Minimally Invasive Quadriceps Tendon Single-Bundle, Arthroscopic, Anatomic Anterior Cruciate Ligament Reconstruction With Rectangular Bone Tunnels

Abstract

Many surgeons use quadriceps tendon (QT) graft for anterior cruciate ligament (ACL) revision surgery; however, despite excellent clinical results, the QT has not achieved universal acceptance for primary ACL reconstruction. One of the reasons for this may be that the QT is technically demanding to harvest and the scar from open harvesting techniques is less cosmetically favorable than that from hamstring tendon techniques. Recent evidence has suggested that broad flat QT grafts may more closely mimic native ACL “ribbon-like” morphology than hamstring tendon grafts. Furthermore, rectangular bone tunnels may more accurately re-create native ACL attachments, allowing grafts to simulate native ACL rotation during knee flexion and potentially improving biomechanics. Rectangular tunnels have further advantages in revision cases, in which—in comparison with round tunnels—they have reduced overlap with pre-existing transtibial tunnels, increasing the chance of bypassing primary tunnels during revision surgery. Finally, instrumentation for minimally invasive QT harvesting has reduced technical difficulty and improved cosmetic results. Hence, technical and cosmetic concerns are no longer barriers to QT use. These anatomic and biomechanical advantages and technical developments make the QT an increasingly attractive option for both primary and revision ACL reconstruction.

A Bone-Hamstring Autograft for Arthroscopic Anterior Cruciate Ligament Reconstruction

“…Many types of grafts have been used in ACLR—autografts, allografts, and artificial ligaments—but the ideal graft, which should have structural and biomechanical similarity to the native ACL, remains debatable. Among the grafts, the most widely used are bone–patellar tendon–bone (BPTB), 7 hamstring tendon (HT), 8 and bone–quadriceps tendon, 9 as well as the recently described “half-peroneus-longus-tendon graft.” 10 There are many factors that might affect graft selection, including healing, stability, pain, and revision. Traditionally, bone-to-bone healing (BPTB graft reconstruction and bone–quadriceps tendon graft reconstruction) is considerably faster and more reliable than bone-to-tendon healing (HT graft reconstruction).…”

Differences in the Development of Fibrocartilage Layers in the Quadriceps Tendon and Patellar Tendon Insertions in Rabbits: A Quantitative Study

“…Clinically, insertional tendinopathies such as QT and PT rupture and jumper’s knee are difficult to repair and treat. 6,17 The QT and PT, including part of the patella, are used as grafts in ACL reconstructions 4,8 and are difficult to regenerate. 5,15 Our results suggest consideration of appropriate treatment strategies based on age and the development of new treatment methods for regeneration of the tendon-bone interface and insertions.…”

Patient-Reported Knee Outcome Scores With Soft Tissue Quadriceps Tendon Autograft Are Similar to Bone–Patellar Tendon–Bone Autograft at Minimum 2-Year Follow-up: A Retrospective Single-Center Cohort Study in Primary Anterior Cruciate Ligament Reconstruction Surgery

“…11,32,35 While it has been suggested that a bone block is important for QT in order to increase graft stiffness, length, and anatomic fixation, 9 multiple studies have described alternative fixation techniques that maintain appropriate stiffness and anatomic fixation without any reported complications. 8,30,31,36…”