So, no relevant disclosures to the talk, I guess the biggest relevant disclosure is when I first started practice about 10 years ago, I was doing about half BTBs and half quads, and just naturally evolved more towards quads as I saw in my patients post-op. I'm going to talk about the surgical technique and sort of how it's evolved, I'm going to talk about how we harvest and prep the graft, and then I'm going to show you my surgical technique for all-inside quad, hopefully how to avoid some of the snake pits and show some pearls, and I'll talk about complications. So, as Mary mentioned earlier, this is really not a new idea, Dr. Fulkerson put this on Twitter not too long ago when he saw his soft tissue graft quad catching on. And again, it's been around for a long time, but really it's evolved, the surgical techniques have evolved, how we use the quad graft has evolved, and how we fix it has evolved significantly. And I think it didn't catch on for a lot of reasons, some early poor outcome studies, but really very different than what we do now. But it's not taught commonly, and so people don't do it in training, and I think that is changing. But we also have a lot of instrumentation and fixation devices that are much better now at fixing the quad. So you saw earlier the sort of initial quad came out as we know it with a central quad tendon with bone, and I think a lot of studies have shown that we probably don't need bone, but I agree there's a bit of paucity of literature here, but there's at least a couple studies that really show not a significant difference whether you choose to use bone or no bone. We've gone to a minimally invasive harvest, so the historical quad was harvested through a very big incision. There's nothing wrong with that, but you can now do it through a relatively small incision that's a little bit more cosmetic. You know, when you look down at the quad, it's certainly anterior and more proximal on the leg, so you can see it while sitting. That's different to a lot of the other incisions that we use about the knee. I've gone from a full tibial tunnel to an all-inside technique, and I think a lot of people have also done that, but there's nothing wrong with using a full tibial tunnel, and there's some good data. There's some data that suggests there's probably no difference in using an all-inside technique versus a full tibial tunnel, but there is some data that suggests there may be better outcomes with an all-inside technique, and I think time will tell if there's a difference. And for me, I started off trying to harvest every quad as a partial thickness graft, and now I harvest every quad as a full thickness graft. I think it's easier, I think it's more teachable, I think it's much more approachable, especially for people as they're learning how to do the surgery, and most studies would actually show there's really no difference whether you use a full thickness or partial thickness graft. Again, no difference. Actually, this study showed better biomechanical properties with a full thickness graft. This study did mention that there may be a poor quad function with a full thickness graft versus a partial thickness graft, and again, I think time will tell if there are significant differences there, but for me, I think it's much easier to harvest a full thickness graft. The things that I really like about using a quad graft, especially with an all-inside technique, is there's very low donor site morbidity. I find it very easy and reproducible for me. You can take what you need and leave normal anatomy behind, and I think the less that you take from the patient, the less postoperative pain they have, the better quad function they have, and the quicker they get back to doing what they want to do. And then I like the ability to tension and re-tension with an all-inside technique. So getting to our case presentation, this is a 16-year-old female, non-contact injury, history and exam concerning for an ACL tear. Not hyperlax, no other risk factors for increased risk of ACL failure, and her ligamentous exam was otherwise stable. So the time of surgery, medial compartment was fine, torn ACL. She had this lateral meniscus root oblique equivalent tear that we elected to fix. And so let's talk a little bit about graft harvest. So I like to make about a two-centimeter incision. There's absolutely nothing wrong with making a bigger incision. I think especially if you are transitioning into the quad world, make a bigger incision. Females tend to have a little bit more fat between the quad tendon and the skin. I think it's really important that you excise that fat to improve your visualization. So this is sort of our skin incision just over the quad. I'll mark out the VMO. I want to avoid the VMO, but mark it at or just proximal to the superior pole, the patella. So once we excise this fat, you can sweep away the soft tissue, overlying the quad, and develop a space between the subcutaneous tissue and the quad. And then what I'll do is I'll stick an Army-Navy retractor in the apex of the incision, and I'll stick the camera in, and I'll visualize the VMO. I'll visualize the lateralis, and I'll visualize the distal musculotendinous junction of the rectus. And I take a spinal needle from the skin, and I'll stick it in the quad tendon. And if you want to, you can measure to look at your length. I've never had one that's too short in doing an all-inside technique. And I also will use that almost like a flagstick for a golf hole, but it's also a depth stop. So I know when to stop so I don't get into that rectus musculotendinous junction. If you need a little bit more, you can take a little bit more. But for me, that's been a very useful trick. And then I'll mark our width on the tendon. There's lots of different ways to do that. I make full-thickness parallel incisions. I think taking your incisions up as proximal as you can go makes this harvest easier. The error that I see people try and make is they make a small incision, and then they try and use whatever harvest device to do the majority of the dissection. I don't do that. I like to use medicine balm scissors or a knife and take up the parallel incisions as proximally, pretty much as far as I can get through my incision. And if you make a three centimeter or four centimeter incision, you're only trying to harvest a 65 millimeter graft. You can see most of what you want to see pretty easily. And so then we dissect the distal tendon off of the patella, continue the dissection proximally after we whip stitch it. We transect the graft proximally and then close the defect. And I usually shoot for grafts that are about 65 millimeters in length for most adults and about 10 millimeters in width for most adults. And obviously that's modified, bigger patient, smaller patient, pediatric patient. But that really gives you, you know, 20, 15, 20 centimeters in each tunnel and, you know, the appropriate of interarticular length as well. You want to taper both ends of the graft. I think this is important, different than your hamstring graft that sort of naturally gets bulleted, the quad graft naturally is squared. And so as you're going to pull the graft into the tunnel, it can hang up a little bit. So if you taper the ends of the graft a little bit, it can make passing the graft a lot more simple. I'm going to show in a surgical technique here in a little bit. I didn't do a good job of that and how I fix that when that happens. You want to ensure that all layers of the tendon are captured with the suture. As Mary mentioned earlier, that proximal quad is multilaminar. So you want to make sure you're grasping all that with your suture. And then I really find these compression tubes helpful. So I can usually compress the graft down by at least one millimeter from where I start. So if I measure it at a 10, I can usually get it back down to a nine. If I get it into a nine, I usually upsize to a nine and a half with my reamer just to help pass the graft. And I think that over time, that graft's going to expand and really fill that tunnel. So this is how we prep the graft. There's lots of different ways to use this. This particular technique is using a tape construct. We just published a study recently that tape constructs for prepping quad grafts are stronger biomechanically, especially for the multilaminar proximal layer where there's the biggest difference between just whip stitching the graft. This was with a PGY2 resident who'd never seen a quad prep before. He was kind of helping me. It's very easy to do. For years, I was whip stitching the graft and tying it to the button. You can do that. There's lots of different techniques out there, but this works well for me and I think biomechanically is very favorable. Basically, you lay the tape over the quad graft. You whip stitch through the graft, piercing the tape each time. You'll come back up through the button and then whip stitch back the other way on the graft and then cut it and tie it. And it's very simple. It does not take a very long time. And you do the same thing for both sides for an all-in-side reconstruction. And this is kind of what the graft looks like when you're done. You can see it's a little bit squared. So we use these graft compression tubes and the sort of before is on the left and the after is on the right. And you can see it's a much more rounded graft that I think is easier for graft passage. So this is how we do the all-in-side ACL reconstruction. We're going to identify our footprints. Pretty simple. We're going to retro drill our femur and place our passing stitch. I used a pin here. When filming this video, when I first started, I was like, oh man, I missed. This isn't good. I'm going to refilm it next time. I thought, you know what? This is real life. This is what happens. So this is how I fix this. So I don't like my pin position. In this case, what I'll do is I'll tap in my bullet a little bit. And I'll just kind of walk the pin in the direction that I want to go freehand. And I'm able to move it, in this case, just a couple of millimeters from where it started to where I thought it needed to go. And you can kind of see here kind of where I started and where I wanted it to be. Not too far off, but just ways to make small adjustments at the time of surgery. So we were able to make that correction. I come in with the device that I like to use for retro drilling, but there's a lot of different companies that make their own version of this product. And so I usually drill to about 25 millimeters, planning to bring about 20 millimeters of graft into the tunnel. You can drill a little bit more, but you want to leave a little bit of space after you get your graft in the tunnel to tension and retention. So there's our socket. We pass a passing stitch. I like to mark the tibial footprint, and then I'll extend the knee. And I want to make sure that mark corresponds with the apex of the notch. And that usually tells me if I'm in the right position. And I kind of want to visualize where I think the ACL will be if my tunnel's right there. And then we do the same thing. And guess what? I missed again with my pin. So did the same thing. Walked the pin over to the spot where I wanted it to be. As you can see here, kind of a little bit off. And if you just sort of gently put pressure on the bullet, you can kind of walk that pin over into a bit of a better position where you want it to be. So here we are with our, again, our retro drill. Same thing. I like to clear the soft tissue around the aperture because I think that sometimes causes you to get stuck. So in this case, we'll just ablate a little bit of that soft tissue as we pass our graft. I'm going to grab both sutures and bring them out a slightly enlarged intermedial portal, making sure that I've cleared away a lot of that soft tissue and fat. And then we pass our graft through the intermedial portal. I also like to visualize the button flipping from the inside. I didn't actually do that in this case. But I'll show you that I also like to visualize the button flipping or flipped from the outside. So we've passed our femoral sutures. Here I am. I'm now looking through the lateral side of the thigh, following my sutures down. That's IT band. And you can sneak through IT band and see your femoral button deployed on the cortex. And for me, that's been a very useful tool. I don't use C-arm to confirm that button position. I just look at it directly arthroscopically. And then we'll pull our femoral graft up into the tunnel, as you can see here. Usually the sutures are about at two centimeters, so that's just a good reference for how much graft to pull up. But I usually will measure it before I pass the graft. And then a little bit of another technical error here. This is what I was alluding to earlier. As I go to pass the tibial side of the graft, I get hung up. And I don't think I did a great job of trimming these sutures. So I'll show you my technique for dealing with a quad graft that won't dunk into the tibial side. You can see there I left a little bit too much tissue. So what I like to do is actually come in with a right angle clamp, and I'll stuff some of that tissue down into the socket, almost like a shoehorn. I'm pulling really hard there, and that graft is not going. So I'll come in with a right angle clamp, and I'll just stuff some of that tissue in. And then as soon as you pull tension and cycle the knee, that graft will dunk into the tibial socket. So there we cycle our graft with tension. Then I put the tibial button on, and I'll tension the tibial side. I'll re-tension the femoral side. I'll cycle the knee again and re-tension one last time. And then I like to tie the sutures over the tops of the buttons. And this is our final construct. So are there complications with quad grafts? Absolutely. Nothing is perfect. Most studies show similar rates of re-tear with quad grafts compared to BTB and hamstring grafts. There is some concern about loss of terminal knee extension with quad grafts. I'm not sure if that's real. It very well may be. I think it may be related to sort of graft notch mismatch. So quad graft can be a big graft. I think if you overstuff the notch, you can lead to some extension problems. So I'm careful to not make the graft too big. Certainly don't want it too small. And then I like to fix the knee in full terminal knee extension, or really neutral knee extension. So right at zero, I'll fix the graft on both sides in order to minimize the risk of that loss of knee extension. And I hammer knee extension early in the post-op period. We talked about quad tendon deformity that can happen after a quad graft. As long as you're not going past that original picture that we published with the proximal rectus retraction was very early on in our quad experience. So now we were shooting for eight plus grafts. Now we're shooting for 65. So we're getting nowhere near that musculotendous junction of the rectus. And I'm not worried about really that rectus retraction anymore. Anterior knee pain, definitely lower in the quad tendon group compared to the BTB group. Quad tendon rupture, very low, probably 1% or less reported in the literature. And I do think patella fracture, if you take bone, is a real complication. There's some more recent data that shows up to, in one study out of Pittsburgh, up to 7% risk of patella fracture with taking bone. So I don't think you need to take bone. I think you can take bone. If you do, I would recommend taking a triangular bone plug and I would keep it fairly short. The proximal pole of the patella has a much smaller area, I think, to harvest from than the distal pole of the patella, which has a lot of non-articular bone. So if you're interested in getting to quads, I think you should. Jump on in. The water's fine. I had my boy surfing about a year ago in Fiji, so thank you very much.

surgical techniques

quad grafts

instrumentation

graft harvest

complications