Deroche Etienne, Erasmus Pieter, Roberts Cecilia
Knee Clinic Stellenbosch, Stellenbosch, South Africa.
Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, Lyon, France.
Video J Sports Med. 2022 Jan 20;2(1):26350254211058731. doi: 10.1177/26350254211058731. eCollection 2022 Jan-Feb.
Quadriceps tendon autograft is used increasingly worldwide for primary anterior cruciate ligament (ACL) reconstruction, but remains at the third place after patellar tendon and hamstring grafts. It has shown very good results in biomechanical and clinical studies, but most of the authors describe a partial thickness tendon graft.
This presentation describes the technique for a full-thickness quadriceps tendon autograft with an original technique of fixation on the femur and provides tips and tricks to avoid pitfalls.
Arthroscopic preparation of the tunnel is performed before graft harvesting, to obtain the exact length of the graft needed. The femoral tunnel is drilled through the anteromedial portal, 30 to 40 mm long. For the tibial tunnel, a classic drill guide system is used, set at an inclination of 40°. The total length from the tibia to the femur is measured, which allows to position the femoral fixation on the cortex without pulling it into the soft tissue. Harvesting of the graft is done using a double-bladed scalpel, using the entire thickness of the quadriceps tendon. The bone block is detached with an oscillating saw and osteotome, and the defect in the quadriceps tendon closed in 2 layers. The graft is calibrated according to the tunnel preparation and sutured on the bony end with non-absorbable sutures tied to an endobutton. Tibial fixation is achieved by tying 2 non-absorbable sutures over a cortical screw in maximum tension with a sliding type knot, to automatically adjust the tension. Final fixation is performed with a titanium interference screw.
In the senior author series over the last 20 years, there was only 1 intraoperative patella fracture, treated with osteosynthesis. In accordance with the literature, full-thickness quadriceps tendon graft is strong and allows back to play at the same level as before the injury, in most cases, with lower donor site morbidity than patellar tendon and hamstrings grafts, without a difference in muscle strength compared with partial thickness grafts.
DISCUSSION/CONCLUSION: ACL reconstruction with full-thickness quadriceps tendon has shown very good clinical outcomes, with very few complications. It can be recommended for primary and revision ACL reconstruction.
在全球范围内，股四头肌腱自体移植越来越多地用于初次前交叉韧带（ACL）重建，但仍排在髌腱和腘绳肌移植之后位列第三。它在生物力学和临床研究中显示出非常好的效果，但大多数作者描述的是部分厚度的肌腱移植。
本报告描述了全厚度股四头肌腱自体移植技术以及一种在股骨上的原始固定技术，并提供了避免陷阱的技巧。
在采集移植物之前进行关节镜下隧道准备，以获得所需移植物的确切长度。通过前内侧入路钻股骨隧道，长30至40毫米。对于胫骨隧道，使用经典的钻孔导向系统，设置为40°倾斜。测量从胫骨到股骨的总长度，这使得股骨固定能够定位在皮质上而不会将其拉入软组织。使用双刃手术刀采集移植物，采用股四头肌腱的全层厚度。用摆动锯和骨刀分离骨块，股四头肌腱的缺损分两层闭合。根据隧道准备情况校准移植物，并用不可吸收缝线缝合在骨端，缝线系在内置纽扣上。通过在皮质螺钉上以最大张力系两根不可吸收缝线并采用滑动式结来实现胫骨固定，以自动调节张力。最终固定采用钛质挤压螺钉。
在资深作者过去20年的系列病例中，仅发生1例术中髌骨骨折，采用骨固定术治疗。根据文献，全厚度股四头肌腱移植物强度高，在大多数情况下能使患者恢复到受伤前的相同水平，供区并发症发生率低于髌腱和腘绳肌移植物，与部分厚度移植物相比肌肉力量无差异。
讨论/结论：全厚度股四头肌腱重建ACL已显示出非常好的临床效果，并发症极少。可推荐用于初次和翻修ACL重建。
