Christian Hoser

Bony and cartilaginous anatomy of the patellofemoral joint

The patella as the largest sesamoid bone of the human body forms the patellofemoral joint with the patellar groove of the femur. The patellofemoral joint is a complex articulation with high functional and biomechanical requirements. Several anatomical variants of both patella and the trochlea exist. Multiple clinical problems of the knee may be caused by anatomical and physiological abnormalities of this joint. Exact knowledge about the anatomy, the biomechanics and the function of the patellofemoral joint is therefore required to understand its wide range of pathology.

Single-Bundle Anterior Cruciate Ligament Reconstruction: A Biomechanical Cadaveric Study of a Rectangular Quadriceps and Bone–Patellar Tendon–Bone Graft Configuration Versus a Round Hamstring Graft

PURPOSE The purposes of this study were to investigate anterior tibial translation under loading conditions after single-bundle (SB) anterior cruciate ligament (ACL) reconstruction using a rectangular tunnel placement strategy with quadriceps and bone--patellar tendon--bone (BPTB) graft and to compare these data with a SB hamstring reconstruction with a round tunnel design. METHODS In 9 human cadaveric knees, the knee kinematics were examined with robotic/universal force-moment sensor testing. Within the same specimen, the knee kinematics under simulated pivot-shift and KT-1000 arthrometer (MEDmetric, San Diego, CA) testing were determined at 0°, 15°, 30°, 60°, and 90° of flexion under different conditions: intact knee, ACL-deficient knee, and SB ACL-reconstructed knee. For the SB ACL-reconstructed knee, 3 different SB reconstruction techniques were used: a rectangular tunnel strategy (9 × 5 mm) with quadriceps graft, a rectangular tunnel strategy with BPTB graft, and a round tunnel strategy (7 mm) with hamstring graft. RESULTS In a simulated Lachman test, a statistically significant difference was found at 0° and 15° of knee flexion between the rectangular reconstruction with quadriceps graft (5.1 ± 1.2 mm and 8.3 ± 2 mm, respectively) or BPTB graft (5.3 ± 1.5 mm and 8 ± 1.9 mm, respectively) and the reconstruction using hamstring graft (7.2 ± 1.4 mm and 12 ± 1.8 mm, respectively) (P = .032 and P = .033, respectively, at 0°; P = .023 and P = .02, respectively, at 15°). On the simulated pivot-shift test at 0° and 15°, rectangular ACL reconstruction with quadriceps graft (3.9 ± 2.1 mm and 6.5 ± 1.7 mm, respectively) or BPTB graft (4.2 ± 1.8 mm and 6.7 ± 1.7 mm, respectively) showed a significantly lower anterior tibial translation when compared with round tunnel reconstruction (5.5 ± 2.1 mm and 7.9 ± 1.9 mm, respectively) (P = .03 and P = .041, respectively, at 0°; P = .042 and P = .046, respectively, at 15°). CONCLUSIONS Under simulated Lachman testing and pivot-shift testing, a reconstruction technique using a rectangular tunnel results in significantly lower anterior tibial translation at 0° and 15° of flexion in comparison to knees reconstructed with a hamstring SB graft using a round tunnel strategy. CLINICAL RELEVANCE ACL reconstruction with a rectangular tunnel and BPTB and quadriceps tendon might result in better anterior knee stability at low flexion angles than ACL reconstruction with hamstring SB graft and a round tunnel in the clinical setting.

Computerassistierte Zielbohrungen an der unteren Extremität Technik und Indikationen

ZusammenfassungNavigationstechnisches Operieren stellt für Chirurgen eine neue und interessante Herausforderung dar. Es ist jedoch zu beachten, dass diese neuen Techniken a) nicht einem Selbstzweck dienen, b) dem Patienten keinen zusätzlichen Schaden bringen und c) deshalb nur dort eingesetzt werden, wo sie eine effiziente Lösungsmöglichkeit von bisher problematischen oder ungenauen Operationschritten bringen können.Die vorliegende Studie zeigt, dass mit einer nichtinvasiven Fixierungsmethode (FISCOFIX-Schale) Herdlokalisationen zwischen Sprunggelenk und Kniegelenk unter Navigationskontrolle exakt registriert und gezielt therapiert werden können. Dies ist aufgrund der schwierigen Erreichbarkeit von Läsionen v. a. in den hinteren Anteilen der Talusrolle von Vorteil gegenüber der arthroskopischen Therapie und transmalleolaren Zugang. Bei allen Patienten konnte durch die perkutane retrograde Bohrkanallegung (vgl. [6, 7, 9, 15, 20, 21]) der Gelenkknorpelüberzug geschont werden. Am Kniegelenk sehen wir den Wert dieser Methode bei komplexeren Problemen (vgl. [12, 13]) mit der Notwendigkeit, genaue Bohrungen zu setzen.AbstractComputer assisted navigation-based surgery is a novel and interesting challenge for todays surgeons. One must however keep in mind, that the indications for these techniques (a) should be carefully considered, (b) used only if morbidity is not increased and (c) when previously problematic or inacurrate surgical methods can be inproved upon.This study reports that, using a non-invasive fixation method (FISCOFIX-Cast), lesions between the ankle- and knee- joints can be precisly localized, registered and treated. Due to the difficult access to lesions especially in the posterior areas of the talus, using conventional arthroscopic methods this procedure is very useful. Percutaneous retrograde drilling (cf. [6, 7, 9, 15, 20, 21]) spared the joints cartilage in all cases. At the level of the knee joint we see the usefullness of this method for complex situations (cf. [12, 13]) requireing precise drilling.

MPFL reconstruction using a quadriceps tendon graft: part 2: operative technique and short term clinical results.

BACKGROUND We describe the preliminary clinical results of a new operative technique for MPFL reconstruction using a strip of quadriceps tendon (QT). METHODS PATIENTS 17 patients (7 male, 10 female; mean age 21.5 years ± 3.9) have been operated on with this technique. All patients were evaluated clinically, radiologically and with subjective questionnaires (Tegner-, Lysholm-, Kujala Score) pre-operatively and post-operatively at 6 and 12 months (m). SURGICAL TECHNIQUE A 10 to 12 mm wide, 3mm thick and 8 to 10 cm long strip from the central aspect of quadriceps tendon is harvested subcutaneously. The tendon strip is then dissected distally on the patella, left attached, diverged 90° medially underneath the medial prepatellar tissue and fixed with 2 sutures. The graft is fixed in 20° of knee flexion with a bioabsorbable interference screw. RESULTS Lysholm score at 6m was 81.9 ± 11.7 and at 12 m 88.1 ± 10.9, Kujala score at 12 m was 89.2 ± 7.1 and Tegner Score was 4.9 ± 2.0 (6m) and 5.0 ± 1.9 (12 m). Two patients had a positive apprehension test at 12 months. There was no re-dislocation during the follow-up period. CONCLUSION MPFL reconstruction with a strip of QT harvested in a minimal invasive technique was found to be associated with good short term clinical results. We think that this technique presents a valuable alternative to common hamstring techniques for primary MPFL reconstruction in children and adults, as well as for MPFL revision surgery. LEVEL OF EVIDENCE IV, prospective case series.

Computerassistierte minimalinvasive Therapie der Osteochondrosis dissecans tali Computer-Assisted Minimally Invasive Treatment of Osteochondrosis Dissecans of the Talus

ZusammenfassungOperationszielRevaskularisation der Nekrosezone im Talus und Anregung der Knochenneubildung bei Schonung des talaren Knorpelüberzugs durch computerassistierte minimalinvasive Anbohrung oder retrograde Spongiosaunterfütterung des osteochondrotischen Herdes.IndikationenOsteochondrosis dissecans tali Stadium I–III nach Berndt & Harty.KontraindikationenOsteochondrosis dissecans tali Stadium IV nach Berndt & Harty.Allgemeine Kontraindikationen wie z. B. schlechte Haut- und Weichteilverhältnisse oder schlechter Allgemeinzustand.OperationstechnikPräoperativ: Anpassung einer abnehmbaren Schale für das obere Sprunggelenk (OSG-Fixationsschale), anschließend Computertomographie des Sprunggelenks mit angelegter OSG-Fixationsschale. Planung der Lage des zentralen Bohrstifts im Talus mit einem Navigationssystem im Labor. Einstellung und Arretierung der Zielvorrichtung.Intraoperativ: Anlage der sterilisierten OSG-Fixationsschale. Retrograde Platzierung des 2,4-mm-Kirschner-Drahts über die arretierte Zielvorrichtung. Bildwandlerkontrolle der Lage des Kirschner-Drahts.Arthroskopie des OSG; je nach Befund werden weitere Parallelbohrungen gesetzt oder eine retrograde Spongiosaplastik mit Spongiosaentnahme aus dem Kalkaneus durchgeführt.WeiterbehandlungBei retrograder Anbohrung/Parallelbohrung: 1 Woche Teilbelastung mit 30 kg.Bei retrograder Spongiosaplastik: 4 Wochen Teilbelastung mit 15 kg, dann 2 weitere Wochen Teilbelastung mit 30 kg.Physiotherapie.ErgebnisseVon Dezember 1999 bis Januar 2005 wurde bei 41 Patienten eine computerassistierte Behandlung der Osteochondrosis dissecans tali zur retrograden Anbohrung oder retrograden Spongiosaplastik gewählt. Bei 39 der 41 Patienten wurde die osteochondrale Läsion—wie im postoperativen Magnetresonanztomogramm (MRT) verifiziert—erreicht, d. h., der Bohrkanal führte in die Läsion. In zwei Fällen lag intraoperativ ein nicht behebbarer Materialfehler vor, so dass die vorgestellte Methode an 39 Patienten angewendet werden konnte. Für die ersten 15 Patienten, die eine retrograde Anbohrung/Parallelbohrung mit begleitender Sprunggelenkarthroskopie erhielten und keine retrograde Spongiosaplastik, werden die 1-Jahres-Ergebnisse anhand der MRT-Verlaufskontrolle (Bohrkanallage, Vitalitätsbeurteilung des osteochondrotischen Areals) und eines klinischen Scorings präsentiert. Die vier Frauen und elf Männer waren durchschnittlich 34,1 Jahre alt (14–55 Jahre). Im radiologischen Vergleich zwischen den prä- und postoperativen Stadien der Osteochondrosis dissecans ließ sich bei 46,7% der Patienten eine Verbesserung des Stadiums nach Berndt & Harty nachweisen. Bei 40,0% zeigte sich im MRT postoperativ das gleiche Osteochondrosis-dissecans-Stadium, und bei 13,3% verschlechterte es sich um einen Grad.In der klinischen Nachuntersuchung betrug der AOFAS-Score im Mittel 88,9 Punkte.AbstractObjectiveRevascularization of areas of necrosis in the talus and stimulation of bone regeneration whilst protecting the talar hyaline cartilage using computer-assisted minimally invasive drilling or retrograde cancellous bone relining of the osteochondrotic zone.IndicationsOsteochondrosis dissecans of the talus, Berndt & Harty stages I–III.ContraindicationsOsteochondrosis dissecans of the talus, Berndt & Harty stage IV.General contraindications such as poor skin and soft-tissue conditions or poor general condition.Surgical TechniqueBefore the operation: fitting a removable cast for the ankle (ankle fixation cast), then computed tomography of the ankle with the ankle fixation cast fitted. Planning the site of the central Kirschner wire in the talus using a navigation system in the laboratory. Adjusting and locking the aiming device.Intraoperative procedures: fitting the sterilized ankle fixation cast. Retrograde placement of the 2.4-mm Kirschner wire through the locked aiming device. Check on the position of the Kirschner wire using an image intensifier.Arthroscopy of the ankle; further parallel holes may then be drilled depending on the findings or retrograde cancellous bone grafting may be performed by harvesting cancellous bone from the calcaneus.Postoperative ManagementFor retrograde drilling/parallel drilling: 1 week of partial weight bearing at 30 kg.For retrograde cancellous bone grafting: 4 weeks of partial weight bearing at 15 kg, then 2 more weeks of partial weight bearing at 30 kg.Physiotherapy.ResultsFrom December 1999 to January 2005, 41 patients with osteochondrosis dissecans of the talus were selected for computer-assisted treatment by retrograde drilling or retrograde cancellous bone grafting. In 39 of the 41 patients, the osteochondral lesion—as verified by postoperative magnetic resonance imaging (MRI)—was accessed, i.e., the drilled hole led to the lesion. In two cases, irreparable flaws in the materials were discovered intraoperatively, so that the above method was only performed on 39 patients. The 1-year results for the first 15 patients treated with retrograde drilling/parallel drilling and concomitant ankle arthroscopy without retrograde cancellous bone graft are presented here based on the follow-up MRI (position of drill hole, assessment of vitality of the area of osteochondritis) and a clinical score. The four women and eleven men were, on average, 34.1 years old (14–55 years). In the radiologic comparison of the pre- and postoperative stages of the osteochondritis dissecans, 46.7% of patients showed an improvement in the Berndt & Harty stage. 40.0% showed the same osteochondrosis dissecans stage in the postoperative MRI, and in 13.3% it deteriorated by one grade.In the clinical follow-up examination, the AOFAS Score averaged 88.9 points.

Transplantatfixation bei der vorderen Kreuzbandrekonstruktion Metall- vs. bioresorbierbare Polyglykonatinterferenzschraube – Eine prospektive randomisierte Studie von 40 Patienten

ZusammenfassungDurch die Verwendung von resorbierbaren Interferenzschrauben zur Transplantatfixation bei vorderer Kreuzbandrekonstruktion sollen potentielle Nachteile von Metallschrauben vermieden werden. In einer prospektiv randomisierten Studie wurde bei 20 Personen (Gruppe A) der femorale Knochenblock eines Lig.-patellae-Knochen-Sehnen-Knochentransplantats mit einer resorbierbaren Polyglykonatschraube befestigt, bei 20 Personen der Kontrollgruppe (Gruppe B) mit einer Metallinterferenzschraube. Über einen Zeitraum von 2 Jahren wurden die Patienten klinisch und radiologisch nachuntersucht. Sowohl Tegner- (im Mittel 7,4±1,1 für Gruppe A bzw. 7,5±0,8 für Gruppe B bei Studienende) als auch Lysholm- (im Durchschnitt 98,1±2,3 für Gruppe A, 97,7±3,0 Gruppe B) und IKDC-Score (5,6% normal, 88,8% fast normal, 5,6% abnormal in Gruppe A bzw. 11,1% 77,8% und 11,1% in Gruppe B) zeigten einen ähnlichen Verlauf den gesamten Zeitraum über, es bestand zu keinem Zeitpunkt der Untersuchung ein signifikanter Unterschied zwischen beiden Gruppen. Anhand der Röntgenbilder konnte die Polyglykonatschraube bis 6 Wochen postoperativ identifiziert werden und war dann nicht mehr erkennbar. Abnorme radiologische Veränderungen (Osteolysen etc.) traten in beiden Gruppen nicht auf. Bei mit bioresorbierbaren Schrauben behandelten Patienten kam es zu keinen entzündlichen Abwehrreaktionen. Polyglykonatinterferenzschrauben eignen sich in gleicher Weise wie Metallimplantate zur Fixierung des autologen Lig.-patellae-Transplantats bei der vorderen Kreuzbandplastik.SummaryTo overcome some of the potential problems (e.g. hardware removal during revision surgery) of metall interference screws used for patellar tendon anterior cruciate ligament reconstruction, bioabsorbable screws have recently been introduced. Forty patients who underwent endoscopic ACL reconstruction using patella tendon autograft were included in the study, they were randomized intraoperatively to either Group A (femoral bone block fixation: polyglyconate screw; tibial: metall screw) or Group B (both bone blocks fixed with metall interference screws). The patients were evaluated clinically preoperatively as well as 6 weeks, 3 months 12 months and 24 months post op. Lysholm Score at 24 months was 98,1±2,3 for Group A and 97,7±3,0 for Group B. Tegner Score was 7,4±1,1 for Group A and 7,5±0,8 for Group B. Two years post op overall IKDC-Score for group A was 5,6% normal, 88,8% nearly normal and 5,6% abnormal. The result for group B was 11,1%, 77,8% and 11,1%, respectively. KT-1000 (at 89 N) at two years revealed a side to side difference of 1,5±0,3 mm (Group A) and 1,6±0,7 (Group B). The results of the two groups did not show significant differences at any stage of follow up. In our study polyglyconate interference screw fixation for patellar tendon grafts has not found to be associated with increased clinical complications. It provided equivalent fixation and clinical results compared to metall screws.

Case Reports: A Stener-like Lesion of the Medial Collateral Ligament of the Knee

When the superficial fibers of the medial collateral ligament of the knee are torn without tearing of the deep fibers, the anterior superficial fibers may displace over the pes anserinus tendons, so that healing back to the tibial insertion site may be jeopardized. As only the anterior superficial and not the posterior superficial or deep fibers are disrupted, the knee will not have increased valgus laxity in extension whereas there is not a firm end point in 30° flexion. The clinical findings could be confused with those of a Grade 2 medial collateral ligament sprain that generally is not associated with displacement of the anterior fibers over the pes anserinus tendons. We describe the diagnostic findings confirmed with surgical exploration of two Stener-like disruptions of the medial collateral ligament of the knee.

Computerassistierte minimalinvasive Therapie der Osteochondrosis dissecans tali

ZusammenfassungOperationszielRevaskularisation der Nekrosezone im Talus und Anregung der Knochenneubildung bei Schonung des talaren Knorpelüberzugs durch computerassistierte minimalinvasive Anbohrung oder retrograde Spongiosaunterfütterung des osteochondrotischen Herdes.IndikationenOsteochondrosis dissecans tali Stadium I–III nach Berndt & Harty.KontraindikationenOsteochondrosis dissecans tali Stadium IV nach Berndt & Harty.Allgemeine Kontraindikationen wie z. B. schlechte Haut- und Weichteilverhältnisse oder schlechter Allgemeinzustand.OperationstechnikPräoperativ: Anpassung einer abnehmbaren Schale für das obere Sprunggelenk (OSG-Fixationsschale), anschließend Computertomographie des Sprunggelenks mit angelegter OSG-Fixationsschale. Planung der Lage des zentralen Bohrstifts im Talus mit einem Navigationssystem im Labor. Einstellung und Arretierung der Zielvorrichtung.Intraoperativ: Anlage der sterilisierten OSG-Fixationsschale. Retrograde Platzierung des 2,4-mm-Kirschner-Drahts über die arretierte Zielvorrichtung. Bildwandlerkontrolle der Lage des Kirschner-Drahts.Arthroskopie des OSG; je nach Befund werden weitere Parallelbohrungen gesetzt oder eine retrograde Spongiosaplastik mit Spongiosaentnahme aus dem Kalkaneus durchgeführt.WeiterbehandlungBei retrograder Anbohrung/Parallelbohrung: 1 Woche Teilbelastung mit 30 kg.Bei retrograder Spongiosaplastik: 4 Wochen Teilbelastung mit 15 kg, dann 2 weitere Wochen Teilbelastung mit 30 kg.Physiotherapie.ErgebnisseVon Dezember 1999 bis Januar 2005 wurde bei 41 Patienten eine computerassistierte Behandlung der Osteochondrosis dissecans tali zur retrograden Anbohrung oder retrograden Spongiosaplastik gewählt. Bei 39 der 41 Patienten wurde die osteochondrale Läsion—wie im postoperativen Magnetresonanztomogramm (MRT) verifiziert—erreicht, d. h., der Bohrkanal führte in die Läsion. In zwei Fällen lag intraoperativ ein nicht behebbarer Materialfehler vor, so dass die vorgestellte Methode an 39 Patienten angewendet werden konnte. Für die ersten 15 Patienten, die eine retrograde Anbohrung/Parallelbohrung mit begleitender Sprunggelenkarthroskopie erhielten und keine retrograde Spongiosaplastik, werden die 1-Jahres-Ergebnisse anhand der MRT-Verlaufskontrolle (Bohrkanallage, Vitalitätsbeurteilung des osteochondrotischen Areals) und eines klinischen Scorings präsentiert. Die vier Frauen und elf Männer waren durchschnittlich 34,1 Jahre alt (14–55 Jahre). Im radiologischen Vergleich zwischen den prä- und postoperativen Stadien der Osteochondrosis dissecans ließ sich bei 46,7% der Patienten eine Verbesserung des Stadiums nach Berndt & Harty nachweisen. Bei 40,0% zeigte sich im MRT postoperativ das gleiche Osteochondrosis-dissecans-Stadium, und bei 13,3% verschlechterte es sich um einen Grad.In der klinischen Nachuntersuchung betrug der AOFAS-Score im Mittel 88,9 Punkte.AbstractObjectiveRevascularization of areas of necrosis in the talus and stimulation of bone regeneration whilst protecting the talar hyaline cartilage using computer-assisted minimally invasive drilling or retrograde cancellous bone relining of the osteochondrotic zone.IndicationsOsteochondrosis dissecans of the talus, Berndt & Harty stages I–III.ContraindicationsOsteochondrosis dissecans of the talus, Berndt & Harty stage IV.General contraindications such as poor skin and soft-tissue conditions or poor general condition.Surgical TechniqueBefore the operation: fitting a removable cast for the ankle (ankle fixation cast), then computed tomography of the ankle with the ankle fixation cast fitted. Planning the site of the central Kirschner wire in the talus using a navigation system in the laboratory. Adjusting and locking the aiming device.Intraoperative procedures: fitting the sterilized ankle fixation cast. Retrograde placement of the 2.4-mm Kirschner wire through the locked aiming device. Check on the position of the Kirschner wire using an image intensifier.Arthroscopy of the ankle; further parallel holes may then be drilled depending on the findings or retrograde cancellous bone grafting may be performed by harvesting cancellous bone from the calcaneus.Postoperative ManagementFor retrograde drilling/parallel drilling: 1 week of partial weight bearing at 30 kg.For retrograde cancellous bone grafting: 4 weeks of partial weight bearing at 15 kg, then 2 more weeks of partial weight bearing at 30 kg.Physiotherapy.ResultsFrom December 1999 to January 2005, 41 patients with osteochondrosis dissecans of the talus were selected for computer-assisted treatment by retrograde drilling or retrograde cancellous bone grafting. In 39 of the 41 patients, the osteochondral lesion—as verified by postoperative magnetic resonance imaging (MRI)—was accessed, i.e., the drilled hole led to the lesion. In two cases, irreparable flaws in the materials were discovered intraoperatively, so that the above method was only performed on 39 patients. The 1-year results for the first 15 patients treated with retrograde drilling/parallel drilling and concomitant ankle arthroscopy without retrograde cancellous bone graft are presented here based on the follow-up MRI (position of drill hole, assessment of vitality of the area of osteochondritis) and a clinical score. The four women and eleven men were, on average, 34.1 years old (14–55 years). In the radiologic comparison of the pre- and postoperative stages of the osteochondritis dissecans, 46.7% of patients showed an improvement in the Berndt & Harty stage. 40.0% showed the same osteochondrosis dissecans stage in the postoperative MRI, and in 13.3% it deteriorated by one grade.In the clinical follow-up examination, the AOFAS Score averaged 88.9 points.

MPFL reconstruction using a quadriceps tendon graft Part 1: Biomechanical properties of quadriceps tendon MPFL reconstruction in comparison to the Intact MPFL. A human cadaveric study

BACKGROUND The aim of this study was to analyze the structural properties of the original MPFL and to compare it to a MPFL-reconstruction-technique using a strip of quadriceps tendon. METHODS In 13 human cadaver knees the MPFLs were dissected protecting their insertion at the patellar border. The MPFL was loaded to failure after preconditioning with 10 cycles in a uniaxial testing machine evaluating stiffness, yield load and maximum load to failure. In the second part Quadriceps-MPFL-reconstruction was performed and tested in a uniaxial testing machine. Following preconditioning, the constructs were cyclically loaded 1000 times between 5 and 50 N measuring the maximum elongation. After cyclic testing, the constructs have been loaded to failure measuring stiffness, yield load and maximum load. For statistical analysis a repeated measures (RM) one-way ANOVA for multiple comparisons was used. The significance was set at P<0.05. RESULTS During the load to failure tests of the original MPFL the following results were measured: stiffness 29.4 N/mm (+9.8), yield load 167.8 N (+80) and maximum load to failure 190.7 N (+82.8). The results in the QT-technique group were as follows: maximum elongation after 1000 cycles 2.1 mm (+0.8), stiffness 33.6 N/mm (+6.8), yield load 147.1 N (+65.1) and maximum load to failure 205 N (+77.8). There were no significant differences in all tested parameters. CONCLUSIONS In a human cadaveric model using a strip of quadriceps-tendon 10 mm wide and 3mm deep, the biomechanical properties match those of the original MPFL when tested as a reconstruction. CLINICAL RELEVANCE The tested QT-technique shows sufficient primary stability with comparable biomechanical parameters to the intact MPFL.

Minimally Invasive Harvest of a Quadriceps Tendon Graft With or Without a Bone Block

The quadriceps tendon (QT) as a graft source for anterior cruciate ligament (ACL) and posterior cruciate ligament reconstruction has recently achieved increased attention. Although many knee surgeons have been using the QT as a graft for ACL revision surgery, it has never gained universal acceptance for primary ACL reconstruction. The QT is a very versatile graft that can be harvested in different widths, thicknesses, and lengths. Conventionally, the QT graft is harvested by an open technique, requiring a 6 to 8 cm longitudinal incision, which often leads to unpleasant scars. We describe a new, minimally invasive, standardized approach in which the QT graft can be harvested through a 2- to 3-cm skin incision and a new option of using the graft without a bone block.