Late quadriceps tendon rupture at the donor site following cruciate ligament reconstruction using central quadriceps tendon graft

Pandey, Vivek; Madi, Sandesh; Joseph, Anthony J.; Acharya, Kiran

doi:10.1136/bcr-2015-212621

Cited by 8 publications

(6 citation statements)

References 31 publications

(33 reference statements)

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“…Chen et al reported that 9 % of subjects exhibited donor site pain after quadriceps graft harvesting, and the risk of occult partial rupture of the remaining quadriceps tendon may exist. Late quadriceps tendon rupture at the donor site following harvesting of a quadriceps tendon graft has been reported (Pandey et al 2015). Loss of quadriceps muscle strength of 20 % after harvesting the quadriceps tendon graft for anterior cruciate ligament reconstruction and prolonged weakness of knee extension strength, predominantly in women, have also been reported (Chen et al 2006;Yasuda et al).…”

Section: Discussionmentioning

confidence: 99%

New insight in the architecture of the quadriceps tendon

et al. 2016

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BackgroundPublished data regarding the structure of the quadriceps tendon are diverse. Dissection of the quadriceps muscle group revealed that beside the rectus femoris, vastus lateralis, vastus intermedius and vastus medialis a fifth muscle component– named the tensor vastus intermedius consistently fused into quadriceps tendon. It can be hypothesized that all these elements of the extensor apparatus of the knee joint must also be represented in the quadriceps tendon. This study investigated the multi-layered quadriceps tendon with special emphasis on all components of the quadriceps muscle group including the newly discovered tensor vastus intermedius.MethodsTen cadaveric lower limbs were dissected. All muscle bellies of the extensor apparatus of the knee joint were identified and traced distally until they merged into the quadriceps tendon. Connections between the different aponeurotic layers of each muscle were studied from origin to insertion. The fusing points of each layer were marked. Their distance to the patella and the distances between the fusing points were measured.ResultsSix elements of the quadriceps muscle group form a tri-laminar structure of the quadriceps tendon. The intermediate layer could be further sub-divided. The elements of the quadriceps tendon are 1. lateral aponeurosis of the vastus intermedius, 2. deep and 3. superficial medial aponeurosis of the vastus intermedius, 4. vastus lateralis, 5. tensor vastus intermedius and 6. rectus femoris. Even with differences in fiber direction – these elements join each other a certain distance proximal to the patella.All elements were fused over a region measuring 13 to 90 mm proximal to the patella. Lateral parts of the vastus intermedius formed the deepest layer of the quadriceps tendon. The superficial and deep layer of the medial vastus intermedius aponeurosis fused 56 mm (range, 30 to 90 mm) and 33 mm (range, 13 to 53 mm) above the patella with the aponeurosis of the tensor vastus intermedius and vastus lateralis respectively. Together they built the two-layered intermediate layer of the quadriceps tendon. The tendon of the rectus femoris forms the superficial layer. The vastus medialis inserts medially in all layers of the quadriceps tendon.Fibers of the lateral muscle components were oriented towards the medial, and fibers of the medial muscle components were oriented towards the lateral femoral condyle.ConclusionsThe three-layered quadriceps tendon is formed by six elements. These are 1. lateral aponeurosis of the vastus intermedius, 2. deep and 3. superficial medial aponeurosis of the vastus intermedius, 4. vastus lateralis, 5. tensor vastus intermedius and 6. rectus femoris. These elements of the extensor apparatus join each other proximal to the patella in a complex onion-like architecture. Its two-layered intermediate layer shows variable fusions points. The vastus medialis contributes to the quadriceps tendon with its medial insertion into all layers of the quadriceps tendon.

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Section: Discussionmentioning

confidence: 99%

New insight in the architecture of the quadriceps tendon

et al. 2016

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“…A recent report of delayed-onset QT ruptures has been described in ACL reconstruction with adult QTs. 21…”

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confidence: 99%

Quadriceps Tendon Graft Anatomy in the Skeletally Immature Patient

Shea

Burlile

Richmond

et al. 2019

Orthopaedic Journal of Sports Medicine

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Background:The quadriceps tendon (QT) is increasingly considered for primary and revision anterior cruciate ligament reconstruction in skeletally immature patients, as it may be harvested as a purely soft tissue graft with considerable tissue volume. Because of distinct rectus tendon (RT) separation from the QT complex, the potential for RT retraction exists and could lead to QT weakness after QT graft harvest.Purpose:To describe the anatomy of the pediatric QT and clarify decussation of the RT and QT to avoid the risk of delayed RT retraction and QT weakness after QT graft harvest.Study Design:Descriptive epidemiology study.Methods:Nine cadaveric knee specimens (aged 4-11 years) underwent gross dissection. Coronal-plane width and depth of the QT were measured at intervals proximal to the superior pole of the patella at distances of 0.0, 0.5, 1.0, and 1.5 times the length of the patella. The distance was measured from the superior patellar pole to the point of RT separation from the remainder of the deeper/posterior QT.Results:The median patellar length was 28 mm (interquartile range, 26-37 mm). The coronal-plane width of the QT was larger superficially/anteriorly when closest to the patella but wider when measured deeper/posteriorly as the tendon extended proximally. The median distance between the superior pole of the patella and RT separation from the QT was 0.95 times the patellar length. The distance to widening of the deeper/posterior aspect of the QT was 1.14 times the patellar length proximal to the patella.Conclusion:The RT begins a distinct separation from the QT above the superior pole of the patella at a median of 0.95 times the patellar length in skeletally immature specimens. The deeper/posterior aspect of the QT begins to increase in coronal-plane width proximally after a distance of 1.14 times the patellar length above the knee, while the superficial/anterior aspect of the tendon continues to narrow. Awareness of the separation of the RT from the QT, and the coronal-plane width variation aspects of the QT proximally, is important for surgeons utilizing the QT as a graft to avoid inadvertent release of the RT from the rest of the QT complex.

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“…Donor-site quadriceps tendon rupture following QT ACL-R is an extremely rare complication; only two occurrences have been published in the literature at the time of writing. A 2015 case shared an instance of QT rupture 10 years following combined ACL and posterior cruciate ligament reconstruction, which were performed with QT and quadrupled-hamstrings graft, respectively [62]. One instance of QT rupture four years after QT ACL-R was reported in a 2020 retrospective cohort study [16].…”

Section: Discussionmentioning

confidence: 99%

“…Donor‐site quadriceps tendon rupture was defined by imaging‐diagnosed physical tear of the remnant quadriceps tendon at the harvest site [62]…”

Section: Discussionmentioning

confidence: 99%

Less than 1% risk of donor-site quadriceps tendon rupture post-ACL reconstruction with quadriceps tendon autograft: a systematic review

Singh

Glassman²,

Sheean³

et al. 2022

Knee Surg Sports Traumatol Arthrosc

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PurposeThe purpose of this study is to develop a comprehensive complications profile for quadriceps tendon‐autograft anterior cruciate ligament reconstruction (QT ACL‐R). MethodsA traditional and grey literature search was conducted in accordance with PRISMA and R‐AMSTAR guidelines. PubMed, EMBASE, MEDLINE, CINAHL, Cochrane, Web of Science, and many grey literature sources were searched from inception to May 29, 2022. All studies were searched and screened in duplicate with included studies being of all levels of evidence, reporting complications, and with patients of all ages undergoing primary ACL reconstruction with quadriceps tendon autograft in the last 15 years. Studies were excluded if they had cadaveric or animal subjects or were reviews. Risk of bias assessment was conducted using MINORS criteria for non‐randomised studies and Cochrane’s RoB 2.0 for randomised studies. Data were summarised with weighted event rates generated under a random‐effects model. ResultsA total of 55 studies (5315 reconstructions) were included: 32 used quadriceps tendon with bone block (B‐QT), 19 used all‐soft tissue quadriceps tendon (S‐QT), and four did not report the QT graft subtype used. Included patients had an age range of 6.2–58 years and an average reported follow‐up time of 28.1 months (range, 6–90 months) for non‐randomised studies and 34.3 months (range, 0.233–120 months) for randomised studies. Pooled incidence rates for clinically relevant major complications included contralateral ACL injury at 6.0%, postoperative meniscal issues at 5.4%, cyclops lesions at 4.8%, graft failure at 4.1%, patellar fracture at 2.2%, hardware removal at 1.7%, infection at 1.5%, and donor‐site quadriceps tendon rupture at 0.7%. Pooled incidence rates for clinically relevant minor complications included anterior knee pain at 9.7%, kneeling pain at 9.5%, sensation deficits at 4.4%, loss of extension at 4.2%, donor‐site tendinopathy at 3.9%, cosmetic issues at 1.8%, and hematoma at 1.5%. ConclusionsQT ACL‐R resembles other graft types in its rates and types of postoperative complications. In this exploratory systematic review, no complications of QT ACL‐R were found to be disproportionately represented in the literature. This graft type should remain an option with comparable complication rates to other graft choices. Level of evidenceLevel IV. RegistrationThis study was preregistered under PROSPERO with preregistration code CRD42022302078.

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Late quadriceps tendon rupture at the donor site following cruciate ligament reconstruction using central quadriceps tendon graft

Cited by 8 publications

References 31 publications

New insight in the architecture of the quadriceps tendon

New insight in the architecture of the quadriceps tendon

Quadriceps Tendon Graft Anatomy in the Skeletally Immature Patient

Less than 1% risk of donor-site quadriceps tendon rupture post-ACL reconstruction with quadriceps tendon autograft: a systematic review

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