Research

Functional Knee Recovery after Quadriceps Tendon

Autograft in Anterior Cruciate Ligament Reconstruction:
A systematic review

STUDENT ID: 2753972

WORD COUNT: 1753
DATE OF SUBMISSION: 26 APR 2023

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Table of Contents
Cover Page……………………………………………………………………………Page 0

Table of Contents……………………………………………………………………Page 1

Introduction…………………………………………………………………………....Page 2

Background
Anterior Cruciate Ligament Injury……………………………………………………Page
3
Anterior Cruciate Ligament Reconstruction Surgery and Choice of Grafts……Page 3-
4
The Quadriceps Tendon…………………………………………………………...Page 4-

Functional Knee Recovery after QT ACLR

Knee extensor and flexor strength………………………………………………..Page 7-
8
Quadriceps muscle strength…………………………………………………………Page

Return-to-sports activities……………………………………………………………Page 9

Other clinical outcomes to be considered………………………………………Page 9-

10

Conclusion…………………………………………………………………………...Page 10

Bibliography…………………………………………………………………..….Page 10-15

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Functional Knee Recovery after Quadriceps Tendon Autograft in Anterior
Cruciate Ligament Reconstruction

Introduction

Given the rising incidence of Anterior cruciate ligament (ACL) injuries in sports
medicine (~50%) (Musahl et al., 2019), there has been a topical debate over the
graft selection for athletes which is an essential starting point in the ACL
reconstruction (ACLR). To date, there has not been a universal consensus on the
optimal choice of graft (Sim et al., 2022). Autografts are preferred to allografts, and
particularly, hamstring tendon (HT) autografts have been most commonly used since
2014 (~60%) (Arnold et al., 2021). Over time, these traditional autografts are shown
to be associated with various shortcomings leading the surgeons to seek an
alternate option.
Though traditionally viewed as inferior among autografts, recently, the utility of
quadriceps tendon (QT) grafts has garnered interest with the emerging hypotheses
stating that by using appropriate harvesting techniques, a QT graft with comparable
properties to native ACL and least donor site morbidity can be obtained (Mouarbes
et al., 2019).
However, as an emerging option, there has been a relative paucity of clinical data
regarding QT grafts compared to other autografts. Specifically, the least has been
studied functional knee recovery after QT ACLR and return-to-sport rates in athletes,
to whom this issue is of integral concern. Regaining sufficient knee muscle strength
is a key to successful knee recovery and thus, this aspect is pivotal for athletes in
making a return to sport decisions as a hastened choice could precipitate reinjuries
in athletes (>4 folds risk) (Bahr et al., 2016).
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Hence, this review will provide a background overview of ACLR surgery and QT
autografts and evaluate its functional knee recovery and return-to-sports rates in
comparison with HT grafts. This review thus aims to facilitate a better understanding
of functional knee recovery after QT grafts which is imperative to joint decision-
making of the patient and the surgeon on the optimal choice of graft and
commencement of physical activities.

Background

Anterior cruciate ligament (ACL) injury

The ACL is a flexible band of connective tissue that runs from the end of femur to the
top of tibia. Together with posterior cruciate ligament (PCL), ACL forms a cruciate
form within the knee joint thereby maintaining knee stability and preventing
dislocation of tibia and femur from their anatomical sites (Evans and Nielson, 2022).
Majority of the tears occur by noncontact mechanisms (e.g., rotational forces) to
which basketball players are at high risk and contact mechanisms (e.g., a direct blow
to the knee) which are mostly prone in football players (Evans and Nielson, 2022).
Partial tears can be alleviated with rehabilitative therapy, but complete tears may
require surgical intervention depending on the severity, patient's age, physical
activity levels and associated knee injuries (Weii Su, 2019).

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Figure 1. Anatomy of ACL and ACL tear (Mayo Foundation, n.d.)

Anterior Cruciate Ligament Reconstruction (ACLR) surgery and choice of

grafts

Typical surgical treatment is reconstruction with a tissue graft and traditionally,

patella tendon (PT) graft and HT autografts have been used (Arnold et al.,2021).
Over time, PT grafts declined in usage due to its associated risk with anterior knee
pain (Anderson et al., 2008) and patellofemoral osteoarthritis (Middleton et al.,
2014). Moreover, HT grafts have hamstring weakness and a considerably high
failure rate of 28% in young female athletes (Webster et al., 2016) whereas allografts
have approximately 13 times increased risk of reinjuries compared to autografts
(Kaeding et al., 2017).
QT grafts were first described by Marshall et al., (1979) and Blauth (1984) but were
viewed as inferior due to conventional open harvesting techniques. Given the
emergence of modern harvesting techniques, QT graft usage has resurfaced since
2014, occupying approximately 10% of the grafts used for ACLR (Arnold et al.,
2022).

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Figure 2. Locations of autografts for ACLR surgery (Regents of the University of
Colorado, 2017)

The Quadriceps tendon (QT)

Anatomy
The QT serves as an insertion site of four quadriceps muscles (as shown in Figure
3) to the proximal pole of patella. Together with patella tendon and patella bone, the
quadriceps tendon provides a pulley mechanism for knee extension (Evans and
Nielson, 2022).

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Figure 3. Anatomy of QT (vastus medialis obliquus (VMO), vastus medialis (VM),
rectus femoris (RF), vastus lateralis (VL), medial patellofemoral ligament (MPFL),
Patella Tendon (PT)) (Moatshe et al., 2021)

Measurements
The width of QT ranges from 2.5-3cm and has an average length of 7-8.5 cm but this
length can be varied (Sheean et al., 2018). According to an anatomical study of
cadaveric specimens by Strauss et al. (2013), QT graft is thickest at its central and
distal portions closest to the patella, with a median of 8.5 mm and thinnest at its
proximal portion with a median of 5.4 mm.

Harvesting techniques
QT can be obtained by both conventional open or minimally invasive techniques, soft
tissue only (SQ-T) or with proximal patellar pole bone block (QT + BB) and full
thickness (FT-Q) or partial thickness (PT-Q). Either a FT-Q or PT-Q can be obtained
for a single-bundle ACL reconstruction and particularly, FT-Q is used in double-
bundle (anteromedial and posterolateral bundles) ACL reconstruction (Catarev et al.,
2016). QT + BB is used in revision ACL surgery if there are enlarged tunnels after
surgery (Haner et al., 2016).

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Figure 4. QT graft with bone plug (QT+BB) (Moatshe et al., 2021)

Today, using a transverse incision of approximately 2-3cm made over on the patella
bone’s superior border, Fink et al., (2014) proposed a minimally invasive QT
autograft harvest technique yielding a sturdy and durable soft tissue, for which
Clinger et al. (2022) stated that this could contribute to the least donor site morbidity
of QT grafts.
With QT running 2–4 cm into the distal portion of rectus femoris muscle, the harvest
can be extended if there is a need for additional length without losing the graft
integrity nor harming the suprapatellar pouch. Nonetheless, the risk of hematoma
formation and potential deficits in remaining knee muscle strength should be
considered in the process (Sheean et al., 2018).

Figure 5. A transverse skin incision over patella bone using a minimally invasive
harvesting technique (Clinger et al., 2022)

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Functional Knee Recovery (In comparison with HT grafts)

Knee extensor and flexor strengths

(Using Isokinetic strength testing)
During a retrospective study of knee strength deficits with Isokinetic strength testing
using a Dynamometer (a device for assessing force generated by muscles), it was
found that knee extensor and deficits in knee flexor strength remained at 12 months
after QT and HT ACLR. Notably, only 33% of QT patients showed knee extensor
strength compared to 62% of HT patients, whereas 73% of QT patients showed knee
flexor strength compared to only 38% HT patients, for which Johnston et al., (2021)
commented that this may influence return-to-sport decisions for athletes. However, it
should be noted that the participant numbers in this study were quite limited (n~100).
This finding of knee extensor deficit concurred with Johnston et al., (2020) previous
meta-analysis on 18 studies, which stated that lower limb symmetry index (LSI-
affected limb’s strength as a percentage of healthy limb strength) of knee extensor in
QT ACLR patients could not score 90% even after post-operative 24 months period.
Knee flexor strength LSI after QT ACLR was significantly higher than that of HT ACL
at 5-8 months post-operative period, exceeding 90% at 9-15 months (Johnston et al.,
2020).

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Figure 6. Isokinetic strength testing with a Dynamometer (José et al., 2021)

(Using Hop-testing)
In contrast, hop testing (LSI calculated from patient’s hopping performance)
demonstrated satisfactory results in both QT and HT participants (LSI> 90%) at
6 months after ACLR and this result was found to be consistent (Nagai et al., 2019)
(Johnston et al., 2021). However, it is worth noting that hopping performance can
also be achieved by compensation of other joints (e.g., hip joint) regardless of
deficits in knee muscle strength, thus this test alone cannot be a reliable indicator of
functional recovery.

Figure 7. The 6-meter timed hop test (patient has to hop on one limb over a distance
of 6 meters) (Ebert, 2016)

Quadriceps muscle strength

According to the available data, a retrospective study on athletes stated that 87% of
QT-ACLR patients and 74% of HT-ACLR patients did not have the adequate
quadriceps muscle strength to meet return-to-play and return-to-running criteria after
5-8 months postoperative period (Hughes et al., 2019). However, the limited number
of participant samples in this study (n=73) should be considered.

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Return-to-sport rates

Data about return-to-sport rates have not been documented in most studies
specifying QT grafts. In his prospective study, Grindem et al., (2016) proposed that
there could be a protective effect of postponing return-to-play activities until at least 9
months after surgery which coincided with the findings of Hughes et al., (2019) as
mentioned above. It was concluded that quadriceps strength deficit could precipitate
reinjuries after the commencement of sports activities (3% decreased risk reinjury for
every 1% increase in quadriceps muscle strength) and that such reinjury rate could
be mitigated by 51% with every one month postponement to sports activities
(Grindem et al., 2016).

Other clinical outcomes to be considered

Patient reported outcomes (PRO)

No inferior result was detected in QT compared to HT in terms of PRO [International
Knee Documentation Committee Score (IKDCCS), Knee Injury Osteoarthritis
Outcome Score (KOOS), Lysholm scores, Tegner activity] and these results were
found to be consistent in the existing data; randomized controlled trials by Lind et al.,
(2020), a meta-analysis by Hurley et al., (2022) and a 2 year prospective study by
Runer et al., (2017).

Graft Failure
A meta-analysis by Mouarbes et al. (2019) reported a QT graft failure of 2.1% and
interestingly, Runer et al., (2020) concluded that QT grafts show half of ipsilateral
graft rupture rates compared to HT grafts (2.8% vs 4.9%). However, no further
investigation has been documented on this finding and evidence available from other
systematic reviews show no significant difference in rates of graft failure between HT
and QT autografts (Dai et al., 2021).

Donor site morbidity

A crucial benefit of QT graft is its pronounced decrease in donor site morbidity (i.e.,
anterior kneeling pain) as reported by the majority of existing evidential data. Fewer

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complaints about kneeling pain (Barie et al., 2020), 50% lower incidence of harvest
side morbidity (Lind et al., 2020) and a significant difference in harvest site pain with
30% less drug consumption during the immediate postoperative period in the FT-Q
ACLR patients compared to HT ACLR (Buescu et al., 2017) had been documented
as such.

Conclusion

According to the existing literature, QT graft has been recognized as a promising

alternative to traditional autografts with equivalent to or even better functional
outcomes with least donor site morbidity. Being a versatile graft with manual
adjustability and flexibility in size during extraction, QT grafts could negate technical
difficulties like graft-tunnel mismatch. Anyhow, as an emerging option, it should be
noted that most studies are of short-term data, retrospective and limited number of
subjects with relatively lower levels of evidence. Specifically, to date, least is studied
about functional knee recovery and return-to-sport rates after QT ACLR. Long-term
prospective studies inclusively using athletes as participants, to whom this issue is of
integral concern, are required to mitigate variables, especially in terms of pre-injury
activity levels. Owing to its increasing popularity, more sufficient data from
forthcoming studies could be hopefully expected which may shed more light for a
better understanding of this matter.

Bibliography
1. Anderson, M.J., Browning, W.M., Urband, C.E., Kluczynski, M.A. and Bisson, L.J.
2016. A Systematic Summary of Systematic Reviews on the Topic of the Anterior
Cruciate Ligament. Orthopaedic Journal of Sports Medicine. 4(3),
232596711663407.
2. Anon 2019b. What’s the Best Way to Reconstruct an ACL?
Childrenscolorado.org. [Online]. Available from:
https://www.childrenscolorado.org/conditions-and-advice/sports-articles/sports-
injuries/acl-graft-options/.
3. Arnold, M.P., Calcei, J.G., Vogel, N., Magnussen, R.A., Clatworthy, M., Spalding,
T., Campbell, J.D., Bergfeld, J.A. and Sherman, S.L. 2021. ACL Study Group
survey reveals the evolution of anterior cruciate ligament reconstruction graft
11
choice over the past three decades. Knee Surgery, Sports Traumatology,
Arthroscopy.
4. Barié, A., Sprinckstub, T., Huber, J. and Jaber, A. 2020. Quadriceps tendon vs.
patellar tendon autograft for ACL reconstruction using a hardware-free press-fit
fixation technique: comparable stability, function and return-to-sport level but less
donor site morbidity in athletes after 10 years. Archives of Orthopaedic and
Trauma Surgery. 140(10), pp.1465–1474.
5. Brígido-Fernández, I., García-Muro San José, F., Charneco-Salguero, G.,
Cárdenas-Rebollo, J.M., Ortega-Latorre, Y., Carrión-Otero, O. and Fernández-
Rosa, L. 2022. Knee Isokinetic Profiles and Reference Values of Professional
Female Soccer Players. Sports. 10(12), p.204.
6. Buescu, C.T., Onutu, A.H., Lucaciu, D.O. and Todor, A. 2017. Pain level after
ACL reconstruction: A comparative study between free quadriceps tendon and
hamstring tendons autografts. Acta Orthopaedica et Traumatologica Turcica.
51(2), pp.100–103.
7. Caterev, S., Nistor, D.V. and Todor, A. 2016. Anatomic Double-Bundle Anterior
Cruciate Ligament Reconstruction With a Free Quadriceps Tendon Autograft.
Arthroscopy Techniques. 5(5), pp.e1063–e1067.
8. Clinger, B., Xerogeanes, J., Feller, J., Fink, C., Runer, A., Richter, D. and
Wascher, D. 2022. Quadriceps tendon autograft for anterior cruciate ligament
reconstruction: state of the art. Journal of ISAKOS. 7(6).
9. Ebert, J.R., Du Preez, L., Furzer, B., Edwards, P. and Joss, B. 2021. Which Hop
Tests Can Best Identify Functional Limb Asymmetry in Patients 9-12 Months
After Anterior Cruciate Ligament Reconstruction Employing a Hamstrings Tendon
Autograft? International Journal of Sports Physical Therapy. 16(2).
10. Evans, J. and Nielson, J. l 2019. Anterior Cruciate Ligament (ACL) Knee Injuries.
Nih.gov. [Online]. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK499848/.
11. Fink, C., Herbort, M., Abermann, E. and Hoser, C. 2014. Minimally Invasive
Harvest of a Quadriceps Tendon Graft With or Without a Bone Block.
Arthroscopy Techniques. 3(4), pp.e509–e513.
12. Grindem, H., Snyder-Mackler, L., Moksnes, H., Engebretsen, L. and Risberg,
M.A. 2016. Simple decision rules can reduce reinjury risk by 84% after ACL

12
reconstruction: the Delaware-Oslo ACL cohort study. British Journal of Sports
Medicine. 50(13), pp.804–808.
13. Häner, M., Bierke, S. and Petersen, W. 2016. Anterior Cruciate Ligament
Revision Surgery: Ipsilateral Quadriceps Versus Contralateral Semitendinosus-
Gracilis Autografts. Arthroscopy: The Journal of Arthroscopic & Related Surgery:
Official Publication of the Arthroscopy Association of North America and the
International Arthroscopy Association. 32(11), pp.2308–2317.
14. Hughes, J.D., Burnham, J.M., Hirsh, A., Musahl, V., Fu, F.H., Irrgang, J.J. and
Lynch, A.D. 2019. Comparison of Short-term Biodex Results After Anatomic
Anterior Cruciate Ligament Reconstruction Among 3 Autografts. Orthopaedic
Journal of Sports Medicine. 7(5), 232596711984763.
15. Hurley, E.T., Mojica, E.S., Kanakamedala, A.C., Meislin, R.J., Strauss, E.J.,
Campbell, K.A. and Alaia, M.J. 2021. Quadriceps Tendon Has a Lower Re-
Rupture Rate than Hamstring Tendon Autograft for Anterior Cruciate Ligament
Reconstruction – A Meta-Analysis. Journal of ISAKOS. 7(2).
16. Johnston, P.T., Feller, J.A., McClelland, J.A. and Webster, K.E. 2021. Knee
strength deficits following anterior cruciate ligament reconstruction differ between
quadriceps and hamstring tendon autografts. Knee Surgery, Sports
Traumatology, Arthroscopy. 30(30).
17. Johnston, P.T., McClelland, J.A., Feller, J.A. and Webster, K.E. 2020. Knee
muscle strength after quadriceps tendon autograft anterior cruciate ligament
reconstruction: systematic review and meta-analysis. Knee Surgery, Sports
Traumatology, Arthroscopy. 29.
18. Kaeding, C.C., Pedroza, A.D., Reinke, E.K., Huston, L.J., Hewett, T.E., Flanigan,
D.C., Spindler, K.P., Parker, R.D., Andrish, J.T., Jones, M.H., Wright, R.W.,
Matava, M.J., Brophy, R.H., Marx, R.G., McCarty, E.C., Wolcott, M.L., Vidal, A.F.,
Amendola, A., Wolf, B.R. and Dunn, W.R. 2017. Change in Anterior Cruciate
Ligament Graft Choice and Outcomes Over Time. Arthroscopy: The Journal of
Arthroscopic & Related Surgery. 33(11).
19. Kyritsis, P., Bahr, R., Landreau, P., Miladi, R. and Witvrouw, E. 2016. Likelihood
of ACL graft rupture: not meeting six clinical discharge criteria before returning to
sport is associated with a four times greater risk of rupture. British Journal of
Sports Medicine. 50(15), pp.946–951.

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20. Lind, M., Nielsen, T.G., Soerensen, O.G., Mygind-Klavsen, B. and Faunø, P.
2019. Quadriceps tendon grafts do not cause patients to have inferior subjective
outcome after anterior cruciate ligament (ACL) reconstruction than do hamstring
grafts: a 2-year prospective randomized controlled trial. British Journal of Sports
Medicine. 54(3), pp.183–187.
21. Mayo Clinic 2021. ACL injury - Symptoms and causes. Mayo Clinic. [Online].
Available from:
https://www.mayoclinic.org/diseases-conditions/acl-injury/symptoms-causes/syc-
20350738.
22. Middleton, K.K., Hamilton, T., Irrgang, J.J., Karlsson, J., Harner, C.D. and Fu,
F.H. 2014. Anatomic anterior cruciate ligament (ACL) reconstruction: a global
perspective. Part 1. Knee surgery, sports traumatology, arthroscopy: official
journal of the ESSKA. 22(7), pp.1467–1482.
23. Moatshe, G., Floyd, E.R., Martin, R.K., Engebretsen, L. and LaPrade, R.F. 2021.
Emerging Topics in ACL Graft Selection: Best Evidence for the Use of
Quadriceps Tendon Graft. Operative Techniques in Sports Medicine. 29(2),
p.150835.
24. Mouarbes, Dany, Jacques Menetrey, Vincent Marot, Louis Courtot, Emilie
Berard, and Etienne Cavaignac. "Anterior cruciate ligament reconstruction: a
systematic review and meta-analysis of outcomes for quadriceps tendon
autograft versus bone–patellar tendon–bone and hamstring-tendon
autografts." The American Journal of sports medicine 47, no. 14 (2019): 3531-
3540.
25. Musahl, V. and Karlsson, J. 2019. Anterior Cruciate Ligament Tear C. G.
Solomon, ed. New England Journal of Medicine. 380(24), pp.2341–2348.
26. Nagai, T., Schilaty, N.D., Laskowski, E.R. and Hewett, T.E. 2019. Hop tests can
result in higher limb symmetry index values than isokinetic strength and leg press
tests in patients following ACL reconstruction. Knee Surgery, Sports
Traumatology, Arthroscopy. 28.
27. Runer, A., Wierer, G., Herbst, E., Hepperger, C., Herbort, M., Gföller, P., Hoser,
C. and Fink, C. 2017. There is no difference between quadriceps- and hamstring
tendon autografts in primary anterior cruciate ligament reconstruction: a 2-year
patient-reported outcome study. Knee Surgery, Sports Traumatology,
Arthroscopy. 26(2), pp.605–614.
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28. Runer, Armin, Robert Csapo, Caroline Hepperger, Mirco Herbort, Christian
Hoser, and Christian Fink. "Anterior cruciate ligament reconstructions with
quadriceps tendon autograft result in lower graft rupture rates but similar patient-
reported outcomes as compared with hamstring tendon autograft: a comparison
of 875 patients." The American Journal of Sports Medicine 48, no. 9 (2020):
2195-2204.
29. Sheean, A.J., Musahl, V., Slone, H.S., Xerogeanes, J.W., Milinkovic, D., Fink, C.
and Hoser, C. 2018. Quadriceps tendon autograft for arthroscopic knee ligament
reconstruction: use it now, use it often. British Journal of Sports Medicine. 52(11),
pp.698–701.
30. Sim, K., Rahardja, R., Zhu, M. and Young, S.W. 2022. Optimal Graft Choice in
Athletic Patients with Anterior Cruciate Ligament Injuries: Review and Clinical
Insights. Open Access Journal of Sports Medicine. 13(13), pp.55–67.
31. Strauss, M., Kennedy, M.L., Brady, A., Moatshe, G., Chahla, J., LaPrade, R.F.,
Lind, M. and Engebretsen, L. 2021. Qualitative and Quantitative Anatomy of the
Human Quadriceps Tendon in Young Cadaveric Specimens. Orthopaedic
Journal of Sports Medicine. 9(9), 232596712110373.
32. Webster, K.E. and Feller, J.A., 2016. Exploring the high reinjury rate in younger
patients undergoing anterior cruciate ligament reconstruction. The American
Journal of sports medicine, 44(11), pp.2827-2832.
33. Weii Su, A. 2019. Anterior Cruciate Ligament (ACL) Tears (for Teens) -
KidsHealth. Kidshealth.org. [Online]. Available from:
https://kidshealth.org/en/teens/acl-injuries.html.

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