AANA Lab Course 1002 -3rd Annual Fellows/Chief Residents-Quad Tendon Primary ACL

Quad Tendon Primary ACL_ Why and How-Nathan K. Endres, M.D.

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This document by Nate Endres from the University of Vermont discusses the use of the quadriceps tendon (QT) as a primary graft option for anterior cruciate ligament reconstruction (ACL-R). QT grafts represent approximately 2.5-11% of ACL reconstructions, offering biomechanical and clinical advantages over the commonly used bone-tendon-bone (BTB) grafts. Biomechanically, the QT has a greater intra-articular volume, higher load to failure, larger cross-sectional area, and contains 20% more collagen than the BTB, suggesting superior strength and durability. Clinically, QT grafts may result in less donor site morbidity compared to BTB grafts.<br /><br />Anatomically, the quadriceps tendon measures about 7-8.5 cm in length, 2.5-3 cm in width, and 7-8 mm in thickness, with dimensions increasing with patient height, weight, and age—height being the most significant predictor of length.<br /><br />The surgical technique involves creating a 25mm femoral socket via a medial portal and a standard tibial tunnel, with the femoral side fixed using a bone block and interference screws. Tibial fixation may be reinforced with an anchor, and any patellar defects can be bone grafted. Postoperative rehabilitation protocols are similar to those used with BTB grafts.<br /><br />Clinical outcomes with QT grafts are favorable: 81-95% of patients achieve normal Lachman test results, 80-95% show no pivot shift, and 88% reach good to excellent IKDC scores, with a Lysholm score averaging 91. Complications are rare but can include hematoma, cosmetic deformity, and a low incidence (1.2%) of patella fractures.<br /><br />In conclusion, the quadriceps tendon is a versatile, biomechanically strong graft option that provides clinical outcomes comparable to other autografts and can be used with or without bone across various ligament reconstructions, including ACL, PCL, and pediatric cases.

Keywords

quadriceps tendon

ACL reconstruction

anterior cruciate ligament

QT graft

bone-tendon-bone graft

biomechanical advantages

clinical outcomes

graft fixation techniques

postoperative rehabilitation

ligament reconstruction