Hi, this is John Pulaski, and I'm going to be talking about quadriceps harvesting for the ACL reconstruction in the pediatric patient. I'd like to especially thank my partner, Dr. Pat Riley, Jr., for obtaining these pictures in a recent case that he had and providing them for this talk. So all these images that you'll see in this talk are his, but I do mine the same way. So quadriceps tendon grafts have been recently becoming much more popular, especially the all soft tissue version for our nearing skeletal maturity patient, and for a lot of people, this is becoming more popular than the hamstring graft. So we'll talk about how to do this. We make a small incision just proximal to the patella and just lateral to the VMO. So you can see in this picture to the right, the VMO is drawn out and there's a small incision just starting at the proximal pole of the patella and extending approximately from there a couple of centimeters. It's easiest to do this with the knee flexed, it puts the skin and also the tendon under a bit of tension, which makes it much easier to manage. Horizontal incisions have been described, placed in longest lines. These produce a very nicely cosmetic incision, however, can make your visualization more difficult and you are somewhat limited in your ability to extend the incision if you're having difficulty seeing. So I think that's a reasonable thing to do once you're more familiar with the anatomy and localizing the tendon, getting good at harvesting it, but it's not as easy to harvest as say a hamstring tendon just because of the fibers of the quad can be somewhat challenging to deal with initially, especially when you start out doing this. So this shows the release of the subcutaneous tissue and the superficial fascia. You can see the tendon down there and even with a small incision, if you release enough of the subcutaneous tissue and that superficial fascia over the tendon, you can make this mobile window so that you can really see along about seven and a half centimeters from the proximal pole of the patella all the way to the more proximal extent of where you're going to take your graft. So you really want to be able to see that and once you can, you can proceed. So you want to start distally on the patella. There are commercially available blades that you can score the superficial aspect of the tendon. You can choose different widths and you can talk to some of the companies about these, but they'll make a parallel cut and score that tendon for you so then you can dissect it off of the patella and then follow it more proximally. So once you've scored the tendon, then you undertake sharp periosteal or subperiosteal dissection right off of the patella, which gives you control of the distal portion of your graft and you can grasp it there with a forcep while your assistant holds the retractors and then you just kind of follow it proximally. Moving proximally, it's nice to get some control over the distal aspect of it. I usually put a whip stitch suture in that more distal end and then I have better control. This picture shows that it's a partial thickness graft and you can see the deeper layers of the tendon down below there with the graft flipped back proximally. So you can do partial thickness or full thickness. If you do a full thickness, you have to repair it or at least it's helpful to repair it prior to starting arthroscopy so you don't have fluid going all over the place and you have much better visualization. But here you can see it's partial thickness. When moving proximally, Ted Ganley taught a nice trick to separate these layers of using an osteotome to kind of separate those deeper layers off the tendon. One of the things that can be difficult with the quadriceps tendon harvest is that fibers go in multiple different directions. So unlike a hamstring tendon harvest, you don't have a bunch of straight fibers and they can be kind of crossing in your field and if you're not careful, you can kind of get on a plane and wander through these different planes and you end up with a much smaller caliber graft, sometimes more proximal than you had distally. So an osteotome helps you more bluntly separate these layers and can be quite helpful in maintaining the same thickness throughout the length of the graft. So you want to dissect this to about 55 to 75 millimeters in length. Usually the minimum is about 55 millimeters. I like to get a little bit more than that. 75 is nice, but you have to remember if you're doing an all-in-side type technique, sometimes by the time you add your button fixation, it can be a bit long and kind of bind up in your tunnel. So be wary of that. It seems like 65 is kind of a sweet spot and works well with all-in-side reconstruction, but kind of know your tunnel placement and know how deep you generally drill your tunnels and then you can kind of find what the right graft length is. And there are these commercially available cigar cutters, which are shown in the picture that have measurement devices on them. So basically pull the tendon through the middle and then take it all the way up to the length that you want and then it'll amputate that and then it can be prepared on the back table. And this shows the measuring that's available off those devices and you can see this one's right about 75 and then you can take that measurement and then amputate and pull the graft out. And then you just prepare it generally as a regular soft tissue graft. Again, there are commercially available systems and devices that can be used to attach these to button devices with sutures and you can really do whatever kind of fixation that you want. You want to measure the caliber after you've put the sutures in because a lot of times it'll change. It's usually much wider after you've got some sutures in it. And if you're doing all-in-side technique, the femoral and tibial ends may be a little bit different. You want to know that before you drill your tunnels because you want a nice tunnel fit. So for all-in-side, I usually measure both ends and then decide which one I'm going to take up into the femur and which one I'm going to take to the tibia and then drill my tunnels appropriately. Another Ted Ganley trick is using the sizing blocks to kind of compress the graft. So after you've sutured it, while it's tensioning on the back table, you put the sizing blocks over to kind of squeeze the graft and that can make for easier passage. Again, these grafts tend to be somewhat fuzzy, I guess is a good term to describe it. They're not the nice, smooth, slippery tendon like a hamstring tendon. They've got kind of fibers coming off of them and they don't look as neat and tidy as the hamstrings do, but they seem to function quite well. But they can be a little bit difficult to pass just because of some of the fibers hanging off the edges. So a little bit more irregular than the hamstrings. So if you take a partial thickness graft, it doesn't need to be repaired and you can see the deep fibers there. You can just leave that alone. Obviously, as we talked about before, a full thickness graft requires repair prior to arthroscopy just for fluid management purposes and it's likely a little bit better for their strength afterwards. This is the repaired graft after it's been sutured, being passed through the medial portal up into the femur and then down into the tibia. This is an all inside technique, but that's the graft there and this technique tends to work quite nicely and we're getting longer and longer term results with this. Thank you.

quadriceps harvesting

ACL reconstruction

pediatric patients

quadriceps tendon grafts

hamstring grafts