to the American Journal of Sports Medicine's webinar in conjunction with the American Orthopedic Society for Sports Medicine. Thank you for joining us. I'm Donna Tilton, Editorial and Production Manager for the American Journal of Sports Medicine, and I will be the operator for the webinar today. Before we get started, I would like to take a moment to acquaint you with a few features. There are options for how you can listen to this webinar. If you have any difficulties listening or hearing the audio properly, please try clicking the phone call option and calling in for the audio or switching the speakers that you're using. At any time, you may adjust your audio using your computer volume settings. To send a question, click in the text box and type your question. When finished, click the send button. Questions you submit are seen by today's presenters and will be addressed throughout the presentation, so please just send those questions as you watch rather than at the end. There is CME available for this online activity. Here are the learning objectives and the faculty disclosures. At the conclusion of today's program, we ask that you complete a brief evaluation by going to education.sportsmed.org and logging off. Please take a moment to complete this if you wish to collect the CME for this activity. At this time, I would like to introduce our moderator, Dr. David Wasserstein. Dr. Wasserstein is a sports medicine and trauma surgeon practicing at Sunnybrook in Toronto, Canada. He is a member of the AJSM Electronic Media Editorial Board and will be moderating the webinar. With that, I'll turn the microphone over to Dr. Wasserstein. Thank you very much. This is exciting. We have a webinar planned today to discuss the quadriceps tendon autograft, as you know, and we have an excellent panel. I will ask the panel members to turn on their video and join me and I'll do the introductions. We have first to log in is Dr. Martin Lind, who's a professor of orthopedics in Denmark. I'm sure well known to everybody logging on. Next is Dr. Peter McDonald, a professor at the Pan Am Clinic in Manitoba, Winnipeg. Then we have next is Volker Musall, who's in Pittsburgh, professor of orthopedic surgery at UPMC. And then finally, Dr. Christian Fink, who is as well, a well-known orthopedic surgeon from Austria. So we are very lucky today to have a panel that really represents some global perspectives on this topic and even more lucky that our colleagues over in Europe have agreed to stay up close to midnight and join us today. So we can go to the next slide. So today's webinar is going to take a little bit of a different approach than some of the previous ones. We thought it might be interesting for viewers to see something modeled after maybe an ESPN rapid fire or something like that, where we each hear from the panel members one at a time, going over their answers, their thoughts to some standard questions that will encompass areas of the quad stent and autograph, including indications, usage, outcomes, and some techniques. So it will go with the question up on the board that everyone can read, and then we'll have each panel member weigh in on their thoughts on that question. There's, I think, about six or seven of those. And then we'll move on to a review of a few papers, recent papers, two in the AJSM and one in KSSTA, including papers that are authored by folks on our panel. And you will hear a brief overview of the article with the references have been listed. I'll give the brief overview, and then each of the panel members will give us their interpretation and answer a few questions we have about that. And then finally, we'll open up some questions at the end. Okay, let's start with the rapid fire. We're not really going to score it, but it's always fun. And I guess bonus points if you can answer these questions with your own work. So we're going to, maybe we'll go across the top and we'll start with Dr. Lin. The first question is, in your practice, what is the ideal patient where you would utilize a quadriceps tendon autograft? So in my practice, it's my standard graft for athlete patients, contact sport athletes. And the reason for this is that we have a graft that is providing a high amount of collagen for strong reconstruction. And the graft makes sure that you preserve the hamstring function, which could be quite important for pivoting sport athletes, as the hamstrings can be considered the sort of the seatbelt of an ACL reconstruction. And with the capacity also of the graft to have very low donor site issues, on athletes, that is also an issue that they can come back to have pain-free activity, despite having had a graft harvested. So in my practice, it's for the athletes, where it's very beneficial. Thank you. Next, Dr. McDonald. Thank you very much, David. And thanks to you and AOSSM for organizing this excellent session. In my practice, it is also the predominant graft. It's become that way in the last five years, since John X from Atlanta convinced me to switch from hamstrings. And I haven't regretted that switch. It's a very strong graft. I've had very good luck with a low revision rate, probably in the 5% to 6% range, or full failure rates, I should say, 5% to 6% range. For most of my cases, I will use quads. I will say the exception would be in an older patient over age 40, where I tend to use either hamstring or an allograft, usually allograft cut down on morbidity as well. If a patient is less than five feet tall, I'm a little bit worried about length of the graft. So that might be an issue with a quads tendon graft in a very short patient. And also, I don't really have the answer for generalized ligament dyslaxia, a part of the LET2 study with Volcker. And we'll have the answer on the best graft for those people who have hyperlaxity and hyperextension. So those are my quads graft is the primary go-to. And I would say in a partial ACL tear, which is rare, I might do a hamstring graft. Thank you. Great. Dr. Meusel? David, I'll give you a short answer and a long answer. Short answer is everyone. I don't see a contraindication. Maybe more long-winded, I would point to those that kneel and say, well, BTB may not be the best graft there. Carpenters or wrestlers would come to mind. I like Martin's argument with the hamstring tendon. So I like to preserve it in ACL, just about in everyone, but especially in those that do high active knee flexion, sprinters or say judo, somebody like that. And then maybe some exceptions. Also pediatric, I think is a good point to bring up. If you're looking for all soft tissue graft, people go to the hamstring tendon and people have shown so much failure rates. So I think quadriceps is a great option there. And an exception for me, maybe I don't like to go and swim upstream too much. So if in my world, the big NFL data is the so-called gold standard with BTB, then in football players, sometimes I just use BTB. So I don't have to make the argument with anyone. Although I don't believe it is the better graft. I think quad tendon is equal as BTB and the stability two trial that Peter just mentioned, I think would give a ton of very interesting data in about four to six years from now. So we're looking forward to that. Thanks. Thank you, Dr. Fink. Good evening. Well, I would say the same as my panelists colleagues here. So quad tendon really turned to my predominant graft over the years. And actually, we started using quad tendon as a revision graft initially. Then we started to use quad tendon in case of medial laxity or additional medial collateral ligament injuries and also valgus alignment in especially in the young girls. And then we moved to get getting more and more confident with quad tendon. We really moved to making it our predominant graft. And again, I rather say what's the contraindication to a quad tendon. Sometimes you see quadriceps tendinitis. If you have a soccer player, I just recently had a soccer player who has some history of quad tendonitis. I mean, you wouldn't necessarily like to like to harm the insertion site there. But in general, I think it's a good graft. And as we said, we published in 2020, we published a paper in HSM and showing that when with low activity levels, it doesn't make a difference if you use hamstring, hamstring graft or quad tendon. But above a technical level of six, it becomes an issue. And you do see a lower rupture rate in this more active patients, at least in this 800 patients we looked at. And therefore, I think it's a good graft pretty much to use in everybody. Thank you. Looks like I picked the appropriate panel. Everyone loves this graph. So the next question is, what is the biggest unsolved question or biggest unknown right now about using a quad tendon autograft? Why don't we change it up and maybe start with Dr. McDonald? Yeah, the biggest unsolved thing for me is just getting the size. We all know that there's probably 20% more collagen in a quads graft versus a patellar tendon graft. And talking about the mid substance, we're going to talk about studies, Volcker studies in particular, which talks about that later. But sometimes in a small or a female, you put a quads graft in that's nine millimeters in diameter, and it looks a little bit too bulky. So getting that size right for the individual person might be a question that I would like to see answered. The other is, what is the morbidity in terms of we need more detailed strength studies in terms of recovery of the quad and the graft dependent, graft site dependent morbidity? So it'd be nice to see more studies come up in that area. Volcker? Of course, I want to say there are no unsolved mysteries, but it's probably not quite true. I can tell you that historically, you know, in Pittsburgh, I just saw a patient who had done a quad tendon on 12 years ago, and I'm surprised I've done it that many years ago. But I quizzed the patient, and he told me he came to me because Freddie sent him to me. So Dr. Fu started the quad tendon about 12 years ago and used all bone quad tendon. And we've now switched to all soft tissue. So I wonder if it really makes a difference. I know Christian likes using bone still. I don't know if that's still true. I'm sure you'll tell us here in a second. So that's one question. I like the fact, and I know Freddie used to like the fact that with the bone, you have a longer graft. So in the five-foot patient that Peter mentioned, you wouldn't have such a big issue. And with the bone, you also have a more predictable fixation up top because we don't like the suspensory fixation too much if it has the adjustable loop thingy on it. So I think that's an issue. Another issue in my mind is the quad weakness that we see particularly in the young female sort of half-athletic, half-not-so-athletic patients. They struggle sometimes to get the quadriceps back, and we're struggling to find out what it is on our end that we need to do better to get the quad activated earlier and do short arc quads earlier in the rehabilitation sets and question the validity of BFR there a little bit. And I think the third question is, of course, with everyone pushing towards LET, is LET needed in quad tendon? And so again, stability will tell us this. GetGood showed us that with hamstring tendon, you should probably use an LET. His data is strong on it. I doubt that that's going to be true for our Stability2 study, but the data is not there yet. So those would be my main points, the quad weakness, the bone versus soft tissue, and LET or not. Christian, do you still use bone? Well, as you said, we started with bone, but now I completely went away from bone, and it's all soft tissue. We use a periosteum flap, which basically we use in the top of the graph. And there's also a paper coming out. We compared 350 patients with bone block compared to no bone block, and there was actually no difference, neither in clinical results nor in morbidity. So I think bone blocks are great for revision sometimes, but I think all soft tissue is okay. But to me, the answer of the question is still we could get better with fixation of the graft. I'm still thinking what's the best way of fixing it, especially on the femur. Adjustable loops with some different techniques, and some easier, some quicker technique to fix the quad tendon, like to make it as quick as a hamstring, for example. I think we still have to work on that, and there's some unsolved issues, and I'm sure we can get better in that. Harvesting, as you know, we like the minimal invasive harvesting tools also here, of course. I think there's improvement in the technology, so we are working on this to get a really good cosmetic harvest of the tendon, and as Peter said, to get it in the appropriate size, like to really get a graft which fits to the patient, as we will talk about later. So I think these are some technical issues. Quad strength, to me, actually, it doesn't make a difference which graft I use. Some patients just really have problem with quad activation. Even with hamstrings, we have problem with quad activation. I don't find a difference. For me, it's still a challenge, but with any graft, to really get early quad activation, and I think that's, to me, that's the biggest challenge. But as it comes to quad tendon, I think fixation, to me, is the biggest technical challenge. We could get easier and better. Martin? Yeah, I can't add too much, but the three main issues is which formulation should we use, soft tissue or including a bone block, and then fixation, what is the best and most safe fixation of the graft, and finally, is there a way to minimize the quad tendon, quad muscle strength loss that we see for the quad tendon a little bit more than we see for hamstrings, at least what we showed in our studies, that there is a little more impact on the quad strength with the harvest of the quad tendon compared to hamstring. So these three things are what we still need to improve on. I may go off the set path here and just ask the panel, the concern on fixation, is that because of a big tunnel and maybe a bioscrew in a big tunnel for revision, or is it really just a concern about the strength of the fixation? I think for revision situations, I tend to use a BTB graft just because you get bone on both ends. You could use a quad tendon, of course, with bone, but I tend to use my quads all soft tissue. So the fixation, I mean, when I first started using quads, I was really worried about fixation because I didn't really know the best way, but I think the modern devices, I don't want to mention company names, but with suture tags and things like that, improved fixation, less creep, and so we're better at it than we were. I'm definitely better than I was a few years ago, so I'm not as worried about it. I tend not to use a bioscrew if there's a short graft. If there's a long graft, I'll use a bioscrew and usually back it up with an anchor on the tibia, but on the other side, on the femoral side, I'll use an adjustable loop button with a tag type device. Anyone else put some thoughts or should we move on to the next? Well, as I said, I'm not worried about the tunnel, it's just I like to get it quicker and better as I do now. I use crackle stitches and the pullout is really good and we never had any problem, but I just wanted to be quicker in a way and this is why we work on this a little bit, but it's not a huge concern really. Great, okay, let's move on to the next question. So, I'll ask a bit of the next three questions actually are some comparisons. I think that this is a panel obviously with a high use of quad tendon grafts, so what are your thoughts on that graft versus BTB or hamstring autograft for anterior knee pain? Is it better, same, worse? Do we really have this answer yet? Are we speaking about our own experience? What are your thoughts? Well, we can start with Volker actually, we'll go. Yeah, that sounds good. This is an easy answer for me. It is clearly less pain than any of the other grafts. The only reason you still have anterior knee pain is, in my mind, because you also have an anterior medial skin incision to get your tibial tunnel in there, so you still may have some infrapatellar branch saphenous issues just because of that incision. Now when you're talking about later in the recovery, maybe at six months, that patellofemoral syndrome that some people get, if that is what your question is, then I don't think there's a difference between quad or BTB. I think they all might get it. There's an interesting study that came out of Bill Garrett's group a few years back, maybe about 10 years back, stating that patella tendon gave more patellofemoral contact pressures compared to hamstring tendon. And I've been thinking about this study a lot all these years, and I wonder if quadriceps is the same. I think you do get patellofemoral pain with all these grafts later in the recovery, but the true anterior knee pain from kneeling that you get with the BTB, you do not get this with the quad tendon because the incision is superior to the patella, not where you kneel. So those are my thoughts. Christian? Yes, I think the same as Falk. I think there are good data out there actually from different studies, and even if some show the same clinical results of the grafts, but what I would say the majority of studies show is that the morbidity of quad tendon is really lower compared to all the other grafts really. And there is a paper now coming out from, we looked at results five to six years, a hamstring where those quad tendon, it's coming out in the Journal of Physicals in the next issue actually, and you can see that it was even the morbidity was lower than with hamstrings. And with hamstrings, what really hamstrings get, and I didn't even look, and patients not necessarily tell you, they get really big sensibility loss, some of them. And if you talk to the patient, they can show you and say, oh yeah, I feel numb here. And it never occurred to me, unless we really looked at this. And I think this is also, as I said, you only make for the quad tendon, you only needed like a small incision for the drill hole, but it's cosmetically better, but most of all, it's better from a point of sensibility. So I think we do have good data that to answer this question, that yes, there is also much lower anterior knee pain in these patients with quad tendon. Martin? Yeah, so the answer is easy. It's certainly less anterior knee pain. We did the randomized studies comparing both with quad tendon with B2B and hamstrings that was published some years back, and both of these studies unanimously show that there was less anterior knee pain with the quad tendon compared to both graft types. So that's how it is. So that's the really most important advantage of the quad tendon. How did you define anterior knee pain in your papers, in your RCT? So it was different. The first one, comparing B2B, there was some functional testing with knee walking, and in the second study comparing to hamstring, it was a score, the Swedish developed donor site score. So it was different outcomes, but in both studies, clearly the quad tendons came out superior. Thank you. Peter? We need more controversy. We're all agreeing too much. But yes, less pain than, definitely less anterior knee pain than the bone patella tendon and bone. When they do get pain, of course, it's superior. It's not inferior to the patella. It's near the graft site, but it's not as, not nearly as much, and I would say less pain than even the hamstring. But later on, they all get some degree of patellofemoral, especially if they're under rehabbed or under-conditioned in the rehab, and they'll get some patellofemoral pain later, but that's really not, that's something that's ubiquitous to all grafts. I would say that, you know, you do get a little more quads lag with the quad tendon, but six weeks, that seems to disappear. The thing I don't miss with the hamstrings, when I did the hamstrings, about 10% of patients will get a pop around six weeks, and their hamstrings retract, and they get a balled up hamstring, and those people are not happy patients. So I don't miss that type of outcome. Okay, we'll move on to the next. So what about the same comparisons for failure? Let's start with Christian. Yes, well, I think compared to PTB, again, when you look at the literature, there's comparable results, so about lower rerupture rate than hamstrings, and about the same as PTB. I think, well, we still need more data, really, to answer all these questions. And now with the addition of an LAD, I think it's also not a question, but as we see from now, I think, with the exception of Martin's study, which adds some controversy when he's presenting it, I think it's really shown that the failure risk is about the same as PTB, and lower than hamstrings. Yeah, so at this point, I would say the failure risk is at the same level between the graft types. We published on our sort of first 500 quadtendons in Denmark, and found out there was some concern of a high risk, but additional studies and more recent data extraction showed that this high level has actually been eliminated, and the sort of most recent data show actually equality, and to some degree, slightly better outcome for quadtendons. So what we showed, and we're going to discuss that when we come to that paper, was the outcome of a very early sort of cohort in a national cohort. So by now, when the graft has been sort of more learned by the surgical community, it looks quite promising. So there doesn't look to be an issue with the quadtendons, as we saw in the beginning. Great. Peter? Yeah, I'm glad to hear Martin say that, because I was worried looking at his early data, that people would say to me, why are you switching to quads? The failure rate is higher, but it didn't make sense to me, based on what everything else we knew, and our early experience with quads. So I would say our failure rate is probably similar to BTB, and better than a hamstring graft. So similar to the other panelists. Okay, Volker? You know, I think it's a really controversial topic, and I listened to everyone, what you said about failure rates. We're looking at our own failure rates right now, and you know, when I look at the studies from Denmark, the failures are quite low, Martin. So I like seeing that, but I wonder how we compare all this, when some people come up with 17% failure rates. And I know Freddie and Al had a good argument over the stability data. I think it really depends what athlete group, if you're looking at the very young, very active group, there will be high failure rates. I believe there's a little bit less failure with either the quadriceps or patella, compared to the hamstring. Just historically, and what we've learned from the Kaiser Registry, from other registries, and our own data looks like that. We're right now looking at something like 5% or so failure rate, but this is within two years, so it's probably still increasing in a very young and active group here in our Pittsburgh Registry. So I think we still need more data on this as we go forward, and I'm sure the pendulum will swing back and forth a little bit, and we do use all grafts in Pittsburgh, but mostly still quadriceps in this current time, because we believe there's a little bit less failure rate in the young athlete compared to hamstring. For sure, likely a lot of nuances still to learn. Yeah. We'll move on to the next question. So it's the same, I think a few have already touched on this a bit. You know, what are you telling your patients when you talk about the quad graft with respect to how they may recover quite early, and if there's anything that you've noticed that's different about a quad graft that is in comparison to previous grafts that you've used? I forget who we started, are we back on the original track? Is it Martin first? Yeah. So regarding the early recovery, there is a little bit of an issue for the quad tendons, where the patients have in some instances an issue with activating the quad again, which takes them some weeks to get back, compared to hamstrings, where that is not the same issue. It's the same as for patellar tendon, because that's more or less the same harvest issue, but certainly there's an activation issue for the muscle to get back, which takes a little bit longer. So I would say that sort of early muscle activation is prolonged with the quad tendon compared to the other ones. Great. I'll also add, if anyone has changed or modified their early rehab protocol, I would be interested to hear about that. Peter, next? Yeah, I would agree that the... I just want to start getting back to Volker's comment on failure rates. I think it depends how strictly you define failure rates, because, I mean, there's different ways. You have to, like, compare apples to apples, whether your failure is re-operation versus whether you have a one-plus pivot glide, is that a failure, even the patient is asymptomatic. So it depends how strict you are with your failure rates as to what the percentage actually is. But, yeah, getting into the post-operative protocol, you have to warn the patients a little bit that they're going to have a quad slag and a slow activation of the quads the first four to six weeks, so that they used to hang on to their crutches maybe a little bit longer than they would with hamstring grab. Yeah, I was going to ask if anybody braces or crutches for longer while ambulating. No, so I like using crutches only for about two weeks and they get off. I'm not a brace fan. I think they get off those braces also very early. I must say that the worst or the most pain post-operatively I see, and that's reflected in our stability data as well early on, with LETs more than with any of the other grafts. But all of that is temporary. So I tell all my patients the initial pain is, I mean, by four weeks they have a non-tender quadriceps incision. It's my experience. But Christian made me give a talk on complications once in our IQTI, International Quadriceps Tendon Intergroup meeting, and that is just something you need to be aware of. Not sure that I tell every single patient about all the possible complications you can have with this, but as a surgeon you have to be aware of hematoma formation. If you work with tourniquet, you may want to let it down and get the bleeders. Retraction of the quadriceps, if you go too proximal, is a real issue. So you got to close it. I've seen a compartment syndrome, and of course if you harvest bone and you're not central on the patella, you may fracture it. But you do that with BTB as well. So those things you just have to really be careful. If you don't have complications, it is about the same recovery in my hands. Yes, well, I did change my real protocol, but not with respect to quarten and with respect to really. So I always tell them the three most important things early post-op is extension, extension, extension. I think it's really it's really a key issue and it's getting the quadriceps activation back. And as I said, I don't find a huge difference between the individual grafts, but I think this is really, really important. And if somebody can, you know, lift the leg up straight in extension, in full extension, not just, you know, flexed in full extension, I think it's, to me, it's going into a good recovery. And so this is the biggest focus. And to that we use all kind of, you know, biofeedback. If somebody has difficulties, biofeedback therapy. We really work on extension. That's my key issue. Well, they do get crutches. I mean, mostly depending on meniscus repair, normally for two weeks, if you have a root abortion, whatever, it's four to six weeks. But braces, yes, we do use braces, mostly to limit the motion after meniscus repair, not for the simple for the simple ACL reconstruction. But as I said, we really changed and really the pure focus is, for me, is in extension, because I think that's a key key to the reopening. It sounds like the panel thinks they're probably a bit weaker in extension early on. Has anybody noticed that manifest as an inability to maintain extension? And so there being a permanent extension loss in these patients? Any data that anyone's come across on that? I think the extension loss, it depends a little bit if we're talking an extensor lag because of weakness, or we're truly talking about like a Cyclops lesion. There are probably a little more occurrences of Cyclops lesions with quadriceps tendon. And you have to know that the quadriceps tendon obviously feathers out proximally and has two layers of rectus and intermedius. And it may be a good idea to flip that graft and have the proximal part be in the tibial tunnel, so that you don't have so much of the layers come up and maybe give that Cyclops. If that's what you're asking, so that's certainly a controversy and something to work on. If you're talking about lag because of weakness, I don't think I see that beyond the first couple of weeks. And I agree with Christian, like pre-op, I tell every patient, fire your quad. Remember how it feels to fire it when you wake up from surgery? That's the first thing I want you to do. Great, let's move on. Yeah, before we move on, you mentioned BFR. Do you think that's the way that we should be going with all our rehabs, especially with quads grafts? What's that? The blood flow restriction. Oh. Sorry that I mentioned that. No, I don't think, I'm not a huge fan of it. I think it's something that we do when everything else fails and we kind of outsource to last resort, let's get BFR going. So, that's my opinion. I don't have a strong opinion on it. Curious. Thanks. And sorry, any more comments? No? We touched on this question a little bit. I don't know if anybody else has anything to add about preferred fixation methods. It sounds like maybe a screw for a longer graft and suspensory fixation on the femur. Anybody else have anything else to add on this question? Yeah, I'll just say that like the basic science studies are showing better ingrowth with suspensory fixation. I don't know if everybody agrees, but like basic science wise, it's kind of pointing us towards suspensory and a nice tight graft in a tunnel being for a better incorporation of the graft into the tunnel. But I still follow, I haven't switched over completely from screws. I agree, Peter. I'd love to see the study that Scott Rodio did in the 90s with hamstring tendon healing in a bone tunnel. I'd love to see that with quadriceps tendon. I feel like the tendon is so thick and so rough, I believe it will heal better into the tunnel if it's pressed fit and tight in there and no screw is preventing any of the healing surfaces. So, I do like suspensory for that reason. I don't like the adjustable loop too much, although I think it's fine. But we created a technique where we just use a continuous loop and treat the tendon as if it was a bone block and just punch a hole in it and put our suspensory in it in a continuous loop. So, hopefully it elongates less. So, I'm still a bone block user and use a continuous loop for the bone block to get circumferential healing. But still in the tibia, I like to use a long peak screw to get compression. It always works well. I've never had any problems. So, why change a winning team there? So, even though biologically there might be some advantages in circumferential graft healing, but it works and never gives any problem with a peak screw compared to other screw types. Yeah, same thing. I use suspensory fixation on the femur and the screw. I always use hybrid fixation on the tibia. I put the suture through a small bone bridge. Always use this hybrid fixation. But I'm always thinking of getting rid of the screw on the tibia as well. So I haven't done it on a regular base. We do it in children, of course, and I think it does heal well and I'm never sure if it really needs a screw additionally to the extracortical fixation. So I agree with Volker and Peter. Okay, great. Let's move on to the next. So for people listening to the webinar who are maybe not as experienced, what is one technical tip that you might be able to share that you learned using this graft over the last 5, 12, whatever years it is? Maybe you learned it the easy way or maybe you learned it the hard way. Well, I think there's a few things. You should start off with a longitudinal incision so you can extend it. But I do find that the transverse incisions, once you get good at your harvest, in my hands, they tend to heal a little bit better, a little more cosmetic incision and less irritated. But you should probably start off with a longitudinal incision. It's good to stick your scope in dry and look at the path of the quads because if you're off and go harvest into the BMO or the VLO, you're going to get a short graft with a muscle on the end of it and that's not going to be very satisfactory. And Volker already mentioned that you can't get into the myotendinous junction of the quads, which is not very good either. So I would start off with a longitudinal incision and make sure you visualize well. But after a while, you can make your incisions much smaller. And I also use a Scorpion device that we use in the rotator cuff to suture side to side after so you can reach up under the incision far up into the quads to sort side to side after to do a nice repair. Yeah, I still use a vertical incision and I just use a 10 blade and a forceps. A Richardson retractor is good so you get all the fat out of the way. And most of the tricks I learned either from Christian or from John, so I may steal his thunder already, but you know, a Peyoncé elevator to get the fat off the tendon is really helpful. I think Christian told me that trick. And then once you harvested the first piece of the tendon off the patella, the first two centimeters, then I use the blunt portion of the knife to bluntly dissect underneath and find my layer between rectus intermedius. I think that's a nice trick then you can avoid cutting into the super patella pouch. And if you can avoid that, you can start scoping right away and don't have to repair it. Yes, I would agree with Pete that when you start with even when you start with minimal invasive instrumentations, start with a long longitudinal incision and see what you do. I think as you as I say, as you get more comfortable, you can harvest it in the end through a possible two centimeter transverse incision, but start with a longitudinal incision and watch what you're doing. When I use a bone block, I always like to take the bone block last. So I cut the tendon from the top and then prepare the tendon down to the patella and then actually use the saw to make a cut that is comes from proximal to distal. So you can just elevate the bone block. So I think it's very dangerous to use a chisel to hammer on the patella from the front because the bone on top of the patella is extremely hard. So I think harvesting the bone block last gives you also a bone block in the appropriate size as the tendon as your tendon graft is and is maybe a little bit safer than do it the opposite. Yeah, and I can just accolade and say the really important thing is to start with the vertical incision. That gives you complete overview of everything you need to see, your direction, how deep you are cutting. And also where things can go wrong is how you separate your graft when you sort of go proximal. And here it's good to have an instrument that sort of dilates your cut a little bit so you can see exactly how you separate whatever system you're using and make sure that separation runs all the way in right layer approximately. And that is really facilitated by having this vertical incision and being able to see everything. So in the beginning we saw some issues with having thinner graft approximately if this was not performed. But agreeing to have this full view of what you're doing has avoided any sort of graft thickness issues. And also like Christian said how when you use a bone block sawing exactly as Christian mentioned and avoid using an osteotome that impacts the cartilage. That's really an important thing. I have two questions for the panel on this. What type of suture are you using to repair the quad? And is anybody who takes a bone block taking some of the cancellous reamings let's say from the tibial tunnel and bone grafting? Or any other tricks on bone grafting or we're just leaving it alone? I can start. I used ovicle to close it with interrupted sutures. I just adapt the layers. And then if I do bone I definitely fill it back. And I do like using the reamings from the tibial tunnel. I think that's a nice way to pack it. You can also, Dr. Fu used to do that, take a core reamer and ream your tibial tunnel, ream a whole core out. You can harvest that core and then put that in as one big piece into the patella defect. So those are options. For closing, I use a wire curl on the round needle. That's a special round, small round needle. So you can get really up far on especially if you use a small transverse incision. So I use a running, I do your running sutures and I start always from distally to proximally because that helps you closing the tendon and taking off the tension. So again, bone block I use because on the femur I always make a rectangular tunnel instead of a round tunnel. So if I use a bone block, I use a very thin bone block. So I'm not going to bone graft it normally. Just leave it this way. I don't routinely take a bone block, but when I do BTBs, I always bone graft. So I think it's a good idea, especially on the patella where, you know, it minimizes the risk of fracture. I like the idea of taking a core like Fred used to do and using that. I think that makes a lot of sense. I just bone graft with whatever overused bone tissue that from preparing the graft. But typically it's not a lot. I try to take as Christian a small bone block as possible with a trapezoid cut. So typically there's not a whole lot of extra bone that needs to be cut off. Great. Okay, we'll move on. I think that's the end of our sort of rapid fire session. We've touched quite a bit on a few of the studies we'll talk about now in a little bit more detail. And what I'll do is introduce the study and then open to the panel to comment on the strengths and weaknesses of the study, the questions they had from the study. And I've also left a few questions of sort of food for thought at the end. So actually I didn't have a chance, Volker, did you want to talk about your study or would you like me to introduce it? No, sure. This is great. Also, if I may ask, are we going until 6 or 6.30? We don't have a time limit, but we'll try not to go too much past six. Well, maybe the next. So this paper I like very much. I quote it all the time. And Christoph Offerhaus was a fellow with us who only spent a few weeks and had such an impactful paper in a few weeks time. And Jürgen Hörer is one of the quadriceps people in Germany. He does probably 1,200 a year or something like that. And also with a very interesting hollow reamer, like Martin, he still takes quadriceps bone. In this particular study, we looked at what graft size can best match what native ACL size. And obviously, and this is something that Jürgen worked on when he was Freddy's Fellows in the 90s, the patella tendon, although we harvest a tendon, is the smallest graft. I think people just need to understand that because the tendon is a thin sliver of a tendon, even if it's 10 wide. And hamstring tendon is next biggest. And then you can see on that lower part of the graph, the quadriceps tendon. I mean, you have a wide range. You can do whatever you want. In fact, I think important that you can, it wasn't part of the study, but you can overstuff the notch quite easily with a quadriceps tendon. You must be aware of that. So based on what we found in this study, we say that one, all grafts are really important and relevant in a small notch. A hamstring graft may be the right graft. And two, in this MRI image on the lower left, the quad tendon is just much thicker. It's like a patella tendon on steroids. And then three, we do make measurements on the native ACL and the notch prior to every primary ACL. So we know roughly what graft size we're looking at replacing. I think that's very important. I don't know if you all do that, but I do that on every case. Thanks for letting us highlight this paper. Thank you. Yes. Excellent paper. So the questions that I thought came out of this and I thought were worth discussing further is, and some have been touched on. So could a graft be too large or maybe a patient's notch is too small? Could there be a role for differential thickness of this graft and how are people on the panel using that? And then other than the graft being too large, like what do we think is the cause of this or what is not the cause, but the sequelae of this? Is too low footprint coverage correlated with failure? I mean, the BTB data may not say that's true. And does overcoverage risk failure or motion loss? So I'll just open it up to, I guess we can continue to go to my, it's that direction, my left. Pardon? Yeah. So surely a graft can be too large. You can overstuff the notch and get maybe cyclops lesion formation and extension problems. But certainly a partial thickness hamstring or quad tendon graft is never going to overstuff. And certainly in most cases, not even a full thickness one. And I use a partial thickness, but that is not that partial thickness. We only keep partial thickness. We only keep some of the lowest or deepest layer, which is not that big. So for quad tendon, unless you take a full thickness and not controlled by a cutting system and having maybe a 12 or 13 wide something, then you can be too large. But if you have a controlled 9 or 10 wide, then you won't be too big unless you have very small patients. And we don't know a whole lot about the risk of failure regarding to footprint coverage. I mean, there's not a lot of data on this. And so we don't know if these things are correlated. Peter, thoughts on footprint coverage issues, graft size, this paper specifically? Yeah. I think I mentioned earlier that there's some, in my experience with quads, there's some, as it's a rather thick graft, more collagen there. There's some cases, especially smaller females where I feel like I may have put in too large a graft. And so I'm worried about overstuffing the notch and taking too much bone as well out of the lateral femoral condyle. So I think that I like Volcker's approach to measure and Freddie's before that to measure the footprint, try and customise the graft size to the native anatomy. I would say that it's easier said than done. Sometimes when you, you know, if you measure like an 8mm graft, you start off, especially this is, quads is one where I actually do most of the harvest. I don't let the resident or fellow do the harvest because it's very easy to get it mixed up and end up with an insufficient graft. So it is some tricky, you start off with the intention of going partial thickness and sometimes you end up full thickness. So it's a little bit tricky. There's some nuances. I would say I always try and take too much graft rather than not enough and then trim it down if I have to. I don't know if footprint coverage correlates with failures. I think, I love this study out of Pittsburgh, but I don't know if it correlates with failures. So that data is yet to come in, I think. Christian, that's still data that's out there that that's coming. And I think if you can preserve the footprint, if you can preserve the stump and have the graft within it, I think you're setting yourself up for success. Of course, if the stump falls down on you and becomes a cyclops, then it's a problem, but try to preserve the stump at any given time, because then you obviously can't be too anterior, so you can't impinge on the notch. And also you won't be too large because you're within the confines of the stump. Yes, well, I do think a graft can be too large. I mean, especially if you use a round, thick graft. Partial thickness, it's to me, it's always an interesting discussion because we, it's, so I use partial thickness, but I use mainly a five by 10 millimetre graft or a five by 12. The first one is about, approximates an eight millimetre graft round, and the second one has the cross section of about a nine millimetre graft. Using a flat graft or partial thickness with the flat tunnel or a rectangular tunnel on the femur is, leads to, when you extend the knee, the graft gets more vertical into the notch. So the graft impingement is less than you have a bulky, round, full thickness graft in there. If it makes a difference clinically, I don't know, but this is just my experience. So the risk of overstuffing with a flat graft is less and you still have the same amount of collagen in the knee when you use a round graft. So that's the difference. As footprint coverage, I mean, we can have a long discussion upon footprints with the, you know, the ribbon-like anatomy and the C-shaped footprints. The question is, where is the footprint on the MRI? I think it's very hard to really identify the footprint because the ACL is kind of folded in the sagittal fuse, so it's always difficult for me to find this. But yes, I think that's interesting stuff we have to closely look at in the future, for sure. Okay, great. Let's move on to the next paper. So this is Dr. Lin's paper. This was referred to already a couple of times, the Danish Registry publication in the ESCA journal, which was from 2019, looking at the early results in Denmark. I know that in my practice and in our center here, that did put a little bit of a break maybe on what was a very fast-paced conversion to doing more quadriceps tendons autografts. So let's move to the next slide. Long story short, which was already discussed a little bit, these results did show that the revision rate was a bit higher for the QT graft versus hamstring or patellar tendon, and also associated with a bit of an increased measured laxity and higher degree of pivot versus the hamstring graft. In about 530 or so quadriceps tendon grafts, 54% of which had a bone block. And you can see the Kaplan-Meier estimate curve there, comparing the three graft types, and I pulled out a piece of the discussion that talked about actually things that we've already discussed, bone block or not bone block, is there a learning curve, and was this early data. So let's go maybe one more slide. So the questions that I pose, and of course, anybody on the panel can take this in the direction they would like. How do we interpret registry data in general, not necessarily this specific registry data, but versus comparative clinical trials? How do the experts on this panel, when they're looking at literature, maybe they publish in one or the other or both types of work as well, and how do you typically view this type of different data from a registry versus a comparative trial and then back to the learning curve and maybe it was a data premature which Martin already alluded to and we'll probably go to him next and then you know what do we know what do we feel about the bone block versus all soft tissue which I think the panel has discussed so why don't we start with with dr. Lin yeah so as we heard a few times we have this small quad tendon study group and when we met the first time in in Austria we sort of had the goal of we should look at registered data and this was actually what this study was all about so in Denmark when we sort of had our first 500 patient that had been operated with the quads and we had the purpose of doing a study on how those first 500 performed and this is what these data are about so of course they represent the early upstart of using quad tendon in more in an entire country and what we saw was this the pricing higher revision rate and of course since it was presented as studies are at conferences and it was presented at the East Coast Congress it gave a little bit of a scare out there but they represent what exactly studies do and this was how the quad tendon performed in an entire nation that was so starting up with using this this graph type then of course we also stopped a little bit to look at the data and getting more data in and also looking at our own and other clinics data we found out that the high revision rates was related to low volume clinics and looking at our own and other high volume clinics the revision rates were extremely fine so less than 2% at two years so so the study is a little bit maybe misleading because it's an average of an entire country and with with low sort of performing clinics that have drawn up the revision rate so that's also why the latest study that we have published shown that learning curve is really an issue so this graph type has some some issues that you need to get the harvest done in a good manner otherwise you might get a thin graph or a graph that is not as strong as you expected it to be and that can lead to failure and revisions but otherwise registry data are good data because they are sort of the real world of how something performs because it's that's what's out there I think it was really astonishing to everybody because the it was really against what what what individual data showed but I think it's I think it's important because as you said it's real data we have to realize it's a learning curve low volume centers don't do us as good in these cases but I think another another concern is really when we look at re rupture and failure rates I mean we really have to see what kind of patients we are dealing with I mean in the high active patients like in when we look at the professional skiers we operate on we have failure rates or re rupture rates of 25% above 20 up to 25% and I say I would almost say regardless of the graph because it's such a high risks high risk sport and it's extremely it's just extremely dangerous so so when we look at this registry data where we have like in general re rupture rates around 2% or 3% I think it's super low in general and I think we have to be very careful interpreting data on graph failures and re ruptures when we don't know exactly what kind of patients we are dealing with young kids with high activity and then female so we have to be extremely careful when we look at graph failure rates I think this is this is something I've learned from from looking at our own data. Peter or Volker any comments? Yeah I think that in registries in general are very good things to help identify especially in the arthroplasty world implants that lead to high failures and so they've really been a very valuable in that in that type of world I think ACL registries are also very valuable but you have to know the nuances as Martin said you have to know what's behind all the data the types of patients as Christian referred to the types of surgeons whether it's early in their learning curve what exactly type of technique they're using what type of fixation whether it be you know early methods of fixation etc so you have to know the nuances especially when you see something that doesn't quite jive with your own experience you have to dig deeper and know the type of patients and the type of surgical techniques that you're talking about. Yeah I don't have much to add I can just say that registry data is very very important I think in our field this is great data that comes out we learn a lot from it you know we've actually started in Pittsburgh looking at our own registry we have two million people in the greater area 50 surgeons that do ACLs and more than half of them do low volume so what Martin has showed we will show very similar data and it's sad but it's that's just how it is and I think that's something for us to work on and educate everyone so that they can come up and and do these types of surgeries important just is them and people interpret data that they don't interpret the wrong way so like that that initial paper was obviously taken by many that are quote-unquote and haters in the wrong direction and that's okay we we can we can show good plenty good data out of the Denmark registry and many others about this your last point there point three bone block versus all self tissue there's some systematic reviews out there but as I said earlier I think it's something we still want to learn a little bit more about but a bone block maybe the more consistent fixation okay great let's maybe move on to the third one we'll try to wrap up in the next five or ten minutes so this paper was in the October 2022 AJSM so it really was actually the one of the reasons to hold a webinar dr. Brett Owens that sent me the paper and said let's look at the topic so this was a meta-analysis actually but quite well done done by an authorship group in China I'm not sure what time it is there but we're already approaching midnight for our Europeans so not on the on the call and what they did here was look at both go to the next slide they looked at a systematic review and and then did a meta-analysis of 24 studies that have been published looking specifically at quadriceps tendon autographed seven of these studies were RCTs of some variable or variation in quality in general when they compile data they didn't find much difference for graft failure for differences in IKDC as the primary patient part outcome or for laxity if it was measured they did note less donor site morbidity which I think you know a lot of these things have been noted by the panel today in the quads tendon versus both BTB and hamstring and felt that although there were less RCTs that there was not a lot of difference in what they were able to analyze in the observational groups versus the randomized prospective groups and so there's a bunch of forest plots that we have just briefly look at showing almost no difference in failure rate for the for the first one this is comparing BTB and then this is the discussion about you know how to define this anterior knee pain and this more morbidity question which I thought was good which is you know looking at anterior knee pain in general looking at tenderness at the donor site or looking at difficulty of kneeling where quads tendon appeared to perform in the in the few studies that did look at it maybe two three or four outperform the BTB and then the same even with the hamstring although maybe a smaller effect size I'm happy to put the forest plots up again but I thought we would just sort of lead into a few questions and one last sort of open for the panel there are actually a couple of questions I may have the panel look at at the end as well and then we'll be ready to wrap up so this paper what what do the panelists think are we gaining valuable information if we're doing a systematic review of primarily level four studies or is there too much bias in that and we should wait and and look for more truly prospective randomized high-quality studies why do we think the donor site morbidity is less than and if anyone is still doing BTV or hamstrings can we look at ways of reducing donor site morbidity in those graphs or is quads just inherently going to be better and then finally which we talked on a little bit in the rapid-fire really are there deficiencies in this knowledge base do we think that the systematic review is state-of-the-art or where where should we go in terms of research wise so we could start with maybe dr. Fink yes well I do think we get some information although we have to say that also especially with respect to cotton and we do need more prospective randomized data I think there is a lack of data compared to other crafts because it's as I say is the youngest craft I think it's really it's really important that we gain some better quality studies for that also I think it's interesting of this paper was that really was not shown any difference between the randomized studies in the other so the outcome was rather rather similar so I think that should suggest at least that we can take this information in general I do think was what this study also showed that I mean there is no in the 90s we had BTP meant the gold standard I think we should go away from from searching for the gold standard graph I think any every graph has some pros and cons for the individual patient and and I say if you have a happy patient on the contralateral side with the hamstring five years ago and he's super happy I do not do a quad tendon on the other side because I think it's now I think now it's better I think I go with the same graph so I think it's a new search and we should really be familiar with all the graphs today and yes reducing the habit side and I think this is important to think of as as I say it would be the patella tendon you can use a very small bone block also from the patella I think the key issue is the patella in the BTP is not there is not the tuberosity it's it's the patella if you have problems and you have it on this side so rather use a small bone block smaller bone block here bone graft that the defect I think that's that's that's helpful with hamstrings well I'm not sure I mean using only the the the semi T rather than using both all the time I think at least reduced subjectively my mobility in my procedure so I I rather use if I use hamstrings I rather try to get away with with just the just the semi T and not both of them so I think we can work maybe transverse incisions incisions also for patella tendon harvest is possible be used to this for quite some time I think it does reduce the at least the sensibility loss which you which you get so there are little ways to to improve on the other grafts I think and we should we should work on and definitely I think with respect to we do need more high-quality studies for that I think all the points because they're made I share I can just maybe add for systematic review and I should probably preface by saying I'm guilty I probably have more than 50 systematic reviews out there to me a systematic review add something if it is at the end of a logical sequence of papers wrapping it up like a summary so when the single versus double bundle systematic review it came out in arthroscopy I thought it was premature and so this one too you know you have level four because all the big studies are still in the making so I think this is an okay study but it is level four it should be taken as such and in a few more years we have randomized control trials and then if you want to summarize those I think you get more valuable information from that so level of evidence is important is my point I think that early on when you have a new graph or relatively new graph let's not forget that Marshall it published on the quads graph 1979 and Walter Herzog used the graft for a long time and Freddy Fu so there's it's not really a new graft the popularity is very new but early on I think you're going to have level four studies and they are important to get an early sense of how the graft is going because let's not forget it takes about six or seven years to do a proper RCT at least in our Center so you're going to wait a long time to get an RCT if you just wait for that so I don't really have any other thing else to add in terms of donor site morbidity reduction but I agree that you should be a good ACL surgeon should know how to use all three graphs and be proficient in all three because there's going to be times when you you have to customize the graft to the patient there's going to be times when you have to use the different graphs in different situations yeah and I think this systematic review represents pretty much what we know right now but the meta-analysis are not that strong because of the still a high proportion of level four studies so it is a little premature to have a good systematic review on the topic right now but it represents what we know and it concludes that we have equality for failure rates revisions subjective outcome instability but there is a certain certainly an advantage regarding donor site morbidity with with this core tendon graft and that is what we should hold on to and certainly it looks like it's a safe graft I don't think the big studies that are ongoing will show us a whole lot more surprisingly results with this graft it's just going to show that it is a very good graft that is gives good stability outcome with little complications great okay well we have I think in the interest of time well maybe only look at two of the questions looking at the list of them and we did cover a lot of the questions that were posed by our viewers so I'm very happy about that I've been unbeknownst to the group of course one thing was not talked about if anyone has any comments is about return to sport any differences any changes with the quad and the second is about double bundle technique if it's possible with a quad graft if anyone has tried that or there may be indications for that I can tell you the double bundle is is something you can do with a quad very well you can split in the natural plane we've published on doing that versus splitting it in half and both work very well there's good mechanical data out there and return to sport this is really about the same it's the same that's a long I mean if you want to go down that path I mean we can we can talk all night what everybody thinks about but I probably have to run pretty soon sorry anybody else for any final comments about double bundle or return to sport yeah certainly you can do double bundle and I mean we've done tons of these with PCL in the back in the day and you can use the same principle for for the quad tendons I don't do double bundle for ACL but it's it's easy with the quad tendon so as Paul said and and also I don't do any difference in return to sport criteria for this graph time yeah I agree with the answer so nothing to add for me for me the same I have no experience with double bundle really return to sports I think about the same there's more and more criterias I think there is with respect to all the graphs so I don't think there's a difference really between the between the individual graphs great so my sincere thanks to this panel this is obviously not just a global panel but really world expert panel so it's been really enlightening for me and I've enjoyed it and thank you all for taking the time out of your day or late night to be with us thanks Dave for organizing it was a great webinar thank you thank you thanks for inviting yeah thanks guys good night good night good night good night I'd like to give a big thanks to our panelists and presenters for their work on tonight's webinar and thank you attendees for your participation if you're interested in CME or you would like to view the recording of this webinar please go to education.sportsmed.org log in click on my resources and then click the course title you can then complete the evaluation for CME or view the recording which will be available later this week this information will be emailed to you in 24 hours so please don't worry about remembering it all thank you again for your participation and have a great rest of your night you

webinar

ACL reconstruction

quadriceps tendon autografts

graft option

hamstring tendon

patellar tendon

harvesting techniques

systematic review

donor site morbidity

patient factors

high-quality research