Ligament or tendon repair is both the bread and butter of sports medicine and one of its most interesting and debated subjects. At the 2018 Orthopaedic Summit of Evolving Technologies, held in Las Vegas this past December, four of the most accomplished sports medicine surgeons—John Xerogeanes of Emory Orthopaedic and Spine Center, Charles Brown, Jr. of International Knee & Joint Centre, Akbar Nawab of University of Louisville Department of Orthopedics and Christopher Kaeding of Ohio State University—gave a master class on this essential subject.
The moderator who kept each speaker’s feet to the fire was Charles A. Bush-Joseph, M.D. of Rush University Medical Center.
John W. Xerogeanes, M.D. was first up, and his point of view could best be described as: “Quad Tendon Grafts are the Answer: Why Are You so Slow to Jump on Board!”
John W. Xerogeanes, M.D.: I’m talking about soft tissue quad tendon. I just finished my 1,000th one. Prospectively followed, the mean age of these patients was 20.1 years, median age 17.6 years and we experienced about a 4.2% failure rate of the ones we followed.
In terms of revisions, I have done 96 revisions using quad tendons. Here the mean patient age was 22.5 years, graft failure was about 4.8% and the side effects KT and IKDCs [International Knee Documentation Committee Subjective Knee Evaluation Form Score] were similar to our primaries.
Also, our historical outcomes of soft tissue grafts quads versus the others are fairly similar.
Why don’t people do it? I think it’s because people don’t understand it.
Consider the biomechanics. A 10 mm width graft is significantly stronger than a patellar tendon, but the modulus is very similar to the native ACL [anterior cruciate ligament]. If you harvest a 10 mm graft, the residual quad tendon remaining is still significantly stronger than an intact patellar tendon.
Also, predictability. With hamstrings, it’s always hard to get in there and get a little wispy hamstring and then the big guy and then you have to do a five- or six-string technique. We developed a 3D MRI technology and compared quads to hamstrings and quads to patellar tendon.
The tip of the rectus femoris to the superior aspect of the patellar graft is greater than 7 cm in 90% of people over 5 feet tall. The thickness is 1.8x the thickness of the patellar tendon and there’s minimal variation over the last 6 cm of the quad tendon.
The average ACL is 2.5-3 cm. So, your graft needs to be 6-7 cm because you put 2 cm in the femur, 3 cm in the joint, 2 cm in the tibia.
What about the intra-articular volume? If we take a 10 mm width graft 3 cm long and compare that to a patellar tendon, the only variable is thickness. Remember, it’s 1.8 times thicker. You’re getting 88% more volume of tissue that is biomechanically and histologically superior to patellar tendon.
What about kids? The average kid has a 3.2 mm thick tendon. His quad is as thick as your adult patellar tendon.
What about morbidity? You don’t get any numbness. Patellofemoral pain is minimal. Any residual weakness is not normal. Other morbidities would include quad weakness, tendon ruptures, patella fractures. You do get hematomas like with anything else, but the pain is significantly less than other two.
Harvest time. It takes me about 25 minutes for patella, 13 minutes for hamstring, and under 8 minutes for a quad.
How do I get it? You don’t want to get a big huge scar. We changed the transverse and you can barely see it.
So, is it the perfect autograft? It’s superior histologically, biomechanically, predictably, superior size, good for all ages, equal or superior outcomes, least morbidity, fastest harvest, in percutaneously, cosmetic is definitely superior.
Don’t be afraid. Try it.
