Minimally Invasive Quadriceps Tendon Harvest Technique for ACL Reconstruction

Abstract

Background:

Graft selection for anterior cruciate ligament (ACL) reconstruction (ACLR) remains a debated topic within the orthopaedic sports medicine community. While the bone-patellar tendon-bone autograft has been considered the gold standard, the quadriceps tendon autograft has gained popularity because of its similarly low failure rate and decreased donor-site morbidity.

Indications:

We present a case of an active 34-year-old woman with a left knee ACL tear. Using a quadriceps tendon autograft can be indicated when the patient is >5 feet tall and a substantial graft can be expected after harvest.

Technique Description:

We present a reproducible, minimally invasive technique of harvesting a quadriceps tendon autograft using the QuadPro Tendon Harvester. We also demonstrate an effective method to close the donor site endoscopically using a suture passer.

Results:

Using this technique, our clinical results align with the current literature, with low retear rates and a high return-to-sport rate.

Discussion/Conclusion:

We present a reliable, minimally invasive technique to harvest the quadriceps tendon for ACLR. We discuss the technical pearls we have learned while performing this technique.

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.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

Background

Anterior cruciate ligament (ACL) injuries are common, particularly among athletes and active individuals participating in pivoting sports such as soccer and basketball. ¹⁴ It is estimated that >200,000 people in the United States each year are affected by an ACL tear, which corresponds to a direct and indirect medical cost of approximately $7 billion annually.^3,12

Evidence for the optimal graft choice for ACL reconstruction (ACLR) continues to evolve. Traditionally, bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) autografts have been considered the gold standard and the predominant grafts utilized in the United States and worldwide.^1,15 A common morbidity encountered by patients who receive a BPTB autograft is anterior knee pain. This can affect a significant portion of patients, with studies^7,8 reporting a range of 17% to 46%. Similarly, there has been donor-site morbidity associated with hamstring autografts in the form of sustained hamstring weakness. ⁴ There is also a concern for an increased rerupture rate in younger active individuals when a hamstring graft is used. ¹³

Another option is the quadriceps tendon. The quadriceps tendon autograft can be harvested with or without a bone block. The literature has demonstrated that quadriceps tendon autografts have similar graft failure rates, joint laxity, and patient-reported outcome measures similar to those of BPTB and hamstring autografts, with lower donor-site morbidity when harvested without a bone block.^5,6,11,16 The quadriceps tendon can also be a good choice for revision cases, as it has a similar graft failure rate in revisions compared with BPTB and a superior failure rate when compared with HTs. ¹⁰ Therefore, the quadriceps tendon autograft has risen in popularity over the past decade. ¹

Indications

We present a case of an active 34-year-old female who sustained a left ACL tear while skiing nearly 2 months before presentation. After a discussion of the risks and benefits of operative and nonoperative management, the patient elects for ACLR. We discussed the pros and cons of the different graft choices, and the patient was interested in a quad tendon autograft, if possible.

Preoperatively, it is important to anticipate the graft size based on the morphology of the individual patient's quadriceps tendon. The patient's height is significantly correlated with the length of the patient's quadriceps tendon. Patients who are at least 5 feet tall should be able to provide a graft length of approximately 6 to 7 cm. ⁹

Finally, it is important to decide whether to use a transverse or a longitudinal incision. A transverse incision within the Langer lines can be more cosmetic, but it can make graft harvest more technically challenging. A longitudinal incision allows for easier graft harvest and a more expansive approach in patients with higher body mass index and in those requiring concomitant procedures, such as high tibial osteotomies, osteochondral implantation, or autologous chondrocyte implantation.

Technique Description

The patient is positioned supine on a standard operating table, and the examination under anesthesia is performed. This patient demonstrates a Lachman 2A laxity and a pivot glide. A foot holder is oriented to maintain the knee in 90° of flexion. The vastus medialis obliquus (VMO) and vastus lateralis are marked. A 2-cm transverse incision is planned 1 finger breadth proximal to the superior pole of the patella. The local anesthetic is administered using the sterile technique. The operative leg is prepped and draped in standard fashion.

After the surgical timeout is completed, anatomic landmarks are reconfirmed, and the incision is made. Soft tissue dissection is performed with the use of Metzenbaum scissors. The subcutaneous fat overlying the quadriceps tendon and the superior pole of the patella is elevated and eventually resected. This is to ensure that the quadriceps tendon is isolated without impediment. The subcutaneous fat that is adhered to the quadriceps tendon is bluntly dissected and elevated using a combination of a Cobb elevator and lap pads. The elevator can then be used to bluntly clear the distal 8 cm of the quadriceps tendon to remove any final adhesions. It is important to visualize the musculotendinous junction and the borders of the VMO and vastus lateralis.

The incision is then retracted using an army-navy retractor, and the arthroscope is inserted proximally until the myotendinous junction of the rectus femoris and the quadriceps tendon is visualized. With the arthroscope centered on the middle third of the quadriceps tendon, the light source is used to transilluminate the skin to mark the length of the graft, typically around 70 mm. The tendon becomes narrow proximally, and care should be taken to center the graft harvest to account for this.

Next, the plunger from the quadriceps pro tendon harvester is removed, and the tip is painted with the marking pen. This is then used to stamp the middle third of the superior pole of the patella in line with the trajectory of the graft harvest. A double-bladed scalpel sized to the width of the target graft diameter is used to score the superficial portion of the tendon as it inserts on the superior pole of the patella. Approximately 2 cm of the distal graft length is scored to establish the borders of the graft. Care is taken to ensure that the graft stays centered as the quadriceps tendon tapers proximally. A 15-blade scalpel is then used to release the insertion of the quadriceps tendon off the superior pole of the patella. At this point, either a partial- or full- thickness graft is harvested, depending on the patient's anatomy.

Once the leading edge has been created, an allis clamp is used to control the tendon. A FiberLoop suture (Arthrex) is then placed as a holding stitch. Start approximately 2 cm proximal from the graft edge and continue in a locking fashion distally for 3 to 4 passes. Ensure that the last pass exits through the distal end of the tendon to facilitate smooth entry into the harvester. While holding tension with the FiberLoop, a double-bladed scalpel is used to confirm the trajectory of the graft harvest, and the tendon is scored proximally by another couple of centimeters.

The weight of the Keith needle then aids in passing the FiberLoop through the end of the quadriceps tendon harvester. The graft edge is brought into the tip of the harvester until the tip is seated on the uncut edge of the quadriceps tendon. Constant tension is held while the quadriceps tendon harvester is rotated back and forth, 90° at a time, in smooth motions. It is important to maintain this tension so that only a slight downward force is needed to advance the harvester proximally as you rotate. Care must be taken to ensure the harvester tool does not inadvertently cut a thinner graft than desired, as it is quite sharp. It is also important to continuously check the trajectory of your harvester to confirm you are harvesting the middle third of the quad tendon. This will ensure cuffs of tendon medially and laterally, allowing for closure of the defect after graft harvest. As the tendon passes into the transparent handle of the harvester, you can continuously measure the length of the graft with the ruler etched on the side. Once you have reached the predetermined length of your graft, generally around 65 mm, the harvester is slowly backed off the tendon, and the FiberLoop is fed through the amputation window adjacent to the tip of the harvester. With constant tension held on the graft, the harvester is then seated again on the uncut edge of the tendon, and the graft length is reconfirmed. The plunger is then inserted into the handle, and with tension on the tendon, the graft is amputated by applying firm pressure on the plunger. Here, you can see that the graft has been harvested from the middle third of the quadriceps tendon and that there is a cuff of tendon both medially and laterally, which will be used for closure.

The arthroscope is then used to assist with closure of the proximal half of the graft donor site. A number 1 Vicryl is loaded onto the suture passer, which is then endoscopically brought to the apex of the incision. Each limb of the suture is then passed individually through the medial and then the lateral tendon edges. Once you are more distal, the suture passer can then be used without the arthroscope to continue closing the quadriceps tendon. The most distal end of the quadriceps tendon can be closed in the usual fashion. If a partial-thickness graft is taken, no closure of the harvest site is performed. The subcutaneous space is then packed with a moist lap. It is our preference not to close the subcutaneous layers until the end of the case to be able to identify any sutures that are compromised during the arthroscopy and to allow for drainage of arthroscopy fluid.

Results

Using this technique, our clinical results have mirrored the current literature on quadriceps tendon autografts for both primary and revision ACLR with a low failure rate and a high rate of return to sports after the appropriate postoperative rehabilitation protocol is followed. Generally, 80% to 90% of patients return to sport or activity at a mean of 8 to 9 months from surgery after following a graduated, phase-based rehabilitation protocol and passing multifactorial functional assessments.^2,13

Discussion/Conclusion

We present a reliable, minimally invasive technique to harvest the quadriceps tendon for ACLR. When performing this procedure, there are certain technical pearls that we would like to highlight. First, a transverse incision allows for a more cosmetic incision, as it is disguised within the Langer lines. We have found it critical to clear the quadriceps tendon of all subcutaneous fat overlying it for visualization. We also highly encourage using the arthroscope to transilluminate the target end of the graft harvest on the skin. The quadriceps tendon narrows proximally, and care must be taken to harvest the graft while following this trajectory. Additionally, establishing the borders of the graft by stamping the superior pole of the patella is essential to harvesting the middle third of the quadriceps tendon. While using the harvester, it is also important to apply a controlled, but firm, slightly downward pressure while rotating the tip 90° at a time. This will allow for smooth gliding of the harvester. Avoid aiming the harvester upward as this can lead to premature graft truncation.