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

Donor-Site Morbidity in Anterior Cruciate Ligament (ACL) Reconstruction With All-Soft Tissue Quadriceps Tendon Autograft vs. Hamstring Tendon Autograft: A Retrospective Monocentric Observational Study

Background: Graft choice, together with operative technique, remains the most controversial topic surrounding ACL reconstruction. The ideal graft choice should recreate normal anatomy and biomechanics, allow for rapid return to play and have minimal harvest-site morbidity. The purposes of this study were to compare donor-site morbidity in all-soft-tissue quadriceps autograft vs. hamstring autografts based on Hacken et al.'s ACL Donor-Site Morbidity Questionnaire (32,587,874) and to assess the role played by external factors such as sex, mood, activity level and smoking status. Materials and Methods: We performed a retrospective analysis of our patients' records to identify individuals who were 30 years old or younger at the time of surgery and underwent ACL reconstruction using the anteromedial portal technique, without any additional treatments for ligament or meniscal injuries. At 12 months postintervention, donor-site morbidity was evaluated using the ACL donor-site morbidity questionnaire by Hacken et al. (2020). Analyses were performed using Jamovi freeware Version 2.3.19.0 (the Jamovi project, 2021). Independent samples t-test with Cohen's d as the effects' size statistics were used to compare donor-site morbidity and functional outcomes. Results: Significant differences between quadriceps tendon (QT) and STG groups were found for ACL donor-site morbidity questionnaire total score, numbness, size of numbness and muscle atrophy, all in favour of the QT cohort. Weak associations were found between female sex and low mood, both negatively impacting the reported donor site morbidity. No statistically significant differences were found for functional outcomes. Conclusion: ACL reconstruction with all-soft-tissue QT autograft showed overall superior donor-site morbidity outcomes when compared with HT autograft. Statistically significant results were also found in favour of QT when comparing numbness and size of numbness at the donor site and self-perceived muscle atrophy. Female sex and low mood have been found to impact donor-site morbidity negatively although larger samples are necessary to confirm this association. Graft choice in ACL reconstruction should always remain an individualized choice, but QT should be considered an equal, if not superior, alternative to other autologous autografts when comparing donor-site morbidity. Trial Registration: CINECA: 6458.

4-Strand hamstring versus single-bundle quadriceps tendon grafts in anterior cruciate ligament reconstruction at 2 years: A systematic review and meta-analysis of randomised controlled trials

Purpose

To compare the 2-year postoperative outcomes of hamstring tendon (HT) grafts to quadriceps tendon (QT) grafts in anterior cruciate ligament (ACL) reconstruction. We hypothesised no significant differences between the two methods.

Methods

A systematic review and meta-analysis were conducted following the 2020 PRISMA guidelines. Five online databases (Cochrane, Embase, PubMed, Scopus and Web of Science) were screened for prospective randomised controlled trials (RCT). IKDC, Lysholm, Tegner, side-to-side KT-1000 scores and ages were collected. Statistical analysis was conducted with SPSS v29. Between the two groups, a test of between-subgroup homogeneity p-value < 0.05 was used to assess statistical significance, while a Δ Cohen's d ≥ 0.8 was used to assess clinical significance.

Results

Five RCTs were included in the final analysis. The HT group included 87 patients, and the QT group included 93 patients. The mean ages for the HT and QT groups were 28.3 ± 6.6 and 26.5 ± 8.4 years, respectively. HTs yielded clinically higher IKDC scores (Δ Cohen's d = 2.27, p = 0.24), clinically lower side-to-side KT-1000 differences (Δ Cohen's d = 1.65, p = 0.08), and clinically and statistically higher Lysholm scores (Δ Cohen's d = 2.93, p = 0.00). However, QT yielded higher Tegner scores (Δ Cohen's d = 1.68, p = 0.00), whereas HT led to a moderate clinical reduction (Cohen's d = -0.55, p = 0.06, 95% CI [-1.11 to 0.02]).

Conclusions

Compared with the use of the QT graft, the HT graft for ACL reconstruction may result in greater knee function and stability, while QT ACL reconstruction may be associated with increased levels of postsurgical activity in terms of return to sports and work. Future long-term RCTs are needed to confirm our findings.

Level of Evidence

Level I.

Anterior Cruciate Ligament Revision Using Quadriceps Tendon Autograft and Lateral Extra-Articular Tenodesis

Revision of anterior cruciate ligament (ACL) reconstruction presents numerous challenges not encountered in the primary setting and therefore requires thorough preoperative planning. Addressing tunnel widening is the primary concern, and therefore the appropriate graft choice is pivotal. Quadriceps tendon autograft recently has gained popularity for its dimensions and the possibility to harvest a bone block from the patella that can fill potential tunnel bone defects. Adjunctive procedures to isolated ACL reconstruction such as lateral extra-articular tenodesis (LET) may help in sharing the loads with the neoligament, with recent findings recommending LET in the revision setting. The technique presented in this Technical Note describes a 1-stage revision ACL combined with LET using a quadriceps tendon autograft with a bone plug.

Quadriceps tendon autograft diameters are routinely above 8 mm, and preoperative size estimation before anterior cruciate ligament reconstruction may not be necessary for this graft type: A systematic review

PURPOSE

To identify values of reported quadriceps tendon (QT) autograft diameter and length in anterior cruciate ligament reconstruction (ACLR), and to identify methods to predict these parameters.

METHODS

A search was conducted across three databases from inception to 30 March 2024. Data on study characteristics, demographics, anthropometric data, imaging techniques, and QT autograft or harvested QT tendon parameters were extracted. Values quantifying the statistical strength of associations between imaging or anthropometric characteristics and graft or tendon parameters as well as for associations between these parameters and postoperative outcomes were recorded.

RESULTS

A total of 3633 patients were included. The weighted mean QT autograft diameter and length were 8.9 (standard deviation [SD]: 0.7, range: 7.8-10.4) mm and 8.1 (SD: 1.3, range: 5.6-9.3) cm, respectively. A total of 93.8% of studies that reported mean QT autograft diameter found a value of 8 mm or greater. The QT groups had similar or significantly greater mean autograft diameter compared to the hamstring tendon (HT) groups in 91.7% of studies that reported significance. Regarding MRI measurements, 71.4% of the correlation coefficients reported showed a moderate positive correlation, 28.6% showed a low positive correlation and 14.3% showed a high positive correlation. Regarding anthropometric characteristics, 33.3% and 16.7%, 16.7% and 14.3% of studies that reported on the relationship between QT autograft diameter and height, weight, body mass index or age, respectively, found a low positive statistically significant correlation. Only statistically nonsignificant associations were reported between QT autograft parameters and post-operative outcomes and complications.

CONCLUSIONS

QT autografts used in ACLR have a mean diameter of 8 mm or greater and are consistently larger than HT autografts. Preoperative MRI measurements are better than anthropometric characteristics at predicting QT autograft parameters; however, preoperative prediction may not be necessary for this graft type. QT autograft parameters were not found to be significantly associated with any post-operative complication or outcome.

LEVEL OF EVIDENCE

Level IV.

Anterior Cruciate Ligament Reconstruction Basics: Quadriceps Tendon (All-Soft Tissue) Autograft Preparation-Part 2

Anterior cruciate ligament reconstruction with quadriceps tendon autograft is a reliable graft option that has recently increased in use. Varying harvesting and graft preparation techniques available and improved technology and implant design continue to make quadricep tendon preparation more efficient and reproducible. In this Technical Note, we describe our preferred technique for all-soft tissue quadriceps tendon autograft preparation after harvest for anterior cruciate ligament reconstruction.

Navigating Post-operative Challenges: A Comprehensive Review of Complications Following Anterior Cruciate Ligament (ACL) Tear Surgery

Anterior cruciate ligament (ACL) injuries are among the most common and debilitating sports-related injuries, often necessitating surgical intervention to restore knee stability and function. ACL reconstruction surgery, which has evolved significantly over the years, aims to enable patients, particularly those who are young and physically active, to return to their pre-injury activity levels. However, despite advancements in surgical techniques and rehabilitation protocols, post-operative complications remain a significant concern that can adversely affect patient outcomes. This comprehensive review explores the spectrum of complications that can arise following ACL tear surgery, ranging from common issues such as infection, graft failure, and knee stiffness to less frequent but clinically significant complications like osteoarthritis and neurological injuries. The review also delves into the various factors influencing the likelihood of these complications, including patient-related variables, surgical techniques, and the effectiveness of rehabilitation protocols. By providing an in-depth analysis of these post-operative challenges, this review aims to enhance the understanding of ACL reconstruction outcomes and guide healthcare professionals in implementing preventive strategies and optimizing patient care. Through a multidisciplinary approach, the goal is to minimize the risk of complications, improve surgical outcomes, and ultimately enhance the quality of life for patients undergoing ACL reconstruction.

Pattern of strength recovery differences Exist in Adolescent athletes after anterior cruciate ligament reconstruction when using quadriceps versus Hamstring tendon autograft

OBJECTIVES

To compare the timeline for post-operative quadriceps and hamstrings strength recovery following anterior cruciate ligament reconstruction (ACLR) using either a quadriceps tendon (QT) or hamstring tendon (HT) autograft.

METHODS

Patients (≤18 years) who underwent ACLR using autograft QT or HT were included. Isokinetic strength was extracted at 3, 6, and 12 months post-operatively. Effects of time and graft type on quadriceps or hamstring limb symmetry index (qLSI/hLSI) was assessed with two-way repeated measures ANOVA. Between group differences at each time point were assessed with unpaired t-tests. Chi-square and Kaplan-Meir analysis analyzed the proportions of subjects able to achieve ≥90% LSI.

RESULTS

A total of 75 subjects (QT n = 38 HT n = 37,15.8 years) were included. There were significant differences in qLSI, with greater symmetry within the HT group at all time points. A higher proportion of subjects with HT grafts were able to achieve ≥90% qLSI within 12 months of surgery (81% vs 45%, p = 0.001).

CONCLUSION

Compared to those with HT autografts, adolescents with QT autografts demonstrate a prolonged timeline for quadriceps recovery. While mean strength values above 90% are achieved, a significantly lower percentage of QT patients are able to achieve 90% qLSI by 12 months post-op.

Increased risk for early revision with quadriceps graft compared with patellar tendon graft in primary ACL reconstructions

PURPOSE

Bone patella-tendon bone (BPTB) and hamstring tendon (HT) autografts are the most used grafts in primary anterior cruciate ligament (ACL) reconstructions (ACLR) in Norway. Quadriceps tendon (QT) autograft has gained more popularity during the past years. The purpose of this study is to compare revision rates and patient-reported outcomes of primary QT with BPTB and HT autograft ACL reconstructions in Norway at 2-year follow-up. It was hypothesized that there would be no difference in 2-year revision rates between all three autografts.

METHODS

Data included primary ACLR without concomitant ligament surgeries, registered in the Norwegian Knee Ligament Register from 2004 through 2021. Revision rates at 2 years were calculated using Kaplan-Meier analysis. Hazard ratios (HR) for revision were estimated using multivariable Cox regression analysis with revision within 2 years as endpoint. Mean change in patient-reported outcome was recorded preoperatively and at 2 years through the Knee Injury and Osteoarthritis Outcome Score (KOOS) subcategories 'Sport' and 'Quality of Life' was measured for patients that were not revised and analysed with multiple linear regression.

RESULTS

A total of 24,790 primary ACLRs were identified, 10,924 with BPTB, 13,263 with HT and 603 with a QT graft. Patients in the QT group were younger (23.5 years), more of them were women (58.2%) and over 50% had surgery <3 months after injury. The QT group had the highest prevalence of meniscal injuries (61.9%). Revision estimates at 2-years were 3.6%, 2.5% and 1.2% for QT, HT and BPTB, respectively (p < 0.001). In a Cox regression analysis with QT as reference, BPTB had a lower risk of revision (HR 0.4, 95% Cl 0.2-0.7, p < 0.001). No significant difference was observed in the revision risk between QT and HT (HR 1.1, 95% Cl 0.7-1.8, n.s.). The two most common reported reasons for revision were: traumatic graft rupture and nontraumatic graft failure. There were no differences between the groups in change of KOOS in subcategories 'Sport' and 'Quality of Life' at 2-years follow-up.

CONCLUSION

The 2-year risk of revision after ACLR with QT was higher than BPTB and similar to HT. No difference was found between the groups in patient-reported outcomes. This study provides valuable insights for both surgeons and patients when making decisions about the choice of autografts in primary ACL reconstructions.

LEVEL OF EVIDENCE

Level II.