Dimensions of Quadriceps Tendon Autograft Are Variable Based on Patient Age and Graft Type: A Systematic Review

doi:10.21203/rs.3.rs-5233510/v1

Purpose

The purpose of this study is to compile graft dimensions reported in quadriceps tendon anterior cruciate ligament reconstruction surgical papers.

Methods

A systematic literature search was conducted in accordance with PRISMA and R-AMSTAR guidelines. PubMed, EMBASE, MEDLINE, and Web of Science were searched from inception to June 18, 2024. All studies were searched and screened in duplicate; Cohen’s kappa was calculated at each stage. Quality assessment was conducted using MINORs for non-randomized studies and Cochrane’s RoB 2.0 for randomized studies. Descriptive statistics are presented.

Results

Thirty-one studies featuring 2,756 knees were included. Twenty-one papers used quadriceps tendon autograft with bone block (B-QT) and 10 used all-soft tissue quadriceps tendon autograft (S-QT). Included patients had a weighted mean age of 24.2 years and a range of 7–58 years. Of the papers featuring an adult population (average age ≥ 18 years), mean B-QT total graft length was 72.5mm (range: 50-90mm), bone block length was 18.5mm (range: 15-20mm), width was 9.9mm (range: 7-12mm), and diameter was 6.5mm (range: 5-9mm). For S-QT grafts in the adult population, the mean graft length was 78.8mm (range: 60-100mm), width was 10.6mm (range: 9-12mm), and diameter was 8.4mm (range: 5-10mm). In studies featuring a pediatric population (average age ≤ 18 years), the mean B-QT total graft length was 70.0mm (range: 60-80mm), bone block length was 16.7mm (range: 15-20mm), width was 9.7mm (range: 9-10mm), and diameter was 9mm (range: 8-10mm). For S-QT grafts in the pediatric population, the mean graft length was 64.2mm (range: 50-80mm), width was 10.0mm (range: 9-11mm), and diameter was 7.8mm (range: 5-10mm).

Conclusions

This review highlights the variability in graft dimensions for QT ACL-R grafts based on patient age and graft type. The paucity of consistent reporting of graft dimensions highlights the need for standardized reporting to promote the comparability of studies using QT ACL-R.

Level of evidence Level IV

ACL

Reconstruction

Quadriceps tendon

Dimensions

Autograft.

The anterior cruciate ligament (ACL) stabilizes against anterior tibial translation and maintains the integrity of the knee joint (1,2). More than 250,000 cases of ACL rupture are reported in the United States annually,resulting in over 100,000 ACL reconstructive procedures (3). ACL reconstruction (ACL-R) can be performed with several autograft varieties including hamstring tendon (HT), bone-patellar tendon-bone (BPTB), and quadriceps tendon with and without bone block (B-QT and S-QT) (4,5). There is further variation within these techniques, namely in the dimensions of grafts harvested.

A number of studies have examined the relationship between graft size and failure rates following ACL-R in HT and BPTB, mostly concluding that larger grafts are less likely to fail (6–8). No such studies have been conducted for QT ACL-R, though the clinical success of this graft may be due to its favourable dimensions (9–11). QT grafts are usually thicker than BPTB for the same width of graft harvested and offer a greater degree of versatility for the surgeon during harvest, allowing for maximal graft size (12,13).

The use of QT autograft in ACL-R is a relatively modern development in orthopaedics and literature surrounding the technique is expanding rapidly. No study has been conducted to determine whether there is variation in the graft dimensions being reported among surgeons using the same techniques of adult and pediatric QT ACL-R The purpose of this study is to compile graft dimensions of QT autograft for ACL-R in the available literature. The hypothesis was that there would be variability in graft dimensions for QT autograft for ACL-R grafts based on patient age and graft type. This study will offer surgeons an up-to-date resource on the graft dimensions being used in a variety of patient populations.

Search Strategy:

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and R-AMSTAR (Revised Assessment of Multiple Systematic Reviews) criteria were followed in the development of the study, and four online databases (PubMed, EMBASE, MEDLINE, and Web of Science) were searched from inception until June 18, 2024 (14,15). The search strategies used for each of these databases are available in Supplementary File 1.

Assessment of Study Eligibility:

Inclusion criteria were 1) all levels of evidence; 2) all ages; 3) human studies; 4) published in English; 5) use of QT autograft for primary ACL-R; 6) direct reporting graft dimensions and graft subtype; 7) published in the past 5 years. Exclusion criteria were: 1) lack of reporting of graft preparation details directly in the manuscript, 2) cadaveric or animal studies; 3) review articles or book chapters.

Study Screening:

Two reviewers (HS and IG) independently and blindly screened titles, abstracts, and full texts of retrieved studies in the Covidence tool (Veritas Health Innovation, Melbourne, Australia.) Conflicts at the title and abstract screening stages were included at subsequent stages, and discrepancies at the full text stage were discussed with a senior author (DdS) to arrive at a resolution. References of included studies were screened to identify any studies which were not identified in the initial search. Inter-reviewer agreement for each stage of study screening was calculated with the kappa statistic (κ). The values were categorized a priori as follows: κ of 0.81 to 0.99 was considered excellent agreement; κ of 0.61 to 0.80, substantial agreement; κ of 0.41 to 0.60, moderate agreement; κ of 0.21 to 0.40, fair agreement; and κ of 0.20 or less, slight agreement (16).

Quality Assessment:

Quality assessment of included non-randomized studies was completed independently by two reviewers (PS and IG) using the Methodological Index for Non-Randomized Studies (MINORS) Criteria, with maximum scores of 16 for noncomparative and 24 for comparative studies (17). We considered a score of less than 10 poor quality, 10-13 moderate quality, and greater than 13 good quality for non-comparative studies. For comparative studies, a score of less than 15 was considered poor quality, 15-19 moderate quality, and greater than 19 good quality. Inter-reviewer agreement for MINORS assessments was calculated with an intraclass correlation coefficient index (ICC). A priori categorization was as follows: values less than 0.5 was considered poor agreement; between 0.5 and 0.75, moderate agreement; between 0.75 and 0.9, good agreement; and greater than 0.90, excellent agreement.

Risk of bias assessment of included randomized studies was completed independently by two reviewers (PS and IG) using the Cochrane Risk of Bias (RoB) 2.0 tool, with combined scores ranging from “low risk of bias”, “some concerns of bias”, and “high risk of bias” (18). An RoB 2.0 assessment summary diagram is shown in Fig 1(19).

Data Extraction:

A standardized extraction template within Covidence tool was used to record (i) study details (author, year, country, level of evidence), (ii) population characteristics (number of participants, mean age, sex), (iii) and ACL-R procedure details (number of procedures performed, B-QT or S-QT, graft length, width, diameter, and bone block length (20). Study data were collected blindly, in duplicate (I.G. and H.S.), and were reviewed by a senior author (DdS).

Statistical Analysis:

An a priori decision was made between reviewers that a minimum of two studies would be required for the pooling of a graft dimension finding. Due to heterogeneity in reporting formats for dimensions presented in the included studies, both mean values and ranges were compiled for each dimension (21). When multiple values were provided for a study, an average of these values was calculated and used for further analysis to determine the overall mean across all studies. Weighted mean values were also calculated based on the number of procedures performed in each included paper.

Study Characteristics

The search yielded 2,952 unique citations, 31 of which were included in the study (Fig. 1). Thirty-one studies were classified as non-randomized and four as randomized. A total of 2,756 primary QT ACL-reconstructions with a patient age range of 7-58 years and a weighted mean of 24.2 years were included in this study. Of the 31 included studies, 21 featured an adult population (average age ≥18 years) and 10 featured a pediatric population (average age ≤18 years). Fourteen studies used B-QT autografts and 17 used S-QT; most pediatric studies used S-QT (seven out of 10 studies) while adult studies used B-QT and S-QT evenly (11 studies and 20 studies, respectively).

Quality Assessment - Non-randomized Studies

MINORS scores for the seven adequately reported non-comparative studies ranged from one to 12, and scores for the 20 included comparative studies ranged from 15 to 22. Overall, 29% of included non-comparative studies were deemed to be of “moderate” or greater quality and 100% of included comparative studies were of “moderate” or greater quality. In terms of study design, the median level of evidence within the non-randomized studies was III, with 14 level III studies, eight level IV studies, and five level V studies (20).

Quality Assessment - Randomized Studies

Three out of the four included randomized studies were assigned “high” risk of bias in accordance with the Cochrane RoB 2.0 tool, and one studies was assigned to “some” concern of bias. Notably, the risk of bias arising from the randomization process and data collection of these studies was low. Conversely, many studies had some risk of bias arising from issues of selection, lack of blinding, and interpretation of endpoints. All included randomized studies had a level of evidence of II.

Fig. 1 RoB 2.0 assessment for all included randomized studies

Inter-rater Agreement

Inter-rater agreement was strong at all levels of study screening and quality assessment. Cohen’s kappa (κ) was calculated at each stage of the screening process: κ at title screening was 0.80 (SE: 0.02), κ at abstract screening was 0.89 (SE: 0.01), and κ at full text screening was 0.89 (SE: 0.03).

Table 1 Study characteristics for all included non-randomized studies

Author	Year	Level of evidence	MINORS score	# primary QT ACL-R	# male	Graft type	Mean age (y)
Afana (22)	2021	5	1	1	1	SQT	12
Aitchison (23)	2021	3	15	33	20	SQT	13.7 ± 1.2
Baghdadi (24)	2021	3	16	169	98	SQT	NR
Brinkman (25)	2023	3	16	37	17	SQT	23.4 ± 7.0
Daniel (26)	2024	5	9	60	19	SQT	16.8
Fu (27)	2019	5	9	57	NR	BQT	NR
Gagliardi (28)	2019	3	16	157	75	BQT	15.7 ± 1.8
Galan (29)	2020	4	9	291	268	BQT	23.2
Goto (30)	2021	4		73	0	BQT	33.8 ± 11.4
Greif (31)	2022	3	18	124	96	SQT	NR
Haley (32)	2023	3	17	721	387	SQT	NR
Johnston (33)	2021	3	17	35	28	SQT	20.0 ± 8.0
Komzak (34)	2021	3	15	40	21	BQT	29.8
Letter (35)	2021	3	19	17	14	SQT	25.8 ± 4.9
Mutsuzaki (36)	2019	5	7	8	2	BQT	41.6 ± 10.6
Panos (37)	2021	3	21	23	16	SQT	22.0 ± 6.1
Parker (38)	2023	4	10	70	29	SQT	28.03
Pennock (39)	2019	4	17	28	19	SQT	14.8 ± 1.3
Perez (40)	2019	4	16	28	17	SQT	23.07
Pomenta Bastidas (41)	2022	3	20	20	17	BQT	30.2 ± 2.38
Renfree (42)	2023	4	16	32	13	SQT	17.6 ± 2.8
Retzky (43)	2024	4	18	29	17	SQT	13.57 ± 1.12
Runer (44)	2020	3	18	217	127	BQT	28.9 ± 11.9
Runer (45)	2023	3	22	45	29	BQT	28.9 ± 11.6
Schmucker (46)	2021	4	19	223	140	SQT	26.6 ± 8.6
Vaughn (47)	2022	5	18	22	11	BQT	15
Yamasaki (48)	2021	3	12	30	21	BQT	24.5 ± 2.6

Table 2 Study characteristics for all included randomized studies

Author	Year	Level of evidence	RoB 2.0 overall score	# primary QT ACL-R	# male	Graft type	Mean age (y)
Irrgang (49)	2021	2	High	57	38	BQT	NR
Lind (50)	2020	2	Some concerns	50	29	BQT	27.2 ± 6.4
Sinding (51)	2020	2	High	42	25	BQT	28.7 ± 6.4
Tang (52)	2023	2	High	17	17	SQT	28.06 ± 6.24

Fig. 2 PRISMA flowchart for this review

Average B-QT graft dimensions in the adult population

Of the papers featuring an adult population that directly reported on the graft dimensions used, the average B-QT total graft length was 72.5mm (range: 50-90mm), the average bone block length was 18.5mm (range: 15-20mm), the average graft width was 9.9mm (range: 7-12mm), and the average graft diameter was 6.5mm (range: 5-9mm).

Average S-QT graft dimensions in the adult population

For S-QT grafts in the adult population, the average total graft length was 78.8mm (range: 60-100mm), the average graft width was 10.6mm (range: 9-12mm), and the average graft diameter was 8.4mm (range: 5-10mm).

With regards to the numbers of ACL-R performed, the weighted mean graft length, width, diameter, and bone block length among all included adult studies (B-QT and S-QT) were 71.5mm, 10.4mm, 8.4mm, and 19.1mm, respectively.

Average B-QT graft dimensions in the pediatric population

In studies featuring a pediatric population that directly reported on graft dimensions used, the average B-QT total graft length was 70.0mm (range: 60-80mm) the average bone block length was 16.7mm (range: 15-20mm), the average graft width was 9.7mm (range: 7-12mm), and the average graft diameter was 9mm (range: 8-10mm).

Average S-QT graft dimensions in the pediatric population

For S-QT grafts in the pediatric population, the average total graft length was 64.2mm (range: 50-80mm), the average graft width was 9.75mm (range: 9.0mm to 10.5mm, 5 studies), and there was insufficient data to calculate the average graft depth and graft diameter.

With regards to numbers of ACL-R performed, the weighted mean graft length, width, diameter, and bone block length among all included pediatrics studies (B-QT and S-QT) were 66.3mm, 9.6mm, 9.0mm, and15.2mm, respectively.

Table 3 Graft dimensions by population and technique

The most important finding of this study was that the dimensions of quadriceps autograft are variable on patient age and graft type. The most reported graft dimension among studies was length (77.4% of studies), followed by width (74.2% of studies), bone block length (64.3% of B-QT studies), and diameter (61.3% of studies). Two-thirds (66.7%) of the included adult studies reported on all of graft length, width, and diameter, whereas only half (50%) of the included pediatric studies reported on all three metrics. B-QT and S-QT studies were approximately equally likely (71.4% and 70.5%) to report on graft length, width, and diameter. Although most of the calculated values from this study are reasonable with regards to patient population and graft subtype, of note are the weighted and unweighted graft diameter values for the included pediatric studies, which are both greater than the same values for the included adult studies.

It is essential that researchers performing QT ACL-R report the surgical techniques and graft dimensions used in their studies. Failure to do this contributes to heterogeneity and may produce bias. In previous projects featuring QT ACL-R, the authors noticed numerous discrepancies in the reporting of graft dimensions within the included studies (10). For instance, in two adult SQT studies employing identical techniques, one did not report on graft length (53,54). In two more adult BQT studies using the same interference screw fixation techniques, only one reported the graft diameter (55,56). Two other studies which used three different techniques (all-epiphyseal, hybrid, and transphyseal techniques) reported only one combined graft length (57,58). It was also noted that in some cohort studies, surgeons set graft lengths that were applied to the entire cohort, and in others all grafts length were adjusted based on the morphology of each patient (59,60). More homogenous reporting of graft dimensions across QT ACL-R studies is needed if sound comparisons between techniques are to be made.

There is a clear relationship between graft size and clinical outcomes of ACL-R, with larger grafts offering lower rates of failure due to increased strength across techniques (6–8,12,13,61–64). Some disagreement as to the extent of this claim has been raised in studies on HT ACL-R, proposing that there is no significant benefit to increasing graft diameter past a cutoff point (8mm, in this case) (65–67). These papers do not suggest that larger grafts offer inferior outcomes but rather that other elements of graft preparation should be optimized to reduce rates of failure (68,69). Indeed, area of harvest, trimming, bundle preparation, and surgical experience have been shown to significantly affect clinical outcomes after ACL-R, and we agree that these factors should be controlled to maximize positive outcomes (61,64,70–75). However, any variables in ACL-R technique cannot be soundly compared if graft dimensions are not reported as it is undeniable that this metric plays at least a partial role in the success of the procedure.

The authors thus recommend that researchers studying QT ACL-R report the graft dimensions used in their papers. Researchers should provide the average and ranged dimensions after graft preparation across all patients in the cohort. Table 4 outlines the proposed reporting fields.

Table 4 Proposed list of dimensions to be provided in QT ACL-R studies

	Total graft length (mm)	Graft width (mm)	Graft diameter (mm)	Bone block length, if applicable (mm)
Average
Range

A strength of this review is that it is the first study to offer an up-to-date summary on the dimensions used in adult B-QT, adult S-QT, pediatric B-QT, and pediatric S-QT graft preparations. This study also employed a rigorous systematic methodology to ensure that data was collected in full and with little bias.

This review is not without limitations. The number of studies used to calculate the pooled averages for some graft dimensions is low, providing lower-quality evidence. Moreover, due to limitations in the provided data, such as papers providing data only in ranges, averaging was used to calculate some mean values, increasing variance. A final limitation is that a certain degree of variation in graft dimensions is inevitable across studies due to factors outside of surgeons’ control, thus our descriptions of inadequate reporting may sometimes be due to heterogeneity in patient populations.

Considering the increasing popularity of QT autograft, the key contribution of this review is a summary of up-to-date graft dimensions as described in the adult and pediatric QT ACL-R literature.

This review presented a summary of graft dimensions used in QT ACL-R and highlighted issues of consistent reporting of dimensions in the literature. Future research is needed to understand the direct impacts of graft dimension on clinical outcomes in QT ACL-R and to establish evidence-based recommendations for ideal dimensions.

ACL

Anterior cruciate ligament

ACL

R–Anterior cruciate ligament reconstruction

B

QT–Bone–quadriceps tendon

BPTB

Bone–patellar tendon–bone

HT

Hamstring tendon

IKDC

International Knee Documentation Committee

KOOS

Knee Injury and Osteoarthritis Outcome Score

MINORS

Methodological index for non–randomized studies

NR

Not reported

PCL

Posterior cruciate ligament

PRISMA

Preferred reporting items for systematic reviews and meta–analyses

PROMs

Patient reported outcome measures

QT

Quadriceps tendon

R

AMSTAR–Revised Assessment of Multiple Systematic Reviews

SE

Standard error

S

QT–All–soft tissue quadriceps tendon

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No competing interests reported.

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Dimensions of Quadriceps Tendon Autograft Are Variable Based on Patient Age and Graft Type: A Systematic Review

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