Name: Alternative ACL Graft Options: Quadriceps Tendon
Uploaded: 2020-05-29T00:00:00Z
Channel: Arthrex
Description: J. Lee Pace, MD (Farmington, CT), discusses graft options for ACL reconstruction and the benefits of quadriceps tendon grafts.

<p>J. Lee Pace, MD (Farmington, CT), discusses graft options for ACL reconstruction and the benefits of quadriceps tendon grafts.</p>

Not Hidden

English  - en

video

VID1-000945-en-US | A | Alternative ACL Graft Options: Quadriceps Tendon

J. Lee Pace

Human

A video of a live presentation reviewing Arthrex products or techniques.

Video einer Live-Präsentation, die Arthrex Produkte oder Techniken überprüft.

Präsentationsvideos

Presentation Videos

Vídeo de apresentação ao vivo analisando produtos ou técnicas da Arthrex.

Apresentação vídeos

Video de presentación en vivo que revisa los productos o técnicas de Arthrex.

Video presentaciones

Alternative ACL Graft Options: Quadriceps Tendon

So, contrary to popular belief, the quadriceps tendon is it's actually a fairly well described graft that's been around for a long time. I think as we're all aware, it's been used fairly sparingly in a historical fashion, but it is definitely the hot topic nowadays. You know, my number I have here is, you know, up to 11% of ACL grafts, but, I mean, we may be even getting closer to 15 to 20% at this point of all autograft options with the quad. The reason why this, why the quad has sort of been the forgotten graft is due to sort of an unfair showing in this old 1984 biomechanical study where the quad got lumped into this what's called substitution graft, where it was a combination of, like, prepatellar fascia and patellar tendon. I mean, of course, that's going to fail. And so the BTB and hamstrings had a much more favorable biomechanical profile. And so the quad got equated with not good. So off people went with the BTB and the hamstrings for autograft options for ACL reconstruction. Well, in the late 90s, people started looking at the pure quad tendon and its biomechanical properties. And there's a couple of studies here that are that are mentioned. But the summation of these studies showed favorable comparisons to the patellar tendon, especially higher load to failure, lower elastic modulus, and significantly more collagen than the patellar tendon. And then in the last 20 years, there have been several favorable clinical reports. And John Fulkerson you know, the Fulkerson AMC was actually one of the first guys to publish on early clinical results from all soft tissue quadriceps tendon. And he showed here you know, fantastic stability, good patient, reported outcomes. And this is followed by further studies looking at bone plug on the quad tendon. A good again, good patient reported outcomes. Great. Great stability. Low donor site morbidity, and Fulkerson also published this article showing that the early rehab with the quad tendon was better than the other grafts. They were able to get their range of motion back quicker. They were off pain meds earlier, especially compared to the patellar tendon harvest. So what are the advantages of the quad tendon? This slide is the summation of a lot of studies done recently by John Xerogeanes in Atlanta, who has really popularized the quadriceps tendon and really sort of brought it back online for everybody. But in short, you're getting almost triple the amount of intra-articular collagen compared to the patellar tendon. You get a very predictable length and volume, significantly less donor site morbidity, even less than the hamstrings, equivalent to superior biomechanics and comparable to superior outcomes compared to the other two autograft options. And now with technology through Arthrex, a much smaller, much more cosmetic harvest incision, which was honestly one of the big things. So what are the other advantages? Well, it's very customizable. So if you love bone plugs, you can take a bone plug off the patella, and this can allow you to get up to 100mm of graft. And if you're all soft tissue, if you've got someone who's at least I believe it's like five eight, you can almost reliably get 80mm of graft. So you can customize whatever length, whatever technique you want with this graft. It's fantastically versatile and it's the versatility continues into skeletal maturity or immaturity. Excuse me. So for a standard skeletally mature patient, my preferred graft length is only about 60mm. I put about 15mm in each graft socket. If I'm going to do a hybrid technique where I want to cross the tibial apophysis with soft tissue to keep that open, I'll take a little bit longer graft. And if I do say, you know, a 10 or 11 year old kid and I go all epiphyseal, then I'll harvest a 50 millimeter graft so I can use any graft length that I need or want for the exact technique that I want, so I can use it in any age group. Okay. And if we look at the anatomy of the quad tendon, you can see it's huge. It's by far the biggest tenant in the knee. It averages about 70 to 80mm long. It's about seven millimeters thick. And you can see this is, you know, a rough representation of what a 60 millimeter graft harvest would look like. John Xerogeanes showed that you take less than 50% of the quad tendon with an 80 millimeter graft, versus 65% of the patellar tendon with a standard ten millimeter wide graft harvest. There have now been several comparative studies looking at the quad tendon versus either BTB or hamstrings. And in summary, all these studies show equivalent patient reported outcomes, equivalent retear rates, and equivalent to superior patient reported outcomes. And this is looking at all age groups across the board. This was the most read article in AGM last year. Was this systematic review and meta analysis of the different grafts? And again it showed what I just said that BTB versus quad, no differences in patient reported outcomes or objective measures. The graphs had similar failure rates. The quad had significantly less donor site morbidity than the BTB and significantly better. Patient reported outcomes. Functional outcomes than the hamstrings. Okay, so what about donor site morbidity? This is the this graph here has the least donor site morbidity profile of the other graphs. There have been literally a couple case reports in the literature of late quad tendon rupture. So there's been like 1 or 2 reported that we're aware of. And an overly aggressive graft harvest, if you get trying to get like a 80 plus 90 plus millimeter, all soft tissue graft, you can sometimes detach the detach the rectus femoris which is a cosmetic issue. And usually with all-inside, you don't even need to get anywhere near that. And obviously, anytime you harvest a bone, block off the patella, you do risk patella fracture. So I'm all soft tissue. I haven't harvested a bone plug in, I don't know, 4 or 5 years. And then the large scar is historical, I think, now with with current technology. So my question to you guys, is BTB really the gold standard for ACL reconstruction, and if it is, then the quad is the platinum standard. Right. So here is the instrumentation for quad tendon harvesting. You have a a graft cutting guide as well as a quad tendon stripper slash cutter. So I'll walk you through my harvest technique. I now do horizontal incisions. But you can see this is my old vertical incision here. This is less than two centimeters in length. And here's my my horizontal incisions now okay. Make an incision dissect. You basically kind of create a degloving injury. You get all that soft tissue off the off the quad tendon, get a Joker or something like that. Just sweep everything off. And then what I do unique, a little bit different than the technique guide is, I will actually use the arthroscope. I'll stick it up into the incision, and I'll place my cutting guide proximal where I want my harvest to end. And that way, I know that I'm between the muscle bellies. I'm not going to, you know, veer off and go one way or the other, and then I'll pull back, and then I'll go back and forth, back and forth, back and forth to complete my side cuts. It's a very reliable way. When I teach my fellows, it gives them a lot more confidence in doing this harvest when they start off in practice. And then from there, I will elevate it off the insertion, off the patella, usually with some Metzenbaum scissors. And then from there, once I have it elevated up enough, then you use the stripper cutter. It's graduated. So it tells you exactly what length you're harvesting. So I'll just push it up until I'm at 60, 65, and then I'll squeeze and detach and out it comes. Just like that. Click okay. The next step is prep. I would say if there was one knock on the All-inside quad tendon graft prep, it was that it was a little bit of an onerous graft prep. You needed to have a capable assistant to do this for you. Now, Arthrex has made a FiberTag with the TightRope attached to it. So I'm a very fortunate person. I have the world's best physician assistant. He would have my quads prepped the old way, typically by the time I was done drilling tunnels. Now I'm getting the femoral tunnel done and he's coming up to help me with the tibial tunnel. This is how fast this FiberTag TightRope is made. Graft prep. So here's a little video. There's a special clamp, and you have a FiberTag TightRope on this backer card that you can then then pass the whipstitch through with this really robust, strong Keith needle. And as you do your whipstitch, as soon as you're done, you've already got your TightRope attached. So that's it. It's it's really literally cut our graft prep time in half. So it's like under ten minutes to put to prep this graft at this point. Okay. And you guys will get a chance to play around with this today. Tunnel preparation I again I'm all-inside. My most common graft size or tunnel size is a nine and a half. I'm not accommodating bone blocks. I'm I'm accommodating collagen. Okay. So this is just a huge graft. And now with the FlipCutter three again here's a picture of this. You guys get a chance to play around with this today. As you said, it's an all in one RetroCutter. And then here's an example of my tibial tunnels. Fiberstick TigerStick just like Jason said. And then graph passage, just like they said, pull it through the the medial portal. You know, I mark my my middle 30 of the graft, dunk my femoral side, dunk my tibial side. And then from there then I'll adjust. I'll usually under pull in my femoral tunnel so that I can then make that final adjustment. You can see me just adjusting the femoral tunnel up to the purple mark right there and done. And similar to Jason here is what my implant, my x rays look like. You know, all-inside TightRope PT on the femur, abs TightRope on the tibia and then post-op a straight up ACL reconstruction without meniscal work, without additional work weight. Bear motion is tolerated. Crutches for comfort. Similar graft rehab. You can see. Here's what the incisions look like. Here it is relative to a water bottle. And then here we are going horizontal now, And you can see just and these are like three months, three month post imaging photos here and these things disappear okay. Pretty fantastic. So the other thing that I really love about the quad is it looks to mature quick. So Freddie who's looked into this and he's shown that compared to the hamstrings that if you look at post-surgical MRIs that the quad tendon tends to go dark i.e. mature quicker than a hamstring. So this is one of my patients at five months out with that's that's what her ACL looks like five months out. Is that just cable of dark homogeneous tissue okay. And if there was one thing about the quad is that, you know, sometimes it may be too big. John Xerogeanes published he's got about an 8% risk of Cyclops lesions. And Freddie Fu published that the quad compared to the hamstrings, actually may tend to sometimes overstuff the footprints. So you know, I'm very I don't need to get a 1011 graft on this. I'm very happy between, you know, around nine. I'm, you know, in my smaller kids, if I If I get an eight and a half, I'm, I'm I'm more than happy. So then if we look at some of the SOS data, you can see again equivalent SOS scores on SOS. Here visual analog scale activity scores here looks great. Okay, so future directions, you know, as far as the QuadCore is concerned, routine internal bracing, I actually do that in every single one of my ACL reconstructions now and then, as Jason mentioned, biological augmentation. There's actually a recent arthroscopy techniques article in which Chad Lavender uses the GraftNet to collect his tunnel drillings and then fertilizes his tunnels even further. So there's a lot of continued work we can do to continue to augment our our ACL reconstructions. I would say that QuadCore at this point has become probably the preferred graph for more and more people on a daily basis when it comes to Autograft ACL reconstruction. Thank you very much.

Alternative ACL Graft Options: Quadriceps Tendon

Páginas Relacionadas

Joelho

Preparo e extração do tendão quadricipital

Produto

Joelho

Revisão de reconstrução do LCA

Procedimento