Updated: 9/6/2017

ACL Reconstruction - Quadriceps Tendon Autograft

Review Topic

Preoperative Patient Care


Outpatient Evaluation and Management


Postoperative Weeks 1-3

  • Discuss goals with patient.
  • Range of motion: 90 degrees flexion, full extension. No more than 90 degrees flexion.
  • Independent quadriceps contraction.
  • Gait without crutches by end of week 2.
  • Educate patient on exercises.
  • Continue with postoperative program, add weight to straight leg raise if no extension lag.
  • Add bike for range of motion, strength, and cardio benefit. Pedal as tolerated.
  • 4-way hip machine, initiate closed kinetic chain to include toe and heel raises, dynamic terminal extension, and minisquats.
  • Gait training with mini-hurdles to restore normal gait kinematics.


Postoperative Weeks 4-6

  • Discuss goals with patient.
  • Range of motion: 0-120 degrees as tolerated.
  • Normal gait by weeks 3-4.
  • Testing
  • KT 1000 at 6 weeks post-op to assess for laxity.
  • Educate patient on exercises
  • Continue with postoperative program as home exercise program.
  • Advance closed kinetic chain program to include step-ups and modified lunges.
  • Initiate isotonic weight machines
  • Leg extension 90-30 degrees.
  • Hamstring curls
  • Leg press
  • Initiate proprioceptive program, including single leg stance and balance board.


Postoperative Weeks 6-12

  • Discuss goals with patient.
  • Full range of motion.
  • Swelling <1-2 cm at midpatella.
  • Prevent patella femoral pain with exercises.
  • Testing
  • KT 1000 and isokinetic test at week 12
  • Educate patient on exercises
  • Continue with postoperative program.
  • Begin isokinetics 90-30 degrees, practice starting at week 8 with progression from fast speed (300d/sec) to slow speed (60d/sec). Practice only once per week.
  • Add shuttle for plyometrics at week 10


Postoperative Weeks 12-26

  • Discuss goals with patient.
  • KT 1000 side to side difference <3 mm
  • Quad and hamstring isokinetic difference <30% on side to side comparison
  • Testing
  • KT 1000, isokinetic, functional hop test at 26 weeks
  • Educate patient on exercises.
  • Continue gym program.
  • Began plyometrics if goals above met.
  • Sports specific training at 5 months.
  • Progress into sports at 6 months.


Return to Activity Guidelines

  • Swimming: Week 4 (Freestyle only)
  • Treadmill Walking: Week 4-6
  • Elliptical: Week 4
  • Stair Stepper: Week 6
  • Rowing: Week 10
  • Outdoor Biking: Week 12
  • Golf: Week 16-20
  • Running: Month 3-4
  • Skiing/Basketball/Tennis/Football: Month 6-8

Advanced Evaluation and Management


Recognizes concomitant associated injuries (LCL, multiligament, OCD): PCL, Collateral ligaments, PL Corner instability, reverse pivot shift

  • Dial Test
  • Reverse Pivot Test


Appropriately orders and interprets advanced imaging studies: Standing views, MRI, Segond fx, bone bruising

  • Radiographs
  • Identifies Segond Fracture
  • MRI
  • ACL tear best seen on sagittal view
  • bone bruising occurs in more than half of acute ACL tears
  • middle 1/3 of LFC (sulcus terminalis)
  • posterior 1/3 of lateral tibial plateau
  • subchondral changes on MRI can persist years after injury


Provides complex non-operative treatment: WB status, Bracing as appropriate, vascular studies


Modifies and adjusts post-operative treatment plan as needed: Loss of knee motion treatment, sport specific drills, return to sport

  • Postop: 4-6 Week Postoperative Visit
  • identifies loss of knee motion

Preoperative H & P


Perform focused orthopedic exam

  • check for effusion
  • quadricep avoidance gait (does not actively extend knee)
  • Lachman's test
  • most sensitive exam test
  • grading A= firm endpoint, B= no endpoint
  • Grade 1: < 5 mm translation
  • Grade 2 A/B: 5-10mm translation
  • Grade 3 A/B: > 10mm translation
  • PCL tear may give "false" Lachman due to posterior subluxation
  • Pivot shift
  • extension to flexion: reduces at 20-30° of flexion
  • patient must be completely relaxed (easier to elicit under anesthesia)
  • mimics the actual giving way event
  • KT-1000
  • useful to quantify anterior laxity
  • measured with knee in slight flexion and externally rotated 10-30°


Perform preoperative medical history and physical exam


Ensure biplanar images and MRI of the knee are present


Perform operative consent

  • describe complications of surgery including
  • surgical technical error
  • inadequate fixation
  • overaggressive rehab
  • cyclops lesion
  • infection
  • loss of motion & arthrofibrosis
  • infrapatellar contracture syndrome
  • patella Tendon Rupture
  • RSD (complex regional pain syndrome)
  • patella fracture
  • hardware failure
  • tunnel osteolysis
  • late arthritis
  • local nerve irritation

Operative Techniques


Preoperative Plan


Radiographic and MRI assessment

  • diagnose ACL tear and any other pathology that will be addressed during the ACL reconstruction.
  • If MRI has been obtained, estimate thickness of quadriceps tendon. Measure thickness at midsagital patella and 3 cm proximal to the proximal pole. Partial thickness harvest is preferred (tendon thickness >8 mm) to full thickness (tendon thickness <7 mm) if possible.
  • assess for physeal closure on femur and tibia.


Discuss options with the patient

  • discuss graft options with the patient.
  • autograft vs. allograft
  • allografts lack donor site morbidity, but have increased cost and increased failure rates in the young patient population.
  • quadriceps autograft shown to have equivalent outcomes to hamstring and patella tendons


Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • description of potential complications and steps to avoid them

Room Preparation


Surgical Instrumentation

  • arthroscopy tower and ACL tray
  • quad tendon graft cutting guide from Arthrex
  • quad tendon stripper/cutter from Arthrex
  • adjustable loop button and FiberLoop suture


Room setup and Equipment

  • operative table, choice of leg post, leg holder, or neither


Exam under anesthesia

  • once the patient is under anesthesia
  • examine the operative and non-operative leg.
  • assess range of motion, Lachman, Pivot Shift, LCL, MCL, and pulse exam.


Patient positioning

  • place patient supine on the table.
  • thigh tourniquet is used throughout the procedure
  • position legs to surgeon's preference. One option is to place the operative leg in a circumferential leg holder, and the non-operative leg in a lithotomy positioner.
  • take care to pad the peroneal nerve in the non-operative leg

Graft Harvest


Mark the incision and anatomical landmarks

  • With the leg flexed at 90 degrees, mark the superior pole and the medial and lateral borders of the patella. Mark the harvest site incision as a 2 cm horizontal line that is centered on the patella and is 1 cm proximal to patella.
  • Distinguish the lateral border of the patella from the lateral trochlear ridge.
  • Palpate and mark the border of the vastus medialis oblique


Make the skin incision

  • A 15 blade is used to make the 2 cm horizontal incision
  • Widely excise the underlying subcutaneous fat and peratenon for adequate visualization.


Mobilize the tissue proximally

  • A ray-tech sponge is used to bluntly dissect the soft tissue from the quadriceps tendon and anterior patella.
  • After mobilization, one should be able to feel approximately 8 cm proximally from the superior pole of the patella and distally to the mid portion of the patella.


Mark tendon length and incise tendon

  • Place an Army-Navy retractor into the proximal apex of the incision and insert an arthroscope with the fluid off.
  • Identify the vastus medialis and the approximate midportion of the proximal quadriceps tendon.
  • Drop your hand with the arthroscope so that the tip is easily palpable underneath the skin surface proximally, identify the point of illumination, and make a mark.
  • This will allow you to identify the ideal section for harvesting and direction of cutting.
  • From the proximal pole of the patella, make a skin mark 7 cm proximally and in line with the previous mark.
  • Use a harvesting device to make a longitudinal cut in the quadriceps tendon. The device is made to create a 10 mm wide and 6 mm deep longitudinal cut. The proximal aspect of this cut should correlate with the skin mark.
  • With a 15 blade, connect the 2 vertical incisions made by the harvesting device just off the superior pole of the patella.
  • There is a thin layer of fat deep to the tendon and superficial to the capsule. If fat is encountered, the surgeon should note that the cut has gone through the tendon, and care should be taken to avoid deeper dissection or capsular violation.
  • With a scalpel or metzenbaum scissors, carefully dissect proximally while controlling the graft end with an Allis clamp. Dissect to 2-3 cm proximally.
  • Then use the Key Elevator to finish the blunt discection proximally. Use this both underneath and on the sides of the graft.
  • Trim down the distal 1.5-2 cm of the graft to the desired circumference. IF this is not done, then the ends of the graft will tend to be larger than the center of the graft.
  • Whipstitch the tendon with a FiberLoop suture. Start 1.5 cm proximal to the tendon end and exit the central portion of the graft after 4 throws. Do not remove the needle at this time.
  • With firm tension on the sutures, use the Arthrex stripper/cutter to strip the tendon proximally and to the desired graft length.
  • Bring the graft to the back table for preparation. Often, the grafts shorten a few millimeters with preparation and should be 6.5-7 cm in length at this time.


Close harvest site

  • With the arthroscope reinserted, evaluate for a capsular rent and confirm thickness of harvest.
  • If breached, the deep portion of the tendon harvest site or capsule can be closed with 0 Vicryl.
  • If a small harvest incision was utilized, a rotator cuff suture passer (Express Sew or Scorpion) can be utilized to more easily reach the proximal portions of the harvest site.
  • If a partial thickness harvest is confirmed, the defect does not need to be closed, and skin can be closed in a standard fashion.

Graft Preparation


Trim the graft

  • Secure the FiberLoop end of the graft to a graft preparation clamp. Place an allis clamp on the free end of the graft to be held by assistant in tension.
  • Trim the free side of the graft to the desired diameter.
  • After being tubulerized by the FiberLoop, this end of the graft will increase in diameter approximately 0.5 - 1 mm.


Prepare the free end of the graft

  • Use a FiberLoop to whipstitch this end of the graft in the same manner as done during graft harvest. Start 1.5 cm away from the free end of the tendon and lock the last stitch as it exits the center of the tendon.


Assess the graft

  • Measure the diameter of each end of the graft.
  • The surgeon has the flexibility to decide which side of the graft will be placed in the femur or tibia. This can be helpful in revision settings where the larger end of the tendon can go in the larger tunnel.


Secure graft fixation

  • Adjustable loop suspensory fixation is preferred for ability to adjust graft after passing through tunnels.
  • Pass FiberLoops through the loop of the TightRope RT. Then pass the needle through the center of the graft, exiting 5 mm away from the end of the graft. Throw 3-4 whipstitches.
  • Cut the needle. Wrap the 2 limbs of the suture around the graft in opposite directions and tie.
  • The end of the suture can be passed through the needle and the knot passed into the middle of tendon before cutting tails.
  • The length of the femoral adjustable loop button is shortened to the length of the potential femoral tunnel + 5 mm (the distance between ACL insertion and lateral femoral cortex).
  • The additional 5 mm allows for the button to completely exit the femur and engage the femoral cortex when the tip of the graft reaches the opening of the femoral tunnel through the iliotibial band. This minimizes the chance of deploying the button. The tunnel should be approximately 25 mm to allow for 20 mm of graft to fit in it.
  • Resize the graft and place under tension, covered with a wet 4x4.
  • Tubular graft compressors work well with this graft to enhance graft passage.

Diagnostic Arthroscopy



  • anterolateral
  • an 11 blade is used to create the portal at a 45 degree angle into the joint just lateral to the patella tendon and just inferior to the distal pole of the patella
  • insert the blunt trocar at the same angle as incision
  • anteromedial
  • often created under direct visualization once the medial compartment is entered
  • place knee in approximately 30 degrees of flexion with valgus moment applied. Use a spinal needle to assess direction and appropriate superior/inferior direction visualizing the entrance from the lateral viewing portal
  • the medial portal should be located just off the medial patella tendon and able to provide access to the anatomic ACL footprint on the femur as well and the medial meniscal root if needed
  • auxiliary far medial
  • Use a spinal needle to assess direction. Enter the joint just above the medial meniscus as close to the medial femur as possible.
  • The far medial portal incision should be made transversely and large enough for later graft passage.



  • visualize
  • Suprapatellar pouch
  • undersurface of the patella and trochlear groove
  • lateral and medial gutters
  • medial compartment
  • visualize the medial femoral condyle and follow it while bringing the knee into slight flexion and applying a valgus stress to the knee as you go into the medial compartment
  • the foot will be positioned on your opposite hip for control
  • medial meniscus, medial femoral condyle, and medial tibial plateau
  • once the anteriomedial portal is created, a probe is used to assess the medial meniscus and cartilage
  • intercondylar notch – ACL/PCL
  • use probe to assess the ACL and PCL
  • lateral compartment
  • the surgeon can bring the leg into a figure-4 position or place the operative limb on the surgeon's hip to create a varus stress and flexion to the knee to enter the lateral compartment
  • lateral meniscus, lateral femoral condyle, and lateral tibial plateau
  • a probe is used to assess the lateral meniscus and cartilage

Tunnel Placement and Site Preparation


Debride the ACL footprint

  • the ACL remnant is removed from the notch usually with a shaver and/or a radiofrequency ablation device while noting the anatomic footprint on the femoral and tibial side for later reconstruction
  • care is taken not to injure the PCL


Mark the femoral footprint

  • Using the auxiliary far medial portal, mark the center of the femoral footprint with the shaver or electrocautery. The knee must be flexed to 90 degrees.
  • the anatomic footprint is used as a guide, marking between the anteromedial and posterolateral bundles of the ACL origin.
  • this position is typically in the center of the bifurcate ridge in the center of the femoral origin of the ACL.


Drilling the femoral tunnel

  • Drill the femoral tunnel to 25 mm. The average potential tunnel length is normally 30-40 mm, but no more than 25 mm is needed because our graft length is 6.5-7 cm.
  • We do not want more than 2 cm in the femoral tunnel, thus keeping the tunnel length to 25 mm prevents excess graft being pulled into the femoral tunnel with insufficient graft remaining in the tibia.
  • A dilator may or may not be used to increase the size of the tunnel.
  • Place a looped graft-passing suture in the femoral tunnel.


Mark the tibial footprint

  • Looking through the anterolateral portal, place the electrocautery through the AM portal and mark the tibial footprint.
  • the anatomic footprint is used as a guide, with the mark placed a few mm anterior to the center of the footprint.
  • this position is typically 1 mm anterior to the posterior aspect of the anterior medial bundle insertion of the anterior horn of the lateral meniscus in the center of the tibial footprint.


Drilling the tibial tunnel

  • The tibial drill guide is placed through the anteromedial portal while the scope is viewing from the anterolateral portal. With the guide set at 55 degrees, mark the position on the anteromedial tibia. Make a small poke hole incision with an 11 blade.
  • Place a guide pin through the incision. Extend the knee to ensure pin does not impinge in notch.
  • Drill appropriate sized tunnel. A dilator may be used as needed.
  • Place a looped graft-passing suture in the tibial tunnel.
  • Once the tunnel is drilled, the looped suture in the femoral tunnel can be retrieved through the far medial portal, with the aid of a grasper, to be used for graft passage.

Graft Placement


Pass the graft

  • Place a grasper through the far medial portal and grasp both the tibial and femoral passing sutures.
  • the femoral sided graft sutures are placed through the looped end of the passing suture which has been brought out through the far medial portal.
  • tension is applied as the sutures are brought through the joint and out the lateral skin.


Seat and secure the graft on the femoral side

  • the femoral sided graft is pulled into the femoral tunnel
  • The button should be deployed on the lateral cortex of the femur.
  • The sutures should no longer be visible once the graft is pulled into the tunnel.
  • This ensures that at least 20 mm of graft are within the tunnel.
  • a probe or clamp can aid in obtaining the desired orientation of the graft


Seat and secure the graft on the tibial side

  • the tibial sided graft sutures are placed through the looped end of the tibial passing sutures and pulled through the tibia.

Graft Tensioning


Cycle the knee

  • With tension applied to the tibial fixation sutures, cycle the knee 20 times to full flexion and extension
  • Assess for range of motion and impingement of the graft.


Fix the tibial side

  • Place the knee in full extension when tensioning and securing the tibial side.
  • This ensures that the patient does not lose terminal extension.
  • The tibial side can be fixed with either a simple tie-over-post screw.


Re-assess the knee

  • Perform Lachman maneuver to assess for laxity.

Wound Closure



  • Drain excess fluid from the knee and remove cannulas.
  • Close incisions appropriately.
  • Apply appropriate dressings, including sterile gauze, webril, and a loosely wrapped Ace bandage.

Postoperative Patient Care


Postoperative Management


Discuss goals with patient.

  • Minimize swelling.
  • Minimize quadriceps inhibition.
  • Protect graft.


Provide patient with instructions to meet goals.

  • Non weight bearing for 3 days, then as tolerated with crutches. Knee brace not required.
  • Perform exercises at home.
  • Quad sets, straight leg raises.
  • Hamstring stretch, calf towel stretch, ankle pumps.
  • Hip extension
  • Range of motion: prone hangs, knee flexion while sitting (but not past 90 degrees for first 6 weeks).

Complex Patient Care


Performs revision/transphyseal ACL reconstruction : Hardware removal, outside in drilling techniques


Develops unique, complex post-operative management plans


Surgically treats complex complications


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