Page 42 - ISAKOS 2020 Newsletter Volume 2

CURRENT CONCEPTS
Quadriceps Autograft in Primary ACL Reconstruction: An Evidence- Based Synthesis
Darren de SA, MBA(c) MD FRCSC
McMaster Children’s Hospital, McMaster University Hamilton, ON, CANADA
Luc Rubinger, MD
McMaster University Hamilton, ON, CANADA
Ben Murphy, DPT
Niagara Orthopaedic Institute Hamilton, ON, CANADA
Yuichi Hoshino, MD, PhD
Kobe University Hyogo, JAPAN
Volker Musahl, MD
University of Pittsburgh, Pittsburgh, Pennsylvania, UNITED STATES
Olufemi R. Ayeni, MD, PhD, FRCSC
McMaster Children’s Hospital, McMaster University Hamilton, ON, CANADA
Change is coming. In fact, “change,” often framed as “innovation,” remains the only constant in the ever-evolving world of health care. In sports medicine, nowhere is change more evident than in the diagnosis and treatment of anterior cruciate ligament (ACL) injuries. Despite continued technical improvements and technological innovations, those of us in the orthopaedic sports medicine community have been humbled.
We have been humbled by the high failure rates and less- than-ideal rates of return to the preinjury level of activity that we have observed following ACL reconstruction – particularly among our young, most active (and arguably high-risk) athletes.
These disappointing results have inspired some of the thought leaders in our field to identify, and examine critically, all facets of this all-too-common, and ever-increasing, injury. But where the correct answers lie remains elusive, with >21,000 peer-reviewed studies and a wonderfully curated ISAKOS evidence-based textbook devoted to such ongoing controversies as whether we should focus on factors such as injury-prevention programs, surgical timing, concomitant procedures (i.e., osteotomies and / or lateral extra-articular tenodesis), bone morphology, or graft choice, to name a few. Herein, we focus on the hotly debated and relative influence of graft choice, with a special focus on the quadriceps tendon (QT) autograft.
Although there often exists an inherent skepticism regarding the adoption of new technology and / or techniques in surgery, we can rest assured that employing the QT is, in fact, not new. The use of this graft for knee ligament reconstruction dates back >40 years and has been backed by the strong work of such pioneers in the field as Professors Marshall, Kornblatt, Blauth, Yasuda, Fulkerson, Staubli, Fu, Fink, and Xerogeanes. Yet, for reasons identified only recently, the QT has been dwarfed in popularity in comparison with the hamstring tendon (HT) and / or bone- patellar tendon-bone (BPTB) options in the primary setting. Evidence-based medicine and patient-centered care do not need to be mutually exclusive. Often in the revision (or “salvage”) setting, the QT remains popular. But why? Those who use BPTB grafts at the time of the index operation cite a number of arguments in favor of their approach, including bone-to-bone healing, rigid initial fixation techniques, low re-rupture rates, and intact hamstrings (which can serve as a secondary knee stabilizer postoperatively). Conversely, those who favor the HT at the time of the index procedure cite the advantages of lower donor-site morbidity, preservation of the native extensor mechanism, lower rates of late osteoarthrosis, and / or avoidance of the dreaded graft-tunnel mismatch.
40 ISAKOS NEWSLETTER 2020: VOLUME II