QUAD TENDON SOFT
TISSUE ACL GRAFT
John “X” Xerogeanes, MD
Professor of Orthopaedic Surgery
Chief of Sports Medicine
Emory Orthopaedic and Spine Center
Head Orthopaedist and Team Physician
Georgia Tech, Emory and Agnes Scott University
Atlanta Dream WNBA
Disclosures
• Educational Support
–
–
–
–
Arthrex
Linvatec
Ossur
Don Joy
• Consultant
– Arthrex
• Patents
– Linvatec
• Patents
17 y/o Female Soccer Player
Lateral Meniscal Tear
• Repair at all cost
• Cerclage suture
1.5 cm OCD Lesion
• Micro Fracture
What is the Perfect ACL Graft
Option?
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Allograft
B-PT-B
Hamstring
Quad Tendon w/ bone
A ll soft tissue quad
tendon
The Perfect ACL Graft “Option”
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•
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Equal or superior outcomes
Predictability-Size
Superior Biomechanics
Superior Histology
Least Morbidity
Fastest Harvest
Percutaneous Harvest
– (Cosmesis)
The Perfect ACL Graft “Option”
• Equal or superior outcomes
•
•
•
•
•
•
Predictability-Size
Superior Biomechanics
Superior Histology
Least Morbidity
Fastest Harvest
Percutaneous Harvest
– (Cosmesis)
Whats NOT!
ALLOGRAFT
High Failure Rate
• Treatment
• Biological
incorporation
• Patient Compliance
• Outcome studies
– Moon
– Etc
Autografts?
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B-PT-B
Hamstring
Quad tendon w/bone
Quad tendon all soft
tissue
• Outcomes
– All good
– No Sig Diff
Slone, H. S., et al Quadriceps Tendon Autograft for Anterior Cruciate
Ligament Reconstruction: A Comprehensive Review of Current
Literature and Systematic Review of Clinical Results. Yjars, 1–14.
doi:10.1016/j.arthro.2014.11.010
The Perfect ACL Graft “Option”
•
Equal or superior outcomes
• Predictability-Size
•
•
•
•
•
Superior Biomechanics
Superior Histology
Least Morbidity
Fastest Harvest
Percutaneous Harvest
– (Cosmesis)
Hamstring
• Size?
• No way to predict pre
op
– Length
– Diameter
Hamstring
• < 8 mm diameter
• Increased Failure!
Predictability
An Anatomic and Morphologic Evaluation
of the Quadriceps Tendon Using 3D MRI
Reconstruction: Applications for ACL
autograft choice and procurement
AJSM, Oct 2013
John Xerogeanes, MD
Phillip Mitchel, BS, M4
Spencer Romine, MD
Peter Karasev, MS
Ivan Kolesov, MS
Predictability
Quad Graft Length
– 73.5 ± 12.3 mm in females
– 81.1 ± 10.6 mm in males
• Direct correlation to height
– Like PT
• People over 5 feet
– Graft > 7 cm 90 % of time
RECTUS FEMORIS
Distal Tip Muscle
Volume PT vs QT
Volume = L x W x D
• LQT = LPT = 3 cm
• WQT = WPT = 10 mm
• D = QT 1.8x > PT
average thickness
• QT 88%
more intra articular graft volume
Final Graft
Graft in Tunnel
(Red = Graft)
PT
QUAD
Length
Graft Length
2 cm
2-3 cm
2 cm
7 cm
Question
When is the last time
you had a PT graft with
X = 3 cm
X
?
Length
Graft Length
2 cm
2-3 cm
4 cm
X = 4-5 cm
Graft in Tunnel
(Red = Graft)
PT
QUAD
The Perfect ACL Graft “Option”
•
•
Equal or superior outcomes
Predictability-Size
• Superior Biomechanics
•
•
•
•
Superior Histology
Least Morbidity
Fastest Harvest
Percutaneous Harvest
– (Cosmesis)
Biomechanics Results
Matched 10mm specimens
Native ACL*
Ultimate Load (N)
Modulus (Mpa)
B-PT-B
2160
2186
1580
278
255
337
* Woo et al 1988
ORS, New Orleans 2014
Under Review AJSM
Quad Ten
Biomechanics
• Adams, Fulkerson et al, (Arthroscopy 2006)
- Harvested 10 mm wide partial thickness free quad
tendon auto grafts
- Studied post-harvest reduction in quad extensor
mechanism strength vs. patellar tendon graft
Postharvest strength of quadriceps tendon = (2430 N)
Intact patellar tendon = (1920 N)
• Relevance: Leave a stronger extensor mechanism
behind after harvest of free quad tendon
The Perfect ACL Graft “Option”
•
•
•
Equal or superior outcomes
Predictability-Size
Superior Biomechanics
• Superior Histology
•
•
•
Least Morbidity
Fastest Harvest
Percutaneous Harvest
– (Cosmesis)
1
Histology
Quad vs PT
• Same Size Graft
• Quad Sig >
– fibril-interstitium ratio
– higher fibroblast density
• 20% more collagen
•
Hadjicostas et al. Arthroscopy.
2007 Jul;23(7):751-6.
Slide 28
1
John Xerogeanes, 1/9/2015
The Perfect ACL Graft “Option”
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•
•
•
•
•
•
Equal or superior outcomes
Predictability-Size
Superior Biomechanics
Superior Histology
Least Morbidity
Fastest Harvest
Percutaneous Harvest
– (Cosmesis)
Harvest Time
• Patella Tendon = 25 min
• Hamstring = 13 minutes
• Quad Tendon < 10 minutes
Quad
B-PT-B
Hamstring
Morbidity
Graft type
Patellofemoral Residual Numbness
Pain
Weakness
Tendon Rupture
Patella Fracture
Quadriceps
BPTB

Hamstrings

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
Hematoma
Increased Pain
?





Fixation Complaints
“its not strong enough”
• Prospectively followed 300 ( 3 months to 3.5 years)
– No increase in KT-1000 from 6 weeks to 6 months
– No failures < 3 mos
– Aggressive PT, no brace, immediate ROM and WB on
crutches
• Tie over post = 300-800N, Interference screw = 200600N
– Circumferential healing
– No foreign substance in tunnel
– Heals 6-8 weeks
Fixation Is Like Overkill
22 vs 50 Cal
50 Cal
Return to Play
• ACL 8-12 months
– Functional (single hop etc)
– Strength (biodex 60 and 180, <10%)
– Biology ?
• Lateral meniscal tear 4 months
• Micro Fracture 9-12 months
– Location size
All Soft Tissue Quad
he
The BEAST!
Technique Video
http://youtu.be/xg1Mv3HU9uc