Anterior Cruciate Ligament Reconstruction with Quadriceps Tendon Autograft

Anatomic Anterior Cruciate Ligament Reconstruction with Quadriceps Tendon Autograft





Keywords


• Anterior cruciate ligament • Quadriceps tendon • Autograft • Harvest





Introduction


Reconstruction of the ruptured anterior cruciate ligament (ACL) requires selection of a graft that best accommodates the patient’s individual needs. Numerous grafts, including allograft and autograft options, have been described. These options include grafts consisting of soft tissue alone and grafts allowing for osseous healing. Research surrounding ACL reconstruction has led to a further understanding of the native anatomy of the ACL. The function of the anteromedial (AM) and posterolateral (PL) bundles of the ACL have led to a better understanding of not only the translational but also the rotational stability provided by the native ACL. As a result, ACL reconstruction may be better approached with a versatile graft that can reproduce the stability provided by the native ACL and allow for graft incorporation and healing. The quadriceps tendon autograft is a versatile option, which takes advantage of osseous healing and allows for both single-bundle and double-bundle reconstruction.


Blauth1 first described use of the quadriceps tendon for ACL reconstruction in 1984. The original description of this technique describes a double-bundle reconstruction, by which the central third quadriceps tendon is harvested with a bone block from the superior pole of the patella. The bone block was then fixed within the tibia; 1 bundle was fixed to the medial wall of the lateral femoral condyle and the other bundle of the quadriceps tendon was fixed in the over-the-top position. Staubli and colleagues2 elaborated on this technique, including fluoroscopic evaluation and the development of a press fit, outside in modification. This technique was further popularized because studies reported biomechanical advantages and good clinical outcomes comparing the patellar tendon and quadriceps tendon grafts.24 Harvesting quadriceps tendon grafts showed promise, with less apparent anterior knee pain when compared with patellar tendon grafts.5,6 Still, a risk of patellar fracture exists not only during harvest but as a result of the defect within the patella postoperatively.6 Fulkerson and Langeland7 later described harvesting of the central third quadriceps tendon as a free-tendon graft, thereby reducing the morbidity of harvest regarding anterior knee pain and patellar fracture.5 The effect of patellar tendon and quadriceps tendon graft harvest on extensor mechanism strength has not been clearly answered, because some studies show an apparent benefit for quadriceps tendon harvest, whereas others show no difference.8,9



Anatomy and biomechanics



Anatomy and Biomechanics of the Native ACL


The ACL acts as a primary restraint to anterior translation and tibial rotation. Recent research has led to a more profound understanding of the native ACL. The AM and PL bundles of the ACL provide differential tensioning as the ACL moves through a normal range of motion, with the AM bundle resisting translation and the PL bundle resisting rotation.


The ACL originates on the medial wall of the lateral femoral condyle. Osseous landmarks have been described to improve anatomic ACL reconstruction.10 The lateral intercondylar ridge identifies the anterior border of the ACL, whereas the bifurcate ridge marks the junction of the AM and PL bundles. The AM and PL bundles are named for their relative insertion on the tibia. Anatomic landmarks used to locate the tibial insertion of the ACL include the intercondylar eminence, anterior horn of the lateral meniscus, and the posterior cruciate ligament. The insertion of the ACL is variable, especially with regartd to the orientation of the AM and PL bundles. As a result, preserving the ACL remnant can aid in determining tunnel position, and may be even more important when a double-bundle reconstruction is planned.11




Apr 2, 2016 | Posted by in Reconstructive surgery | Comments Off on Anterior Cruciate Ligament Reconstruction with Quadriceps Tendon Autograft

Full access? Get Clinical Tree

Get Clinical Tree app for offline access