Minimally invasive harvest of a quadriceps tendon graft with or without a bone block

Abstract

The quadriceps tendon (QT) as a graft source for anterior cruciate ligament (ACL) and posterior cruciate ligament reconstruction has recently achieved increased attention. Although many knee surgeons have been using the QT as a graft for ACL revision surgery, it has never gained universal acceptance for primary ACL reconstruction. The QT is a very versatile graft that can be harvested in different widths, thicknesses, and lengths. Conventionally, the QT graft is harvested by an open technique, requiring a 6 to 8 cm longitudinal incision, which often leads to unpleasant scars. We describe a new, minimally invasive, standardized approach in which the QT graft can be harvested through a 2- to 3-cm skin incision and a new option of using the graft without a bone block.

Fig 1

Skin incisions. A 2.5 to 3 cm transverse skin incision (solid line) may be recommended for the best cosmetic result. Alternatively, a 2.5 to 3 cm longitudinal incision (dotted line) may be used.

Fig 2

A double knife is introduced starting slightly lateral to the middle of the superior patellar border and pushed up (white arrow) to the desired tendon length. There are centimeter markings on the instrument.

Fig 3

Graft thickness is determined using a 5 mm tendon separator. The tendon separator is then pushed proximally (white arrow) to the previously determined length. There are centimeter markings on the instrument.

Fig 4

The tendon strip is cut subcutaneously by a special tendon cutter at the determined length (white arrow).

Fig 5

The bone block is harvested using an oscillating saw. (A) First, the longitudinal and transverse cuts are made. (B) The last cut determines the thickness of the bone block and is made from proximal to distal. (C) Finally, the block is easily elevated.

Fig 6

(A) After retrieving the QT graft, it is pulled distally, and (B) a strip of periosteum in the appropriate width is detached about 2 cm in length.

Fig 7

Graft preparation without bone block. (A) Final graft with strip of periosteum measuring approximately 2 cm. (B) The periosteum is folded in the middle and (C) fixed in the clamp of a preparation board. (D) Web-stitch sutures are placed on each side of the graft using nonresorbable No. 2 suture material. (E, F) This results in a smooth, round end of the graft, which allows easy graft passage.