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Quads tendon grafts for ACL reconstruction: is ‘the new kid on the block’ really all it’s hyped up to be??

Weaker Quadriceps Muscle Strength With a Quadriceps Tendon Graft Compared With a Patellar or Hamstring Tendon Graft at 7 Months After Anterior Cruciate Ligament Reconstruction
Holmgren et al
American Journal of Sports Medicine 2024 Jan; 52(1): 69-76.
doi: 10.1177/03635465231209442

There are a number of different graft types available replacing a torn anterior cruciate with surgical ACL reconstruction. These include:

  • taking some of the hamstring tendons from the patient’s own leg (an ipsilateral hamstring tendon autograft)
  • taking the central 1/3 of the patellar tendon from the front of the knee, along with a small section of bone at the top, from the patella, and a small section of bone at the bottom, from the tibial tuberosity (an ipsilateral bone-patellar tendon-bone autograft)
  • taking tendons from the patient’s other leg (a contralateral autograft) or
  • using a donor tendon (an allograft)

Recently, some surgeons have, instead, started taking a section of the tendon from the distal end of the patient’s quadriceps tendon, and using this instead. This allows a nice big chunky graft; however, does this potentially have any negative consequences?…

In this recently published study by Holmgren et al from Stockholm, Sweden, the authors looked at over 100 patients undergoing ACL reconstruction surgery and they tested the patients’ post-op muscle strength at > 6 months post-op, comparing results between the different types of graft that were used.

Their results showed that the patients who had had a distal quads tendon grafts showed significantly greater muscle weakness with a significantly bigger side-to-side difference in strength between their legs (operated side vs non-operated side).

Importantly, impaired quadriceps muscle strength after ACL surgery is known to be associated with poorer clinical outcomes and a bigger risk of reinjury, with graft rupture.

Take home message:
Just cos it’s new or fashionable, doesn’t mean it’s better! … and this very much applies to ACL surgery, like many other things. There are pros and cons with all the different types of tendon that can be used for replacing / reconstructing a torn ACL in a knee, and no type of graft is ‘perfect’. Importantly, however, it is the patient who is having the surgery and who is receiving the graft, and hence the pros and cons of the different graft types really must be discussed with the patient in advance, and ultimately, it is the patient who should be able to pick and choose what specific type of graft they might want to have implanted into their knee. (Informed consent!)

To find out more about ACL graft options, CLICK HERE


Meniscal transplantation actually improves articular cartilage quality!


Lateral Meniscal Allograft Transplantation Shows a Long-Term Chondroprotective Effect on Quantitative MRI T2 Mapping at 7 Years’ Minimum Follow-Up
Lee et al.
Arthroscopy 2023, ISSN 0749-8063,

It’s already well-known and well-documented that meniscal transplantation gives pretty good results – not perfect… but pretty good, with ~90% success at 5-year follow-up and ~80% success at 10-year follow-up [LINK]. However, what is the definition of success???…

We addressed the issue of ‘success’ in our study that was published in 2020:

The results of meniscal allograft transplantation surgery: what is success?
Searle, Asopa, Coleman, McDermott
BMC Musculoskeletal Disorders 2020; 21, 159 (2020).

However, what are the objective effects of meniscal transplantation on the articular cartilage in that compartment of the patient’s knee?

In a recent study by researchers from South Korea, 31 patients undergoing lateral meniscal allograft transplantation surgery were observed, with a minimum 7-year follow-up (mean 8.9 years). The quality of the articular cartilage in the lateral compartment of each patient’s knee was assessed pre- and post-operatively using quantitative T2 mapping with MRI. The researchers found that meniscal transplantation was actually associated with an improvement in the quality of the patients’ articular cartilage! (Normally, we would be happy to see a slowing down of the progression of a patient’s ‘wear and tear’ in their knee, or we’d even be delighted to see a lack of progression of any degenerative changes. However, to actually see an improvement in the state of these patients’ cartilage is beyond what most meniscal transplant surgeons would normally ever hope for!

Further evidence that meniscal transplantation is an excellent procedure (if performed on the right patient at the right time for the rights reasons and by the right surgeon!).

Find out more about meniscal transplantation: CLICK HERE




ACL graft options


Failure rates of common grafts used in ACL reconstructions: a systematic review of studies published in the last decade.
Haybäck et al
Archives of Orthopaedic and Trauma Surgery 2022; 142(11): 3293 – 3299.

Repeatedly, at important national meetings, I have heard ‘eminent’ orthopaedic surgeons stating that “tendon allografts undoubtedly have a higher failure rate”. But is there any real substance to their seemingly cast-iron confidence?…

A recent review performed by a team at Salzburg University looked at a staggering 152,548 patients with ACL reconstructions, specifically to investigate the rate of graft rupture according to graft types. The findings were:

ACL graft type                                     Yearly graft failure rate
Hamstring autografts 1.70%
Bone-patellar tendon-bone grafts 1.16%
Quads tendon autografts 0.72%
Allografts 1.76%

The authors’ very clear and specific conclusion from this large high-quality study was that there is no statistically significant difference in graft failure rates between any of the different graft types.

So, yet further evidence that directly contradicts what some people seem to say about what type of graft might be best vs which might potentially have a higher failure rate.

Importantly, my personal approach to graft choice for ACL reconstruction is to present my patients with accurate information about the pros and cons of the different graft types available (and all of them have not-insignificant pros and cons, and failure rate is not the only relevant and important metric when it comes to graft choice)… and then it is my patients who make the choice about what type of graft they would like to have used for their surgery.

i.e. Informed Consent and proper Patient Choice

To find out more about the pros and cons of the different graft types available for ACL reconstruction, CLICK HERE


Warning published RE: ACL repair (as opposed to reconstruction) in children.


Guidelines have recently been released by the BASK (British Association for Surgery of the Knee) / BSCOS (British Society for Children’s Orthopaedic Surgery) Steering Committee on the Paediatric Knee:

There has recently been some controversy with respect to the potential best management of ACL tears in the paediatric population. It is generally accepted that early ACL reconstruction is usually the best and most appropriate treatment for ACL tears in children, to stabilise the joint and to try and minimise as much as possible the adverse effects of ACL-deficiency in the knee. Over recent years, however, some surgeons have been promoting the technique of ACL repair (where the ligament is stitched back to the bone) instead of ACL reconstruction (where the torn ligament is replaced with a new tendon/ligament: a graft). The outcomes of ACL reconstruction are tried and tested, with many years’ worth of results published. ACL repair, however, is a newer concept with considerably less evidence to support its use.

The BASK/BSCOS Steering Committee has reviewed the published evidence and has now made specific recommendations, advising on standards for UK surgery to promote safe, effective practice.

Specifically with respect to ACL repair vs reconstruction, the guidance states the following:

  • Contemporary ACL repair is unproven in children as of yet and cannot be recommended as a routine treatment for ACL tears… In the absence of a significant body of evidence in support of its use… Patients and their carers should be carefully counselled that the gold standard operative treatment for ACL tears is reconstruction.”

For further information about the issue of ACL repair vs ACL reconstruction, please read:

Mr Ian McDermott, 24th Jan 2021

‘Pie-crusting’ the MCL – the right way to reach the back of the medial compartment safely!

“Need Room to Operate? Partial and Intentional Release of the Knee Medial Collateral Ligament for Medial Meniscal Surgery”
James H. Lubowitz, Michael J. Rossi, Jefferson C. Brand
Arthroscopy 2020; 36(6): 1487-1488

The lead editorial article in June’s edition of the Arthroscopy journal focusses entirely on the technique of partial release of the medial collateral ligament at the time of arthroscopy. Perforating the MCL with multiple holes percutaneously with a needle while appying a valgus stress creates a partial release of the ligament that is akin to a ‘sprain’ of the ligament. This opens up the joint into just very slight valgus, thereby opening up the medial comparment by a few additional millimetres.

This technique takes no more than 1 – 2 minutes, and it is easy, with extremely low risks of any potential morbidity. It allows much clearer visualisation and access to the posterior aspect of the medial compartment at arthroscopy, allowing proper and full evaluation of tears to the posterior horn of the medial meniscus and proper surgical treatment of whatever pathology might be found in this area. Importantly, it also drastically reduces the potential risk of accidental iatrogenic articular cartilage damage whilst trying to access a tight space at the back of the medial compartment.

The partially released ligament heals up absolutely fine on its own (just like a minor MCL sprain does), and research has shown that it does not cause any residual laxity in the ligament or any other significant adverse consequences.

The terms that is often used for this technique is ‘pie-crusting of the MCL’, and it is something that I use on a not-infrequent basis in my practice, for example for medial meniscal repairs or meniscal trimming, but particularly for more technically demanding procedures such as ramp lesion repairs, meniscal root avulsion repairs and meniscal allograft transplantation. This technique should be a routine part of the toolkit of every soft tissue knee surgeon!

CLICK HERE to read more…


High-tech carbon-dating techniques show that the meniscal cartilages do not remodel as you grow older

No detectable remodelling in adult human menisci: an analysis based on the C14 bomb pulse.
Våben C, Heinemeier KM, Schjerling P, et al
British Journal of Sports Medicine. Published Online First: 14 May 2020. doi: 10.1136/bjsports-2019-101360

A fascinating recent research study carried out by investigators in Denmark has used Carbon-14 dating techniques to measure the age of collagen fibres within human meniscal cartilages, compared to the age of the individual themselves. The conclusions from this study are that the meniscal cartilages in the knee do not remodel with time, as one grows older. This now gives a clear explanation as to why the meniscal cartilages tend to become degenerate and hence weaker in older people, and why we see so many degenerate meniscal tears in older patients’ knees.

CLICK HERE to read more

Non-operative treatment of ACL tears FAILS in 89% of younger patients.

“The Role of Patient Characteristics in the Success of Nonoperative Treatment of Anterior Cruciate Ligament Injuries”
van der List et al.
The American Journal of Sports Medicine 2020 (May):

This high quality Level 2 evidence study from The Netherlands evaluated the outcomes of nearly 500 patients with ACL tears. The authors made some interesting and important findings:

  • About 50% of patients initially attempted conservative management, through physiotherapy rehab alone (i.e. without surgery).
  • Of these patients, 60% ended up needing to go ahead with surgical ACL reconstruction.
  • Attempted non-operative treatment failed in 89% of patients under the age of 25, and in 56% of patients aged 25 to 40.
  • The likelihood of failure of attempted conservative management was also significantly higher in those patients who participated in impact-type sports.
  • There were over 500% more new meniscal tears in the group who initially attempted non-surgical treatment compared to the group who went ahead with early surgical reconstruction.

The authors of this excellent study conclude that early ACL reconstruction should be considered particularly in younger, more-active patients, to prevent unnecessary delay and to try and reduce the incidence of meniscal tears developing.

CLICK HERE for further information