# Quadriceps Tendon Autograft Anterior Cruciate Ligament (ACL) Reconstruction With Internal Brace Augmentation: A Case Series

## TL;DR

This case series examines quadriceps tendon autograft ACL reconstruction with internal brace augmentation in athletes, showing no re-ruptures and return-to-play timelines similar to standard methods.

## Contribution

The study introduces quadriceps tendon autograft with internal brace augmentation as a promising alternative to traditional ACL reconstruction methods.

## Key findings

- There was a 0% re-rupture rate among 44 athletes who underwent QAIB ACLR.
- The average time to return to play was 240.5 days, with Division I athletes averaging 255 days.
- Four athletes (9.1%) developed arthrofibrosis requiring manipulation under anesthesia.

## Abstract

Introduction: Anterior cruciate ligament reconstruction (ACLR) is among the most common knee procedures in the United States, particularly in athletes who participate in cutting and pivoting sports. While bone-patellar tendon-bone (BTB) autografts have long been considered the gold standard for this group, drawbacks such as anterior knee pain and difficulty kneeling have prompted interest in quadriceps tendon autografts. With a larger cross-sectional area and higher load-to-failure, the quadriceps autograft is a promising alternative. This study reported return-to-play timelines and re-rupture rates in 44 cutting and pivoting athletes who underwent ACLR using quadriceps tendon autograft with internal brace augmentation (QAIB), offering early insight into its potential as an alternative to BTB autografts.

Methods: A retrospective chart review was performed on cutting and pivoting athletes who underwent ACLR using QAIB. Athletes were included if they participated in organized sports or sustained their injury while engaging in a cutting and pivoting sport. Five sports were classified as cutting and pivoting: football, soccer, basketball, lacrosse, and rugby. Patients were excluded if postoperative care was transferred to outside providers. Through chart review, time to return and re-rupture rates were collected. Time to return was defined by either direct documentation of the return date or the earliest documented clearance for return. Patients lacking this data were excluded from the time-to-return analysis. One patient was omitted due to a postoperative infection requiring graft removal and revision with a non-quadriceps autograft. Patients undergoing additional ligamentous reconstructions, such as posterolateral corner repairs, were also excluded from time-to-return calculations due to prolonged expected recovery.

Results: A total of 44 athletes were included, with an average age of 20.3 years. Of these, 29 (65.9%) were male and 15 (34.1%) were female. Eleven (25%) were Division I athletes. The most common sports were football (n=15) and basketball (n=15), followed by soccer (n=11), lacrosse (n=2), and rugby (n=1). Concomitant meniscal surgery was performed in 22 patients (50%). Time-to-return data was available for 36 athletes (81.8%). Seven lacked sufficient documentation, and one patient was excluded from the study entirely due to postoperative infection requiring graft revision. Two patients were excluded from the time-to-return analysis due to concurrent posterolateral corner reconstructions. The average time to return was 240.5 days (range: 166-312). Among Division I athletes (9/11, 81.8%), the average time to return was 255.0 days (range: 181-312), compared to 234.6 days (range: 166-309) for non-Division I athletes (27/33, 81.8%). No re-ruptures occurred. Four athletes (9.1%) developed arthrofibrosis requiring manipulation under anesthesia: one female athlete (basketball) and three male athletes (two football, one basketball)

Conclusion: QAIB ACLR in cutting and pivoting athletes demonstrated a 0% re-rupture rate and return-to-play timelines comparable to existing standards. While early results are promising, limitations in data capture, particularly return-to-play documentation and patient-reported outcomes, highlight the need for more robust, prospective studies to better assess long-term efficacy and safety.