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The selection of a graft for reconstructing the
anterior cruciate ligament (ACL) continues to
be a controversial issue. While the patellar
tendon was long considered the “gold standard”
for ACL reconstructions, in recent years it was
surpassed in popularity by the semitendinosus
and gracilis tendons. Meanwhile, relatively
little attention was given to the quadriceps
tendon (QT) as a graft source. During the
1990s, only a few surgeons favored the QT
for ACL reconstruction. Stäubli
et al.
[10]
demonstrated the advantages of the graft in
their anatomic, biomechanical and clinical
studies. While many knee surgeons currently
regard the QT as a good revision graft, to date
it has not been widely utilized as a standard
graft for primary ACL reconstructions despite
excellent clinical results [1, 4, 6, 7, 9]. We feel
that this is mainly because harvesting of the QT
graft is more technically demanding and often
yields less favorable cosmetic results when
using a conventional technique.
Neither a QT graft nor a patellar tendon graft is
inherently round [3, 8]. Only the reaming
technique makes it necessary to harvest a
cylindrical bone plug that will fit snugly in a
classic bone tunnel. These considerations led
us to develop a technique for creating
rectangular bone tunnels that conform to graft
shape. Furthermore, this modification has been
shown to have a biomechanical advantage with
respect to rotational laxity [5, 8]. We also
wanted to simplify the technique for harvesting
the QT graft and reduce donor-site morbidity,
particularly from a cosmetic standpoint [2, 3].
OPERATING TECHNIQUE
Harvesting a QT Graft with a Bone
Plug
A transverse skin incision approximately
2-3 cm long (or a longitudinal incision of equal
length) is made over the superior border of the
patella. The bursal layer are then dissected
aside to expose the QT, and a long Langenbeck
retractor is introduced. Next a tendon knife
with two parallel blades is advanced to the
6 cmmark (measured from the superior patellar
border) to define the width of the graft (9, 10,
or 12 mm) (fig. 1a). The thickness of the graft
is then defined with the tendon separator, which
is set to a depth of 5 mm (fig. 1b) and is also
advanced to the 6 cm mark. Finally, graft
length is determined with the quadriceps
tendon cutter, a punch-action instrument that is
introduced 1-2 cm proximal to the superior
patellar border. It is advanced to the desired
length (6 cm) and activated to free the proximal
end of the gr
aft
(fig. 1c)
.
The graft is now
reflected distally, and the distal end of the graft
ACL RECONSTRUCTION USING
MINIMAL INVASIVE HARVESTED
QUADRICEPS TENDON
C. FINK, M. HERBORT, P. GFÖLLER, C. HOSER