Minimally Invasive Quad Tendon Harvest System Surgical Technique Quad Tendon Harvest System
Quadricep tendon grafts offer unique benefits for cruciate ligament reconstruction such as a predictably large diameter, low morbidity and a preferable stiffness profile for knee ligament reconstruction. The Minimally Invasive Quad Tendon Harvest System was designed based on published anatomic studies. It allows surgeons to safely harvest a graft of a desired length and diameter through a small incision in a timeefficient manner. The system has the versatility to create grafts to meet the surgeon s needs whether it be all soft tissue, bone-soft tissue, all-inside or transtibial. John Xerogeanes, MD Emory Orthopaedic and Spine Center Atlanta, GA References Xerogeanes JW, Mitchell PM, Karasev PA, Kolesov IA, Romine SE, Anatomic and morphological evaluation of the quadriceps tendon using 3-dimensional magnetic resonance imaging reconstruction: applications for anterior cruciate ligament autograft choice and procurement, Am J Sports Med. 2013 Oct;41(10):2392-9. doi: 10.1177/0363546513496626. Epub 2013 July 26. DeAngelis JP, Fulkerson JP, Quadriceps tendon: a reliable alternative for reconstruction of the anterior cruciate ligament. Clin Sports Med, 2007;26(4):587-596. Fulkerson JP, Central quadriceps free tendon for anterior cruciate ligament reconstruction. Oper Tech Sports Med. 1999;7:195-200. 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. Harris NL, Smith DA, Lamoreaux L, Purnell M, Central quadriceps tendon for anterior cruciate ligament reconstruction, part I: morphometric and biomechanical evaluation. Am J Sports Med. 1997; 25(1):23-28. Lippe J, Armstrong A, Fulkerson JP, Anatomic guidelines for harvesting a quadriceps free tendon autograft for anterior cruciate ligament reconstruction. Arthroscopy. 2012;28(7): 980-984. Staubli HU, Bollmann C, Kreutz R, Becker W, Rauschning W, Quantification of intact quadriceps tendon, quadriceps tendon insertion, and suprapatellar fat pad: MR arthrography, anatomy, and cryosections in the sagittal plane. AJR Am J Roentgenol. 1999;173(3):691-698. Staubli HU, Schatzmann L, Brunner P, Rincon L, Nolte LP, Quadriceps tendon and patellar ligament: cryosectional anatomy and structural properties in young adults. Knee Surg Sports Traumatol Arthrosc. 1996;4:100-110.
QUAD TENDON GRAFT CUTTING GUIDE Low profile blade facilitates subcutaneous tendon cutting at fixed widths of 9, 10 and 11 mm 5 mm depth limit ensures proper graft thickness Depth markings on the shaft allow visual confirmation of graft length QUAD TENDON STRIPPER/CUTTER Safety handle prevents premature cutting of the graft Sharp leading edge strips graft away from surrounding tissue Depth markings on the shaft confirm graft length Cutter allows subcutaneous resection of proximal attachments without a second incision
PREOPERATIVE PLANNING Patient height of at least 5 feet has been shown to provide graft lengths of 7-8 cm in length. Mid-sagittal MRI measurements (measured 3 cm proximal to the patella) will help determine graft thickness. A partial thickness graft will be taken if the tendon is over 7 mm thick. If the tendon is 6 mm or less, a full thickness graft will be taken. 3 cm PATIENT POSITIONING AND LANDMARKS D 1 B A C The knee should be flexed to 90 which will place tension on the quad and facilitate harvesting. Palpate and mark the following areas: Superior pole of the patella (A) Medial aspect of the VMO (B) Lateral edge of quad tendon (C) The incision line 60% from the medial side (D)
INCISION AND DISSECTION Before making the incision, local anesthetic can be injected into the area if desired. 2 Make a vertical incision about 1-2 cm long just lateral to the apex of the patella. After making the skin incision, fat can be dissected and removed proximally and distally from the incision. Bluntly dissect proximally and distally to the incision until the proximal 8 cm of the quad tendon and proximal half of the patella can be felt and adhesions are removed. 3 3a A retractor can be used to lift the skin while an arthroscope is placed under the skin to visualize the course of the tendon. Identify the VMO and stay lateral to this landmark. Advance the scope proximally until the proximal end of the tendon is visualized. Turn the scope upwards so the light can be seen through the skin. This is the proximal limit of the graft harvest. Mark the skin at this point for reference.
QUAD TENDON GRAFT CUTTING GUIDE Place the desired size blade onto the handle using a clamp, in similar fashion to a scalpel blade. 4 4a Retract the skin and insert the Quad Tendon Graft Cutting Blade. Press down into the quad until the roof of the knife is flat and in contact with the quadriceps tendon adjacent to the superior patella. Push proximally until the proximal part of the blade reaches the desired length. The length can be read on the instrument shaft at the proximal border of the patella. It is recommended not to go beyond 80 mm.
GRAFT HARVEST 5 6 After the initial cut, extend the knee and use a #15 blade to continue the cuts down to the patella. Take care to angle the cut inward so the final graft end is tapered (inset); this will facilitate graft passage later. Connect the cuts transversely on top of the patella. Remove the graft from the patella subperiosteally. Grasp the distal end of the quad tendon and use a #15 blade to complete dissection of the harvested 7 mm thickness away from the tissue underneath. Applying tension to the graft will allow approximately 3 cm to be exposed and prepared. Dissect the graft away from soft tissue tethers proximally as possible. Alternatively, bone can be harvested from the proximal patella for a bone tendon graft, if desired (inset). 7 If a tendon-only graft is harvested, the end may now be prepared with a #2 FiberLoop or #2 FiberLoop w/fibertag and attached to an ACL TightRope implant (inset) if desired. Traction can be pulled on the whipstitches to deliver the tendon out of the wound and scissors are used to dissect remaining attachments of the graft to the surrounding tissue. NOTE: Failure to dissect remaining attachments of the graft from the surrounding tendon will decrease effectiveness of the stripper/ cutter.
8 9 Place the suture tails and distal graft through the graft stripper/cutter. Make sure the handle is locked to prevent premature cutting of the graft (a). Advance the stripper/cutter proximally. Rotation may facilitate advancement. If the stripper/cutter will not advance, check for soft tissue tethers and cut manually with scissors. Once the Quad Tendon Stripper/Cutter reaches the desired depth, as indicated by the skin marking and instrument measurements, unlock the handle and squeeze the trigger to cut the proximal tendon (b & c). 10 a b c CLOSURE If there is no violation of the capsule then closure is not needed. For partial thickness capsule violation, simple sutures can be used to close. For full thickness violation close only the capsular layer to stop fluid leakage. Do not close the tendon defect.
GRAFT PREPARATION AND FIXATION a All-inside ACL technique is ideal for quadriceps grafts since only a length of 60-75 cm is needed. Both ACL TightRope and RetroScrew implants can be used to fixate the graft in minimally invasive sockets created with a FlipCutter. ACL TightRope may be attached to the graft with #2 FiberLoop or #2 FiberLoop with FiberTag (a). A standard all-inside technique is used to implant the graft. AR-2382S - Minimally Invasive Quad Tendon Set
ORDERING INFORMATION Minimally Invasive Quad Tendon Set (AR-2382S) Quad Tendon Graft Cutting Guide AR-2383 Quad Tendon Stripper/Cutter AR-2384 Instrument Case AR-2382C Disposable Blades for Quad Tendon Graft Cutting Guide Quad Tendon Graft Cutting Blade, 9 mm AR-2385-09 Quad Tendon Graft Cutting Blade, 10 mm AR-2385-10 Quad Tendon Graft Cutting Blade, 11 mm AR-2385-11 Graft Prep Suture #2 FiberLoop w/straight Needle, 20 (blue), 76 mm needle w/7 mm loop AR-7234 #2 FiberLoop w/curved Needle, 20 (blue), 1/2 circle AR-7234C FiberLoop w/fibertag AR-7264 Implants ACL TightRope AR-1588T TightRope ABS AR-1588TN TightRope ABS Button, 8 mm x 12 mm AR-1588TB TightRope RT Implant System, w/8 mm FlipCutter II AR-1588RT-07 TightRope RT Implant System, w/9 mm FlipCutter II AR-1588RT-18 TightRope RT Implant System, w/10 mm FlipCutter II AR-1588RT-11 TightRope RT Implant System, w/11 mm FlipCutter II AR-1588RT-13 ACL TightRope RT Implant Delivery System, w/acl TightRope Drill Pin AR-1588RTS Disposables: FlipCutter II, 6 mm FlipCutter II, 6.5 mm FlipCutter II, 7 mm FlipCutter II, 7.5 mm FlipCutter II, 8 mm FlipCutter II, 8.5 mm FlipCutter II, 9 mm FlipCutter II, 9.5 mm FlipCutter II, 10 mm FlipCutter II, 10.5 mm FlipCutter II, 11 mm FlipCutter II, 11.5 mm FlipCutter II, 12 mm FlipCutter II, 13 mm AR-1204AF-60 AR-1204AF-65 AR-1204AF-70 AR-1204AF-75 AR-1204AF-80 AR-1204AF-85 AR-1204AF-90 AR-1204AF-95 AR-1204AF-100 AR-1204AF-105 AR-1204AF-110 AR-1204AF-115 AR-1204AF-120 AR-1204AF-130 AR-7264 - FiberLoop w/fibertag
This description of technique is provided as an educational tool and clinical aid to assist properly licensed medical professionals in the usage of specific Arthrex products. As part of this professional usage, the medical professional must use their professional judgment in making any final determinations in product usage and technique. In doing so, the medical professional should rely on their own training and experience and should conduct a thorough review of pertinent medical literature and the product s Directions For Use. View U.S. patent information at www.arthrex.com/corporate/virtual-patent-marking 2015, Arthrex Inc. All rights reserved. LT1-0136-EN_C