Thanks so much. Thanks for having me here. Program committee for be able to share this this my approach to my favorite graph my high-level athletes. Disclosures are in the program. In 2008 I was a far too junior faculty member at the Learning Center. Dr. Walt Shelton was there and he gave us a great talk about the use of quad tendon for ACL reconstruction for primary ACL reconstruction and when he got done my first thought was I think he's lost his mind. You know as luck would have it several years later I had a group of patients kind of cluster in my practice that I thought would benefit from quad reconstruction. They had some inferior patella issues and it I really haven't looked back since. Dr. Shelton was right. So why the quad? I think it's a really good alternative to bone patella tendon bone. Not that there's anything wrong with that graph. It's a reproducible harvest. It really has minimal graph variability. Probably my favorite thing. It's the same graph every single time. It's got a large collagen mass. We could get really robust fixation and start early aggressive rehab and it has acceptable harvest morbidity compared to our other autographs that we have. The technique we'll talk about today is one where I think you can do this Monday. This is all stuff you have in your OR right now. There's a lot of great techniques out there. This one is a fairly straightforward one that I use and it does have bone with it though you can do it without bone as well. This is our patient. He's a 16 year old multi-sport athlete. Tore his ACL playing football. Really no other pathology within his knee. So the incision is lined up starting at the superior pole of the patella. It's about two and a half centimeters long when the knee is straight. When it's in when it's in flexion it stretches to about four centimeters. Sort of standard approach. Get down to the quad tendon and then elevate well under the skin flap. It allows you to work far proximal. 15 blade is in use starting on the medial side to create a cut through the quad tendon at the desired length. And it's really important to stay centered over the patella if you're going to use bone plug. You don't want to take an eccentric bone plug. Once that's done you can use a half inch osteotome. I like this. It's like a vertical knife. You can kind of slide it right up the cut to make sure you have full depth and whatever length that you've chosen depending on your fixation. Next thing is put an extension. This bursal layer is reflected. I think this is important because if you're taking a bone plug I like to bone graft the defect. And by saving this bursal layer you can close this over the top of the bone graft. So you don't have any escapees that can become subcu. The bone plug is then lined up. It's 10 millimeters wide, 20 millimeters long. You can use a shortened ruler here just to make sure. And you can see the patella just fits in the incision. Standard micro-sagittal saw to make your cuts just like a BTB. And then a 15 blade to carefully release the bone plug from the attachment there to make sure you don't disrupt the tendon and bone interface. Once that's done, then I'll use a ruler working under the skin flap to get my length. Alternatively, one of our fellows, Mikael Klemster, last year liked to make a little mark on the Mayo scissor so he knew exactly how long we were going to go. And then it's simply released. And then we wrap this in a vancomycin saline soap sponge on the back table. For prep, again, things that you have in your OR right now, ronger, drill, and high-strength suture. Two in the plug, two in the soft tissue. I shoot for 9 millimeter plug diameter and a 10 millimeter soft tissue diameter, which I think helps with passage. Here's our final x-rays in the operating room. You can see this is standard fixation, a metal screw on the femur, a peak screw then on the tibia, and then a 3.5 millimeter cortical screw. And I'll tie the sutures around that for secondary tibial fixation. Picture on the bottom of the final reconstruction. So as we've already heard discussed, there are lots of good articles showing that the quad is a good option for ACL reconstruction with really well-tolerated harvest morbidity. And some common questions that I get. Do you take full thickness? Yes. Do you close the defect? Yes. That can be done with a standard suture or with the antegrade cuff suture pass through, which is easy to use. Do you bone graft? Yes. I like to use allograft, though you can use autograft. It has to be collected during the case. And then what length of graft do you use? So the bones, 20 millimeters. Total length for males is 90 millimeters and 80 for females. And that puts you right at the external tibial aperture and a standard rehab protocol. Thanks so much.

ACL reconstruction

quad tendon

bone-patella-tendon-bone graph

reproducibility

minimal variability