Quadriceps Tendon-Bone Full-Thickness Autograft: Reproducible and Easy Harvesting Technique Using Simple Surgical Tools

Abstract

Autogenous quadriceps tendon-bone graft is a great choice for knee reconstruction procedures, including primary and revision reconstructions of both anterior cruciate ligament (ACL) and posterior cruciate ligament. In primary ACL reconstruction, one of the most frequently performed procedures in orthopaedic surgery, it is gaining more and more popularity owing to improved or similar biomechanical, anatomic, and histological properties than bone-patellar tendon-bone graft. The clinical outcomes of quadriceps tendon-bone graft in ACL reconstruction are similar to bone-patellar tendon-bone graft, however, lowering the inconvenience associated with donor-site morbidity and making it possible to adjust graft length and diameter. This Technical Note describes a surgical technique for harvesting a full-thickness quadriceps tendon graft with a bone block using simple surgical tools.

© 2021 by the Arthroscopy Association of North America. Published by Elsevier.

Figures

Fig 1

Visualization of 3 blood vessels perpendicular to the patellar base. (A,B) Patients are laying in supine position, suprapatellar regions are shown. Right knees are being operated on in 90° of knee flexion. To harvest quadriceps tendon-bone full-thickness autograft, 4- to 5-cm incision is made in the sagittal plane perpendicular to the superior pole of the patella, starting 4 to 5 cm proximal to the patella and directing distally up to 0.5 to 1 cm over the patellar dorsal surface. Visualization of 3 blood vessels running transversely to the cut plane just proximal to the patellar base means that we are in the right tissue layer for graft harvesting (arrows, 3 blood vessels perpendicular to the patellar base as an indicator of proper layer to start harvesting; D, distal; L, lateral; M, medial; P, proximal.)

Fig 2

Paratenon mobilization and suturing. Patient is laying in supine position; right knees are being operated on in 90° of knee flexion. Suprapatellar region after incision perpendicular to the patellar base is visible. Mobilization and postharvesting suturing of paratenon covering the quadriceps tendon is shown. (A-C) Paratenon is mobilized with scissors; (D,E) it can be seen that paratenon is mobilized enough to cover the gap that will be created during harvesting the graft; (F) suturing the paratenon (straight arrows, paratenon during mobilization; arrowheads, mobilized paratenon grasped with tweezers; curved arrow, paratenon sutured after graft harvesting is finished; D-distal; L-lateral; M-medial; P-proximal.)

Fig 3

Using the osteotome as a guide on how to plan cuts to harvest quadriceps tendon. Patient is laying in supine position; right knees are being operated on in 90° of knee flexion. Suprapatellar region after incision perpendicular to the patellar base is visible. It is shown how to use the osteotome as a guide during harvesting quadriceps tendon-bone full-thickness autograft. (A) Visualize the vastus lateralis muscle belly; (B) visualize the vastus medialis muscle belly; (C) localize the medial border of the osteotome as close as possible to the vastus medialis muscle belly but leave approximately 3 to 4 mm of the “white” part of the tendon. This way, the osteotome will cover its thickest part (D, distal; L, lateral; M, medial; P, proximal; VL, vastus lateralis; VM, vastus medialis.)

Fig 4

Tensioning the graft and performing final cuts. Patient is laying in supine position; right knees are being operated on in 90° of knee flexion. Suprapatellar region after incision perpendicular to the patellar base is visible. Tensioning the graft with the finger and performing final cuts are presented. (A) Surgeon’s index finger is placed under the graft to verify that the graft has been sufficiently released; (B) while tensioning the graft, all the layers of the tendon are incised proximally with a straight scissors to a length of approximately 8 cm proximal to the patella; (C) the proximal aspect of the graft is pulled out of the wound with the index finger and cut with a knife transversely, 7 to 9 cm proximal to the superior pole of the patella (D, distal; L, lateral; M, medial; P, proximal.)

Fig 5

Attachment of the quadriceps tendon to the patella and suprapatellar fat pad. Patient is laying in supine position; right knees are being operated on in 90° of knee flexion. Suprapatellar region after incision perpendicular to the patellar base is visible. (A) The location of the attachment of the quadriceps tendon to the patella is shown, and the edge of the cartilage is shown with scissors; (B) the suprapatellar fat pad is gently cut away from the quadriceps tendon so as not to damage the graft; (C) the site of planned patellar bone plug harvest is marked with a knife, 15 to 18 mm distal to the quadriceps tendon attachment (D, distal; L, lateral; M, medial; P, proximal.)

Fig 6

Attachment of quadriceps tendon to the patella. Quadriceps full-thickness tendon-bone autograft has been harvested and prepared with sutures. Morphology of attachment of quadriceps tendon to the patella is shown. Notice that the attachment is oblique in its shape. Directions were marked as if the patella was localized in anatomic position, with the following abbreviations: A, anterior; P, proximal; D, distal; Post, posterior. Anterior fibers attach more distally (arrow), whereas posterior fibers are attached more proximally (triangle).

Fig 7

Using an automated saw and the osteotome to cut the bone plug from the superior pole of the patella. Patient is laying in supine position; right knees are being operated on in 90° of knee flexion. Suprapatellar region after incision perpendicular to the patellar base is visible. (A) Automated saw with 7-mm depth limiters is used to cut the superior pole of the patella sagittally within markings performed with the knife; (B) automated saw with 7-mm depth limiters is used to cut the superior pole of the patella transversely at the distal end of sagittal cuts; (C) osteotome is applied to the place previously marked with a knife on the base of the patella just below tendon attachment. It has to be positioned parallel to the dorsal patella surface (D, distal; L, lateral; M, medial; P, proximal.)

Fig 8

Suturing quadriceps tendon, paratenon, and subcutaneous tissue. Patient is laying in supine position; right knees are being operated on in 90° of knee flexion. Suprapatellar region after incision perpendicular to the patellar base is visible. (A) The first suture within quadriceps tendon is placed 15 to 20 mm proximal from the patella base to avoid excessive tension; (B) 4 to 6 absorbable sutures are placed within quadriceps tendon; (C) suturing paratenon and subcutaneous tissue (D, distal; L, lateral; M, medial; P, proximal.)