Quadriceps Autograft for Knee ligament Reconstruction

Courtesy: Christopher McCrum, Assistant Professor, UT South Western Medical Centre, Dallas, Texas, USA

Introduction

• The unique anatomy of the anterior cruciate ligament allows it to play a critical role in knee stability.

• It provides:

  • Primary restraint to anterior tibial translation

  • Significant rotational stability

• Anterior cruciate ligament reconstruction is one of the most commonly performed procedures in orthopaedic practice.

• Nonoperative management has shown poor long-term outcomes in active patients, leading to the widespread adoption of surgical reconstruction.

• Early attempts at primary anterior cruciate ligament repair resulted in poor outcomes due to the unfavorable intra-articular healing environment.

• Consequently, reconstruction rather than repair is the preferred treatment strategy.

• The primary goal of reconstruction is to:

  • Restore native knee biomechanics

  • Achieve secure fixation and biological graft integration

  • Minimize donor site morbidity

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Commonly Used Autografts for Anterior Cruciate Ligament Reconstruction

Three autograft sources are most commonly used:

• Hamstring tendon autograft (most frequently used)

• Bone–patellar tendon–bone autograft

• Quadriceps tendon autograft

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Quadriceps Tendon Autograft: Historical Perspective

• The quadriceps tendon autograft was first described in 1979 by Marshall.

• Early clinical outcomes were suboptimal, with:

  • Approximately 20% of patients demonstrating a positive pivot shift test

  • Increased postoperative laxity

  • Extensor mechanism-related complications

• Technique refinement occurred in the early 2000s when Fulkerson described an all–soft tissue quadriceps tendon harvest technique, improving outcomes and reducing complications.

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Anatomy of the Quadriceps Tendon

• Extends from the myotendinous junction of the rectus femoris proximally to the superior pole of the patella distally.

• Average length: 7 to 8.5 centimeters.

• Average thickness: 2.5 to 3 centimeters.

• Demonstrates a characteristic “twin-peaks” configuration.

• Biomechanical studies show the cross-sectional area of the quadriceps tendon is approximately twice that of the patellar tendon.

• This large cross-sectional area allows flexibility in graft sizing and reconstruction technique.

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Biomechanical Properties

• Woo reported the ultimate load to failure of the native anterior cruciate ligament as approximately 2,106 newtons.

• West and Harner reported an ultimate load to failure of 2,352 newtons for the quadriceps tendon autograft.

• Shani demonstrated an ultimate load to failure of 2,185 newtons for quadriceps tendon and bone–patellar tendon–bone autografts.

• Hamstring tendon autografts consistently demonstrate the highest load to failure among commonly used grafts.

• The fixation technique used in reconstruction significantly influences overall construct biomechanics.

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Graft Configuration and Fixation Options

• Quadriceps tendon autograft can be harvested as:

  • Bone–quadriceps tendon graft with a patellar bone plug

  • All–soft tissue quadriceps tendon graft

• Grafts with bone plugs typically use interference screw fixation:

  • Promotes faster graft incorporation

  • Provides fixation closer to the tunnel aperture

  • Improves initial joint stability

• All–soft tissue grafts are often secured with adjustable-length cortical suspension devices.

• Concerns with suspensory fixation include:

  • Increased graft micromotion

  • Tunnel widening

  • Potential compromise of graft healing

• These concerns have led many surgeons to prefer interference screw fixation when feasible.

• Final graft choice should be individualized based on:

  • Patient-specific factors

  • Informed discussion of risks and benefits

  • Surgeon experience

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Graft Harvest and Preparation

• A 2 to 5 centimeter midline incision is made proximal to the superior pole of the patella.

• Skin and subcutaneous tissue are dissected to expose the paratenon and underlying tendon.

• Desired graft width and length are carefully measured and marked.

• When harvesting a bone plug:

  • An oscillating saw followed by an osteotome is used

  • A partial-thickness trapezoidal patellar bone block is harvested

• Risk of patellar fracture exists:

  • Reported rates of 3.5% intraoperatively

  • Up to 8.8% at 2 years, as reported by Fu

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Clinical Outcome Assessment After Reconstruction

Effectiveness of anterior cruciate ligament reconstruction is assessed using:

• Patient-reported outcome measures:

  • International Knee Documentation Committee score

  • Knee Injury and Osteoarthritis Outcome Score

  • Lysholm score

• Postoperative knee stability and range of motion

• Strength of the operated limb

• Complication rates:

  • Graft rupture

  • Donor site morbidity

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Clinical Outcomes with Quadriceps Tendon Autograft

• Current evidence demonstrates no significant difference in postoperative knee instability between:

  • Quadriceps tendon

  • Hamstring tendon

  • Bone–patellar tendon–bone autografts

• Knee flexion and extension strength are important considerations in graft selection.

• Given the role of the quadriceps tendon in the extensor mechanism, postoperative extension strength has been closely studied.

• Recent studies show preservation of satisfactory extensor strength following quadriceps tendon harvest.

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Complications

• Potential complications include:

  • Graft failure

  • Donor site morbidity

  • Hematoma formation

  • Patellar fracture

• Comparative studies report:

  • Overall complication rate of 2.28% for quadriceps tendon autograft

  • 3.48% for hamstring tendon autograft

• Patellar fractures are primarily associated with grafts involving a bone plug.

• Donor site morbidity:

  • Anterior knee pain is significantly higher with bone–patellar tendon–bone grafts

  • Reported rates of anterior knee pain:

    • 39% for bone–patellar tendon–bone

    • 8.3% for quadriceps tendon

• Quadriceps tendon harvest reduces the risk of injury to the infrapatellar branch of the saphenous nerve compared with patellar tendon harvest.

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Quadriceps Tendon Autograft in Revision Reconstruction

Preoperative Planning

• Identify the cause of graft failure.

• Review the previous graft type and fixation method.

• Assess tunnel size, position, and widening.

• Identify associated intra-articular or extra-articular pathology.

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Considerations in Revision Surgery

• Use of quadriceps tendon autograft may raise concern if a prior ipsilateral bone–patellar tendon–bone graft was used.

• Current literature on quadriceps tendon autograft in revision reconstruction is limited but promising.

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Advantages in Revision Reconstruction

• Quadriceps tendon autograft is often available, as it is less commonly used in primary reconstruction.

• All–soft tissue configuration avoids graft–tunnel mismatch.

• Large width and thickness allow effective filling of widened tunnels common in revision cases.

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Conclusion

• Although hamstring tendon and bone–patellar tendon–bone grafts remain the most commonly used autografts, quadriceps tendon autograft usage has increased significantly.

• The unique anatomy and biomechanical properties of the quadriceps tendon provide a predictable and versatile graft option.

• Clinical outcomes following reconstruction with quadriceps tendon autograft are comparable to those achieved with other commonly used autografts, with potentially fewer complications.

• The role of quadriceps tendon autograft in revision anterior cruciate ligament reconstruction is evolving and warrants further high-quality clinical research.