Name: QuadLink™ and GraftLink® ACL Reconstruction
Uploaded: 2019-07-30T00:00:00Z
Channel: Arthrex
Description: J. Lee Pace, MD, (Farmington, CT) discusses graft choices for ACL reconstruction.

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<p>J. Lee Pace, MD, (Farmington, CT) discusses graft choices for ACL reconstruction.</p>

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VID1-000350-en-US | A | QuadLink™ and GraftLink® ACL Reconstruction

J. Lee Pace

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QuadLink™ and GraftLink® ACL Reconstruction

This talk is going to focus on graph choices. We all do a ton of ACL reconstructions. And so I think we're all fairly aware of our different graft options. The BTB graph has sort of been a workhorse for high level athletes. The hamstring has come along and been popular due to ease of use, maybe less donor site morbidity. The quadriceps tendon has historically not been used much, but is obviously growing a lot in popularity. Allograft obviously is not what we're going to talk about today, but does remain an option in select cases. As far as our decision making factors, what what do we do when we consider different graphs? We've looked at retear rates, we've looked at clinical outcomes, we've looked at donor site morbidity. And then there's sort of the intangibles such as like how we were trained, what our experience is and then also dogma. So there's been some clinical or some evidence based and some non-evidence based reasons for our graft usage. When we when we look at retail rates the biggest studies out there, most of the focus over the years has been on looking at B2B versus hamstrings. As far as Autograft, obviously, the moon group the Kaiser Permanente group, some of the Norwegian or some Scandinavian registries have all looked at this stuff with these large, large numbers. The Mayo Clinic. Et cetera. And what it comes down to in general is that there's probably a slightly higher retail rate. If you look at all age groups taken together for ipsilateral hamstrings. So that graph will tear a little bit more than a BTB graph. For the BTB graphs there, they may tear their other knee a little bit more. And that's probably the biggest takeaway I've taken from these big registry studies. If we sort of parse it out and look at the higher risk groups. So high level athletes, females we do see that in general, there seems to be a higher retear rate for hamstrings as opposed to BTB graphs. This study out of San of San Diego showed that their retail rate for BTB was about five and a half, versus about 12.5 for hamstrings. Okay, the quad tendon obviously has received a lot of attention recently. We don't really have any big registry studies yet. I think the the Danish are coming out with a maybe less than favorable study on the quad. But I still think that we're going to a lot more to figure out about that. But when you look at some of these comparative studies looking at BTB versus quad hamstring versus quad we're seeing similar functional outcomes, similar retear rates, if not better, as well as significantly less donor site morbidity. And this has been supported just recently in this big systematic review looking at outcomes for quad tendon versus BTB and versus hamstring. And this looked at 27 clinical studies close to 3000 patients looking at BTB, hamstring, quad tendon, ACL reconstructions. There was no difference in patient reported outcomes with regards to BTB and quad. And then amongst all graphs, no difference in objective measures or graph failure. However, when you looked at quad versus BTB, significantly less donor site morbidity and the quad has actually had significantly better functional outcome scores compared to hamstrings. So let's delve into some of these issues topic by topic here. Donor site morbidity. So BTB is the morbid graft. Okay. We've used it in spite of its morbidity. And we've done stuff to try and minimize its morbidity. But I think that's part of the reason why other graft options have come about was because some of the issues that people have, kneeling pain, especially early on, is ubiquitous. The numb patch is ubiquitous. In fact, an interesting study showed that the size of the numb patch directly correlated to the inability to kneel. Patellar tendinitis can be seen post-operatively patella baja based on. Maybe if you close the tendon, if you're not supposed to patella fracture. And then a recent study showed there was 100% rate of patellofemoral arthritis after a BTB harvest. When we look at the hamstrings you know, we've looked at it as a less a much less morbid graft. But this was an interesting study that was published about 12 years ago by by Xerogeanes and his group, and they found that there was still a significant rate of numbness after hamstring harvest. Most of the numbness actually occurs a little bit lower down in the leg. So a different it's different than the infrapatellar branch. You get it sort of down the medial leg. And I've definitely had patients with it. More interestingly, it does seem to be more commonly a stretch injury. So it does seem to be more temporary than permanent. But you can see 74% rate of overall nerve injury after a hamstring harvest. One of the other things that tends to be common with hamstrings is the cramping, either immediately post-op or when they kind of get back to running. That does seem to go away, but it is an issue. The other hamstring issues which we're all aware of is the size variability. I do think that you can mitigate this with the all-inside technique. Slightly higher CT 1000. It may stretch out a little bit more. And then some other studies from the Kaiser group show a slightly higher rate of post-op meniscal injuries and a slightly higher infection rate, in fact higher than allograft higher than other autographs. Now still less than 1%, but a higher infection rate. And some people are saying maybe all hamstring grafts should be washed in a vancomycin solution to kind of lower that, that that infection rate for hamstrings. When we look at quad, there are some reported donor site morbidity issues, but these are extremely rare. There's been like 1 or 2 case reports literally showing a quad tendon rupture. An aggressive harvest can lead to this rectus femoris detachment, which again is very rare. Patella fractures have been reported with any sort of bone block harvest. And then sort of the historical issue which now has been overcome with technology is the large scar. There are several advantages to the quad, and I've been using this now for a little over three years, and have not looked back since I made the switch. Now all of these statements are supported by literature, mostly published by Xerogeanes out of Atlanta. I'm happy to give you guys the references if you want them, but you're getting as much as three times more intra-articular collagen with a quad tendon than a patellar tendon. It's got a very predictable length and volume, much less donor site morbidity, equivalent to superior biomechanics. And again, as alluded to earlier, at least comparable outcomes to BTB and hamstring tendons. And now with technology you can do it through a much smaller, much more cosmetic harvest incision. So very customizable. So if you love bone blocks, you can almost reliably get up to 100mm of graft. You get 80mm of a quad tendon in any male who's above five, nine plus a 20mm bone block, you get a 100 millimeter graft out of that. Soft tissue, up to 80. You know, a short female. You may only get 70, but then again, you might not need that much space in the joint or in your tunnels. Right? So it's a very modifiable, customizable graft. And here's the anatomy. You can see it's huge. It is by far the biggest tendon in the knee with the most collagen. It averages 70 to 80mm in length in adults about seven millimeters thick. The common tendon itself is about 50 to 60mm. And that's roughly equivalent to the proximal extent of the suprapatellar pouch. You can kind of get an idea of what a rough harvest looks like there in the center. Okay, so Arthrex has this QuadLink technique and they have a harvesting guide here. You can see you've got this quad tendon cutting guide with these sort of little box cutter that will sort of create a either nine, 10 or 11 millimeter cut. And then you elevate the ten and they've got this quad tendon stripper cutter. Both of these things are graduated. So you know exactly how much quad tendon you're harvesting. So we'll kind of walk you through my harvest technique here. This I used to do vertical incisions. And you can see I have these down to less than two centimeters. And I've recently gone to horizontal. And again, I'm about two centimeters or less. The horizontal is great because it's in Langer's lines, so these incisions disappear. And if you're putting you still have your training wheels on, you can make the incision a little bit bigger. And it's still cosmetic. So a vertical incision, the longer it gets, the less cosmetic it is. But you can make this bigger horizontal. And it still looks good. You can see it's roughly the size of my medial portal where I introduced the graft. Because these graphs are so big, you have to widen the portal just to get the thing in. Okay, so once you've made the incision you're going to elevate the soft tissue off of the quad tendon. So get a joker elevator or a cob and just sort of lift that tissue off. And then what I do different is when I stick the when I do the harvest, I'll actually stick a camera in the incision, and then I'll place the cutting guide proximal. I'll stick it all the way proximal where I want my graft harvest to end. And that way I know that I'm between the muscle bellies. And then what I'll do is I'll pull back, and it's giving me a lot more confidence that I'm not going to veer off and get into the muscles and have some awkward harvest. So go start proximal and then work distal, and then take that cutting guide back and forth, back and forth, back and forth. So you have all the the sides of the tendon freed up the way you like it. Okay. And then after that elevated off the patella and then usually with a pair of Metzenbaum scissors. Or you can use a like an osteotomy. Jay loves an osteotomy. Different things like that. You can elevate it off the capsule. And you can see when you pull this thing out, it's so big and beefy out of the small incision. It literally looks like that, that that asteroid worm from Empire Strikes Back coming out of the knee. Okay, once you have it properly elevated, I leave the FiberLoop on. You don't have to, but I'll put my FiberLoop on. Run the stripper cutter up and then just get the the length that I want and then cut it just like that. I probably violate the capsule. I don't know, 30% of the time. I don't worry about closing it. In fact, I don't think you should close the defect, because if you allow a little bit little bit of a scar product to fill in that box cut. That's more tissue that you have afterwards. Nowadays I just stick a sponge up there to minimize fluid extravasation. I just leave it open and it doesn't matter. Okay. Graft prep. I do a GraftLink or a QuadLink technique, so I put TightRope on either side. So this is my PA on a graft prep station here. Has the TightRope on one of the posts and then literally just takes the FiberLoop and we have FiberTag and stuff like that that you can use, you can play with in the lab today. Tunnel preparation is with I use FlipCutter on the femur and the tibia. And this is a 9.5mm FlipCutter. This is my most common graft size that I get. And again, I'm not accommodating a bone block. I'm accommodating, accommodating collagen with these. Okay. So 9.5 is what's sticking in the joint two okay. Femoral and tibial tunnels, sort of standard all-inside technique. Here's my graft passage. This is getting pulled through the medial portal. I've marked out the central 30mm of the quad tendon graft, because that's what I want to stick inside the joint seat that get the femoral side roughly positioned, seat the tibial side. And then you can see I'm going to pull my femoral side up just a little bit more to kind of get my my length to match right there. Boom. Right there. And now I've got my graft in place just like that okay. And this is what my post-op x rays look like TightRope PT on the femur. And then an ABS TightRope on the tibia. Okay. Now when we talk about different age groups, different different patients getting different types of ACL reconstructions for a skeletally mature patient, my graft length is 60mm, and that gives me about 15mm of graft in each tunnel. That has been that's worked out really well for me. There are studies showing you only need even ten millimeters of graft in these tunnels to get good healing. If I'm using a hybrid technique where I put something across the Across the tibia where I want graft across that open tibial apophysis. I'll take something a little bit longer 65 to 70mm, maybe put a little bit less in the femoral tunnel, more in the tibia to make sure I cross that. And then if I'm doing an all epiphyseal technique, I may harvest 50 or so to get make sure that I don't bottom out in the tunnel. So it's a smaller patient, smaller graft, shorter tunnels. Okay. And these are some X-rays of what a hybrid technique looks like. You can see the horizontal femoral tunnel and then a longer tibial tunnel on the down there with the ABS there. And then here's the here's the all epiphyseal technique. And I cut my teeth on the IT band ACL reconstruction I did this a lot. And I've become such a quadricep enthusiast that I now torture myself by doing these all epiphyseal techniques because it is technically more difficult, but the graft is so nice. The femoral side is actually not bad. It's the tibial side that is more of a problem. One of Frank's studies even showed that if you're going to potentially violate a says it's a proximal tibia more likely than the than the than the distal femur with these epiphyseal techniques. So you can see here tibial guide pin coming in when the FlipCutter. And then just, you know, using a ton of x ray to make sure you don't violate the bias. One thing I've done a little bit differently, this is my own thing, is I will angle my tibial tunnel a little bit lateral. I'll put the guide right on the tubercle. So my my tibial tunnel looks a little funky. You can see that button going laterally, but I've given myself the maximum amount of proximal tibial bone to stay away from the bias and actually have a post-op MRI on this patient showing a completely all epiphyseal tibial tunnel with no violation of the proximal tibial faces. Okay, post op any other the same as any other ACL reconstruction. Full weight bearing motion is tolerated unless dictated by a meniscus injury. You know, here's some of my post-op incisions right here. This is when I was on vertical, and you can see less than the size of a water bottle lid. And then as I've switched to horizontal, you can see some of these incisions here again the size of the length of a dime. And then in guys, when they let their hair grow over it, you can barely see these things. And these are all three month out incisions or less. Okay. Another reason that I've become an enthusiast of the quad tendon is this graph may actually incorporate quicker than hamstrings. So as time goes on, we want these graphs on MRI to be very black and homogenous in its in on T2 weighted imaging. This is a new study showing that it looked like the quadriceps tendon tended to mature quicker on MRI than hamstring. And this is one of my patients five months out from a quad ACL. You can see that. Just a huge beautiful graph. Very very dark on T2 imaging very homogenous at five months out. You would love a hamstring to look like this at a year. Okay. Now while not perfect, one of the issues with these big graphs is that you may have a higher risk of Cyclops lesions. A little bit of arthrofibrosis. A recent study by Freddie Fu showed that compared to other graft options, you may actually overfill the ACL footprint with these graphs. So, you know, I've been always trying to get more and more and more, but I might only need to realistically get eight and a half or something like that to get a quality graph with plenty of collagen that doesn't overstuff these footprints. So plenty of collagen, tons of collagen. Okay. If we look at some of the SOS data quad versus BTB, you can see here on the Vas scores equivalent outcomes. If we look at these at this this is a sports rec score. This is again similar. Now let's talk a little bit about the GraftLink. If people like hamstrings you know it's still a viable graft I think. This posterior harvest incision is nice because I think it minimizes the donor site morbidity from it. It's very cosmetic. You can harvest a mitt, and they don't even have much of a visible scar. And you can load it on the TightRope is in a similar fashion we can play around with at the lab today. And you can see if you look at all the SOS scores compared to BTB auto, again, very similar outcomes with the with the GraftLink versus a BTB and all these things here. So future directions we've talked about routine internal bracing, biologic augmentation, you know PRP amnion collagen wraps. I do think that if you like hamstrings Adam Arntz has been doing some interesting work where he's been wrapping all of his hamstrings and amnion, and that has really led to quicker graft maturation on MRI. And that might be a really good adjunct for hamstrings if you really like hamstrings. So in conclusion, I think that you can get a good outcome with any graft. I think all-inside techniques, which is not the focus of this talk, will really allow optimum outcomes and optimum. It's probably the best technique overall. It doesn't just look slick. I think the biology and the mechanics of it are the best. I think quad tenon is very exciting with minimal donor site morbidity, reliable length and volume, and very quick incorporation. I do think that biologic augmentation is the future. Thank you.

QuadLink™ and GraftLink® ACL Reconstruction

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