction (RACLR) with quadriceps tendon (QT) autografts is lacking. The purpose of this study was to perform a systematic review and meta-analysis of RACLR with QT and compare its patient outcomes to RACLR with hamstring tendon (HT) and bone-patellar tendon-bone (BTB) autografts. Adhering to PRISMA guidelines, a search for studies using QT in RACLR was performed within PubMed, Scopus, and CINAHL from database date of inception through December 26, 2022. Primary outcomes sought included: failure rate, Lysholm scores, International Knee Documentation Committee (IKDC) scores, IKDC grades, arthrometric knee side-to-side differences (STSD), pivot shift grade, donor site morbidity, return to sport, visual analog scale (VAS) pain scores. Nine studies were included consisting of 606 RACLR: 349 QT, 169 HT, and 88 BTB. Overall failure rates were 7.6% QT, 13.3% HT, and 8.7% BTB. Mean weighted Lysholm scores were 85.8 ± 3.8 QT, 82.5 ± 3.8 HT and 86.6 ± 4.5 BTB. IKDC average scores were 82.3 ± 1.6 QT, 80.1 ± 1.7 HT, and 81.7 ± 5.5BTB. Combined rates of IKDC A/B grades were 88.4% and 80.0% for QT and HT, respectively. VAS average scores were 0.9 ± 1.1 QT, 1.4 ± 0.2 HT, and 0.7 ± 0.8 for BTB. Side-to-side difference was reported for QT and HT with average values of 1.7 ± 0.6mm and 2.1 ± 0.5mm, respectively. Grade 0 or 1 pivot shifts were reported in 96.2% of QT patients and 91.3% of HT. Donor site morbidity, only reported for QT and HT, was 14.6 ± 9.7% and 23.6 ± 14.1%, respectively. QT resulted in a mean Tegner score of 5.9 ± 1.5 versus HT 5.7 ± 1.5. Rate of return to pivoting sports was 38.0% QT, 48.6% HT, and 76.9% BTB. Across all outcomes, there was no significant difference when comparing QT to HT, QT to BTB, and QT compared to HT and BTB combined. RACLR with QT yields satisfactory patient reported outcomes, satisfactory improvement in knee laxity, expected return to sport rates, and has an overall 7.6% failure rate. Outcomes are comparative to those of HT and BTB making it an acceptable graft choice for RACLR. Surgeons should consider using QT autograft for RACLR, especially when other autografts are unavailable. IV.

Role of Quadriceps Tendon Autograft in Primary and Revision Anterior Cruciate Ligament Reconstruction.

» The quadriceps tendon (QT) autograft is becoming increasingly popular in both primary and revision anterior cruciate ligament reconstruction (ACLR).» The biomechanical properties of the QT are similar to those of the native ACL, the hamstring tendon (HT), and bone-patellar tendon-bone (BTB) autografts.» QT autograft allows surgeons to be flexible with their graft size and reconstruction technique.» The QT autograft performs in a similar fashion to the BTB and HT autografts, with excellent patient-reported outcomes, consistent postoperative knee stability, and low rates of postoperative complications including graft failure and donor site morbidity.» There are emerging data that the QT autograft is a viable option in revision ACLR.

Current development in surgical techniques, graft selection and additional procedures for anterior cruciate ligament injury: a path towards anatomic restoration and improved clinical outcomes-a narrative review.

Anterior cruciate ligament (ACL) reconstruction has been widely used for ACL injury for a long time. However, residual rotational instability and osteoarthritic changes after ACL reconstruction have been identified as problems. Thus, anatomic reconstruction techniques, various types of grafts and additional procedures have been desired to improve the clinical outcomes and knee instability. Although clinical outcomes and knee stability are better than in the past, ipsilateral graft failures still occur in 4-17% and osteoarthritic changes are seen in about 20% of patients after ACL reconstruction. To remedy these problems, it is necessary to improve the understanding of various surgical techniques and grafts and to pursue further improvement of surgical techniques. Therefore, the objective of this review is to summarize the advantages and disadvantages of various surgical techniques and graft selection, and additional procedures for ACL injury. A literature review was conducted on the surgical procedures for ACL injury. Recent trends in surgical techniques, graft selection, and additional procedures for ACL injury were described. We performed a literature search in PubMed for studies published from origin to May 8, 2023. Studies were required to be English-language articles. Although many reports indicate that double-bundle ACL reconstruction is comparable to anatomic single-bundle (SB) reconstruction, intraoperative complications such as tunnel coalition exist in double-bundle reconstruction, and the technique needs to be improved. ACL repair has shown good short-term results, but long-term results need to be examined in the future. Quadriceps tendon autograft is being used more frequently, but hamstrings tendon autograft and bone-patellar tendon-bone autograft also have good results. In addition, in higher-risk cases, lateral extra-articular tenodesis (LET) and anterolateral ligament (ALL) reconstruction can be performed with good results. To further improve clinical outcomes, more anatomical reconstructions should be pursued. Autografts are better than allografts and synthetic grafts, but further study is needed to determine which graft is better. Additional procedures should be performed in highly unstable cases and in revision cases.

Impact of Quadriceps Tendon Graft Thickness on Electromechanical Delay and Neuromuscular Performance After ACL Reconstruction.

Both partial- and full-thickness quadriceps tendon (QT) graft harvests are used for anterior cruciate ligament reconstruction (ACLR). To evaluate the impact of QT graft harvest depth (full or partial thickness) on electromechanical delay (EMD), peak torque (PT), and rate of torque development (RTD) after ACLR. Controlled laboratory study. A total of 26 patients who underwent either partial-thickness (n = 14) or full-thickness (n = 12) autograft QT ACLR were recruited between June and November 2021 (>1 year before participation). Patients performed isokinetic knee extension testing with surface electromyography of the quadriceps muscles. Mixed repeated-measures analysis of variance with least significant difference post hoc testing was used to determine significant differences (mean difference [MD] ± SE) or interactions for all variables. A significant speed×depth interaction was seen for the vastus medialis (P = .005). Pairwise analyses showed significantly longer EMD for the partial-thickness graft than the full-thickness graft (MD ± SE, 19.92 ± 6.33 ms; P = .006). In the partial-thickness graft, the EMD was significantly longer at 90 deg/s versus 180 deg/s (MD ± SE, 19.11 ± 3.95 ms; P < .001) and 300 deg/s (MD ± SE, 16.43 ± 5.30 ms; P = .006). For PT, the full-thickness graft had a significantly lower PT on the operated versus nonoperated side at all speeds (MD ± SE: 90 deg/s, -57.0 ± 10.5 N·m, P < .001; 180 deg/s, -26.0 ± 10.2 N·m, P = .020; 300 deg/s, -20.3 ± 8.9 N·m, P = .034). For RTD, the full-thickness graft showed significantly Slower RTD for the operated versus nonoperated side at all time points (MD ± SD: RTD0-25 (0-25% of the range of motion), -131.3 ± 50.9 N·m/s, P = .018; RTD25-50, -197.0 ± 72.5 N·m/s, P = .014; RTD50-75, -113.3 ± 39.8 N·m/s, P = .013; RTD75-100, -149.4 ± 35.9 N·m/s, P < .001). Compared with partial-thickness QT, full-thickness QT showed a shorter vastus medialis EMD at higher loading, and therefore greater stiffness, as well as slower RTD and lower PT across all testing speeds. The impact of full-thickness QT autograft on EMD and neuromuscular performance should be considered for ACLR.

Autograft patellar bone-tendon-bone use does not increase operative time in anterior cruciate ligament reconstruction

BackgroundAnterior cruciate ligament reconstruction (ACLR) is a common procedure that has been shown to have relatively good outcomes amongst various graft types. Operative time in ACLR has been found to influence outcomes and cost. The purpose of this study was to evaluate the association of operative time in primary arthroscopically performed anterior cruciate ligament reconstruction (ACLR) and graft type while controlling for confounders that influence time. MethodsAll patients who received ACLR between 2018 and 2022 were included in this retrospective cohort study. Exclusion criteria consisted of age (≤16 years), revisions, concomitant ligament reconstruction or tendon repairs, or other simultaneously performed procedures that could potentially add substantial variation in operative time. The primary outcome was operative time. Graft types included allograft, bone-tendon-bone (BTB) autograft, hamstring tendon (HS) autograft and quadriceps tendon (QT) autograft. ResultsA total of 1813 primary ACLRs were included. The average operative time was 98.9 ± 33.0 min. Graft utilization varies considerably among surgeons. The most used graft type was BTB autograft (42.6%) followed by HS autograft (32.3%) and allograft (21.4%). Only 68 cases (3.8%) used a QT autograft. Seven of the 15 included surgeons primarily used BTB autograft. One surgeon predominately used QT autograft. No difference in operative time was observed among the autograft types (p = 0.342). Allograft ACLR was significantly faster by 27–33 min compared to using BTB autograft, HS autograft, or QT autograft (p < 0.001). ConclusionOperative time did not vary by type of autograft selected. Allograft ACLR was performed approximately 30 min faster than autograft ACLR. Further studies examining the effect on patient outcomes of reduced operative time and minimizing graft harvest morbidity in ACLR is important to more accurately determine the cost-effectiveness of allograft ACLR.

Anterior Cruciate Ligament Tears in the Adolescent Population: Injury Demographics and Risk of Reinjury Among High School Athletes.

The incidence of anterior cruciate ligament (ACL) injuries is increasing among the adolescent population with a peak occurring in the high school age range. To characterize recent epidemiologic trends of ACL injuries, ACL reconstruction (ACLR), and retear rates in high school adolescents based on age, participating sport, and mechanism of injury. Retrospective case series. A prospectively maintained institutional database was retrospectively reviewed for all patients 18 or younger who underwent primary ACLR between 2015 and 2020. Odds ratios were calculated for baseline patient characteristics and their association with risk of retear. Multivariate regression analysis was also performed to identify the relationship between retear and specific categorical variables. A total of 482 patients were included, with a mean follow-up time of 13.0 ± 11.8 months. Patients were an average age of 16.1 ± 1.3 years old (range: 13 to 18 y). Initial presentation of ACL injuries in high school athletes often occurred at 16 years old regardless of the sport played. Based on age, high school freshmen and seniors are found to have an increased risk of ACL retear. One hundred three patients (21.6%) completed at least 2 or more years of follow-up after ACLR. Of these patients, 38.8% received a bone-tendon-bone (BTB) autograft, 36.9% hamstring autograft, 14.6% quadriceps tendon autograft, and 3.9% received hamstring allograft or other graft (eg, tibialis anterior and BTB allograft), respectively. There were 25 ipsilateral ACL retears that occurred in the patient cohort (5.2%). Thirteen (52%) of retears were females. Football and soccer were the most common sports played by patients with a retear of the ipsilateral knee (31.8% and 27.3%, respectively). Patients who were 13 to 14 or 18 years old ( P = 0.009 and 0.035, respectively) or who received a tibialis anterior/BTB allograft ( P = 0.002) were found to have increased risk of ACL retear compared with other age groups. When evaluating by sex, female soccer players had a greater risk of retear compared with male soccer players ( P = 0.007). When adjusting for multiple variables, (including age, sex, body mass index, primary reconstruction graft choice, sport, and length of follow-up), the odds of ipsilateral retear in patients who received hamstring autograft ( P = 0.02), sustained a contralateral ACL tear ( P = 0 .04), or a contact injury ( P = 0.01) were increased. Initial presentation of ACL injuries in high school athletes often occurs at 16 years old regardless of the sport played. Based on age, high school freshmen and seniors are found to have an increased risk of ACL retear. However, the overall rate of ACL retear in high school athletes of all ages is low. Patients who underwent ACLR with hamstring tendon autograft had a greater risk of retear compared with other graft types. Female soccer players also had a greater risk of ACL retear. High school athletes must take caution when in the early high school years (underclassman) and more senior years (upperclassman), as susceptibility for ACL retears is elevated. Level IV.

Tips and Tricks for Anatomic ACL Reconstruction With Soft-Tissue Quadriceps Tendon and Remnant Repair

Background: Quadriceps tendon (QT) autograft represents an excellent option for anterior cruciate ligament (ACL) reconstruction (ACLR), with minimal donor site morbidity and failure rates comparable with bone-patellar tendon-bone (BPTB) autograft. This video aims to provide technical tips for ACLR using all-soft-tissue QT autograft. Indications: ACLR with QT autograft is indicated in young, active ACL-injured patients who desire a return to sport. It represents a viable option in both primary and revision ACLR, as well as in skeletally immature patients. It is particularly indicated in those who kneel frequently, such as wrestlers or laborers, due to the lower incidence of postoperative anterior knee pain. Technique Description: A vertical incision is used to harvest a 10 mm × 70 mm partial thickness, all-soft-tissue QT graft. Care is taken not to violate the capsule or musculature. If necessary, graft size is modified based on preoperative magnetic resonance imaging (MRI) measurement of the notch width. The graft is then prepared with continuous loop suspensory fixation on the femoral side and draw sutures on the tibial side. The lateral femoral notch is debrided to allow for visualization of the posterior wall to enable anatomic tunnel placement. When possible, the tibial stump is preserved. The femoral tunnel is drilled via an anteromedial portal and the tibial tunnel via a tibial guide. The graft is then passed through the tibial stump into the femur. It is fixed on the tibial side with a PEEK interference screw in full extension with application of a posterior drawer. Results: Outcomes following ACLR with QT autograft are excellent, with laxity and patient-reported outcomes comparable with those following ACLR with BPTB and hamstring autograft. Furthermore, QT ACLR has been shown to result in less donor site morbidity than BPTB autograft, and lower rates of failure and infection compared with hamstring autograft. Conclusion: ACLR with QT autograft is a good option in young, active patients in both the primary and revision settings. Advantages of QT ACLR include less donor site morbidity than BPTB, and lower rates of failure compared with hamstring autograft in young patients. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Return to Sport Following ACL Reconstruction With Slope-Correcting High Tibial Osteotomy in the Elite Athlete

Background: Increased posterior tibial slope is a strong predictor of anterior cruciate ligament (ACL) graft re-injury. A concomitant slope-reducing high tibial osteotomy (HTO) has been suggested to decrease re-tear risk in these cases although little is known regarding outcomes following ACL reconstruction with HTO, especially in elite athletic patients. Indications: A 19-year-old National Collegiate Athletics Association (NCAA) Division 1 running back presented with an ACL tear, lateral meniscus tear, and posterior tibial slope of 19° (case 1). A 19-year-old NCAA Division 1 soccer forward presented with an ACL graft re-tear and posterior tibial slope of 21° (case 2). Technique: Anterior closing wedge HTOs were performed along with a primary ACL reconstruction with quadriceps tendon autograft (case 1) and a revision ACL reconstruction with quadriceps tendon autograft (case 2). Following the arthroscopic procedures, an anterior approach was used to insert the first guide wire distal to the patellar tendon insertion from anterior to posterior aiming toward the posterior curve of the tibia. A second guide wire was placed at the previously templated distance. The osteotomy was then performed utilizing a saw and then osteotome. The reduction was performed by gently lifting the ankle anteriorly and applying axial pressure, and a new posterior tibial slope was calculated. After the osteotomy site was reduced, a preliminary reduction was performed by applying a clamp to both wires followed by placing a wire across the osteotomy site aiming from anterolateral to posteromedial. An anterolateral proximal tibial plate was applied, as well as a lag screw across the osteotomy site. Results: At 6 months after surgery, case 1 demonstrated &gt;90% Limb Symmetry Indices (LSI) with quadriceps strength, single leg hop tests, and change of direction tests. At 12 months after surgery, case 2 demonstrated &gt;90% LSI with all functional testing and competed in 17 games. Both patients returned to preinjury performance metrics including top speed and vertical jump height. No significant postoperative complications or instability was observed. Discussion/Conclusion: Primary or revision ACL reconstruction with HTO shows potential to assist athletes in returning to high-level sport while reducing posterior slope. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Prospective Comparison of Postoperative Pain and Opioid Consumption Between Primary Repair and Reconstruction of the Anterior Cruciate Ligament.

Anterior cruciate ligament (ACL) reconstruction (ACLR) is associated with postoperative pain and necessitates using perioperative nerve blocks and multimodal analgesic plans. To assess postoperative pain and daily opioid use after ACL repair versus ACLR and to assess whether ACL repair could be performed successfully without using long-acting nerve blocks. Cohort study; Level of evidence, 2. All eligible patients who underwent ACL surgery between 2019 and 2022 were prospectively enrolled. Patients were treated with primary repair if proximal tears with sufficient tissue quality were present; otherwise, they underwent single-bundle ACLR with either hamstring tendon or quadriceps tendon autograft. The patients were divided into 3 groups: ACLR with adductor canal nerve block (up to 20 mL of 0.25% bupivacaine with 2 mg dexamethasone), primary repair with nerve block, and primary repair without nerve block. Pain visual analog scale and number of opioids used were recorded during the first 14 postoperative days (PODs). Furthermore, patients completed the Quality of Recovery-15 (QoR-15) survey, and range of motion was assessed. Group differences were compared using Mann-Whitney U test and chi-square test. Seventy-eight patients were included: 30 (39%) underwent ACLR, 19 (24%) ACL repair with nerve block, and 29 (37%) ACL repair without nerve block. Overall, the ACL repair group used significantly fewer opioids than the ACLR group on POD 1 (1 vs 3, P = .027) and POD 2 (1 vs 3, P = .014) while also using fewer opioids in total (3 vs 8, P = .038). This difference was even more marked when only analyzing those patients who received postoperative nerve blocks (1 vs 8, P = .029). Repair patients had significantly higher QoR-15 scores throughout the first postoperative week, and they had greater range of motion (all P < .05). There were no significant differences in pain scores, opioid usage, or QoR-15 scores between patients who underwent repair with versus without nerve block. The ACL repair group experienced less postoperative pain during the first 2 weeks after surgery and used significantly fewer opioids than the ACLR group. Furthermore, they had improved knee function and higher recovery quality than patients who underwent ACLR during the initial postoperative period. Postoperative nerve blocks may not be necessary after ACL repair.

Minimal differences in acute postoperative pain after anterior cruciate ligament reconstruction with quadriceps versus hamstring autograft.

Studies are lacking that evaluate early postoperative pain after all-soft-tissue quadriceps tendon anterior cruciate ligament reconstruction (ACLR), particularly in young patients. The purpose of this study was to investigate differences in early postoperative pain between adolescent patients undergoing ACLR with quadriceps tendon versus hamstring autograft. A retrospective review was performed of 60 patients (mean age, 15.6 ± 1.3 years) who underwent ACLR using either quadriceps tendon ( n = 31) or hamstring ( n = 29) autografts between January 2017 and February 2020. Intraoperative and postoperative milligram morphine equivalents (MMEs), postanesthesia care unit (PACU) length of stay and PACU pain scores were recorded. Pain scores and supplemental oxycodone use were recorded on postoperative days (POD) 1-3. Differences were compared between the two groups. There were no statistically significant differences in age, sex, body mass index or concomitant meniscus repairs between the two groups ( P > 0.05). There were no statistically significant differences in intraoperative MMEs, PACU MMEs or PACU length of stay between groups ( P > 0.05). There were no statistically significant differences in maximum PACU pain scores (3.7 ± 3.0 vs. 3.8 ± 3.2; P = 0.89). Maximum pain scores on POD 1-3 were similar between groups ( P > 0.05). There were no statistically significant differences in supplemental oxycodone doses between groups on POD 1-3 ( P > 0.05). Adolescent patients undergoing ACLR with quadriceps tendon and hamstring autografts have similar pain levels and opioid use in the early postoperative period.

Harvest location has a minimal impact on differences in cross-sectional area of quadriceps tendon in anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) reconstruction with quadriceps tendon (QT) has been gaining popularity. However, it is unknown how differences in harvest location of the QT affect its thickness and cross-sectional area (CSA). The present study aimed to clarify the differences in thickness and CSA of the QT based on location of tendon harvesting. Patients scheduled for, or who underwent, ACL reconstruction were prospectively included in the study. The short-axis images on ultrasound were used to assess the CSA of the QT at 30 and 60mm proximal to the superior pole of the patella. QT autografts with CSAs greater than or equal to 10mm of width were included and measured at three different locations, namely the center, medial one-third, and lateral one-third at the widest diameter of the QT. Patients with less than 10-mm width of the QT at 60mm proximal to the superior pole of the patella were excluded. The thickness and CSA were compared based on the location of tendon harvest. Thirty-seven patients were recruited for the study. The mean thickness and CSA were larger in the center of the QT compared to the lateral one-third at 30mm proximal to the superior pole of the patella (thickness, 6.7 ± 1.3mm vs. 5.9 ± 1.3mm; P = 0.009; CSA, 65.6 ± 11.4 mm2 vs. 58.8 ± 11.9 mm2; P = 0.036). There were no significant differences in thickness and CSA of the QT among the three assessment locations at 60mm proximal to the superior pole of the patella (n.s.). The thickness and CSA of QT was greater in the center compared to the lateral one-third at 30mm proximal to the QT insertion point. However, the difference in value was clinically non-significant, and therefore, harvest location of the QT autograft may not meaningfully impact intraoperative graft diameter. As a result, surgeons may choose the harvest location without concern for resultant graft diameter as long as the enough length of QT is secured. III.

Clinical outcomes of different autografts used for all-epiphyseal, partial epiphyseal or transphyseal anterior cruciate ligament reconstruction in skeletally immature patients – a systematic review

BackgroundDifferent types of grafts can be used for anterior cruciate ligament reconstruction (ACLR). There is little published data regarding skeletally immature patients. The purpose of this systematic review was to assess the clinical outcomes and complications for different autograft types used in all-epiphyseal, transphyseal and partial epiphyseal/hybrid ACLR in skeletally immature children and adolescents.MethodsPubMed, Embase and Cochrane databases were systematically searched for literature regarding ACLR using hamstrings, quadriceps or bone-patellar-tendon-bone (BPTB) autografts in skeletally immature patients. Studies were included if they examined at least one of the following outcomes: graft failure, return to sport(s), growth disturbance, arthrofibrosis or patient reported outcomes and had a minimum follow-up of 1 year. Case reports, conference abstracts and studies examining allografts and extra-articular or over-the-top ACL reconstruction techniques were excluded. Graft failure rates were pooled for each graft type using the quality effects model of MetaXL. A qualitative synthesis of secondary outcomes was performed.ResultsThe database search identified 242 studies. In total 31 studies were included in this review, comprising of 1358 patients. Most patients (81%) were treated using hamstring autograft. The most common used surgical technique was transphyseal. The weighted, pooled failure rate for each graft type was 12% for hamstring tendon autografts, 8% for quadriceps tendon autografts and 6% for BPTB autografts. Confidence intervals were overlapping. The variability in time to graft failure was high. The qualitative analysis of the secondary outcomes showed similar results with good clinical outcomes and low complication rates across all graft types.ConclusionsBased on this review it is not possible to determine a superior graft type for ACLR in skeletally immature. Of the included studies, the most common graft type used was the hamstring tendon. Overall, graft failure rates are low, and most studies show good clinical outcomes with high return to sports rates.

Medial Patellofemoral Ligament Reconstruction Using Pedicled Quadriceps Tendon Autograft Yields Similar Clinical and Patient-Reported Outcomes but Less Donor-Site Morbidity Compared With Gracilis Tendon Autograft

To compare clinical and patient-reported outcome measures (PROMs) in patients with recurrent patellar dislocation after medial patellofemoral ligament (MPFL) reconstruction using either a gracilis tendon (GT) or quadriceps tendon autograft (QT). All MPFL reconstruction performed between 2017 and 2019 were reviewed retrospectively. Only patients with isolated MPFL reconstruction, without any major patellofemoral risk factors and a minimum follow-up of 24 months, were included in the study. Patients were matched with respect to sex, age, and body mass index. All patients were evaluated clinically and using PROMs. A total of 64 patients with an average follow up of 28.7 ± 7.5 months were included in this study. The mean Kujala score (GT: 84.8 ± 12.9, QT: 88.9 ± 10.1), Lysholm score (GT: 89.4 ± 10.2, QT: 88.4 ± 5.0), and visual analog scale score for pain (GT: 1.9 ± 1.8, QT: 1.1 ± 1.3) did not significantly differ between both groups. Tegner activity level was significantly greater (P= .027) in the QT group (5.5 ± 1.9) compared with the GT group (4.6 ± 1.8), but within the minimal clinically important differences. Occasional patellar instability events, but no recurrent dislocation, were reported in 12.5% in the GT group and 6.3% in the QT group (P= .39). Of all patients, 90.6% in the QT and 68.8% in the HT group exceeded the PASS for the Kujala score (P= .06). Significantly more patients (59.4%) treated with GT reported donor-site morbidity in the form of sensitivity deficit at the lower leg compared with those treated with QT (3.1%, P= .001). GT and QT MPFL reconstruction have comparable PROMs and patellar redislocation rates 2 years' postoperatively. Significantly more patients treated with GT reported lower-leg sensitivity deficit compared with those treated with QT. Level III, retrospective case-control study.

A prospective randomized controlled study of hamstring and bone-free quadriceps tendons autografts in arthroscopic ACL reconstruction.

Anterior cruciate ligament (ACL) reconstruction is one of the most common surgical procedures worldwide. However, the ideal graft source is still debatable. This study compared hamstring (HT) and bone-free quadriceps (QT) tendon autografts in terms of muscle strength and patient-reported outcomes. Between June 2018 and December 2019, 46 patients were enrolled in the study and randomly assigned to one of two groups for the ACL reconstruction surgery-the HT autograft group or the QT autograft group. An experienced examiner performed preoperative and postoperative examinations. The HUMAC NORM isokinetic machine (Computer Sports Medicine International-CSMI, 2004) was used to assess flexor and extensor thigh muscle strength. Both groups received the same surgical technique and fixation method. All patients were examined after three, six, nine, and 12months. The final evaluations were performed at the 24-month follow-up. Patients' scores on the International Knee Documentation Committee (IKDC) evaluation form and the Lysholm Knee Scoring Scale were used to evaluate patient-reported outcomes. The two groups were also compared in terms of postoperative complications and activity levels. The difference between preoperative and postoperative knee flexor peak torques (FPT) was lower in the QT group than in the HT group. The average difference between preoperative and postoperative knee extensor peak torque (EPT) was higher in the QT group than in the HT group. As a result, the HT group had a lower postoperative H/Q ratio (flexor strength normalized to body mass divided by extensor strength normalized to body mass) than the QT group (p < 0.001). The mean IKDC scores for the HT and QT groups were 90.13 ± 6.99 and 87.12 ± 6.61, respectively. The scores of the two groups postoperatively were close, and both groups showed significant improvement. The average graft size in the QT group was significantly greater than that in the HT group. Saphenous nerve palsy was the most common complication in the HT group (22%). Thigh hematomas were observed in two patients in the QT group and required urgent intervention (12%). After ACL reconstruction, we found a significant decrease in strength at the donor sites in both techniques, with similar patient-reported measures and stability outcomes. The H/Q strength ratio was higher in the QT group postoperatively, which may have a protective effect on the reconstructed ligament. Level of Evidence I It is a randomized controlled trial.

Poster 346: Revision Anterior Cruciate Ligament Reconstruction with an All-Soft Tissue Quadriceps Tendon Autograft Produces Similar Outcomes to Index Surgery

Objectives: Anterior cruciate ligament reconstruction (ACLR) using all-soft tissue quadriceps tendon (QT) autograft has not yet been studied as a viable revision option in the pediatric population. This study aimed to compare short- to mid-term outcomes between patients undergoing revision ACLR and primary ACLR using all-soft tissue QT autograft. Methods: A retrospective review of prospectively collected data included patients aged 8-18 years old who underwent revision ACLR using an all-soft tissue QT autograft over a ten-year period (2011-2021). One-to-two matching by age and gender was performed to select a control group of patients who underwent primary ACLR utilizing all-soft tissue QT autograft during the same period. All procedures were performed by a single surgeon using a minimally invasive graft harvest technique and suspensory fixation. Subjective assessment of knee function was obtained pre- and postoperatively with the International Knee Documentation Committee (IKDC) survey. Postoperative knee laxity was measured with a KT1000 arthrometer at 6 weeks, 3 months, and 6 months. Isokinetic quadriceps strength at 60° and 180° was collected at 6 months and 12 months. Complications, including hematomas, infections, graft failures, and the need for subsequent surgery were recorded. To determine clinical significance ( p≤0.05), outcomes were compared using two-sided Student t-tests and Pearson’s chi-squared tests. Results: Thirty-nine patients underwent revision ALCR (59% female; 15.67±1.6 years old; BMI 23.7±4.6) and 78 underwent primary ACLR (59% female; 15.73±1.46 years old; BMI 23.5±3.9) with all-soft tissue QT autograft ( p=1.00 for gender; p=0.83 for age; p=0.82 for BMI). Length of follow up was 20.9 months (revision) and 23.4 months (primary) ( p=0.543). Mean IKDC scores improved significantly in both groups (Revision: 59.17±16.4 vs. 85.87±10.57, p&lt;0.001; Index: 55.85±16.8 vs. 88.38±14.2 p&lt;0.001). Mean time to postoperative IKDC for revision and primary ACLR was 14.67±5.7 months and 15.22±6.5 months, respectively ( p=0.865). There were no significant differences in mean pre- or postoperative IKDC scores between the index and revision groups (Table 1, p&gt;0.05). However, postoperative knee laxity was significantly greater after revision surgery at 6 weeks ( p=0.006) and 6 months ( p=0.009) (Table1). Contrarily, patients undergoing primary surgery had a greater isokinetic quadriceps strength deficit during both time points at 60° and 180°, which was statistically significant at full extension at 12 months postoperatively ( p&lt;0.039) (Table 1). Finally, although patients undergoing revision surgery exhibited fewer complications, this difference was not statistically significant (Table 2). Conclusions: Patient reported outcomes after ACLR revision surgery using all-soft tissue QT autograft in the paediatric population is equivocal to those undergoing primary reconstruction. Despite minor differences in the progression of postoperative isokinetic strength and knee laxity, a history of previously failed ACLR does not seem to portend inferior outcomes or increased risk for complications in pediatric patients undergoing revision surgery with all-soft tissue QT autograft. [Table: see text][Table: see text]

Poster 149: Donor Site Morbidity Following Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Versus Bone-Patellar Tendon-Bone Autograft: Results at 2-Year Follow-up

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&gt;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&gt;0.05). Correlations between PROMS and DSM showed correlations with IKDC, Marx, and SANE(P&lt;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.

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

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]