Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Using Rectus Femoris Tendon Autograft

Abstract

Anterior cruciate ligament (ACL) reconstruction is among the most performed orthopaedic surgical procedures. Combining ACL reconstruction with a lateral extra-articular procedure is crucial to improve the graft survival rate, especially in patients presenting with associated rotational instability. Multiple grafts and surgical techniques can be used to perform this combined procedure, each having its own advantages and disadvantages. This technical note describes a minimally invasive technique to perform combined ACL and anterolateral ligament reconstruction using a single autologous continuous graft: the rectus femoris tendon.

Anterior cruciate ligament (ACL) rupture can severely compromise knee stability, leading to functional limitations and increasing the risk of secondary meniscal and cartilage damage and osteoarthritis.^1,2 Reconstruction can be performed with multiple autologous grafts and different surgical techniques. Classic autologous grafts include bone–patellar tendon–bone graft and hamstring tendon graft, which have well-documented favorable success rates, but they present some disadvantages. The quadriceps tendon (QT) autograft is an alternative that has gained popularity because of its strength and size, reduced anterior knee pain, and reduced incidence of arthrofibrosis compared with bone–patellar tendon–bone graft.³ The use of the QT, however, has never achieved great popularity for multiple reasons, mainly because of the absence of a consensus on the best harvesting and fixation techniques. This technical note presents a simple technique to perform combined ACL and anterolateral ligament (ALL) reconstruction using a long continuous autograft, the superficial layer of the QT: the rectus femoris tendon (RFT).

Surgical Technique

Patient Preparation

After receiving spinal anesthesia and antibiotic prophylaxis with 2 g of cefazolin, the patient is positioned supine with the tourniquet at the proximal thigh. We use double holders (one at the level of the affected thigh and the other on the contralateral iliac crest to avoid patient lateral shifting during application of valgus stress to the knee). A roller is placed at the end of the operative table to support the knee when positioned at 90° of flexion.

Rectus Femoris Graft Harvest

The superior border of the patella is marked and divided into 4 quadrants (Video 1). A 4-cm longitudinal skin incision is made 5 cm proximal to the superior pole of the patella at the junction of the lateral third and fourth quadrants, extending proximally (Fig 1). Subcutaneous dissection is then performed until the tendon layer is reached. The graft is harvested from the lateral superficial third of the QT, which represents the RFT. Two parallel longitudinal incisions are made superficially 8 to 10 mm apart. The plane between the superficial and intermediate layers is identified by the presence of a thin layer of fat; this layer is then developed using blunt forceps. The distal end is detached from the superior border of the patella using a blade and whipstitched with sutures (Fig 2). While traction is maintained on the distal end, the dissection of the RFT is extended proximally using Metzenbaum scissors (Fig 3), with care taken to preserve the intermediate and deep laminae of the QT.

Fig 1.

The superior border of the patella of the left knee is marked and divided into 4 quadrants. A 3-cm longitudinal skin incision is made 4 cm proximal to the superior pole of the patella at the junction of the lateral third and fourth quadrants, extending proximally.

Fig 2.

Rectus femoris graft harvesting from left knee. With the knee at 20° of flexion, the superficial layer of the distal rectus femoris tendon is detached and whipstitched.

Fig 3.

Rectus femoris graft harvesting from left knee. The dissection of the graft is extended proximally with Metzenbaum scissors, with care taken to preserve the deeper layers.

The tendon is harvested using a closed stripper, with the knee at approximately 20° of flexion to relax the quadriceps muscle (Fig 4). The tendon stripper needs to be pointed toward the anterior inferior iliac spine.

Fig 4.

Rectus femoris graft harvesting from left knee. The tendon is harvested using a closed stripper pointed in the direction of the anterior inferior iliac spine, with the knee at approximately 20° of flexion to relax the quadriceps muscle.

Graft Preparation

The graft is prepared on a separate table; the muscle fibers are removed from the tendon, and its proximal end is whipstitched with suture (Fig 5). The total length of the graft is usually 28 to 35 cm. The distal part is thicker and is folded asymmetrically over a suspensory fixation system (TightRope; Arthrex, Naples, FL) to create a 3-strand segment of about 7 to 8 cm in length and 8 to 9 mm in diameter. The remainder of the graft is left as a single strand and is used for the ALL reconstruction in a “monoloop”⁴ (Fig 6). The graft tendon is soaked in vancomycin solution (5 mg/mL) until it is introduced into the joint.

Fig 5.

The total length of the graft is measured. In this case, the graft measures 310 mm.

Fig 6.

Final configuration of rectus femoris graft. The distal graft is folded asymmetrically over a suspensory fixation system, which is used for tibial fixation. The single strand is used to perform anterolateral ligament (ALL) reconstruction. (ACL, anterior cruciate ligament.)

Diagnostic Arthroscopy

Diagnostic arthroscopy is performed, using standard anterolateral and anteromedial portals with a 30° arthroscope, to identify and treat any associated meniscal or cartilage lesions.

ACL Tunnel Preparation

The remnant of the native ACL is debrided using a biter and shaver, and the tibial socket is prepared using a retrograde drill (FlipCutter; Arthrex) angled around 55° in the sagittal plane and matching the diameter of the ACL portion of the graft. The tibial socket should be around 25 to 30 mm in length. A carrier wire is introduced into the tibial tunnel and retrieved through the anteromedial portal. The femoral tunnel is created using an outside-in guide. The K-wire’s extra-articular entry point is located at the femoral lateral epicondyle—because this is the anatomic origin of the ALL—and is directed toward the femoral ACL anatomic footprint. The entry point on the lateral femoral condyle should be slightly proximal and posterior to the popliteus tendon insertion.⁵ The femoral tunnel is then created by introducing progressively larger drills, starting with a diameter of 4.5 mm and increasing to match the diameter of the graft. The carrier wire is retrieved through the femoral tunnel.

ACL Graft Passage and Fixation

The triple-folded portion of the graft on the tibial side is inserted from the femoral tunnel and shuttled into the tibial socket using the carrier wire (Fig 7). The graft is pulled until the button flips over the tibial cortex. Tibial fixation is achieved by tightening the adjustable loop system (TightRope) over the cortical button. Femoral fixation is then obtained using an absorbable screw of the same diameter as the graft, while maintaining traction on the graft and with the knee at 90° of flexion (Fig 8). The initial femoral fixation is performed at 90° of flexion while the foot rests on the distal roller. Eight to ten cycles of flexion-extension are then performed. Final fixation is performed by bringing the knee to 30° of flexion; while a posterior drawer force is applied, the graft is re-tensioned by pulling on the suspensory fixation system on the tibia. At the end of the procedure, proper tensioning of the ACL graft is arthroscopically confirmed.

Fig 7.

Rectus femoris graft insertion into left knee. The single strand is passed into the joint through the femoral tunnel.

Fig 8.

Femoral fixation of the rectus femoris tendon graft using an absorbable interference screw with the knee at 90° of flexion.

ALL Reconstruction

A lateral incision of 2 cm is performed slightly posterior to the Gerdy tubercle; blunt forceps are used to develop the subcutaneous space toward the femoral tunnel. The single-strand portion of the graft is passed beneath the iliotibial tract and shuttled with hemostat forceps from proximal to distal toward the Gerdy tubercle (Fig 9).

Fig 9.

Lateral view of left knee. The graft for anterolateral ligament reconstruction is passed beneath the iliotibial tract and shuttled with hemostat forceps from proximal to distal toward the Gerdy tubercle.

The insertion point on the Gerdy tubercle is identified, and a double-loaded suture anchor is inserted (FiberTak; Arthrex). The graft is then tensioned, and the desired insertion point on the graft is marked. With the knee flexed at 30° and the foot in neutral rotation, the first suture is used to tie the free end of the graft to the anchor using the locking-loop suturing technique. The second suture loop is used to tie a knot around the graft to reinforce fixation (Fig 10). The fascia lata is then sutured over the graft. Figure 11 presents a schema of the fixation system.

Fig 10.

Lateral view of left knee. Distal fixation of the neo–anterolateral ligament is obtained with the knee flexed at 30° and the foot in neutral rotation.

Fig 11.

Schema of fixation system. (A) Anterior cruciate ligament (ACL). (B) ACL tibial fixation using adjustable loop. (C) ACL and anterolateral ligament (ALL) femoral fixation using absorbable screw. (D) ALL. (E) ALL tibial fixation using double-loaded suture anchor.

Rehabilitation

For the first 4 weeks, the goal is to achieve a range of motion (ROM) of 0° to 90° of flexion; a ROM of 0° to 120° is then allowed for the successive 4 weeks, with a full ROM afterward. A partial weight-bearing protocol is adopted, followed by progressive advancement to complete weight-bearing. Early rehabilitation focuses on isometric strengthening of the quadriceps and extensor-flexor muscles of the hip. In the case of meniscal injuries, the rehabilitation protocol must be adapted. Pearls and pitfalls of our technique are presented in Table 1.

Table 1.

Pearls and Pitfalls for RFT Harvesting

Pearls	Pitfalls
Harvest the graft at the lateral one-third of the superficial layer of the QT.	A more distal incision does not allow identification of the different layers of the QT and isolation of the RFT.
Incise the graft to a width of 8-10 mm to obtain a sufficient graft diameter.	The initial longitudinal incisions along the QT, if <8 mm, could result in an insufficient diameter for ACL reconstruction.
Dissect the superficial layer from the intermediate up to 5 cm proximal to the superior pole of the patella.	There is a risk of injury to the motor branch of the femoral nerve if the intermediate layer is violated during tendon stripping.
Extend the knee (approximately 20° of flexion) while using a tendon stripper to relax the quadriceps muscle tension during graft stripping.	Harvesting in the wrong direction can result in graft amputation.
Point the tendon stripper toward the AIIS.

ACL, anterior cruciate ligament; AIIS, anterior inferior iliac spine; QT, quadriceps tendon; RFT, rectus femoris tendon.

Discussion

The recent literature shows that the risk of graft rupture is higher when isolated ACL reconstruction is performed compared with ACL reconstruction combined with a lateral extra-articular procedure (LEAP)^6,7 regardless of the graft used. Therefore, ACL reconstruction associated with an LEAP has become increasingly popular because it guarantees a lower graft rerupture rate.^1,2,6,7

The literature has shown that, among the various LEAPs, ALL reconstruction yields slightly better clinical outcomes compared with lateral extra-articular tenodesis.^6,8 With a non-isometrically orientated lateral extra-articular tenodesis graft, the tension changes with joint motion and this may result in graft stretching, disruption, or fixation failure.⁷

This technical note describes combined ACL and ALL reconstruction using a single-strand autologous graft, the RFT (superficial layer of the QT), harvested with a minimally invasive approach and used to perform both procedures without interrupting the graft. The QT is a trilaminar structure composed of the rectus femoris, vastus medialis, vastus intermedius, and vastus lateralis. The superficial layer primarily consists of fibers from the rectus femoris, providing excellent tensile strength and thickness suitable for graft harvesting without compromising extensor mechanism function.⁹

The RFT is still not commonly used but has recently gained interest because it provides a graft of sufficient length and diameter for knee ligament reconstruction.^10,11 This article describes a technique to perform combined ACL and ALL reconstruction using a continuous strand of the RFT, which is folded asymmetrically. The major advantage of this techniques is that allows for combined anatomic reconstruction of the ACL and ALL using a single autologous graft in a monoloop fashion. Only the superficial layer is harvested to further reduce associated donor site comorbidities, such as anterior knee pain. Tibial fixation using a cortical button and adjustable loop allows the use of less graft length, leaving more graft available for ALL reconstruction. Moreover, it provides adjunctive tensioning of the graft after femoral fixation. Clinical studies are necessary to show the effectiveness of this technique in primary and, eventually, revision ACL reconstruction combined with ALL reconstruction.

Disclosures

All authors (A.D.M., F.P., E.M., Z.A.T., F.A., R.C., F.M.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

Surgical technique for combined anterior cruciate ligament and anterolateral ligament reconstruction using rectus femoris tendon.