Chapter 15 The Central Quadriceps Free Tendon for Anterior Cruciate Ligament Reconstruction

Introduction

The central quadriceps has been used for anterior cruciate ligament reconstruction (ACLR) for more than 25 years.^1,² Stability results are similar to those with other autograft alternatives, but patients experience less pain and reach rehabilitation landmarks sooner.³ Staubli et al^4,⁵ have studied the anatomy and biomechanical properties of the quadriceps tendon. We became interested in this ACL graft in the early 1990s, first using it with bone⁶ but later discovering that it is a desirable free tendon graft option⁷ for ACLR. We wanted to avoid the risk of postoperative problems noted with bone–tendon–bone–patella tendon graft harvest,^8,⁹ were concerned about subtle weakness after taking out the medial hamstring tendons for ACLR in young athletes,¹⁰ and continue to worry about the possibility of prions in allograft tissue. We wanted to avoid these risks by using the central quadriceps free tendon (CQFT) for our ACLR. We confirmed and later reported the strength of the quadriceps tendon after harvesting the graft.¹¹ Our experience has remained very positive as we begin our 10th year with the CQFT graft. Also, patients frequently come into our office impressed with how little postoperative pain and difficulty they have compared with bone–tendon–bone and hamstring ACLR patients they encounter in physical therapy, as noted by Joseph et al³ in their short-term recovery study of ACLR patients.

Technique

We use the CQFT graft in all patients except those who specifically request another graft type, usually an allograft.

To harvest the CQFT, make a short 1.5- to 2-inch incision from the mid proximal patella upward (Fig. 15-1), and retract to view the quadriceps tendon. Retract slightly medially and note the vastus medialis obliquus (VMO). The graft should be taken preferentially from the thicker medial part of the quadriceps tendon but started proximally by retracting upward to the proximal VMO where the first incision is placed. Use a #10 scalpel blade and draw it distally at a 6- to 7-mm depth (just slightly less than the breadth of a #10 blade). The medial border of the graft then will usually be about 5 to 8 mm from the VMO at the level of the proximal patella.