The Quadriceps Tendon: The Forgotten graft?

Systematic Review of

Primary ACL Reconstruction utilising

Autograft Quadriceps Tendon

S Hutchinson, J Mulford

• Quadriceps tendon had increased interest in recent times as a graft for primary ACL surgery.

• We wanted to know the outcomes utilising this graft when compared to traditional autografts

Technique

Aim

• Clarify the outcomes with use of the quadriceps tendon in primary ACL surgery.

• Systematic review process was utilised.

Proposed Benefits of Quads Graft

• Thicker tendon cf patella tendon• Ability to be consistently used as a

double bundle graft• Provides bone healing on one side• Less anterior knee pain cf patella

tendon• Less stretching cf hamstring tendon

Method

• A search process utilising: MEDLINE (1966-2010), EMBASE (1980-2010), CINAHL, Google search engine.

• Review of references of all articles identified in the search.

Inclusion and Exclusion Criteria• Inclusion criteria

– 1. Original articles with patients with primary ACL rupture treated with a quadriceps tendon autograft.

– 2. Articles which reported on one or more of the primary outcomes.

• Exclusion Criteria– 1. Articles which did not document minimum length of patient follow-

up.– 2. Studies with less than 12 months of patient follow-up.– 3. Duplicate publication of any type, for example abstracts,

comments, review or technique articles, duplicate reports and articles based on preliminary data from larger series.

Pre Determined Outcomes• Subjective

– Anterior/patellofemoral/ kneeling pain – patient satisfaction.

• Objective – Range of motion (flexion loss or extension loss > 5 degrees)– Lachman Grade, pivot shift grade– IKDC score– KT-1000– return to pre-injury level, – muscle strength (flexion and extension strength), – Lysholm score– surgery complications (Specifically graft rupture or failure, patella

fracture and infection).

• Data extracted independently by two reviewers

• Recorded – Methodology– predetermined outcome measures

Results

• Initial search identified 45 article for review

• 16 articles met the inclusion criteria

• 4 articles compared graft types – 3 patella tendon vs QT; 1 hamstrings

Comparison Articles• 3 compared PT to Quads• 1 compared Quads to HT

• Poor methodology and variability in reporting of outcomes

• No real difference except

• Anterior Knee Pain– 43 of 114 (38%) in patella tendon– 12 of 108 (11%) in quadriceps group

All Articles

• All retrospective studies

• 1539 grafts

Subjective Outcomes

• Patient satisfaction: 91% (303 of 332)

• Anterior knee pain: 3% (22 of 699)

Objective Outcomes• Lachmann grade >1: 7% (52 of 684)

• Pivot Shift grade > 1: 8% (41 of 534)

• IKDC score A or B: 88% (592 of 676)

• Lysholm Score: Acceptable post op outcomes (89-94)

• Fixed flexion > 5 degrees 4% (27 of 730)

• Quads strength (<80%): 1 of 398

Complications

• Graft failure: 3% (21 of 666)

• Patella fracture: 5

Conclusion

• The quadriceps tendon is a viable alternative to traditional autografts.

• Anterior knee pain is less for quadriceps graft compared to patella tendon grafts.

• Thus our goal to set up a randomised trial

Thankyou

Stephen Hutchinson Jonathan Mulford