Hey, guys. Welcome to San Francisco, my hometown, which I abandoned for Atlanta. It's a little warmer, a little less chaotic. So my job is to talk about quad-tendon graft harvest. But when I go there, I want to kind of start back kind of at the beginning. Disclosures are important because I am conflicted, OK? The stuff, and there's no way to get this talk without me talking about the stuff we came up with for harvest, OK? So I am conflicted. Just know that. The talk structure, we're going to talk a little bit about anatomy. Mary kind of went into that. How to harvest, fixation, morbidity, and complications, and graft passage options is what Mary set me up with. So it's kind of like when I started this process, it's kind of like there's my dog on the right. He's 80 pounds, that bulldog. And then we adopted this unknown little creature on the left. So we didn't know anything. My experience, I'm an ACL surgeon. I've done about 3,500 ACL recons. And I've done 1,600 of those are quads, OK? The mean age of that cohort of quads is 20. Every single one of these, we have followed prospectively. We have PROs. We have data. Stephanie Bowden, who's one of our ex-residents, was in charge of that database. And Ehab, one of my other residents, is at Pitt right now. You know, they've worked on that database. Of those, about 30 are skeletal immature, ficeal sparing, a little over 30. So it's a young group. In anatomy, what Mary talked about is true. That's a skinned quad. And if you look on the right, when you take the muscle off, it's a massive tendon, OK? Mary misspoke. On Doug Adams' study, when he harvested a 10 millimeter graft from the quad, it was stronger than the intact patella tendon. That's what got us thinking about this. I made my fellow cut this in half so I didn't cut my fingers. And there's a lateral view. And if you look at this segment, about the distal half of that tendon, when you go about 5 centimeters up, is solid. And then you have a variable anatomy proximal. That becomes really important when we talk about fixation. Predictability, it's a very predictable graft. This is a study we did in my labs in Applied Mathematics out of Georgia Tech. And we went in and we did 3D modeling of a bunch of people's MRIs. And what we found, if you look at the tip of the rectus femoris to the tip of the patella, that a graft is greater than 7 centimeters 90% of the time. OK? Now that's important if someone's over 5 feet. And remember that number because we're going to talk about that when we talk about lengths of the graft. If you need more, if you have someone that is small, all you have to do is reflect that graft or the rectus femoris. You reflect it and you get 2 to 3 centimeters more of tendon if you need it. The thickness is about 1.8 times that of the same person's patella tendon. So it's a much thicker stuff. And there's very little variation of the distal 6 centimeters of the graft. We published a study on pediatric quads. On the average 6-year-old, 5.5 centimeters in length, measuring the same way, and 3.2 millimeters thick. Now if you do skeletal immature kids, you do fisial sparing, their hamstrings are nothing. OK? You can't do a patella tendon. So you either do something where you maim them on the side by taking their IT band, or you take a quad that's 3.2 millimeters thick, which is as thick as your patella tendon. And again, these are the measurements that got us thinking about this. You can customize the graft on these big guys. When I have my big offensive linemen, these guys have huge quads, you can get too big a graft. So you've got to be careful because that's a problem. So what is the optimal length and diameter of the graft? Freddie showed us this that in most people, it's 2.5 centimeters. That's the interarticular length. So let's just call it 3. And I'm going to say the optimal graft length is 6.5 to 7. Now why do I come up with that? Because you put 2 centimeters in the femur, 2 centimeters in the tibia, and then 2 to 3 centimeters in the joint. That gives you 6.5 to 7 centimeters. My problem with hamstrings, I was mostly a hamstring guy. I still do, and I've always done patella tendons. But my problem with the hamstring is you can't predict the size of it. There are algorithms. Harris Sloan wrote a nice paper. The guys at Pitt have written papers on it. But sometimes you get the Ethiopian guy on the right or one of the soccer players on the right there. And even though she has great legs, you get in there and she has tiny tendons. And then you get a predicament. Do you augment that? Do you do 15,000 weaves like the Arthrex guys talk about? I'm just not crazy about that. So how do we harvest it? My first, probably 600 or 700 were done with a vertical incision. And that works fine. Christian Fink, who was my counterpart at Pitt, we both trained together. And he was doing all horizontal incisions. And Christian probably has the most experience in Europe. And he did mostly bone and quad, bone and tendon. And now he's transitioning to more soft tissue. But you can do it either way. Cosmetically, the Europeans say it looks better. I'm not sure it does. But it allows you to visualize better, which is what we'll get into. Instrumentation. So we kind of sat there and said, we need to make precise cuts. We need a certain width, depth, and a length. So how do we figure out how to do that? Well, one is that this has been done before with teletenons. We just added a top to it. So like a three-sided knife that you can go, and I'll show you how we use this. And you can cut various widths, 8, 9, 10. I use 10 in almost every one. If I'm doing a big revision, I'll use 11. If they have big tunnels, if it's a little kid, a lot of times I'll use a nine. The graph gun is a simple stripper and something that can cut the tendon. If you go up it, you can measure the length and cut it. If you do the way Christian does it when he saves a bone block, then they at stores makes a different cutter where you can slide it up and cut it proximally first and keep it attached distally. So it's different. Those are the two main groups of instrumentation that are available for you guys. This is a new tube tendon harvester. This thing really will show it to you. It works pretty well, especially if you haven't done a lot of them. And now let's go over some tips for harvest and prep. What I'm gonna do is give you like 10 tips I want you to remember. Then we're gonna go like a real time harvest and then look at it. Position, it doesn't matter whether you hang it or do it flat, but you want the leg in a comfortable position, 70 to 90 degrees. You want the quad not on a lot of tension, just some tension. Mark your harvest site in the position you're gonna harvest. So don't like have the guy at full extension mark the harvest site, then flex them. Residents make that mistake and then we're in the wrong location. I like a transverse incision because all your work is done distally. That's what I need to see. Proximately, the instruments do that for you. Again, the Europeans say it's cosmetically superior. When you do this, take out that fat pad. It won't leave a divot. You have to be able to see that tendon. So take your time. This is probably what takes the most part to take that big chunk of fat out so you're left with the tendon and the peritoneum underneath. Number four, determine the direction of harvest. Put an Army, Navy, stick your scope in there and you're gonna look up. You'll see here, I can see my vastus lateralis on the left, medialis on the right and I go right to that point until I see the rectus femoris. Then we mark it. Why is that important? Because it keeps you away from the bleeders. She showed, Mary showed one of my pictures when I, my second or third one when I decided to do an eight or nine millimeter, centimeter long graft. That wasn't smart, compartment syndrome and an ugly looking quad. So I learned early not to go above. A lot of what you're gonna see out of Pittsburgh, when you look at their data that was done, those studies they did, they were harvesting eight to nine centimeter grafts. That's why their complication rates were so high on those studies. On the distal end of the graft, with this plunger thing that comes with the new cutter, you can mark it and then you cut on each side of it and that gives you a 10, that's a 10 millimeter, whatever size you're gonna harvest and you gotta cut it away distally, okay? Now, make sure you get it freed up about two to three centimeters up and then put some sort of a holding stitch on it. It's really important to free that whole thing up. The first 600, 500, I was all doing partial thickness and I couldn't teach my residents and fellows how to do it. I had to harvest everything. That wasn't gonna work. Then we started in John Fulkerson, he looked at me and said, you know, X, just do full thickness, it doesn't matter. It doesn't change the outcome. We did it, it doesn't, okay? You do have to close that defect if you do a full, because they'll feel it like you do on a patella tendon, but it doesn't change the outcome. Don't forget about this little blade. Remember, I did my first 11, 1200 with this blade and you use that to cut the first, especially when you're starting, cut the first three to four centimeters of it. Then you have the perfect length. You take your regular scalpel, you go in and you cut underneath it and free it up well. I mean, I don't, I still use it. I don't need to, but on my residents, I love them when they're, and the fellows when they're learning that. So I think that's a really important thing. So how do we make it easier? That's our key. When we, you know, we got through, we still couldn't teach people. So that little dog, that's my 80 pound bulldog, as we started getting better at this, he started growing, okay? This is a tube harvester and you'll see, we get, you free up the distal part of the tendon, you stick this thing on, and then you let it do its work. You just twist it. Now, when we first started this, people were jamming it up there, transecting the graft. This is sharp and dangerous. Be careful. Do not over-tension the flexion. In fact, some guys will even just let it hang naturally or even extend the leg a little bit and let that thing cut for you, okay? Don't push it. It'll find the track. Think of yourself as cutting butter. If you manhandle this thing, you're gonna transect something and then you're gonna end up with a four centimeter graft you can't do anything with, okay? Graft site closure. It's, you know, how do we do it through a little tiny incision? Get an Army, Navy in there, get your scope in there, and then use your, you know, a rotator cuff, a suture retriever. That my residents have felt, my residents love it. The junior guy doesn't get, because my partner doesn't let him operate on shoulders. They get to go in there and practice, and they just run a suture. Just forward, dump it upside down, use a self-retrieving one. You'll close that thing in no time. And we use some sort of non-absorbable suture there. Graft length, six and a half centimeters. That's plenty of length. I like it between six and a half and seven centimeters. Sometimes you'll bottom out if you're doing an all inside on the tibia. You gotta be a little careful because you don't want to bottom out. But a six and a half to seven millimeters, a seven centimeter graft is perfect in almost everyone. So here's a real time harvest. We're gonna go and we're gonna make this cut. Okay, and this we're using here, I think probably a two and three centimeter incision. Still looks nice, and you can see really well. Now take your time to take out the fat pad. Don't go fast through this part of it, okay? Just take it out and make sure you, and look, this is a big honk out of this knee, but it won't leave, it's crazy. It won't leave, it's like liposuction, knee liposuction. It doesn't leave a dimple, okay? Then once you get it out, you take a key elevator and scrape right along. You'll feel the medialis and lateralis and scrape that stuff clear, okay? Then you stick a scope up, pull that, and you'll see, again, you go up, you're taking a look, and then you'll mark your, as we're looking inside, again, we'll go right up, we're seeing it, and there's the lateralis. You go right to that point, go as far up as you can, turn your light so you can see it, and mark it. And then you measure it, and just to kind of see, you're always gonna be seven, eight centimeters up. So now we mark it with this. This is a 10-millimeter one. I see what it looks like. Then I'll take the triple-bladed knife, I go right over it, and I know the direction I'm gonna harvest so I don't get into those bleeders. Then I take a knife and free it up. So I have the distal three centimeters of graft completely free, put it just some sort of whip stitch suture in there. This loop suture works good for me. You can't have it too big on the end. You gotta trim it down or it won't fit in this thing. And then once it fits in, make sure it engages with that thing, and then just let it twist. And then it'll harvest for you. The graft thing that I have, the gun that we talked about, that works great, but you have to make sure your graft is freed all the way up to seven centimeters to look at it. It won't strip. That's the advantage of this thing is it strips for you. The disadvantage is it's sharp, so be careful. Then you come out, you pull the suture out, slide it up right next to it. I use the old cutter to do it, but this works really well too. And then you just pop it and then you'll hear it. And sometimes you'll hear it like a snap and then it'll come out. Okay, and there's your graft. Okay, harvest time used to take me about the same. It's less than five minutes. So it's fast harvest time. And I don't know how, you hear Darren Johnson will tell you he can do a patella tendon in six minutes. I can't. It takes me 25 minutes to harvest and close that thing. I'm just not as good as him. Hamstring takes is around 13, but this thing is less than five. So there's my dog when he was about nine months old. So he's now can't sit in my truck. His head goes above the thing. So he's grown and so have our knowledge. Now, fixation is important. Clayton and I talked about this a couple of years ago, beginning of COVID. And we did a op-ed thing in arthroscopy. It's interesting. I think for me, the adjustable loop is a game changer and a button fixation I use on bone size I like a lot. Okay. The tape strut on the bottom is new. And that is really important because the proximal part of this graft oftentimes is not quite as strong as the distal part of the graft. Okay. So the proximal part, this allows you to fix the graft. So you'll see me, I sit there about one and a half centimeters down. I pull this thing and there's the strut on top of it. Then you come around and you go through the strut twice and then come through the graft and come through the strut again. And so it's much faster than doing multiple sutures. And it's a lot stronger, which I'll show in a second. Now, the beauty is this pulls through that strut. So it's like a finger trap and it pulls through the struts and you're not pulling through the soft tissue. So it doesn't rip out. Joe Lamplot, one of my younger partners is from HSS and he's a patella tendon guy. And he said, oh, this is all BS. So he went and tested it. And it's pretty interesting what he found. The sutures alone had about 637 Newton pull outs. The tape strut is 556. So it looks better, right? The problem is guys, if you look at interference crew between two and 600 and tie over posts between three and 800, and this is them lifting me up and down, okay? Great promotional video, but ultimate load means nothing, okay? What's important is down below. So even though the sutures, actually I have those numbers reversed, I'm sorry. The tape strut was stronger than the sutures, but the sutures elongated 32 millimeters prior to failing where the tape strut only went 5.6 millimeters. So it's very important when you're looking at biomechanics, everyone wants to think about ultimate load, but you got to think about either creep and how much elongation you had before you popped. Because if you elongate three centimeters, well, hell, your KTs are going to be terrible, okay? What about morbidity and complications? They went into this a little bit, but with a quad, you don't get numbness. I published a hamstring. I didn't think I got numbness on my hamstrings either. My residents published that in 2007 in AJSM, and we had a lot of numbness. Telefemoral pain, you don't see it like you do in teletenning, especially with kneeling. Residual weakness, it's not like, neither one of those are like the hamstrings. I did a hamstring on my wife when she was my ex-girlfriend, and she can't do a hamstring curl. She was happy with it and married me after the fact, but she can't do a hamstring curl on her side she had the hamstring on. Okay, ACL works fine. You don't see tendon ruptures. You don't see fractures, but you do see hematomas, like with all those, and we just did a, we do a lot of pain studying, and it's interestingly, the quad even did better than allografts, and this is a big blinded study we did that's a double-blinded study, and I couldn't believe that outcome, but it's interesting. Okay, complications, that unfortunately is my patient that Mary showed in the last one. Hematoma rates, less than 2%. You can get them. If you get one, you're gonna get them eventually, and if they come back within three days with pain, swelling above the knee, you can ultrasound it, just evacuate it, they'll do fine. Post-op deformities, I've had three of them, all early, all greater, when I was greater than eight centimeters up. Compartment syndrome, one. I think it was on my second one. That's the one I talked about. Loss of extension. We just finished this too, and they presented it early today. Cyclops is around 7%, okay? The biggest people we have those in are females and between our favorite group to operate on, 14 and 20 years old, but that's a real problem. This graph synovializes incredibly well. You get a forced extension back really quick, and then infection rate, we just finished this, 1,400.28% using MOON criteria, okay? Now, MOON criteria is anytime you have to bring them back to the OR for anything, hematoma, it's considered an infection rate. There were no interarticular positive cultures on any of those first 1,400, okay? So I think it's as good as the others. It's much better than a hamstring in terms of that stuff, and we don't soak our grass, or didn't soak our grass until the, for the guys in these studies, no vancomycin or anything. Okay, this is fast. Mary wanted me to talk about this. All inside versus trans-tibial. The question you need to answer yourself is why do you drill tibial tunnels first, okay? And why do you pass the graph through the tibia? Now, some of you younger people may not, you may look and say, well, that's stupid. Why would you do that? Well, for those of us who started doing things trans-tibially, that makes sense. If you're doing a trans-tibial, it's one straight line. You go through the tibia, through the femur. So you have to drill the tibia first. Then when you do, when you pass the graph, it's easy. It's in one line, you go up. So then we started doing anatomics in about 2005, and we were in Rio de Janeiro, Sao Paulo, Brazil, and Freddie and I were looking at, talking about our first hundred double bundles. And we were talking to people, and people were still drilling the tibia first. And we're like, why would you do that? If you drill the tibia, water goes all over the place. You can't see, you have all that mess in the knee. The hard tunnels to drill are in the femur, not the tibia. Why pass the graph through the tibia? Another thing that doesn't make sense. It's a hard turn on an anatomic, and that means you always have to make your tibial side bigger or the same size as your femur. You can't do a bigger femur. And oftentimes with a quad graph, if you used a distal side for your femur, it's gonna be bigger than the tibia. Now you're gonna have too big a tibial tunnel. All inside has advantages. It's easy femoral placement. It's straight in line. So you're not going around a corner. And then as I talked about the size of the tibial advantage tunnel, the disadvantages, if you use a long graft, like a patella tendon, I don't do all inside on a patella tendon. I'm afraid of getting stuck inside the knee. Jim Bradley does it and says he can do it fine. Again, I'll let Jim do that. And in suture management, you gotta be careful. It's harder with suture management. So it's not without problems. And I did these, my first, I think, four or 500, no, 400 were all, even though I drilled two full tunnels, I passed them the first 80 trans-tibially. Then I went to all inside. Then I went to doing a flip cutting the tunnels. So that's my talk. My dog's now 165 pounds and owns our house. We know a lot. We know a lot more than we did, but we still don't know that much. Outcomes are key. We have a lot of good outcome stuff coming out, but we'll know more in about five years. Thank you.

quad-tendon graft

ACL reconstruction surgery

harvest technique

anatomy

fixation options

complications