Transphyseal Anterior Cruciate Ligament Reconstruction in the Skeletally Immature: Quadriceps Tendon Autograft Versus Hamstring Tendon Autograft

Abstract

Background: It is unclear what the optimal graft choice is for performing anterior cruciate ligament (ACL) reconstruction in a skeletally immature patient. Purpose: To evaluate outcomes and complications of skeletally immature patients undergoing transphyseal ACL reconstruction with a hamstring tendon autograft versus a quadriceps tendon autograft. Study Design: Cohort study; Level of evidence, 3. Methods: Between 2012 and 2016, 90 skeletally immature patients from a single institution underwent primary transphyseal ACL reconstruction with either a quadriceps tendon autograft or a hamstring tendon autograft based on surgeon preference (n = 3). Patient demographic, injury, radiographic, and surgical variables were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation (SANE), Tegner activity score, pain, satisfaction, and complications such as graft tears and physeal abnormalities. Results: A total of 83 patients (56 hamstring tendon, 27 quadriceps tendon) were available for a minimum follow-up of 2 years or sustained graft failure. The mean age of the patients was 14.8 ± 1.4 years at the time of ACL reconstruction. No differences in chronological age, bone age, sex, patient size, or mechanism of injury were noted between groups. There were no differences in surgical variables, except that the quadriceps tendon grafts were larger than the hamstring tendon grafts (9.6 ± 0.6 mm vs 7.8 ± 0.7 mm, respectively; P < .001). Patient outcomes at a mean follow-up of 2.8 ± 0.9 years revealed no differences based on graft type, with mean Lysholm, SANE, pain, satisfaction, and Tegner scores of 96, 93, 0.6, 9.6, and 6.6, respectively, for the quadriceps tendon group and 94, 89, 0.9, 9.2, and 7.1, respectively, for the hamstring tendon group. While there were no physeal complications in either group, patients undergoing ACL reconstruction with a hamstring tendon autograft were more likely to tear their graft (21% vs 4%, respectively; P = .037). Conclusion: Skeletally immature patients undergoing ACL reconstruction can be successfully managed with either a quadriceps tendon autograft or a hamstring tendon autograft with good short-term outcomes, high rates of return to sport, and low rates of physeal abnormalities. The primary differences between grafts were that the quadriceps tendon grafts were larger and were associated with a lower retear rate. ACL reconstruction performed with a quadriceps tendon autograft may reduce early graft failure in skeletally immature patients.

Early Outcomes of Adolescent ACL Reconstruction With Hybrid Hamstring Tendon Autograft-Allograft Versus Hamstring Tendon Autograft Alone

“…Functionally, all patients with adequate documentation of their postoperative follow-up period were reported to have returned to sports, with no significant difference in the time of return to sports between the groups. In addition, both groups had lower retear rates than those previously reported in studies involving hamstring autograft ACLR, 4,18 suggesting that graft size may not be the most important factor in retear rate. Importantly, the mean graft diameter of the autograft before supplementation (6.6 mm) was smaller than that of the autograft of the control group (7.1 mm), so the supplementation may have provided a clinical benefit not detected by the current study methods.…”

Open Full-Thickness Quadriceps Tendon Autograft Harvest With Repair for Anterior Cruciate Ligament Reconstruction

“…In preliminary studies, the quadriceps tendon autograft has shown superior outcomes over the hamstring tendon autograft. 32 , 33 , 34 In a retrospective study with 81 patients who underwent ACLR with a quadriceps tendon–patellar bone block autograft, the incidence of graft failure was 1.2% at 3 years' follow-up. 32 A meta-analysis compared outcomes after randomized controlled trials of graft choice for ACL reconstruction including bone–patellar tendon–bone, double-bundle and 4-strand hamstring tendon, and quadriceps tendon with bone block autografts.…”

“… 35 Another recent study comparing soft-tissue quadriceps tendon autograft and hamstring tendon autograft found a significantly lower retear rate 2.8 years after ACL reconstruction with a soft-tissue quadriceps tendon autograft (4% vs 21%, P = .03). 33 …”

Transphyseal Anterior Cruciate Ligament Reconstruction Using Hybrid Transtibial Femoral Drilling and a Quadriceps Tendon Autograft

“…In this unique population of adolescents, alarmingly high rates of graft failure have been reported (approximately 20%) using hamstring autograft. 4 , 12 Therefore, our preference in this population has been to use an all–soft tissue quadriceps tendon (QT) autograft with suspensory femoral and tibial fixation to avoid any hardware across the physes. The QT autograft continues to gain momentum as a safe and reliable option for ACLR with a potentially reduced incidence of graft retear (4%-8% reported in adolescents).…”

“…The QT autograft continues to gain momentum as a safe and reliable option for ACLR with a potentially reduced incidence of graft retear (4%-8% reported in adolescents). 12 , 13 , 14 , 15 , 16 , 17 …”