this is a lot of fun because I get to go against my friend Pat. My disclosures they are significant and also it's going to be biased because I'm fighting one side of the argument. My disclaimer is I'm not a hater. I trained at Pitt. We did mostly hamstrings. At Stedman Hawkins, 50% hamstrings. In practice, I did greater than a thousand hamstrings from 2000 to 2012. My personal life, I did a hamstring on my wife when she was my ex-girlfriend at the time. It's a long story but she complains of numbness and weakness still. I'm an evolutionist though because I look at data and I think it's important to look at data to make the, you know, to make your evolution in this in this area. Ten reasons the quad tendon is the future. Number one, collagen. 20% more collagen per cross-sectional area than the quote gold standard end quote patella tendon. That's significant. It's massive. There's a picture of the quad on the left as you take off the muscle. It's a very wide, wide tendon. How about the thickness? We published this in AJSM. It's about 1.8 times as thick as your same patella tendon. Okay, so think about that too. Predictability. We've all been there. You harvest a hamstring and it's tiny. Whether you got this big bodybuilder on the right or the little Kenyan runner. What do you do then? We know about the Duke study. It's the fear we have. So the quad tendon is easily predictable pre-op. Okay, we know from my study that we did in AJSM that if you take the tip of the rectus to the tip of the patella that the graph is going to be greater than 7 centimeters 90% of the time in someone over 5 feet, male or female. If you want a longer graph, which you shouldn't really need, but if you do you can just take the rectus and reflect it. You can see the tendon goes two to three centimeters up further. So you can get any length you want. We know the thickness is 1.8 so we can figure out the volume easy. If you want to figure out, you're doing a revision, you want to figure out what size you want, the length times width times depth. That's a pre-op MRI and we standard go three centimeter above and there's no difference in the distal six centimeters of the tendon. It's good for all ages from these little guys here to the big guys. We published this in AJSM in 15. The average six-year-old 5.5 centimeters in length, 3.2 millimeters thick. That's the same thickness as your patella tendon. Okay, number five, morbidity of graft harvest. We know that hamstrings you get significant weakness after two years. We've seen that in multiple studies. With quad you get weakness too with the quad, but you do in patella tendon and the hamstring and the allograft. We published this in ESCA where we're equal to patella tendon at 6 and 12 months, but by one year LSI is less than 10%. We published in 2007 on my hamstring data. My residents did this without me knowing it. 74% of the hamstring ACLs had sensory defects greater than four years post-op all in the saphenous nerve distribution. My wife has it also. Harvest time, it's the fastest. Infection rate, the moon group shows hamstrings at 1.27%. Miletus was from Kaiser, which is a huge study, 0.61%. We just finished this. It's not submitted to a journal yet. Of my 1,410 quad single surgeons, single surgery center, we had two harvest site infections. One was culture positive. The other just had a was leaking. We had two washouts of joints. None of them had positive cultures and they're less than 20,000 white blood cells, but in the moon criterion those all count as infections and our rate is 0.28%. So you see significantly better than what we see on the hamstring. Number eight, failure rate. Systematic reviews, no difference in failure compared to patella tendon, but superior to hamstring in each of these systematic reviews. Direct comparison, Christian Fink, in 2020 published in AJSM, prospective study, experienced surgeon, anatomic technique, 875 patients, hamstring 2.7 times the failure weight rate of the quad tendon. That's a direct comparison. Number nine, good for revision surgery. We published this this year in arthroscopy. Mean age 22, very important when you're looking at revisions. 20% second or third revisions, male, female, almost equal. We can get in tunnels that are 8 to 12 millimeters, so you can fill almost any defect. We use a single piece of tissue, not one that's wrapped up, and failure rates are consistent with PT outcomes, with patella tendon outcomes, and also with the moon outcome data. Number 10, flawed interpretation. This is what everyone points to. This Martin Lin and Marcus Strauss that showed a high failure rate with quads, but look at it. They were recruited between 2005 and 12. There were non-anatomic ACLs. We didn't have a standard quad harvest technique. We didn't have the implants, and it's a government database, so no control of surgeons and patients. They redid this study, and basically this year found that if you picked, if we do 2015 and forward, if we add greater than 100 ACLs done a year at a particular hospital, there's a 2.9% failure rate versus less than 100, there's a 6.4% failure rate. So the quad is the future. Pat, take it away.

quad tendon

ACL surgery

graft harvest

hamstring grafts

predictability