Quad Tendon – A Better Solution Christian Fink, Christian Hoser Disclosure - Consultat/Product Royalties from Karl Storz - Consultant for Synthes/DePuy/Mitek ACL reconstruction is an evolution Quadricepstendon - Anatomy Staeubli H.U. et.al. Quantification of Intact Quadriceps Tendon, Quadriceps Tendon Insertion, and Suprapatellar Fat Pat: MR Arthrography, Anatomy, and Cryosections in the Sagittal Plane. AJR 1999, 173: 691-698 Quadriceps - Anatomy ….The intra-articular volume of the proposed QT graft was 87.5% greater than that of the patellar tendon graft. Anatomic and Morphological Evaluation of the Quadriceps Tendon Using 3-Dimensional Magnetic Resonance Imaging Reconstruction- Applications for Anterior Cruciate Ligament Autograft Choice and Procurement John W. Xerogeanes, Phillip M. Mitchell, Peter A. Karasev,z PhD, Ivan A. Kolesov,z PhD, and Spencer E. Romine,y MD AJSM published on July 26, 2013 Biomechanical characteristics Graft type Ultimate tensile load(N) Native ACL1 Doubled Semi/Gracilis2 B-Patellar Tendon-B(10mm) 3 Quadriceps (10mm) 4 1. Woo SL et al. Am J Sports Med 1991; 19 2. Hamner DL et al. J Bone Joint Surg [Am] 1999; 81-A 3. Cooper DE et al. Am J Sports Med 1993; 21 4. Stäubli HU et al. Am J Sports Med 1999; 27 2160 4140 2977 2352 Stiffness(N/mm) 242 807 455 326 Clinical studies Knee Surg Sports Traumatol Arthrosc. 2013 Aug;21(8):1882-8. Outcomes for primary anterior cruciate reconstruction with the quadriceps autograft: a systematic review. Mulford JS, Hutchinson SE, Hang JR. CONCLUSION: The quadriceps tendon autograft is a promising alternative for primary ACL reconstructions with good outcomes and minimal donor site morbidity. Arthroscopy. 2014 May;30(5):593-8. Is quadriceps tendon a better graft choice than patellar tendon? a prospective randomized study. Lund B, Nielsen T, Faunø P, Christiansen SE, Lind M. CONCLUSIONS: The use of the QTB graft results in less kneeling pain, graft site pain, and sensitivity loss than seen with BPTB grafts; however, similar anterior knee stability and subjective outcomes are seen. The results of this study show that QTB is a viable option for ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2012 (Suppl 1) Quadriceps tendon versus Hamstrings for ACL reconstruction – a matched pair analysis Höher J, et al. CONCLUSION: - no significant difference in any clinical or subjective parameter - donor side morbidity – no difference Knee Surg Sports Traumatol Arthrosc. 2014 Graft maturity of the reconstructed anterior cruciate ligament 6 months postoperatively: a magnetic resonance imaging evaluation of quadriceps tendon with bone block and hamstring tendon autografts. Ma Y, Murawski CD, Rahnemai-Azar AA, Maldjian C, Lynch AD, Fu FH. CONCLUSION: The maturity of quadriceps tendon with bone block was better in comparison with hamstring 6 months after anatomic SB ACL reconstruction. This study is clinically relevant in that modifying the individual rehabilitation according to the extent of graft maturity may be necessary to optimize patient function and prevent re-injury of the ACL graft Quadricepstendon Great(est!!!) graft – for ACL (PCL) Reconstruction (primary and revision)  harvest more difficult, cosmetically less attractive (compared to hamstrings)  New harvesting technique Minimally Invasive Harvest of a Quadriceps Tendon Graft With or Without a Bone Block Fink C, Herbort M, Abermann E, Hoser C Arthroscopy Techniques, Published online: August 11, 2014 Scin incision (2.5 to 3 cm) 1 2 Karl Storz Double knife (8-12mm) Karl Storz Tendon Separator (5mm) 3 Karl Storz Tendon cutter (Lenght 6 cm - ACL, 8 cm - PCL) QT without bone block QT without bone block New Concept of anatomy c/o Robert Smigielski, Warschau Flat midsubstance of the anterior cruciate ligament with tibial "C"shaped insertion site Siebold R, Schuhmacher P, Fernandez F, Smigielski R, Fink C, Brehmer A, Kirsch J. KSSTA 2014 May 20. video Round vs. Rectangular 7mm (38.5mm2) 8x5mm (40mm2) 8mm (50.3mm2) 9x5mm (45mm2) 9mm (63.6mm2) 10x5mm (50mm2) 12x5mm (60mm2) Single-Bundle Anterior Cruciate Ligament Reconstruction: A Biomechanical Cadaveric Study of a Rectangular Quadriceps and Bone-Patellar Tendon-Bone Graft Configuration Versus a Round Hamstring Graft. 0° 110° 135° - Improved rotational stability of rectangular vs round tunnels Femural Tunnel 110° 0° Tibial Tunnel 6m 6w Conclusion • QT reliable technique for ACL reconstruction (primary and revision situations) • QT – low harvest side morbidity and good clinical results • QT – bone block or soft tissue option • AND… ….its the best graft because John Fulkerson assured me that its the best graft…. Thank you