1san.

qxd 2/2/04 10:31 AM Page 31

THE CUTTING EDGE

ACL Reconstruction Using Quadriceps

Tendon
Nicola Santori, MD, PhD*
Ezio Adriani, MD†
Luigi Pederzini, MD‡

Noyes et al15 in 1984 and will not be

Quadriceps tendon has recently become a viable graft addressed in this article.
The quadriceps tendon graft consists
option for primary and revision anterior cruciate ligament
of four leaves of collagenous tissue run-
reconstruction. It offers excellent biomechanical strength, a ning longitudinally and obliquely merg-
large cross-sectional area, and an appropriate length. Its ing at the base of the patella. The ante-
rior fibers of the quadriceps tendon
advantages over bone-patellar tendon-bone and semitendi-
graft continue distally joining the soft
nosus/gracilis tendon are presented. tissues over the anterior aspect of the
patella and creating an anterior tension
Arthroscopic anterior cruciate ligament drome, patellar tendon rupture, and fat band bracing system. The fiber disposi-
(ACL) reconstruction is one of the pad herniation. Of patients who have tion acts as a tension band and contin-
most commonly performed1 and most undergone arthroscopic ACL recon- ues distally with the anterior fibers of
successful procedures in sports medi- struction using BPTB autograft, 40%- the patellar ligament.
cine. Various autograft choices have 60% have one or more of the described The quadriceps tendon graft offers
been used for ACL reconstruction,2 and complications.1,6-9 Hamstring autograft excellent biomechanical strength, large
the results in terms of stability and donor-site morbidity includes ACL ago- cross-section area, appropriate length,
return to sports activities have been nist weakness and disruption of the pro- and the advantage of having a bone
good.3 The ideal autograft should have tective ACL proprioceptive arc.9,10 plug on one end harvested from the
optimal mechanical properties and low The quadriceps tendon graft has upper pole of the patella.16 Anterior
donor-site morbidity. The most recur- several potential advantages over knee pain associated with lower patella
ring graft choices are the bone-patellar BPTB and has recently gained atten-
tendon-bone (BPTB)4 and the semi- tion as a promising option for primary
tendinosus/gracilis tendon.5 and revision ACL reconstruction.2,11-13
Unfortunately, BPTB autograft has Share Your “Pearls”
been extensively associated with persis- QUADRICEPS TENDON-
tent donor-site morbidity, such as ten- BONE GRAFT PROPERTIES Do you have a “state of
derness, anterior knee pain, pain on The quadriceps tendon-bone con- the art topic” to share?
kneeling, infrapatellar contracture syn- struct differs from the simple quadri- ORTHOPEDICS wants to hear
ceps tendon substitution reported by from you. Cutting Edge
Marshall et al,14 which consists of the manuscripts should be
From *Ospedale S. Giacomo, Rome; quadriceps tendon-prepatellar retinac- submitted electronically at
†Clinica Mater Dei, Rome; and ‡Clinica Villa
Fiorita, Sassuolo, Italy.
ulum-patellar tendon construct. This www.rapidreview.com.
Reprint requests: Nicola Santori, MD, PhD, method was discontinued after the
Via AF Pigafetta 1, 00154 Rome, Italy. biomechanical analysis performed by

www.orthobluejournal.com 31
1san.qxd 2/2/04 10:31 AM Page 32
ORTHOPEDICS
bone block removal is eliminated with
this grafting procedure.
Staubli et al17,18 performed an exten-
sive comparison of the quadriceps ten-
don graft and BPTB grafts. Mean
quadriceps tendon graft lengths aver-
aged 87⫾9.7 mm for the right knee and
85.2⫾8.4 mm for the left knee in addi-
tion to the bone block. The tendinous
portion of the patellar tendon measured
on average 51.6⫾6.9 mm in the right
knee and 52.2⫾4.8 mm in the left knee.
Cross-sectional area of a 10-mm wide
quadriceps tendon graft averaged
64.4⫾8.4 mm2. This value is signifi-
cantly greater than the mean measure-
1 ments of the patellar tendon, which
measured 36.8⫾5.7 mm2.
The ultimate tensile load of the intact
ACL is approximately 2160⫾157 N.19
A 10-mm quadriceps tendon graft has a
similar ultimate tensile failure load, ie,
2173⫾618 N compared to 1953⫾325 N
of the BPTB complex.17,18 In a similar
study, Schatzmann et al20 reported the
2 ultimate tensile load of a 10-mm–wide,
full-thickness central section of the
quadriceps tendon to be as high as 2352
N. Harris et al21 showed the ultimate
tensile failure load of the quadriceps
tendon to be 1.36 times that of a com-
parable BPTB graft.
Staubli et al17,18 concluded that the
evidence from anatomic, cryosectional,
3 and structural properties analyses sug-
Figure 1: A 20⫻10-mm bone block is gests that the quadriceps tendon graft
demarcated on the upper patella in line
with the tendinous graft. Bone block
may be a valuable and versatile adjunct
harvesting is similar to the BPTB technique. to the surgeon’s armamentarium in cru-
Figure 2: The incision is retracted ciate ligament reconstruction. The mul-
proximally, and by pulling the bone block tilayer structure of the quadriceps ten-
distally, the quadriceps tendon can be cut don allows this graft to be split, on one
proximally at the preselected graft length
(7-7.5 cm). Figure 3: Two 2-0 Vicryl
end, into two separate tails, making it
sutures are used in a Bunnell–Krackow an option in techniques that use two
fashion on the free tendon extremity. bundles to reconstruct the ACL or pos-
Total quadriceps tendon graft length is terior cruciate ligament.
8.5-10 cm.
QUADRICEPS TENDON
HARVESTING TECHNIQUE
A 3- to 4-cm transverse incision is
made on the patella’s base. The quadri-
ceps tendon is exposed through incis-
ing the fascia over the quadriceps ten-
don including multiple aponeurotic lay-
ers in front of the anterior patellar sur-
32
JANUARY 2004 VOL 27 NO 1
face. Soft tissues are removed distally
to proximally to visualize the insertion
of the vastus medialis muscle in the
quadriceps tendon. This is an important
reference point for graft harvesting.
A longitudinal incision is made on
the quadriceps tendon approximately 3
mm lateral from this muscular insertion.
It must be oriented parallel with the
main body of the tendon and centered
over the base of the patella. A parallel
incision is made 10 mm laterally. Thus,
it is possible to isolate a tendon strip
approximately 10-mm wide and 7-mm
thick, with a cross-section of approxi-
mately 70 mm2. An identical width of
the patellar tendon gives a cross-section
of approximately 36 mm2.
A 20⫻10-mm bone block is demar-
cated on the upper patella in line with
the tendinous portion of the graft with
the knee flexed to 60° (Figure 1). The
knee is flexed to avoid patellar move-
ment while performing the bone cuts.
The bone block is harvested with a small
oscillating saw, and hammering with
chisels is avoided to prevent cracking or
fissuring of the patella. The bone block
is drilled and mounted with a single 2-0
Vicryl passing suture. The knee is
extended, the incision is retracted proxi-
mally, and the quadriceps tendon is cut
proximally at the preselected graft
length (7-7.5 cm) by pulling the bone
block distally (Figure 2). Two 2-0 Vicryl
sutures are used in a Bunnell–Krackow
fashion on the free tendon extremity
(Figure 3).
The patellar defect is packed with
autologous bone obtained while coring,
instead of drilling, the tibial tunnel or
with a conventional biodegradable
gelatin sponge, according to surgeon
preference. The anterior tension band
bracing system is recreated closing the
prepatellar bursa over the bony defect.
The gap of the suprapatellar quadriceps
tendon harvesting site is similarly
closed.
TECHNICAL DIFFICULTIES
Fulkerson and Langeland11 first
popularized the quadriceps tendon as
an alternative for primary ACL recon-
www.orthobluejournal.com
1san.qxd 2/2/04 10:31 AM Page 33
SANTORI ET AL
struction and reported that dissection
through the quadriceps tendon is diffi-
cult. They underlined the potential risk
of opening the suprapatellar pouch and
the resultant loss of intra-articular flow.
This could result in a decreased intra-
operative view, subcutaneous fluid dis-
tension, and increased operative time if
an arthroscopic assisted procedure is
used. Furthermore, if the pouch is
opened, adhesions between the tendon
and anterior aspect of the femur22 may
occur with consequent restricted range
of motion and poor scarring.
A potential solution consists of care-
fully dissecting the tendon and preserv-
ing the synovial layer of the suprapatel-
lar pouch. Another option consists of
maintaining the integrity of the vastus
intermedius and using only three of the
four leaves of the tendon. Both of these
methods increase surgical time and
require a learning curve.
In our experience, we try to save the
synovial layer; however, the pouch is
almost always opened (Figure 4). If
accurate tendon defect closure is per-
formed, this is not a problem (Figure 5).
Knee flexion ⬎120° and a temporary
increase in intra-articular pressure guar-
antee a satisfactory arthroscopic view
during graft insertion and fixation.22
Another delicate step of this proce-
dure is harvesting the upper patella
bone block. The shape of the proximal
extremity of the patella is more oblique
than the distal extremity, therefore a
risk of obtaining a short and oblique
bone block exists. Because the soft-tis-
sue layer over the patellar bone is thick-
er in this area than distally, a needle can
be inserted through the quadriceps ten-
don to delineate the exact upper mar-
gins of the patella.
In our experience, harvesting the
quadriceps tendon is more difficult than
harvesting the BPTB. We recommend
the surgeon begin with an appropriate
(8-10 cm) skin incision and then as
confidence with the procedure builds,
the surgical access can be shortened.
GRAFT FIXATION
The main surgical steps are the same
www.orthobluejournal.com
THE CUTTING EDGE
ones used during every arthroscopic
ACL reconstruction. Fulkerson and
Langeland,11 Shelton,23 Pederzini et
al,24 Staubli,25 Noronha,26 and Kim et
al27 prefer to fix the patellar bone block
in the femoral tunnel, whereas Slullitel
et al22 and Randelli et al28 position the
bone block in the tibial tunnel.
As previously stated, the anatomical 4
features of the quadriceps tendon allow
this graft to be used in a two-strand
fashion (Figure 6). Pederzini et al24
described a technique featuring the
bone block in a single half tunnel on
the femur and a double tibial tunnel
(Figure 7). Advantages are an increased
bone-tendon interface, easier bone
incorporation, and a more anatomical
reconstruction with theoretically better 5
long-term results.
Various fixation devices have been
used, with interference screws remain-
ing the most common. Randelli et al28
fix the tendinous portion in the femoral
tunnel with two bioabsorbable pins and
the patellar bone-block in the tibial
tunnel with an interference screw.
Noronha26 stabilizes the bone block in
the femur with an interference screw
and the tendinous extremity with a sta-
ple or screw in the anterointernal tibial
cortex. Kim et al27 apply an alternative
6
composite graft on the tibial side.
Spongy bone obtained while coring the
tibial tunnel is attached to the tendi-
nous portion of the graft and used to
refill the tibial tunnel.
Adriani (unpublished data, 2001)
achieves bone block fixation in the
femoral tunnel with a transcondylar 7
technique and a pin that passes through Figure 4: Intraoperative view. The
synovial layer has been preserved and
the previously drilled bone block. This joint distension is visible at the bottom of
method uses a U-shaped drill guide. the tendon defect. Figure 5: Arthroscopic
The jaw of the guide is placed inside view of the tendon defect in the
the femoral tunnel and a 3.2-mm suprapatellar pouch. A good closure of
Kirschner wire is drilled in the conven- the defect avoids loss of intra-articular
flow and subcutaneous fluid distension.
tional transcondylar fashion through Figure 6: Thickness and the four-leaf
the lateral condyle. The wire is stopped structure of the tendon allow this graft to
at the margin of the femoral tunnel be used in a two-strand fashion. Figure 7:
(Figure 8). Once the neoligament is Arthroscopic view. Two 7-mm tunnels
positioned, the K-wire is advanced allow reconstruction of the ACL anatomy.
through the bone plug and medial
femoral condyle for 2 cm. The K-wire
is removed, and a 50- to 60-mm long,
33
1san.qxd 2/2/04 10:31 AM Page 34
ORTHOPEDICS
8 50 patients undergoing either quadri-
9
10
Figure 8: Arthroscopic view shows the tip
of a 3.2-mm K-wire at the margin of the
femoral tunnel. Once the patellar bone
block is fully seated in the tunnel, the K-
wire is advanced through the bone block.
Figure 9: A bioabsorbable transcondylar
pin is inserted. The pin crosses the lateral
femoral condyle, tunnel, and medial
femoral condyle fixing the neoligament.
Figure 10: MRI 6 months after ACL
reconstruction.
34
3-mm diameter bioabsorbable pin is
implanted to stabilize the bone block
(Figures 9 and 10). Trials of knee trac-
tion, extension, and flexion/extension
are performed with the graft under ten-
sion. Tibial fixation is achieved with
bioabsorbable interference screws.
CLINICAL RESULTS
One main concern regarding quadri-
ceps tendon graft for ACL reconstruc-
tion is the paucity of literature and the
lack of prospective studies and long-
term results.
Shelton23 compared two groups of
ceps tendon or BPTB ACL reconstruc-
tion and reported the 2-year follow-up
results. Clinical results, KT-1000,
Lachman, and pivot shift tests were
similar in both groups with less har-
vest site morbidity in the quadriceps
tendon group.
Chen et al29 reported a short series
of 12 patients. Ten patients returned to
the same or a higher level of preinjury
sports activity at 15- to 24-month fol-
low-up. According to the International
Knee Documentation Committee rating
system, 10 of 12 patients had normal or
nearly normal ratings. Recovery of
quadriceps muscle strength to 80% of
the normal knee was achieved in 11
patients within 1 year.
Howe et al12 evaluated 83 patients
with ACL reconstructions using quadri-
ceps tendon with a mean 5.5-year fol-
low-up. Ninety-six percent of patients
were satisfied with their results, 4%
were unsatisfied. Ninety-three percent
of patients had no pain, and 95% had no
giving way post-reconstruction. No
increase in failure over time (1-10 years)
was observed. The lack of a formal reha-
bilitation program ⬎4 months postoper-
atively and repaired tears of the medial
or lateral collateral ligaments were sig-
nificant risk factors for poor recovery.
Noronha26 reported 203 primary and
37 revision reconstructions using
quadriceps tendon graft. Results were
similar to those obtained with the
BPTB used in 434 cases, with less mor-
bidity. Magnetic resonance imaging,
JANUARY 2004 VOL 27 NO 1
performed post-reconstruction, provid-
ed compelling evidence of the effec-
tiveness of this graft.
Slullitel et al22 performed 40 ACL
reconstructions using an arthroscopic
full-thickness quadriceps tendon tech-
nique. All knees appeared stable at fol-
low-up and patients were back to nor-
mal activities of daily living in 20 days.
A significant decrease in anterior knee
pain was reported.
Theut et al30 reported high patient
satisfaction with little associated mor-
bidity, and objective data collected at
follow-up were encouraging.
DISCUSSION
Three main autologous graft choices
are currently used for ACL reconstruc-
tion: patellar, hamstring, and quadri-
ceps tendon. Regardless of fixation
technique, clinical studies do not show
major differences in clinical outcome
among these grafts. Therefore, other
factors, such as graft harvest morbidity,
are more important when comparing
different grafts.
The quadriceps tendon-bone graft is
gaining popularity for primary as well
as revision ACL surgery in Europe. The
main reason is the high rate of chronic
patellofemoral problems with the patel-
lar tendon graft. Treating this complica-
tion is frustrating, and suturing the ten-
don gap9 or bone grafting the patellar
defect31 does not reduce anterior knee
problems and kneeling complaints.
Local discomfort in the donor site
region after quadriceps tendon autograft
is rare. In a series of 12 patients, Chen et
al29 reported mild harvest site tenderness
at average 18-month follow-up in 1
patient. Fulkerson and Langeland11
reported no early quadriceps tendon
morbidity in their series of 28 patients.
Both studies regarded the quadriceps
tendon as a low-morbidity graft.
Yasuda et al32 reported postoperative
quadriceps weakness as the main disad-
vantage. They reported 85% quadriceps
strength in men at final follow-up. In
women, quadriceps strength at final
follow-up was 70%, significantly lower
than preoperative strength.
www.orthobluejournal.com
1san.qxd 2/2/04 10:31 AM Page 35
SANTORI ET AL
In our experience with the quadri-
ceps tendon, which is similar to oth-
ers,12,22,23,26,29,30 an aggressive rehabili-
tation program, despite soft-tissue fixa-
tion of the tendon end of the graft, pro-
motes patient compliance and quicker
return to sports activities.
Quadriceps tendon autograft should
be the treatment of choice for patients
whose jobs require kneeling or long
periods of knee flexion. It should also
be used for ACL reconstruction in
cases of low patella, after Osgood-
Schlatter syndrome, patellar tendinitis,
ACL revision surgeries, and multiple
knee ligament injuries. Relative con-
traindication is in poorly motivated
female patients where postoperative
quadriceps weakness could impair the
final result.
Harvest site morbidity is becoming
a central issue for surgeons. In this sce-
nario, quadriceps tendon is a reason-
able alternative for ACL reconstruction
and may, in the future, replace the
patellar tendon as the main graft source
for primary ACL reconstruction.
Additional long-term clinical studies
and improvement in the understanding
of the optimal rehabilitation programs
will increase the popularity of this pro-
cedure in the future.
REFERENCES
1. Stapleton TR. Complications in anterior
cruciate ligament reconstructions with patellar
tendon grafts. Sports Medicine Arthroscopy
Revue. 1997; 5:156-162.
2. Fu FH, Bennett CH, Lattermann C, Ma CB.
Current trends in anterior cruciate ligament recon-
struction, I: biology and biomechanics of recon-
struction. Am J Sports Med. 1999; 27:821-830.
3. Bach BR Jr, Jones GT, Hager CA, Sweet
FA, Luergans S. Arthrometric results of arthro-
scopically assisted anterior cruciate ligament
reconstruction using autograft patellar tendon
substitution. Am J Sports Med. 1995; 23:179-185.
4. Clancy WG Jr, Nelson DA, Reider B,
Narechania RG. Anterior cruciate ligament recon-
struction using one-third of the patellar ligament,
www.orthobluejournal.com
augmented by extra-articular tendon transfers. J
Bone Joint Surg Am. 1982; 64:352-359.
5. Aglietti P, Buzzi R, Menchetti PM, Giron
F. Arthroscopically assisted semitendinosus and
gracilis tendon graft in reconstruction for acute
anterior cruciate ligament injuries in athletes. Am
J Sports Med. 1996; 24:726-731.
6. Graf B, Uhr F. Complications of intra-artic-
ular anterior cruciate reconstruction. Clin Sports
Med. 1988; 7:835-848.
7. Paulos LE, Rosenberg TD, Drawbert J,
Manning J, Abbott P. Infrapatellar contracture
syndrome. An unrecognized cause of knee stiff-
ness with patella entrapment and patella infera.
Am J Sports Med. 1987; 15:331-341.
8. Shelbourne KD, Trumper RV. Preventing
anterior knee pain after anterior cruciate ligament
reconstruction. Am J Sports Med. 1997; 25:41-47.
9. Kartus J, Movin T, Karlsson J. Donor-site
morbidity and anterior knee problems after ante-
rior cruciate ligament reconstruction using auto-
grafts. Arthroscopy. 2001; 17:971-980.
10. Corry IS, Webb JM, Clingeleffer AJ,
Pinczewski LA. Arthroscopic reconstruction of
the anterior cruciate ligament. A comparison of
patellar tendon autograft and four-strand ham-
string tendon autograft. Am J Sports Med. 1999;
27:444-454.
11. Fulkerson JP, Langeland R. An alternative
cruciate reconstruction graft: the central quadri-
ceps tendon. Arthroscopy. 1995; 11:252-254.
12. Howe JG, Johnson RJ, Kaplan MJ.
Anterior cruciate ligament reconstruction using
quadriceps patellar tendon graft, I: long-term fol-
low-up. Am J Sports Med. 1991; 19:447-457.
13. Wirth CJ, Kohn D: Revision anterior cruci-
ate ligament surgery: experience from Germany.
Clin Orthop. 1996; 325:110-115.
14. Marshall JL, Warren RF, Wickiewicz TL.
The anterior cruciate ligament: a technique of
repair and reconstruction. Clin Orthop. 1979;
143:97-106.
15. Noyes FR, Butler DL, Grood ES,
Zernicke RF, Hefzy MS. Biomechanical analysis
of human ligament grafts used in knee-ligament
repairs and reconstructions. J Bone Joint Surg
Am. 1984; 66:344-352.
16. Brand J Jr, Hamilton D, Selby J, Pien-
kowski D, Caborn DN, Johnson DL. Bio-
mechanical comparison of quadriceps tendon fix-
ation with patellar tendon bone plug interference
fixation in cruciate ligament reconstruction.
Arthroscopy. 2000; 16:805-812.
17. Staubli HU, Schatzmann L, Brunner P,
Rincon L, Nolte LP. Quadriceps tendon and
patellar ligament: Cryosectional anatomy and
structural properties in young adults. Knee Surg
Sports Traumatol Arthrosc. 1996; 4:100-110.
18. Staubli HU, Schatzmann L, Brunner P,
Rincon L, Nolte LP. Mechanical tensile proper-
ties of the quadriceps tendon and patellar liga-
THE CUTTING EDGE
ment in young adults. Am J Sports Med. 1999;
27:27-34.
19. Woo SL, Hollis JM, Adams DJ, Lyon RM,
Takai S. Tensile properties of the human femur-
anterior cruciate ligament-tibia complex: the
effects of specimen age and orientation. Am J
Sports Med. 1991; 19:217-225.
20. Schatzmann L, Brunner P, Staubli HU.
Effect of cyclic preconditioning on the tensile
properties of human quadriceps tendons and
patellar ligaments. Knee Surg Sports Traumatol
Arthrosc. 1998; Suppl:S56-S61.
21. Harris NL, Smith DA, Lamoreaux L,
Purnell M. Central quadriceps tendon for anteri-
or cruciate ligament reconstruction, I: morpho-
metric and biomechanical evaluation. Am J
Sports Med. 1997; 25:23-28.
22. Slullitel D, Blasco A, Periotti G. Full-thick-
ness quadriceps tendon: an easy cruciate recon-
struction graft. Arthroscopy. 2001; 17:781-783.
23. Shelton WR. Quadriceps tendon graft for
ACL reconstruction. Presented at: Specialty Day
Meeting of the Arthroscopy Association of North
America; March 3, 2001; San Francisco, Calif.
24. Pederzini L, Adriani E, Botticella C, Tosi
M. Technical note: double tibial tunnel using
quadriceps tendon in anterior cruciate ligament
reconstruction. Arthroscopy. 2000; 16:E9.
25. Staubli HU. The quadriceps tendon-patel-
lar bone construct for ACL reconstruction. Sports
Med Arthrosc Rev. 1997; 5:59-67.
26. Noronha JC. Reconstruction of the anteri-
or cruciate ligament with quadriceps tendon.
Arthroscopy. 2002; 18:E37.
27. Kim DW, Kim J, You JD, Kim SJ, Kim
HK. Arthroscopic anterior cruciate ligament
reconstruction with quadriceps tendon composite
autograft. Arthroscopy. 2001; 17:546-550.
28. Randelli P, Berruto M, Tassi A. Ricostru-
zione endoscopica del legamento crociato anteri-
ore con innesto dal tendine quadricipitale e fis-
sazione rigida: tecnica chirurgica. Rivista
Italiana di Biologia Medica. 2001; 21:226-229.
29. Chen CH, Chen WJ, Shih CH. Arthro-
scopic anterior cruciate ligament reconstruction
with quadriceps tendon-patellar bone autograft.
Journal of Trauma. 1999; 46:678-682.
30. Theut PC, Fulkerson JP, Armour EF,
Joseph M. Anterior cruciate ligament reconstruc-
tion utilizing central quadriceps free tendon.
Orthop Clin North Am. 2003; 34:31-39.
31. Boszotta H, Prunner K. Refilling of
removal defects: impact on extensor mechanism
complaints after use of a bone-tendon-bone graft
for anterior cruciate ligament reconstruction.
Arthroscopy. 2000; 16:160-164.
32. Yasuda K, Ohkoshi Y, Tanabe Y, Kaneda
K. Quantitative evaluation of knee instability and
muscle strength after anterior cruciate ligament
reconstruction using patellar and quadriceps ten-
don. Am J Sports Med. 1992; 20:471-475.
35