Thanks, Michelle, and thanks to the program committee for having me. I'll be talking about quadriceps tendon autograft. My disclosures are not pertinent to this talk. So when we're doing ACL reconstructions, we want to look at our graft qualities and, you know, looking at what makes the best graft. So to me, I always look at this and think about the similar, you want to have similar biomechanical properties of the native ACL. You want to have minimal harvest site morbidity, a low complication rate, safe to use in open growth plates, timely graft maturation, and great clinical outcomes. We look at the biomechanics of the native ACL and also of the autografts and allografts available. And if you look at this, you can see that the quadriceps tendon autograft has, is the most similar in ultimate tensile load and stiffness to the native ACL. We look at complication rates. So in this prospect of randomized trials published in 2014 and 2020, quad tendon was compared to patellar tendon and quad tendon had less kneeling pain, left graft site harvest pain, and also decreased numbness. And quad tendon compared to hamstring had less harvest site pain and less numbness. In a systematic review published in 2021, quad tendon had better isokinetic hamstring versus quad ratio compared to the hamstring. Knee flexion strength exceeded 90% in nine months post-operatively in the quad tendon group. And knee extensor strength was similar to the patellar tendon group at the five to eight-month post-operative window. Also, quad tendon has shown to be, have less pain and lower analgesic requirements than hamstrings in the media post-operative period. Then we talk about an open growth plate. So in adolescence, in this cohort study of trans-ficeal ACL reconstructions published in 2019, they compared quad tendon to hamstring tendon and open fices. It's a two-year minimum follow-up. There were similar outcome scores and there were no ficeal complications in this trans-ficeal group. However, the retear rates were significantly different. It was a 24% chance of retear rate in the hamstring group versus only 4% in the quadriceps tendon group. And in this case series in adolescence published in 2022, the average age of 15, two of the patients had open fices and 19 had closing fices. There was an 86% return to play rate. The Lyshom score was 98. And there was no anterior knee pain and no numbness reported in the group. Then we talk about graft maturation. We look at MRI signal intensity ratio and signal to noise quotient. And this will vary between graft type, the source, and time after ACL reconstruction. When quad tendon has been compared to hamstring, there's a significant decrease in the MRI-SIR between three to six months and 12 months postoperatively, suggesting that there was an improved graft maturation, remodeling, and structural integrity. In a systematic review comparing all three grafts, all three autografts, quad tendon, patellar tendon, and hamstring published in AGSM in 2019, it included 27 clinical studies over 2,800 patients. And they had comparable clinical and functional outcomes and graft survival rates. In this prospective level three cohort in AGSM 2020, there was a 2.7% or sorry, 2.7 times ACL failure in hamstring autografts when compared to quadriceps tendon autografts. And then in the systematic review published more recently in 2021 comparing all three grafts, there were 24 randomized controlled trials. And there was no difference in graft failure, IKDC scores, or stability. And the MRI prospective data on over 1,000 quad tendon grafts, which is ongoing, has shown a failure rate of 4.2%. So why I use a quad tendon graft? It has a similar ultimate tensile load and stiffness to the native ACL. It has more collagen and higher fibroblast density. It has 20% more collagen per cross-sectional area than the patellar tendon autograft. It's stronger, at least a stronger remaining tendon. It has similar extensor strength to the patellar tendon in the five to eight months postoperatively. Better flexion strength in the hamstring, approaching 90% at nine months. There's no reported incidence of anterior knee pain or numbness. It's equivalent or potentially better outcomes in stability than patellar tendon and hamstring. The quad tendon length and cross-sectional area can be tailored. Size is not an issue with this graft. And it's a good option for patients with open growth plates. So when do I use a quad tendon graft? I use it a lot of my female athletes, especially the younger ones, with either open or closing growth plates. I always worry about the quad dominant athletes, especially the lacrosse and soccer players. And older athletes over the age of 30, open growth plates, it's a great graft to use in. Any patients with a history of anterior knee pain, patellar chondrosis, or MRI confirmed significant patellar tendinopathy. And also it's a great graft to use in revisions. The considerations after doing these for probably about 12 years, there's certainly a higher incidence of extension loss. And this may be due to higher collagen density in the graft or greater volume of the graft. The important thing is to work very closely with your physical therapist. You have to stay on top of these patients early on. I actually educate them preoperatively and then also in the pre-upholding area. And we go over that early quad activation, focusing on this terminal hyperextension, active terminal hyperextension, and regaining that active quote heel pop by at least six weeks after surgery. So you want to focus on closed chain and the safe open chain exercises early on. About a two to three centimeter incision. I check the mobility of the skin. Let's see if it works here. My finger is on the superior pole of the patella and I'll mobilize the skin, see how much mobility I get. I harvest a graft initially in flexion at 90 degrees and then extend the knee to about 30 degrees of flexion. It was linked. It was working back there. I have it also loaded up separately if you want to open it separately. Anyway, so I make the skin incision, come down to the quad tendon fascia. I like to use a cob elevator, elevate the soft tissue off the fascia, expose the VMO. You really want to make sure that you see that vastus medialis because sometimes it looks like it's going to be a short tendon. But as soon as you peel off that VMO, you'll see the tendon extends approximately. I use a nine millimeter double blade scalpel to mark my site. And then I use a needle tip bovie to harvest the graft. Anyway, I use a needle tip bovie to harvest the graft. I'll peel it off. I actually try and keep the retinacular layer intact, but on a small patient, I'll go do a full thickness graft. If it's a larger patient and the large quad tendon, I'll just take part of the intermedius. I always close the defect with a thick suture afterwards, a number two suture in a figure of eight fashion. So I do close the whole defect. It's a soft tissue graft. I don't take any bone with the graft. I guess we're not going to have any luck with the video. All right. So then that's it. And I do the same kind of technique. I do the medial portal technique, prepare the graft. I use a button fixation on the femoral side, and then I use a screw fixation on the tibial side. Thank you. That's it.

quadriceps tendon autograft

ACL reconstructions

graft qualities

biomechanical properties

minimal morbidity