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Anterior cruciate ligament (ACL) reconstruction with quadriceps tendon autograft and press-fit fixation using an anteromedial portal technique
© Akoto and Hoeher; licensee BioMed Central Ltd. 2012
Received: 26 September 2011
Accepted: 2 August 2012
Published: 27 August 2012
This article describes an arthroscopic anterior cruciate ligament (ACL) reconstruction technique with a quadriceps tendon autograft using an anteromedial portal technique.
A 5 cm quadriceps tendon graft is harvested with an adjacent 2 cm bone block. The femoral tunnel is created through a low anteromedial portal in its anatomical position. The tibial tunnel is created with a hollow burr, thus acquiring a free cylindrical bone block. The graft is then passed through the tibial tunnel and the bone block, customized at its tip, is tapped into the femoral tunnel through the anteromedial portal to provide press-fit fixation. The graft is tensioned distally and sutures are tied over a bone bridge at the distal end of the tibial tunnel. From the cylindrical bone block harvested from the tibia the proximal end is customized and gently tapped next to the graft tissue into the tibial tunnel to assure press fitting of the graft in the tibial tunnel. The distal part of the tibial tunnel is filled up with the remaining bone.
All patients were observed in a prospective fashion with subjective and objective evaluation after 6 weeks, 6 and 12 months.
Thirty patients have been evaluated at a 12 months follow-up. The technique achieved in 96.7% normal or nearly normal results for the objective IKDC. The mean subjective IKDC score was 86.1 ± 15.8. In 96.7% the Tegner score was the same as before injury or decreased one category. A negative or 1+ Lachman test was achieved in all cases. Pivot-shift test was negative or (+) glide in 86.7%. The mean side-to-side difference elevated by instrumental laxity measurement was 1.6 ± 1.1 mm. Full ROM has been achieved in 92.3%. The mean single one-leg-hop index was 91.9 ± 8.0 at the follow-up.
Potential advantages include minimum bone loss specifically on the femoral side and graft fixation without implants.
To date several techniques for anterior cruciate ligament (ACL) reconstruction have been published. Quadriceps tendon grafts are currently considered only a second choice graft, although clinical studies have demonstrated good results and a low donor site morbidity [1–5]. However, surgical techniques including graft fixation for quadriceps tendon vary widely. More recently, several authors have favoured press-fit fixation of the graft with a more biological approach avoiding screw fixation and the use of implants. To date all press fit techniques for ACL reconstruction using a quadriceps tendon graft have used a transtibial single incision technique [1–4, 6]. However, several studies have demonstrated that the transtibial approach may result in a non-anatomic placement of the femoral bone tunnel [7, 8]. Therefore, it was the goal of this study to develop a surgical technique for ACL reconstruction in which the advantages of using a quadriceps graft and the advantage of using a press fit technique for fixation were achieved when the femoral tunnel was drilled through an anteromedial portal.
After routine arthroscopy including meniscus and cartilage surgery a low anteromedial portal was placed 1 cm medial to the patellar tendon and close to the superior tibial edge with the knee flexed to 90°. This portal was slightly enlarged to be used as the “working” anteromedial portal .
Preparation of ACL insertions
When complete ACL rupture has been verified intercondylar notch preparation was performed until anatomical landmarks, such as the medial aspect of the PCL and the over-the-top position could by identified. On the tibial side the infrapatellar fat pad was partially resected until the anterior horn of the lateral meniscus can be clearly visualized. The tibial footprint was cut longitudinally preserving its proprioceptive and vascular contributions so that the graft would later be surrounded by the remnants of the tibial stump.
We used a 4–5 cm longitudinal incision starting at the proximal aspect of the patella running proximally and centred over the quadriceps tendon. A 10 mm wide and 50 mm long strip of tendon was excised. Care was taken to harvest all layers of the quadriceps tendon, leaving the suprapatellar pouch of the joint intact. The proximal end of the graft was “whipstitched” using a #2 Ultrabraid® suture (Smith & Nephew, Inc.) (Figure 1a).
Tunnel placement and preparation
For creating the tibial tunnel, a tibial drill guide (device “Heidelberg” Richard Wolf, Knittlingen, Germany) was introduced through the anteromedial portal and placed with the alignment hook into the centre of the tibial footprint of the ACL. A 2–3 cm longitudinal skin incision was made on the medial aspect of the tibia so that the drill guide could be placed on the anteromedial aspect of the tibia. A 2.4 mm guide wire was then introduced into the joint through the drill guide. Then the guide wire sleeve was replaced by a drill sleeve, so that a 10.5 mm hollow burr could be used for creating the tibial tunnel. Thus, a cylindrical bone block could be retrieved from the tibial bone.
A cortical bone bridge of about 1 cm length was created distal to the exit of the tibial tunnel and a suture loop was passed around it for later graft fixation.
Preparation of the bone plug retrieved from the tibia
On the back table the bone cylinder retrieved from the tibia was divided into three parts. Additionally, the proximal bone plug of about two cm in length was longitudinally split so that it could be used as a wedge for compressing the graft tissue in the bone tunnel. The middle part of the bone plug might be used to fill up the bony defect in the patella, while the distal part was used to fill up the tibial tunnel distally at the end of surgery.
Graft placement and graft fixation
With the bone block running first the graft was then introduced through the tibial tunnel into the joint in a common fashion. Thus the bone block could easily slide into the femoral bone tunnel to half of its length.
· Immobilization in a 0° splint
· Lymphatic drain, cryotherapy
· Three point gait, partial-weight bearing (up to 15 kg)
· Active/passive range of motion 0/0/60
day 5 -21
· Active/passive range of motion 0/0/90
· Three point gait, partial-weight bearing (up to 20–30 kg) in a brace
· Lymphatic drainage, cryotherapy
· Quadriceps strengthening
· Full weight-bearing without brace
· Full active/passive range of motion
· Quadriceps strengthening
· Cycling, ergometer
· Muscle-strength training
· Swimming, aquajogging
· Continuing strengthening exercises
· Running if tolerated
· Return to sports if muscle strength greater than 90° of the contralateral side
Inclusion and exclusion criteria of patients
In our institute active patients with anterior cruciate ligament rupture participating in pivoting or high valgus stress sports, such as judo, wrestling, or soccer, as well as patients with concomitant medial collateral ligament (MCL) insufficiency were preferably treated with a quadriceps tendon graft in the described technique. The indication for this graft selection in this population was to save hamstring function, specifically for medial dynamic stabilization of the knee.
Since 2010, all patients, who underwent ACL reconstruction using either hamstring or quadriceps tendon graft were enrolled in a prospective data base analysis and defined follow-up evaluations after approval before the beginning of treatment.
Patients with a history of previous ACL reconstruction, concomitant PCL injuries as well as reconstructive cartilage repair other than microfracturing were excluded from the study.
All patients were assessed before surgery, at 6 weeks, 6 and 12 months after surgery, using the International Knee Documentation Committee (IKDC) and Tegner score . Laxity was tested with the Lachman test (graded negative, 1+, 2+ and 3+) and the pivot-shift test (graded negative, (+) glide, + and ++). Instrumental laxity measurement was performed by using the Rolimeter (Aircast Europa GmbH, Neubeuern, Germany), the knee in 20° of flexion, putting a standardized knee roll under the thigh and using maximal force, compared to the contralateral side. Knee function was assessed with ROM (lack of extension: < 3% = none, 3 to 5% moderate, 6 to 10% mild, > 10% serve; lack of flexion: < 5% none, 6 to 15% moderate, 16 to 25% mild and > 25% serve) and one leg hop index (distance hopped on the involved leg divided by the distance hopped on the noninvolved leg x 100) after 12 months. Patellofemoral crepitation elicited by extension against slight resistance was graded in crepitation with none, moderate, mild, severe pain.
Since 2010 eighty-seven patients (75 male, 13 female) underwent ACL reconstruction with the described technique. Their mean age at operation was 31 (range 16–47) years. Secure graft fixation using the press-fit technique was achieved in all cases. There were no other intraoperative complications. Postoperatively no major complications (infection, deep vein thrombosis) were observed. Within this group there was no case of rerupture or persistent effusion.
Follow-up results one year after surgery (n = 30)
Operation time [min] (m + −std)
102.1 ± 12.0
Single one-leg-hop index (m + −std)
91.9 ± 8.0
Instrumented laxity measurement [mm] (m + −std)
1.6 ± 1.1
IKDC subjective score (m + −std)
86.1 ± 15.8
IKDC objective (normal/nearly normal)
ROM full extension (< 3° deficit)
ROM full flexion (> 5 ° deficit)
Lachman test (neg. or 1+)
Pivot-shift test (neg. or (+) glide)
Patellofemoral crepitation (moderate or mild)
Change in Tegner score at follow-up ≤ 1
Twenty-six patients (86.7%) achieved the same Tegner score as before injury, three (10%) decreased one category, one (3.3%) decreased two categories.
Full ROM has been achieved in 92.3%, one patient had a mild lack of extension and one had a mild lack of extension and flexion. The mean single one-leg-hop index was 91.9 ± 8.0. The Lachman test was graded negative in 27 cases (90%) and 1+ in three cases (10%). Pivot-shift test was graded 25 times negative (83.3%), one time (+) glide (3.3%) and four times + (13.3%). The mean side-to-side difference elevated by instrumental laxity measurement was 1.6 ± 1.1 mm. Mild or moderate patellofemoral crepitation was observed in 10% at the follow-up, two patients moderate and one mild (Table 2).
Surgical techniques for ACL reconstruction using press-fit fixation
Orthop Clin North Am
Arch Orthop Trauma Surg
Press-fit fixation of a bone block on the femoral side provides sufficient strength of approximately 400 N when underdrilled by 1 mm and further dilated [11, 13]. Further, this fixation type assures a perfect tendon to bone junction on the femoral side, thus helping graft incorporation and early graft function. Using this technique we have not seen any case when the bone block could be pulled out of the femoral tunnel. As no bony defect remains on the femoral side ACL revision surgery may be easier.
On the tibial side, graft fixation is achieved by tying the sutures over a bone bridge, which was shown by Jagodzinsky et al. to provide sufficient strength to allow graft healing . When the tibial tunnel is filled up with bony material the soft tissue graft can be compressed to the tunnel wall therefore helping graft incorporation and providing direct tendon bone healing . Further, bone loss can also be minimized on the tibial side, therefore making revision surgery easier and avoiding the development of large bony defects such as seen with large screws on the tibial side.
Drilling the femoral bone tunnel through an anteromedial portal allows a more anatomic placement of the ACL replacement graft on the femoral side.
With press-fit fixation a complete ossification of the femoral bone tunnel can be achieved with a minimal bony defect.
The technique represents a biological approach, since no artificial fixation devices, i.e. implants, are utilized.
The tibial tunnel diameter is reduced by filling it with the tibial bone cylinder, therefore decreasing the risk of postoperative bone tunnel enlargement and making revision surgery easier.
The biomechanical function of hamstring tendons can be preserved which may have a potential advantage for patients with MCL deficiency or patients involved in high demand valgus stress sports such as martial arts (judo, etc.).
Further biomechanical and clinical studies are necessary to evaluate this technique in comparison with others.
ACL reconstruction with autologous quadriceps tendon graft using press-fit fixation of the bone block on the femoral side and suture post and press-fit bone wedge on the tibial side represents a reproducible and biological surgical technique. This novel technique ensures bone tunnel placement through a low anteromedial portal, thus resulting in a more anatomical placement than using a transtibial approach.
We thank Mrs. Maria Apreleva for technical assistance in preparing the manuscript and Mr. Hans-Jörg Schuetze for medical drawings of the surgical technique.
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