J Knee Surg 2020; 33(07): 704-721
DOI: 10.1055/s-0039-1685160
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Aperture and Suspensory Fixation Equally Efficacious for Quadriceps Tendon Graft Fixation in Primary ACL Reconstruction: A Systematic Review

Raphael J. Crum
1   Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
,
Darren de SA
2   Department of Orthopaedic Surgery, McMaster Children's Hospital, 1200 Main Street West, Hamilton, Ontario, Canada
,
Ajay C. Kanakamedala
3   Department of Orthopaedic Surgery, New York University Langone Orthopaedic Hospital, New York, New York
,
Obianuju A. Obioha
1   Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
,
Bryson P. Lesniak
1   Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
,
Volker Musahl
1   Department of Orthopaedic Surgery, Center for Sports Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
› Author Affiliations
Further Information

Publication History

09 December 2018

18 February 2019

Publication Date:
08 April 2019 (online)

Abstract

This review is aimed to compare suspensory and aperture quadriceps tendon autograft femoral and tibial fixations in primary anterior cruciate ligament reconstruction (ACL-R), and the clinical outcomes and complication profiles of each fixation method. Greater understanding of the optimal graft fixation technique for quadriceps tendon (QT) autografts may assist surgeons in improving outcomes after ACL-R. PubMed, Embase, and Medline were searched from database inception to September 2017, and again to July 2018, and identified 3,670 articles, 21 studies of which satisfied inclusion/exclusion criteria. Across included studies, 1,155 QT ACL-R patients (mean age, 28.7 years [range, 15–59 years], with mean postoperative follow-up of 36.1 months [range, 3.4–120 months]), were analyzed. Suspensory fixation on both sides demonstrated a higher percentage of patients (81.7%) achieving the highest rating of “A or B” on the International Knee Documentation Committee (IKDC) knee ligament examination form compared with aperture fixation on both sides (67.7%). Moreover, suspensory fixation had a lower side-to-side difference in anterior laxity (1.6 mm) when compared with aperture fixation (2.3 mm). Among studies which reported graft failure, all of which employed aperture fixation, the rate was 3.2%. Across available data, primary ACL-R using QT grafts appears to have successful short-term outcomes with a short-term graft failure rate of 3% independent of fixation method. While there is limited data regarding the comparison of aperture and suspensory soft-tissue quadriceps tendon (SQT) fixation in ACL-R, the findings of this systematic review suggest that suspensory fixation and aperture fixation in both the femoral and tibial tunnels are equally efficacious based on clinical outcome data on IKDC grade and measured laxity. This is a level IV, systematic review study.

 
  • References

  • 1 Marshall JL, Warren RF, Wickiewicz TL, Reider B. The anterior cruciate ligament: a technique of repair and reconstruction. Clin Orthop Relat Res 1979; 143 (143) 97-106
  • 2 Blauth W. . . [2-strip substitution-plasty of the anterior cruciate ligament with the quadriceps tendon]. Unfallheilkunde-traumatology 1984; 87 (02) 45-51
  • 3 Fulkerson JP. Central quadriceps free tendon for anterior cruciate ligament reconstruction. Oper Tech Sports Med 1999; 7 (04) 195-200
  • 4 Lee S, Seong SC, Jo H, Park YK, Lee MC. Outcome of anterior cruciate ligament reconstruction using quadriceps tendon autograft. Arthroscopy 2004; 20 (08) 795-802
  • 5 Antonogiannakis E, Yiannakopoulos CK, Hiotis I, Karabalis C, Babalis G. Arthroscopic anterior cruciate ligament reconstruction using quadriceps tendon autograft and bioabsorbable cross-pin fixation. Arthroscopy 2005; 21 (07) 894
  • 6 Cavaignac E, Coulin B, Tscholl P, Nik Mohd Fatmy N, Duthon V, Menetrey J. Is quadriceps tendon autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? A comparative study with a mean follow-up of 3.6 years. Am J Sports Med 2017; 45 (06) 1326-1332
  • 7 Pigozzi F, Di Salvo V, Parisi A. , et al. Isokinetic evaluation of anterior cruciate ligament reconstruction: quadriceps tendon versus patellar tendon. J Sports Med Phys Fitness 2004; 44 (03) 288-293
  • 8 Gorschewsky O, Klakow A, Pütz A, Mahn H, Neumann W. Clinical comparison of the autologous quadriceps tendon (BQT) and the autologous patella tendon (BPTB) for the reconstruction of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 2007; 15 (11) 1284-1292
  • 9 Kim S-J, Kumar P, Oh K-S. Anterior cruciate ligament reconstruction: autogenous quadriceps tendon-bone compared with bone-patellar tendon-bone grafts at 2-year follow-up. Arthroscopy 2009; 25 (02) 137-144
  • 10 Han HS, Seong SC, Lee S, Lee MC. Anterior cruciate ligament reconstruction : quadriceps versus patellar autograft. Clin Orthop Relat Res 2008; 466 (01) 198-204
  • 11 Adams DJ, Mazzocca AD, Fulkerson JP. Residual strength of the quadriceps versus patellar tendon after harvesting a central free tendon graft. Arthroscopy 2006; 22 (01) 76-79
  • 12 Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy MS. Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Joint Surg Am 1984; 66 (03) 344-352
  • 13 Kurosaka M, Yoshiya S, Andrish JT. A biomechanical comparison of different surgical techniques of graft fixation in anterior cruciate ligament reconstruction. Am J Sports Med 1987; 15 (03) 225-229
  • 14 Rodeo SA, Arnoczky SP, Torzilli PA, Hidaka C, Warren RF. Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg Am 1993; 75 (12) 1795-1803
  • 15 Goradia VK, Rochat MC, Kida M, Grana WA. Natural history of a hamstring tendon autograft used for anterior cruciate ligament reconstruction in a sheep model. Am J Sports Med 2000; 28 (01) 40-46
  • 16 Papageorgiou CD, Ma CB, Abramowitch SD, Clineff TD, Woo SL. A multidisciplinary study of the healing of an intraarticular anterior cruciate ligament graft in a goat model. Am J Sports Med 2001; 29 (05) 620-626
  • 17 Wright RW, Haas AK, Anderson J. , et al; MOON Group. Anterior cruciate ligament reconstruction rehabilitation: MOON guidelines. Sports Health 2015; 7 (03) 239-243
  • 18 van Grinsven S, van Cingel RE, Holla CJ, van Loon CJ. Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2010; 18 (08) 1128-1144
  • 19 Brand Jr J, Weiler A, Caborn DN, Brown Jr CH, Johnson DL. Graft fixation in cruciate ligament reconstruction. Am J Sports Med 2000; 28 (05) 761-774
  • 20 Singhal MC, Fites BS, Johnson DL. Fixation devices in ACL surgery: what do I need to know?. Orthopedics 2005; 28 (09) 920-924
  • 21 DeAngelis JP, Fulkerson JP. Quadriceps tendon--a reliable alternative for reconstruction of the anterior cruciate ligament. Clin Sports Med 2007; 26 (04) 587-596
  • 22 Nagarkatti DG, McKeon BP, Donahue BS, Fulkerson JP. Mechanical evaluation of a soft tissue interference screw in free tendon anterior cruciate ligament graft fixation. Am J Sports Med 2001; 29 (01) 67-71
  • 23 Jagodzinski M, Krettek C. Evolving techniques in ACL graft fixation. Tech Orthop 2013; 28 (02) 119
  • 24 Macaulay AA, Perfetti DC, Levine WN. Anterior cruciate ligament graft choices. Sports Health 2012; 4 (01) 63-68
  • 25 Persson A, Gifstad T, Lind M. , et al. Graft fixation influences revision risk after ACL reconstruction with hamstring tendon autografts. Acta Orthop 2018; 89 (02) 204-210
  • 26 Ishibashi Y, Rudy TW, Livesay GA, Stone JD, Fu FH, Woo SL. The effect of anterior cruciate ligament graft fixation site at the tibia on knee stability: evaluation using a robotic testing system. Arthroscopy 1997; 13 (02) 177-182
  • 27 Morgan CD, Kalmam VR, Grawl DM. Isometry testing for anterior cruciate ligament reconstruction revisited. Arthroscopy 1995; 11 (06) 647-659
  • 28 Giurea M, Zorilla P, Amis AA, Aichroth P. Comparative pull-out and cyclic-loading strength tests of anchorage of hamstring tendon grafts in anterior cruciate ligament reconstruction. Am J Sports Med 1999; 27 (05) 621-625
  • 29 Magen HE, Howell SM, Hull ML. Structural properties of six tibial fixation methods for anterior cruciate ligament soft tissue grafts. Am J Sports Med 1999; 27 (01) 35-43
  • 30 Johnson D, Houle J, Almazan A. Comparison of intraoperative AP translation of two different modes of fixation of the grafts used in ACL reconstruction. Arthroscopy 1998; 14: 425
  • 31 Tsuda E, Fukuda Y, Loh JC, Debski RE, Fu FH, Woo SL. The effect of soft-tissue graft fixation in anterior cruciate ligament reconstruction on graft-tunnel motion under anterior tibial loading. Arthroscopy 2002; 18 (09) 960-967
  • 32 Slone HS, Romine SE, Premkumar A, Xerogeanes JW. Quadriceps tendon autograft for anterior cruciate ligament reconstruction: a comprehensive review of current literature and systematic review of clinical results. Arthroscopy 2015; 31 (03) 541-554
  • 33 Moher D, Liberati A, Tetzlaff J, Altman DG. ; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6 (07) e1000097
  • 34 Kung J, Chiappelli F, Cajulis OO. , et al. From systematic reviews to clinical recommendations for evidence-based health care: validation of revised assessment of multiple systematic reviews (R-AMSTAR) for grading of clinical relevance. Open Dent J 2010; 4: 84-91
  • 35 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33 (01) 159-174
  • 36 Wright JG. Levels of Evidence and Grades of Recommendations. AAOS Bulletin 2005 Available from: http://www2.aaos.org/bulletin/apr05/fline9.asp . Accessed March 04, 2019
  • 37 Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 2003; 73 (09) 712-716
  • 38 Geib TM, Shelton WR, Phelps RA, Clark L. Anterior cruciate ligament reconstruction using quadriceps tendon autograft: intermediate-term outcome. Arthroscopy 2009; 25 (12) 1408-1414
  • 39 Schulz AP, Lange V, Gille J. , et al. Anterior cruciate ligament reconstruction using bone plug-free quadriceps tendon autograft: intermediate-term clinical outcome after 24-36 months. Open Access J Sports Med 2013; 4: 243-249
  • 40 Theut PC, Fulkerson JP, Armour EF, Joseph M. Anterior cruciate ligament reconstruction utilizing central quadriceps free tendon. Orthop Clin North Am 2003; 34 (01) 31-39
  • 41 Joseph M, Fulkerson J, Nissen C, Sheehan TJ. Short-term recovery after anterior cruciate ligament reconstruction: a prospective comparison of three autografts. Orthopedics 2006; 29 (03) 243-248
  • 42 Iriuchishima T, Ryu K, Okano T, Suruga M, Aizawa S, Fu FH. The evaluation of muscle recovery after anatomical single-bundle ACL reconstruction using a quadriceps autograft. Knee Surg Sports Traumatol Arthrosc 2017; 25 (05) 1449-1453
  • 43 Lee MC, Seong SC, Lee S. et al. Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction. Arthroscopy: the journal of arthroscopic & related surgery: official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2007; 23: 771-778
  • 44 Sofu H, Sahin V, Gursu S. et al. Use of quadriceps tendon versus hamstring tendon autograft for arthroscopic anterior cruciate ligament reconstruction: a comparative analysis of clinical results. Joint diseases & related surgery 2013; 24: 139-143
  • 45 Guimarães MV, Junior LH, Terra DL. Reconstruction of the anterior cruciate ligament with the central third of the quadriceps muscle tendon: Analysis of 10-year results. Revista brasileira de ortopedia 2009; 44: 306-312
  • 46 Chen CH, Chen WJ, Shih CH. Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft. J Trauma 1999; 46 (04) 678-682
  • 47 Kim SJ, Chang JH, Kim TW, Jo SB, Oh KS. Anterior cruciate ligament reconstruction with use of a single or double-bundle technique in patients with generalized ligamentous laxity. J Bone Joint Surg Am 2009; 91 (02) 257-262
  • 48 Kim SJ, Kumar P, Oh KS. Anterior cruciate ligament reconstruction: autogenous quadriceps tendon-bone compared with bone-patellar tendon-bone grafts at 2-year follow-up. Arthroscopy 2009; 25 (02) 137-144
  • 49 Han HS, Seong SC, Lee S, Lee MC. Anterior cruciate ligament reconstruction : quadriceps versus patellar autograft. Clin Orthop Relat Res 2008; 466 (01) 198-204
  • 50 Runer A, Wierer G, Herbst E. , et al. There is no difference between quadriceps- and hamstring tendon autografts in primary anterior cruciate ligament reconstruction: a 2-year patient-reported outcome study. Knee Surg Sports Traumatol Arthrosc 2018; 26 (02) 605-614
  • 51 Lee JK, Lee S, Lee MC. Outcomes of anatomic anterior cruciate ligament reconstruction: bone-quadriceps tendon graft versus double-bundle hamstring tendon graft. Am J Sports Med 2016; 44 (09) 2323-2329
  • 52 Lee S, Seong SC, Jo CH, Han HS, An JH, Lee MC. Anterior cruciate ligament reconstruction with use of autologous quadriceps tendon graft. J Bone Joint Surg Am 2007; 89 (Suppl. 03) 116-126
  • 53 Kwak YH, Lee S, Lee MC, Han HS. Anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone allograft: matched case control study. BMC Musculoskelet Disord 2018; 19 (01) 45
  • 54 Lund B, Nielsen T, Faunø P, Christiansen SE, Lind M. Is quadriceps tendon a better graft choice than patellar tendon? a prospective randomized study. Arthroscopy 2014; 30 (05) 593-598
  • 55 Geib TM, Shelton WR, Phelps RA, Clark L. Anterior cruciate ligament reconstruction using quadriceps tendon autograft: intermediate-term outcome. Arthroscopy 2009; 25 (12) 1408-1414
  • 56 Iriuchishima T, Ryu K, Okano T, Suruga M, Aizawa S, Fu FH. The evaluation of muscle recovery after anatomical single-bundle ACL reconstruction using a quadriceps autograft. Knee Surg Sports Traumatol Arthrosc 2017; 25 (05) 1449-1453
  • 57 Chen CH, Chuang TY, Wang KC, Chen WJ, Shih CH. Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon autograft: clinical outcome in 4-7 years. Knee Surg Sports Traumatol Arthrosc 2006; 14 (11) 1077-1085
  • 58 Jiang H, Ma G, Li Q, Hu Y, Li J, Tang X. Cortical button versus cross-pin femoral fixation for hamstring anterior cruciate ligament reconstruction: a meta-analysis of randomized controlled trials. Am J Sports Med 2018; 46 (09) 2277-2284
  • 59 Prodromos CC, Joyce BT, Shi K, Keller BL. A meta-analysis of stability after anterior cruciate ligament reconstruction as a function of hamstring versus patellar tendon graft and fixation type. Arthroscopy 2005; 21 (10) 1202
  • 60 Kowalk DL, Wojtys EM, Disher J, Loubert P. Quantitative analysis of the measuring capabilities of the KT-1000 knee ligament arthrometer. Am J Sports Med 1993; 21 (05) 744-747
  • 61 Berry J, Kramer K, Binkley J. , et al. Error estimates in novice and expert raters for the KT-1000 arthrometer. J Orthop Sports Phys Ther 1999; 29 (01) 49-55
  • 62 Ahmad CS, Gardner TR, Groh M, Arnouk J, Levine WN. Mechanical properties of soft tissue femoral fixation devices for anterior cruciate ligament reconstruction. Am J Sports Med 2004; 32 (03) 635-640
  • 63 Kousa P, Järvinen TL, Vihavainen M, Kannus P, Järvinen M. The fixation strength of six hamstring tendon graft fixation devices in anterior cruciate ligament reconstruction. Part I: femoral site. Am J Sports Med 2003; 31 (02) 174-181
  • 64 Colvin A, Sharma C, Parides M, Glashow J. What is the best femoral fixation of hamstring autografts in anterior cruciate ligament reconstruction?: a meta-analysis. Clin Orthop Relat Res 2011; 469 (04) 1075-1081
  • 65 Pedowitz RA. Editorial commentary: fixation of soft-tissue anterior cruciate ligament grafts in osteoporotic bone. Arthroscopy 2017; 33 (09) 1701-1702
  • 66 Domnick C, Herbort M, Raschke MJ. , et al. Anterior cruciate ligament soft tissue graft fixation in the elderly: is there a reason to use interference screws? A human cadaver study. Arthroscopy 2017; 33 (09) 1694-1700
  • 67 Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy 2005; 21 (08) 948-957
  • 68 Sun K, Tian S, Zhang J, Xia C, Zhang C, Yu T. Anterior cruciate ligament reconstruction with BPTB autograft, irradiated versus non-irradiated allograft: a prospective randomized clinical study. Knee Surg Sports Traumatol Arthrosc 2009; 17 (05) 464-474
  • 69 Sonnery-Cottet B, Saithna A, Cavalier M. , et al. Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI study group. Am J Sports Med 2017; 45 (07) 1547-1557
  • 70 Melugin HP, Johnson NR, Wu IT, Levy BA, Stuart MJ, Krych AJ. Is treatment of Segond fracture necessary with combined anterior cruciate ligament reconstruction?. Am J Sports Med 2018; 46 (04) 832-838
  • 71 van Eck CF, Schkrohowsky JG, Working ZM, Irrgang JJ, Fu FH. Prospective analysis of failure rate and predictors of failure after anatomic anterior cruciate ligament reconstruction with allograft. Am J Sports Med 2012; 40 (04) 800-807
  • 72 Chen T, Zhang P, Chen J, Hua Y, Chen S. Long-term outcomes of anterior cruciate ligament reconstruction using either synthetics with remnant preservation or hamstring autografts: a 10-year longitudinal study. Am J Sports Med 2017; 45 (12) 2739-2750
  • 73 Ardern CL, Taylor NF, Feller JA, Whitehead TS, Webster KE. Sports participation 2 years after anterior cruciate ligament reconstruction in athletes who had not returned to sport at 1 year: a prospective follow-up of physical function and psychological factors in 122 athletes. Am J Sports Med 2015; 43 (04) 848-856
  • 74 Wright RW, Huston LJ, Spindler KP. , et al; MARS Group. Descriptive epidemiology of the multicenter ACL revision study (MARS) cohort. Am J Sports Med 2010; 38 (10) 1979-1986
  • 75 Dargel J, Schmidt-Wiethoff R, Fischer S, Mader K, Koebke J, Schneider T. Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation. Knee Surg Sports Traumatol Arthrosc 2009; 17 (03) 220-227
  • 76 Gadikota HR, Sim JA, Hosseini A, Gill TJ, Li G. The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint. Am J Sports Med 2012; 40 (04) 882-888
  • 77 Chalmers PN, Mall NA, Cole BJ, Verma NN, Bush-Joseph CA, Bach Jr BR. Anteromedial versus transtibial tunnel drilling in anterior cruciate ligament reconstructions: a systematic review. Arthroscopy 2013; 29 (07) 1235-1242
  • 78 Alentorn-Geli E, Lajara F, Samitier G, Cugat R. The transtibial versus the anteromedial portal technique in the arthroscopic bone-patellar tendon-bone anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2010; 18 (08) 1013-1037
  • 79 Rahr-Wagner L, Thillemann TM, Pedersen AB, Lind MC. Increased risk of revision after anteromedial compared with transtibial drilling of the femoral tunnel during primary anterior cruciate ligament reconstruction: results from the Danish Knee Ligament Reconstruction Register. Arthroscopy 2013; 29 (01) 98-105
  • 80 Coleridge SD, Amis AA. A comparison of five tibial-fixation systems in hamstring-graft anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2004; 12 (05) 391-397
  • 81 van Eck CF, Schreiber VM, Mejia HA. , et al. “Anatomic” anterior cruciate ligament reconstruction: a systematic review of surgical techniques and reporting of surgical data. Arthroscopy 2010; 26 (9, Suppl): S2-S12
  • 82 Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL. Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med 2002; 30 (05) 660-666
  • 83 Markolf KL, Hame S, Hunter DM. , et al. Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft. J Orthop Res 2002; 20 (05) 1016-1024