Quadriceps Tendon: The Forgotten Graft (2010)

With great interest, we read “Anterior cruciate ligament reconstruction using quadriceps tendon autograft: Intermediate-term outcome” by Geib et al.1Geib T.M. Shelton W.R. Phelps R.A. Clark L. Anterior cruciate ligament reconstruction using quadriceps tendon autograft: Intermediate-term outcome.Arthroscopy. 2009; 25: 1408-1414Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar The quadriceps tendon has been a useful graft choice for anterior cruciate ligament (ACL) reconstruction since Marshall et al.2Marshall J.L. Warren R.F. Wickiewicz T.L. Reider B. The anterior cruciate ligament: A technique of repair and reconstruction.Clin Orthop Relat Res. 1979; : 97-106PubMed Google Scholar first described its use in 1979. With inspiration from pioneers of the quadriceps tendon autografts, such as Dr. Fulkerson, Dr. Shelton, and others, we have used the quadriceps tendon for both anatomic single- and double-bundle ACL reconstruction in over 30 cases with good results. As described in this article,1Geib T.M. Shelton W.R. Phelps R.A. Clark L. Anterior cruciate ligament reconstruction using quadriceps tendon autograft: Intermediate-term outcome.Arthroscopy. 2009; 25: 1408-1414Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar the quadriceps tendon autograft is a very suitable graft for ACL reconstruction. Furthermore, it is one of the most versatile autografts available. The quadriceps tendon can be used for single-bundle reconstruction with bone block, single-bundle reconstruction without bone block (Fig 1), double-bundle reconstruction with bone block (Fig 2), augmentation of an isolated anteromedial bundle tear or posterolateral bundle tear, and hybrid techniques using both quadriceps tendon autograft and allograft for double-bundle reconstruction. Given such versatility, we are surprised at the small extent to which this graft continues to be used. A pool at a recent American Academy of Orthopaedic Surgeons meeting showed that only 1% of orthopaedic surgeons used the quadriceps tendon as a graft.Figure 2Quadriceps tendon autograft with patellar bone block and split tendon creating both an anteromedial (AM) (purple) and posterolateral (PL) bundle for double-bundle ACL reconstruction.View Large Image Figure ViewerDownload Hi-res image Download (PPT) We are excited to find in this article that the quadriceps autograft has decreased donor-site morbidity when compared with the bone–patellar tendon–bone (BPTB) autograft, and in particular, a decrease in anterior knee pain and numbness.1Geib T.M. Shelton W.R. Phelps R.A. Clark L. Anterior cruciate ligament reconstruction using quadriceps tendon autograft: Intermediate-term outcome.Arthroscopy. 2009; 25: 1408-1414Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar In comparison to the BPTB, the quadriceps autograft is more often of sufficient size for both anatomic single- and double-bundle ACL reconstruction. The goal of ACL reconstruction should be the restoration of 80% to 90% of the native ACL insertion site, and therefore the larger quadriceps tendon is often more advantageous to achieving this goal. Both the quadriceps tendon and BPTB can be measured preoperatively on magnetic resonance imaging, and the quadriceps tendon is often twice the size of the BPTB (Fig 3). Quadriceps tendons that measure greater than 7 mm on sagittal magnetic resonance imaging sequence often are of sufficient size to allow for an anatomic double-bundle reconstruction. In the “Discussion” section, the authors elaborate on the use of soft-tissue quadriceps graft compared with quadriceps graft with bone block (BQT).1Geib T.M. Shelton W.R. Phelps R.A. Clark L. Anterior cruciate ligament reconstruction using quadriceps tendon autograft: Intermediate-term outcome.Arthroscopy. 2009; 25: 1408-1414Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar They found better arthrometer results with BQT but a higher failure rate in this group. No significant differences were found in range of motion, single-leg hop, and IKDC score. We would like to ask the authors whether there are any indications for which they do use the BQT, such as for the additional graft length, for double-bundle ACL reconstruction, or for posterior cruciate ligament reconstruction. We thank the authors for their great study on the use of the quadriceps tendon for ACL reconstruction. We hope this article, as well as the usefulness and versatility of the quadriceps tendon autograft, will inspire other orthopaedic surgeons to consider quadriceps tendon autograft as a graft choice in ACL surgery. We look forward to future publications about the use of this graft. Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Autograft: Intermediate-Term OutcomeArthroscopyVol. 25Issue 12PreviewThe purpose of this study was to compare the intermediate-term outcomes of anterior cruciate ligament (ACL) reconstruction by use of bone–patellar tendon–bone (BPTB), quadriceps tendon with a bone plug (BQT), and quadriceps tendon without a bone plug (QT). Full-Text PDF Author's ReplyArthroscopyVol. 26Issue 4PreviewWe thank Dr. Fu and colleagues for their comments regarding their experience with the use of quadriceps tendon autografts. Our results, like theirs, have been excellent. Full-Text PDF