LIVRE JDG 2016

ACL RECONSTRUCTION USING MINIMAL INVASIVE HARVESTED QUADRICEPS TENDON

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Harvesting the Graft without a Bone

Plug

Another option is to use the QT without a bone

plug. The initial steps are the same as for a QT-

bone graft. If the graft is freed directly at the

superior patellar border, it should be harvested

in a length of 7 cm. As an alternative to the

bone plug, a periosteal strip equal to the graft

width and 1.5-2 cm thick can be dissected from

the anterior patellar surface (fig. 3a). The strip

is then folded over (fig. 3b) and whipstitched

with two nonabsorbable N° 2 sutures. This

yields a rounded end that will facilitate later

graft passage. Double lead sutures are placed in

the distal end of the graft as in the bone plug

technique (fig. 3c).

In both techniques the donor defect in the tendon

is closed superficially with sutures. We do not

recommend definitive wound closure at this

time. Packing the donor site with a subcutaneous

gauze sponge can provide good hemostasis and

reduce any extravasation that may occur (from

opening the suprapatellar pouch).

Femoral Bone Tunnel

A standard arthroscope portal is placed just

lateral to the patellar tendon at the level of the

patellar apex. A low medial portal is then

placed under vision, using a trial needle to

determine the portal site. The cruciate ligament

remnants are resected, leaving a tibial stump.

Generally it is unnecessary to perform a

notchplasty. With the knee flexed 90°, the

anatomic femoral insertion site of the ACL is

marked with a microfracture awl. The position

of this point can be checked by viewing through

the medial arthroscope portal. A 2.4 mm guide

wire is now introduced through the medial

arthroscope portal using a femoral drill guide.

When the correct position of the guide wire has

been confirmed, it is overdrilled with a 4.5 mm

drill bit. Then a rasp (8mm for an 8 or 9 mm

tendon graft or 10 mm for a 10 or 12 mm graft)

is passed through the medial portal. A Half

Pipe® can be used to facilitate rasp insertion.

With the knee flexed 115°, the rasp should be

aligned parallel to the tibial plateau (fig. 4). The

Fig. 3:

(

) Harvesting a QT graft with a 2 cm-long periosteal strip conforming to the graft width. (

) The

periosteal strip is folded over and (

) whipstitched with two nonabsorbable N° 2 sutures.