Skip to main content

Advertisement

SpringerLink
Log in

Tensile properties of a split quadriceps graft for ACL reconstruction

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Anatomic double-bundle ACL reconstruction can be performed using different grafts, such as quadriceps tendon. Grafts can be split in either coronal or sagittal planes to approximate the two bundles of the native ACL, but it is unknown whether a difference exists in the graft tensile properties depending on splitting plane. The purpose of this study was to evaluate the tensile properties of split human quadriceps tendon-bone grafts.

Methods

Twenty full-thickness quadriceps tendon-bone grafts were prepared to mimic grafts for double-bundle ACL reconstruction. Ten grafts were split in the sagittal plane, and ten were split in the coronal plane. Each graft underwent cyclic creep testing and load-to-failure testing to compare creep, ultimate load, ultimate elongation, stiffness, and tangent modulus between splitting planes. All parameters were compared between splitting groups (significance p < 0.05).

Results

Lateral halves of grafts split in the sagittal plane exhibited a percent creep of 42.5 ± 12.4 %, ultimate load of 445 ± 210 N, ultimate elongation of 7.3 ± 1.9 mm, stiffness of 75.7 ± 19.9 N/mm, and tangent modulus of 174.0 ± 99.8 MPa. No differences were found between halves within split tendons or between splitting planes (n.s.).

Conclusions

Overall, splitting quadriceps tendon grafts for anatomic double-bundle ACL reconstruction results in similar tensile properties regardless of splitting plane. Surgeons can split quadriceps tendon in either splitting plane, but should take care to preserve fibres as much as possible. This study provides data that support the use of both coronal and sagittal splits of quadriceps tendons for anatomic double-bundle ACL reconstruction.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Aglietti P, Giron F, Cuomo P, Losco M, Mondanelli N (2007) Single-and double-incision double-bundle ACL reconstruction. Clin Orthop Relat Res 454:108–113

    Article  PubMed  Google Scholar 

  2. Butler DL, Guan Y, Kay MD, Cummings JF, Feder SM, Levy MS (1992) Location-dependent variations in the material properties of the anterior cruciate ligament. J Biomech 25(5):511–518

    Article  CAS  PubMed  Google Scholar 

  3. DeAngelis JP, Fulkerson JP (2007) Quadriceps tendon–a reliable alternative for reconstruction of the anterior cruciate ligament. Clin Sports Med 26(4):587–596

    Article  PubMed  Google Scholar 

  4. Desai N, Bjornsson H, Musahl V, Bhandari M, Petzold M, Fu FH, Samuelsson K (2014) Anatomic single- versus double-bundle ACL reconstruction: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 22(5):1009–1023

    Article  PubMed  Google Scholar 

  5. Fu FH, Shen W, Starman JS, Okeke N, Irrgang JJ (2008) Primary anatomic double-bundle anterior cruciate ligament reconstruction: a preliminary 2-year prospective study. Am J Sports Med 36(7):1263–1274

    Article  PubMed  Google Scholar 

  6. Fulkerson JP, Langeland R (1995) An alternative cruciate reconstruction graft: the central quadriceps tendon. Arthroscopy 11(2):252–254

    Article  CAS  PubMed  Google Scholar 

  7. Geib TM, Shelton WR, Phelps RA, Clark L (2009) Anterior cruciate ligament reconstruction using quadriceps tendon autograft: intermediate-term outcome. Arthroscopy 25(12):1408–1414

    Article  PubMed  Google Scholar 

  8. Hamner DL, Brown CH Jr, Steiner ME, Hecker AT, Hayes WC (1999) Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am 81(4):549–557

    Article  CAS  PubMed  Google Scholar 

  9. Han HS, Seong SC, Lee S, Lee MC (2008) Anterior cruciate ligament reconstruction: quadriceps versus patellar autograft. Clin Orthop Relat Res 466(1):198–204

    Article  PubMed  PubMed Central  Google Scholar 

  10. Harris NL, Smith DA, Lamoreaux L, Purnell M (1997) Central quadriceps tendon for anterior cruciate ligament reconstruction. Part I: morphometric and biomechanical evaluation. Am J Sports Med 25(1):23–28

    Article  CAS  PubMed  Google Scholar 

  11. Howe JG, Johnson RJ, Kaplan MJ, Fleming B, Jarvinen M (1991) Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Part I: long-term followup. Am J Sports Med 19(5):447–457

    Article  CAS  PubMed  Google Scholar 

  12. Jarvela T (2007) Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective, randomize clinical study. Knee Surg Sports Traumatol Arthrosc 15(5):500–507

    Article  PubMed  Google Scholar 

  13. Jones DB, Huddleston PM, Zobitz ME, Stuart MJ (2007) Mechanical properties of patellar tendon allografts subjected to chemical sterilization. Arthroscopy 23(4):400–404

    Article  PubMed  Google Scholar 

  14. Jung HJ, Vangipuram G, Fisher MB, Yang G, Hsu S, Bianchi J, Ronholdt C, Woo SL (2011) The effects of multiple freeze-thaw cycles on the biomechanical properties of the human bone-patellar tendon-bone allograft. J Orthop Res 29(8):1193–1198

    Article  PubMed  PubMed Central  Google Scholar 

  15. Kato Y, Hoshino Y, Ingham SJ, Fu FH (2010) Anatomic double-bundle anterior cruciate ligament reconstruction. J Orthop Sci 15(2):269–276

    Article  PubMed  Google Scholar 

  16. Kim D, Asai S, Moon CW, Hwang SC, Lee S, Keklikci K, Linde-Rosen M, Smolinski P, Fu FH (2015) Biomechanical evaluation of anatomic single- and double-bundle anterior cruciate ligament reconstruction techniques using the quadriceps tendon. Knee Surg Sports Traumatol Arthrosc 23(3):687–695

    Article  PubMed  Google Scholar 

  17. Kim SJ, Chang JH, Kim TW, Jo SB, Oh KS (2009) Anterior cruciate ligament reconstruction with use of a single or double-bundle technique in patients with generalized ligamentous laxity. J Bone Joint Surg Am 91(2):257–262

    Article  PubMed  Google Scholar 

  18. Kim SJ, Jo SB, Kim TW, Chang JH, Choi HS, Oh KS (2009) A modified arthroscopic anterior cruciate ligament double-bundle reconstruction technique with autogenous quadriceps tendon graft: remnant-preserving technique. Arch Orthop Trauma Surg 129(3):403–407

    Article  PubMed  Google Scholar 

  19. Kim SJ, Jo SB, Kumar P, Oh KS (2009) Comparison of single- and double-bundle anterior cruciate ligament reconstruction using quadriceps tendon-bone autografts. Arthroscopy 25(1):70–77

    Article  PubMed  Google Scholar 

  20. Kim SJ, Jung KA, Song DH (2006) Arthroscopic double-bundle anterior cruciate ligament reconstruction using autogenous quadriceps tendon. Arthroscopy 22(7):e791–e795

    Google Scholar 

  21. Kondo E, Yasuda K, Azuma H, Tanabe Y, Yagi T (2008) Prospective clinical comparisons of anatomic double-bundle versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients. Am J Sports Med 36(9):1675–1687

    Article  PubMed  Google Scholar 

  22. Lund B, Nielsen T, Fauno P, Christiansen SE, Lind M (2014) Is quadriceps tendon a better graft choice than patellar tendon? A prospective randomized study. Arthroscopy 30(5):593–598

    Article  PubMed  Google Scholar 

  23. Ma Y, Murawski CD, Rahnemai-Azar AA, Maldjian C, Lynch AD, Fu FH (2015) Graft maturity of the reconstructed anterior cruciate ligament 6 months postoperatively: a magnetic resonance imaging evaluation of quadriceps tendon with bone block and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc 23(3):661–668

    Article  PubMed  Google Scholar 

  24. Mabe I, Hunter S (2014) Quadriceps tendon allografts as an alternative to Achilles tendon allografts: a biomechanical comparison. Cell Tissue Bank 15(4):523–529

    Article  CAS  PubMed  Google Scholar 

  25. Mulford JS, Hutchinson SE, Hang JR (2013) Outcomes for primary anterior cruciate reconstruction with the quadriceps autograft: a systematic review. Knee Surg Sports Traumatol Arthrosc 21(8):1882–1888

    Article  PubMed  Google Scholar 

  26. Muneta T, Koga H, Mochizuki T, Ju YJ, Hara K, Nimura A, Yagishita K, Sekiya I (2007) A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques. Arthroscopy 23(6):618–628

    Article  PubMed  Google Scholar 

  27. Noyes FR, Barber-Westin S (2005) Posterior cruciate ligament replacement with a two-strand quadriceps tendon-patellar bone autograft and a tibial inlay technique. J Bone Joint Surg Am 87(6):1241–1252

    PubMed  Google Scholar 

  28. Rabuck SJ, Musahl V, Fu FH, West RV (2013) Anatomic anterior cruciate ligament reconstruction with quadriceps tendon autograft. Clin Sports Med 32(1):155–164

    Article  PubMed  Google Scholar 

  29. Rainis CA, Brown AJ, McMahon PJ, Debski RE (2012) Effects of simulated injury on the anteroinferior glenohumeral capsule. Med Biol Eng Comput 50(12):1299–1307

    Article  PubMed  PubMed Central  Google Scholar 

  30. Sakane M, Fox RJ, Woo SL, Livesay GA, Li G, Fu FH (1997) In situ forces in the anterior cruciate ligament and its bundles in response to anterior tibial loads. J Orthop Res 15(2):285–293

    Article  CAS  PubMed  Google Scholar 

  31. Shani RH, Umpierez E, Nasert M, Hiza EA, Xerogeanes J (2016) Biomechanical comparison of quadriceps and patellar tendon grafts in anterior cruciate ligament reconstruction. Arthroscopy 32(1):71–75

    Article  PubMed  Google Scholar 

  32. Siebold R, Dehler C, Ellert T (2008) Prospective randomized comparison of double-bundle versus single-bundle anterior cruciate ligament reconstruction. Arthroscopy 24(2):137–145

    Article  PubMed  Google Scholar 

  33. Skelley NW, Castile RM, York TE, Gruev V, Lake SP, Brophy RH (2015) Differences in the microstructural properties of the anteromedial and posterolateral bundles of the anterior cruciate ligament. Am J Sports Med 43(4):928–936

    Article  PubMed  Google Scholar 

  34. Sonnery-Cottet B, Chambat P (2006) Anatomic double bundle: a new concept in anterior cruciate ligament reconstruction using the quadriceps tendon. Arthroscopy 22(11):e1241–e1244

    Article  Google Scholar 

  35. Staubli HU, Schatzmann L, Brunner P, Rincon L, Nolte LP (1996) Quadriceps tendon and patellar ligament: cryosectional anatomy and structural properties in young adults. Knee Surg Sports Traumatol Arthrosc 4(2):100–110

    Article  CAS  PubMed  Google Scholar 

  36. Staubli HU, Schatzmann L, Brunner P, Rincon L, Nolte LP (1999) Mechanical tensile properties of the quadriceps tendon and patellar ligament in young adults. Am J Sports Med 27(1):27–34

    CAS  PubMed  Google Scholar 

  37. van Eck CF, Illingworth KD, Fu FH (2010) Quadriceps tendon: the forgotten graft. Arthroscopy 26(4):441–442 (author reply 442–443)

    Article  PubMed  Google Scholar 

  38. van Eck CF, Kropf EJ, Romanowski JR, Lesniak BP, Tranovich MJ, van Dijk CN, Fu FH (2011) ACL graft re-rupture after double-bundle reconstruction: factors that influence the intra-articular pattern of injury. Knee Surg Sports Traumatol Arthrosc 19(3):340–346

    Article  PubMed  Google Scholar 

  39. van Eck CF, Schkrohowsky JG, Working ZM, Irrgang JJ, Fu FH (2012) Prospective analysis of failure rate and predictors of failure after anatomic anterior cruciate ligament reconstruction with allograft. Am J Sports Med 40(4):800–807

    Article  PubMed  Google Scholar 

  40. Waligora AC, Johanson NA, Hirsch BE (2009) Clinical anatomy of the quadriceps femoris and extensor apparatus of the knee. Clin Orthop Relat Res 467(12):3297–3306

    Article  PubMed  PubMed Central  Google Scholar 

  41. Woo SL, Hollis JM, Adams DJ, Lyon RM, Takai S (1991) Tensile properties of the human femur-anterior cruciate ligament-tibia complex. The effects of specimen age and orientation. Am J Sports Med 19(3):217–225

    Article  CAS  PubMed  Google Scholar 

  42. Yagi M, Kuroda R, Nagamune K, Yoshiya S, Kurosaka M (2007) Double-bundle ACL reconstruction can improve rotational stability. Clin Orthop Relat Res 454:100–107

    Article  PubMed  Google Scholar 

  43. Yanke AB, Bell R, Lee A, Kang RW, Mather RC 3rd, Shewman EF, Wang VM, Bach BR Jr (2013) The biomechanical effects of 1.0–1.2 Mrad of gamma irradiation on human bone-patellar tendon-bone allografts. Am J Sports Med 41(4):835–840

    Article  PubMed  Google Scholar 

  44. Yasuda K, Kondo E, Ichiyama H, Tanabe Y, Tohyama H (2006) Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: comparisons among 3 different procedures. Arthroscopy 22(3):240–251

    Article  PubMed  Google Scholar 

  45. Zeiss J, Saddemi SR, Ebraheim NA (1992) MR imaging of the quadriceps tendon: normal layered configuration and its importance in cases of tendon rupture. AJR Am J Roentgenol 159(5):1031–1034

    Article  CAS  PubMed  Google Scholar 

  46. Zhou T, Grimshaw PN, Jones C (2009) A biomechanical investigation of the anteromedial and posterolateral bands of the porcine anterior cruciate ligament. Proc Inst Mech Eng H 223(6):767–775

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

Support from the Department of Orthopaedic Surgery is gratefully acknowledged. The authors would also like to thank Dr. James Irrgang for assistance with statistical analysis.

Author information

Authors and Affiliations

  1. Orthopaedic Robotics Laboratory, University of Pittsburgh, 408 Center for Bioengineering, 300 Technology Drive, 306 CNBIO, Pittsburgh, PA, 15219, USA

    R. Matthew Miller, Amir Ata Rahnemai-Azar, Levent Sürer, Fabio V. Arilla, Freddie H. Fu, Richard E. Debski & Volker Musahl

  2. Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 300 Technology Drive, 306 CNBIO, Pittsburgh, PA, 15219, USA

    R. Matthew Miller, Amir Ata Rahnemai-Azar, Richard E. Debski & Volker Musahl

  3. Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, 1010 Kaufmann Building, Pittsburgh, PA, 15213, USA

    Amir Ata Rahnemai-Azar, Levent Sürer, Fabio V. Arilla, Freddie H. Fu, Richard E. Debski & Volker Musahl

Authors
  1. R. Matthew Miller
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Amir Ata Rahnemai-Azar
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Levent Sürer
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Fabio V. Arilla
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Freddie H. Fu
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Richard E. Debski
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Volker Musahl
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Richard E. Debski.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Miller, R.M., Rahnemai-Azar, A.A., Sürer, L. et al. Tensile properties of a split quadriceps graft for ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 25, 1249–1254 (2017). https://doi.org/10.1007/s00167-016-4019-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-016-4019-z

Keywords

Search

Navigation