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VID1-00932-EN | A | Quad Tendon Harvest with Patella Bone Block

Jason M. Scopp

Human

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

Eine Videoaufnahme einer Operationsanleitung an einem lebenden Patienten oder Patientin in einem Operationssaal oder eine Demonstration an einem Humanpräparat.

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Quad Tendon Harvest with Patella Bone Block

The first landmark I'm going to mark out is my VMO and I just palpate this. We don't want to harvest this graft contrary to the longitudinal fibers of the tendon. So it really is not going to be a straight up and down harvest. It's going to parallel the anatomy of the quadriceps tendon, which is going to drift slightly more slightly more lateral as it goes proximal. This incision is centered 50% over the patella and 50% over the soft tissues. And I begin my dissection. Now, this fascia also will continue down to the superior pole of the patella. And so in order to make sure that I'm going to get a clean bone plug, I will incise that as well. I will typically take a raytech or a sponge and a key elevator and pass it again just to clear the soft tissue. And if you don't address the peritoneum at this point of the procedure, your your knife can get caught up in it. Elevate the The pair of non medially and laterally. I will take the arthroscope and we can pass it up and it demonstrates that we've got real nice clearance all the way up. I like to make a mark on the skin showing an 80 millimeter skin mark. So I know even though the, the, the entire system is has graduated markings on it, I still like to know when I'm looking at the skin how far up I am. What I'll do is I'll take a the arthroscope at this point, and I will see that the tendon is freed up all the way up to my marking at eight. And I can look down here and I can see that my light is there. So I know that I am freed up, and I have no bands that are going to prevent me from getting a nice, clear and clean swipe with the double bladed knife. Here's the quad tendon knife. It comes in three different widths. Nine millimeters between the two tines, 10mm or 11mm. And as you can see here also on our graft harvesting knife it is marked we have 90, 80, 70 and 60. And this will allow me to know again how far up I'm going so I know how much tendon I'm harvesting. I already know which way my tendon fibers are running from proximal to distal, and I don't want to cross those angling medially, and I don't want to cross them angling laterally. I'm at the superior pole of the patella. I'm now going to sink both blades through the tendon just proximal to the insertion. I then push my finger on top to make sure that I am all the way down where I want to be. So my assistant, with the leg at 90 degrees of flexion draped off of the table, is going to hold the leg and I'm going to run this knife proximally. I'm dimpling the skin up here by eight, but I can also look at my numbers here and see that I've harvested an 80 millimeter tendon length. Once I've reached my desired tendon length, I elevate the graft knife and slide out. That ensures that as I'm backing out, I am not cutting tendon fibers outside of my proposed graft after I used a double bladed knife. The arthroscope can be inserted into our area so we can evaluate the success of our tendon release. This is the quad tendon cutter. It is not intended to be used as a tendon stripper. In fact, if you try to use it as a tendon stripper, it can often get caught up in the soft tissues. I like to use an osteotomy after using the double bladed knife to free up any adhesions or connections that might stop that from successfully working. A size eight osteotomy is then run up both the medial and lateral aspects of my cut to release any tendon connections prior to trying to cut the tendon free, and I can feel with my finger on my eight mark that I am up as high as I need to be. And so now I have freed myself up medially and laterally. I will now go and harvest my patellar bone plug. This is where I began my tendon cut. I am now on bone. So I want to make sure I have at least a 20 millimeter bone plug, and I try to make it nine by 20. I will take a 15 blade now and connect my tendon cut with a patellar cut. As you can see here, there's the end of my tendon cut. And now I've made marks where my bone cut is going to be. I will typically score the bone in a more vertical position. Once I know I've gotten through some of the cortical bone, I will then drop my hand to a 30 degree angle to ensure that I am not going to break through the patella. I will now drop. The width of this blade is a ten, so I know if I've gone two blade widths from proximal to distal, that I have roughly a 20 millimeter bone plug. After the bone plug has been cut, I will take an osteotomy and gently free it up. So we're in 30 degrees of flexion here. We're no longer in 90. I've released it in 30 degrees of degrees of flexion. As you can see, that patella is captured in the groove. If I had them in full extension every time I tried to do anything, the kneecap would be moving all over the place. So at 30 degrees it gives me real good sturdy platform to cut. The second part, as I mentioned earlier, is making sure that our angle of cut because of the curvature of the patella, it's so important that we're not in 90 degrees of flexion. So as I'm cutting, I'm going to get a small short bone plug. I'm in 30 degrees of flexion, which means I'm going to get a much larger bone plug after the bone has been released. I am now going to free up the undersurface of the quad tendon to connect with our medial and our lateral vertical cuts. The bone plug is flipped up proximally, exposing the transition here to the lateral aspect of the tendon. I then free this up and there is a natural plane that develops. I will then flip the bone, plug this direction and do the same on the medial side. To complete the graph release. I will then take the number eight osteotomy and slide it proximally. I am always looking at my eight mark here to know that I am up high enough or proximal enough. We can then insert the arthroscope on the under surface of our graft to demonstrate. Above us is our quad tendon graft, below us is residual tendon. And then you can see our medial and our lateral vertical cuts. In order to pass our quad tendon bone plug through our quad tendon cutter it has to be smaller than an 11. So I will often take arranger and begin some early graft preparation. Oftentimes that's the only bony preparation work that needs to be done. The handle of the quad tendon harvester is a very important feature. This is a safety mechanism as I begin to slide the tendon harvester approximately if I inadvertently closed my hand. I will amputate the tendon. The important position of the quad tendon harvester is with the safety lock in position. I urge everyone to look at this before they begin to slide it approximately in the leg, because now you are unable to close or prematurely amputate your graft. The other feature that is important to notice is it is not going to be a straight push up the leg. You see, there is an angle of approach here. I have now tapered my plug to a size nine by that simple preparation. With the rongeur to release our tendon proximally, I will take a sponge to give me control of the bone plug. So now with the bone plug firmly in my fingers, with my angle of approach at approximately 60 degrees to the femur and the lock on. I slide the device up approximately. I know that I'm up at eight already, but I can also look down here. Once I get to my desired length, I release the lock and I activate the cutting device and I pull the graph out. Here's our harvested graft. As you can see, we have our 20 millimeter by nine millimeter bone portion, and then we have a 70 millimeter tendon. This portion, this circumferentially is just a big fat graft. So I will then prepare this graft with a BTB TightRope on the femoral side. So the patellar bone plug becomes into the femoral tunnel. I will then whip stitch the distal 25mm of the graft that will fill our tibial tunnel. The new GraftPro allows for one graft board to accommodate any graft needs on this corner of the graft board. Were able to drill a central hole through our bone plug. This allows us to have a sunken and stable position so we can safely drill. I like to have a 25 millimeter area of the FiberLoop in our tapered and tight section, to improve the pull out strength between the graft and our interference screw. After we complete our tapered and tight portion of the graph, there are often these little dog ears that can develop at the end. And what I like to do is just take some Mets and smooth it out, basically using the end of this graft. I will then paint the end of the graft. So if the graft is slightly shorter and is up in the tibial tunnel, this gives me visualization. So I know exactly where the end of my graft is. The graft is now being compressed and the size nine tube. We have circumferential fill of the graft within this tube. As you'll note, there are these delivery portals. In the sizing tube. What I'll do is I'll take some ACP through a blunt needle and inject it into these holes and allow the graft to soak in. Acp, while I'm preparing the knee. This is one. I like to pull the graft up with my right hand and hold the other side of the graph with my left hand. That way I can feel as the button goes up the tunnel, I follow my sutures down to ensure that I am deep to the IT band. I think that's an important clinical pearl. You can do this either with a mini c-arm, or you can just literally look to ensure that you're deep to the IT band. I do that every time as we begin to deliver the BTB up into our tunnel. I like to make sure that the graft is rotated correctly so it doesn't go up the way I was not intending it for. And so you can maneuver it with a KingFisher or a probe. So the graft is going up nicely into the knee. We've got real nice tension demonstrating that the that we've got our button flipped, and now we will tension on the tibial side. Here is the our tibial tunnel. You can see this is the tibial end of our graph. We've painted it. So I know that I have full tunnel filled with this graft. It's important before you do your interference screw, to make sure that any soft tissues at the entrance of our tunnel are addressed. I also like to take a starting notch to make sure that the screw will go in easily. I then wrap the sutures around an empty needle holder. The leg is then brought into full extension with a posterior draw applied, and our guide pin is placed, followed by an interference screw. I typically do a ten by 23 screw for completing my graft fixation. Alternatively, if we are using FiberTag on a QuadLink all-inside technique, we would pass the TightRope and the graft sutures through this concave button.