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

Stephen Hutchinson Jonathan Mulford Thankyou Stephen Hutchinson Jonathan Mulford