The Quadriceps Tendon: The Forgotten graft?

1. The Quadriceps Tendon: The Forgotten graft? Systematic Review of Primary ACL Reconstruction utilising Autograft Quadriceps Tendon S Hutchinson, J Mulford

2. 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

3. Technique

4. Aim • Clarify the outcomes with use of the quadriceps tendon in primary ACL surgery. • Systematic review process was utilised.

5. 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

6. 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.

7. 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.

8. 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).

9. Data extracted independently by two reviewers • Recorded • Methodology • predetermined outcome measures

10. 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

11. 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

12. All Articles • All retrospective studies • 1539 grafts

13. Subjective Outcomes • Patient satisfaction: 91% (303 of 332) • Anterior knee pain: 3% (22 of 699)

14. 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

15. Complications • Graft failure: 3% (21 of 666) • Patella fracture: 5

16. 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

17. Thankyou Stephen Hutchinson Jonathan Mulford