Quadriceps Tendon Morphometry in Latin American Population and its feasibility as an autograft for Anterior Cruciate Ligament Reconstruction: An Observational Study

Quadriceps Tendon Morphometry in Latin American Population and its feasibility as an autograft for Anterior Cruciate Ligament Reconstruction: An Observational Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Quadriceps Tendon Morphometry in Latin American Population and its feasibility as an autograft for Anterior Cruciate Ligament Reconstruction: An Observational Study Jose Miguel Luarte Espinosa, Gonzalo Marambio Santana, Diego Munita Benavides, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9224492/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Anterior cruciate ligament (ACL) reconstruction requires grafts with predictable morphometry to optimize surgical outcomes and avoid graft-tunnel mismatch. While the quadriceps tendon (QT) has emerged as a reliable alternative globally, high-quality morphometric data for Latin American populations is scarce, potentially limiting its adoption over traditional bone-patellar tendon-bone (BPTB) or hamstring tendon (HT) grafts. This study aims to characterize QT morphometry in a Latin American population using MRI to assess its clinical feasibility. Methods: A retrospective case series was conducted on 78 adults. Morphometric assessment of the QT was performed using Xero software, adapting established measurement protocols. Three independent observers performed the measurements to evaluate reliability. Inter-observer reliability was assessed via the intraclass correlation coefficient (ICC). Anthropometric correlations were analyzed using linear regression models. Results: The cohort included 34 males and 44 females (mean age 52 years; mean height 165 cm). The mean QT length was 70.82 ± 11.09 mm. Although a statistically significant relationship was found between patient height and tendon length (p < 0.05), the correlation was too weak to serve as a robust predictor for graft sizing. Inter-observer reliability for QT measurements was high (ICC = 0.83). Conclusion: Latin American QT morphometry is predictable and reproducible, supporting its feasibility for primary ACL reconstruction. The reliability of MRI measurements validates its utility for preoperative planning. However, the weak correlation with anthropometric variables suggests that preoperative MRI planning is essential, as height alone is an unreliable predictor of graft dimensions. Level of evidence: IV, retrospective case series. ACL reconstruction MRI Quadriceps tendon autograft Anthropometrics Graft length Figures Figure 1 Introduction clinical outcomes and graft failure rates. Although quadruple HT and BPTB grafts have traditionally been the most utilized autografts, both present well-documented disadvantages. BPTB grafts are associated with an increased risk of patellar fracture, patellar tendon rupture, residual anterior knee pain, and difficulty kneeling [1-3]. Conversely, HT harvesting may result in greater residual instability, delayed graft incorporation, iatrogenic saphenous nerve injuries, hamstring strength deficits, and significant length variability during graft harvesting [1, 2, 4]. Despite extensive study, the selection of the most appropriate autograft remains a subject of ongoing controversy. The historical foundation of the QT as a graft choice dates back to Marshall (1979) and Blauth (1984), who were the first to describe its use in ACL reconstruction [5, 6]. Subsequently, Staubli and Jakob characterized its anatomical and biomechanical properties as suitable for autograft use [7]. Fulkerson et al. further advanced the technique by describing the use of the autograft without the need for a bone plug, establishing the versatility of the central QT as a "free graft" [8]. In this context, the QT has emerged as a reliable and biomechanically superior alternative, demonstrating a higher failure load than BPTB grafts and greater residual quadriceps strength following harvest compared to the patellar tendon [3, 9, 10]. Evidence suggests that the QT autograft offers a significantly larger cross-sectional area (CSA) and structural properties comparable or superior to the native ACL, containing approximately 20% more collagen than a BPTB graft of the same thickness [11]. Furthermore, recent literature has established the QT as a robust option for both primary and revision surgeries, showing postoperative stability and functional outcomes equivalent to traditional grafts while significantly reducing donor-site morbidity [1, 2, 12-18]. Successful ACL reconstruction requires grafts with predictable and reproducible morphometry to optimize surgical planning and avoid graft-tunnel mismatch. Preoperative MRI is essential for evaluating QT length and thickness. While Ugwuoke et al. demonstrated the intraoperative suitability of QT length in Caucasian patients without finding a correlation with weight or height [19], other authors like Yamasaki et al. and Xerogeanes et al. found strong correlations between MRI-based measurements and intraoperative findings [20, 21]. Studies by Xerogeanes, Yuksel, and Yamasaki in North American, European, and Asian populations, respectively, collectively show that their respective populations are suitable for QT grafting [4, 20, 21]. Notably, Yamasaki suggested that patients with a tendon length shorter than 60 mm require the inclusion of a bone block during harvesting to ensure adequate fixation [20]. Furthermore, Xerogeanes and Yuksel reported a significant positive correlation between patient height and QT length in North American and European populations, respectively [4, 21]. Conversely, Goto et al. demonstrated that in small-statured (< 163 cm), female patients series of 73 patients, the use of QT autografts yielded excellent clinical outcomes, including muscle strength recovery, donor-site morbidity, and time to return to sports, despite their smaller physical profile [22]. Phenotypic and anthropometric variations between different ethnicities suggest that international predictive models may not be universally applicable. Therefore, characterizing QT morphometry in a local cohort is vital for validating the QT as a viable alternative in this region and addressing the existing gap in morphometric studies within Latin American populations. Given that the anthropometric dependencies observed in other populations may not be as robust in our setting, it is necessary to determine whether these variables serve as reliable clinical predictors. The purpose of this study was to evaluate QT morphometry in a Latin American population using MRI and to determine the strength of its correlation with individual anthropometric variables. We hypothesized that QT morphometric parameters in this population would allow for its reliable use as an autograft and that these measurements would correlate significantly with the individuals' anthropometric profiles. Materials and Methods Ethics and Patient Selection This retrospective case series was approved by the Institutional Ethics Committee of Clínica Dávila (Santiago, Chile) and conducted in accordance with the Declaration of Helsinki and Chilean Law No. 20,584 regarding patients’ rights and healthcare standards. The study was a collaborative effort between the Departments of Orthopedics and Musculoskeletal Radiology. An anonymized review of the institutional radiology database was conducted, screening thigh magnetic resonance imaging (MRI) examinations performed between January 2023 and October 2025. Eligible participants included patients older than 18 years with complete electronic medical records. Exclusion criteria were defined as: (1) a history of patellar or quadriceps tendon rupture, (2) prior patellar fractures, (3) known musculoskeletal comorbidities, (4) significant imaging artifacts that precluded precise morphometric assessment, or (5) studies deemed technically inadequate according to institutional imaging protocols. Out of 247 initially screened patients, 78 non-contrast thigh MRI examinations met all inclusion criteria and were included in the final analysis. Demographic and anthropometric variables—including sex, age, height, weight, and body mass index (BMI)—were retrieved from the electronic medical records. MRI Protocol and Measurements All thigh MRI examinations were performed using a standard institutional protocol on a 1.5 Tesla clinical MRI scanner (Siemens MAGNETOM Essenza 1.5T, Shenzhen, China or Philips Achieva 1.5T Best, Netherlands), with an average acquisition time of 10 minutes. The use of a dedicated thigh protocol was prioritized over standard knee imaging to ensure a complete field of view (FOV) of the QT, addressing the common limitation of standard knee scans that often fail to capture the full proximal extent of the donor site. QT length was measured primarily using sagittal T2-weighted short-tau inversion recovery (STIR) sequences, which provided optimal contrast to identify the musculotendinous junction. The sagittal plane was utilized to measure the distance from the superior pole of the patella to the most distal aspect of the musculotendinous junction of the rectus femoris, following established morphometric protocols. (Figure 1). Measurements were independently performed by three evaluators to assess inter-observer reliability: a first-year orthopedic surgery resident, a knee surgery fellow, and a musculoskeletal radiology fellow. All assessments were conducted directly on the XERO® universal viewer platform (Agfa Healthcare, Mortsel, Belgium). To ensure objectivity, evaluators were blinded to the patients’ anthropometric data and to each other's measurements. Statistical Analysis Descriptive statistics were expressed as means and standard deviations (SD) for continuous variables and as frequencies/percentages for categorical variables. The normality of data distribution was verified using the Shapiro-Wilk test to ensure the appropriateness of subsequent parametric testing. Inter-observer reliability for all radiological measurements was assessed using the ICC, interpreted according to Koo and Li’s guidelines (values >0.75 indicating excellent reliability). Comparisons of QT length between sexes were performed using independent-samples Student’s t-tests. To evaluate the associations between the primary outcome (QT length) and anthropometric variables (weight, height, and BMI), Pearson correlation coefficients were initially calculated. Subsequently, simple and multiple linear regression models were constructed to determine the predictive capacity of these variables. The coefficient of determination (R²) was used to quantify the proportion of variance in QT length explained by the anthropometric predictors. Statistical analyses were conducted using STATA version 19.0 (StataCorp, College Station, TX, USA). A 95% confidence level and 80% statistical power were adopted. Statistical significance was set at p < 0.05. Results A total of 78 subjects were included, comprising 44 females (56.4%) and 34 males (43.6%). The mean of the three independent measurements per participant was used for statistical evaluation, as inter-observer reliability demonstrated excellent agreement with an ICC of 0.83. Demographic and Anthropometric Profile Significant sexual differences were observed in anthropometric variables. Males exhibited significantly greater body weight (91.9 ± 21.2 vs. 72.2 ± 14.7 kg p<0.0001) and height (173.9 ± 5.7 vs. 158.1 ± 5.3 cm p<0.0001) compared with females. No significant differences in BMI were observed between sexes (30.3 ± 6.1 vs. 28.8 ± 5.5 kg/m² p=0.29). Regarding QT morphometry, males also demonstrated significantly greater QT length than females (74.45 ± 9.88 vs. 68.02 ± 10.16 mm p=0.01). (Table 1) Stratification by Tendon Length When patients were stratified according to QT length, shorter tendons were predominantly found in females. In the QT ≤ 60 mm group (n = 13), which represents the critical threshold for potential bone-block requirement, 92.3% were female, with a mean height of 160.5 ± 7.2 cm. In the QT ≤ 70 mm (n = 36), 69.4% were female, with a mean height of 163.0 ± 9.5 cm. Conversely, in the sufficient tendon length group (QT > 70 mm; n = 42), only 45.2% were female, and the mean height was higher (166.7 ± 9.4 cm). While a progressive increase in mean height was observed across increasing QT length categories, this correlation only reached statistical significance when comparing the QT ≤ 60mm and QT >70mm groups. (Table 2) Correlation and Predictive Analysis Bivariate comparisons showed statistically significant sex-related differences for weight (Δ = 19.7 kg; p < 0.001), height (Δ = 15.8 cm; p < 0.001), and QT length (Δ = 6.43 mm; p = 0.006), but not for BMI (p = 0.28). Correlation analysis revealed only weak positive associations between QT length and height (r = 0.26) and weight (r = 0.24). While simple linear regression identified a statistically significant association between height and QT length (β = 0.28; p = 0.024), the clinical predictive value was markedly limited. The coefficient of determination (R²) was 0.065, indicating that height explains only 6.5% of the total variance in tendon length in this cohort. Neither weight nor BMI demonstrated significant associations with QT length. In multivariable models adjusted for sex, weight, and height, no single variable remained independently associated with QT length, reinforcing the high inter-individual variability of the donor site. Discussion The primary finding of this study is that the studied Latin American population possesses a mean QT length of 70.82 ± 11.09 mm, establishing it as a highly feasible autograft for ACL reconstruction regardless of patient height. Our data demonstrates that height, while statistically significant, is a clinically weak predictor of tendon length, accounting for only 6.5% of its variance (r² = 0.06). This aligns with the findings of Yuksel et al., who also noted that despite a positive correlation, the discriminatory capacity of height was too weak to serve as a reliable diagnostic tool for identifying inadequate graft length [4]. The relationship between patient height and graft dimensions has been a subject of intense debate. Early studies, such as those by Xerogeanes et al., suggested that height was a robust predictor, reporting that in North American cohorts, no patient taller than 167 cm had a free QT graft shorter than 60 mm [21]. However, our results align more closely with the recent observations of Yuksel et al., who noted that the discriminatory capacity of height was too weak to serve as a reliable diagnostic tool, in their series, nearly one-third of subjects had an insufficient free QT length, including many patients taller than 167 cm [4]. In the studied cohort, this independence of QT length from stature is even more pronounced. This phenotypic variation may be attributed to ethnic differences; while Yamasaki et al. found shorter mean lengths (60.9 mm) in Asian populations—partially explained by shorter average patient height (169.3 cm) [20]—our cohort maintained a mean length of 70.82 mm despite a lower average height (165 cm). This suggests that the "70 mm rule" is a stable morphometric trait in our population, reinforcing the feasibility of the QT autograft even for shorter individuals. A pivotal aspect of our study is the stratification by tendon length (Table 2), which reveals a critical gender-based distribution. The majority (92.3%) of patients with a "critical" tendon length (< 60mm) were female. This finding has profound clinical implications: while Goto et al. demonstrated that small-statured female patients (< 163 cm) achieve excellent clinical outcomes with QT autografts [22], our data warns that this specific subgroup is at the highest risk for graft-tunnel mismatch. As Yamasaki et al. suggested, identifying a tendon shorter than 60 mm on preoperative MRI should alert the surgeon to include a bone block during harvest to ensure sufficient length for stable fixation [20]. The fact that height only became a significant predictor when comparing the extremes of our cohort ( 70 mm) further underscores that anthropometric estimates are insufficient for the individual patient. The decision to utilize the QT over traditional BPTB or HT grafts is increasingly supported by its superior biological and biomechanical profile. Histological examinations show that the QT contains approximately 20% more collagen than a patellar tendon graft of the same thickness [11]. This higher collagen density translates into a significantly greater ultimate load to failure and increased stiffness, which are critical for early postoperative stability. Furthermore, the cross-sectional area and volume are vastly superior to the patellar tendon. Research by Xerogeanes et al. demonstrated that the distal 6 cm of the QT has a mean volume 275% larger than the entire patellar tendon, The mean thickness and width of the QT allow for a graft whose volume is approximately 88% greater than an equivalent BPTB graft [3, 21]. This structural robustness is vital, as HT grafts with diameters less than 7-8 mm are associated with higher revision rates. The QT effectively eliminates this concern by providing a consistent and ample donor tissue volume. Additionally, Kanakamedala et al. demonstrated in a systematic review that there are no significant differences in stability or functional outcomes between full-thickness and partial-thickness QT autografts, offering further technical flexibility [23]. Regarding morbidity, BPTB grafts frequently report residual anterior knee pain, kneeling difficulty and risk of patellar fracture [24-26]. Our study supports the growing consensus that the QT offers the mechanical strength of the BPTB [10, 11] with a morbidity profile comparable to, or better than, the HT [1, 13, 16]. Furthermore, a recent systematic review of Level I-II evidence by Hasan et al. corroborated this consensus, demonstrating that QT autografts exhibit failure rates as low as 2–3%—vastly superior to HT grafts (11–17%)—while reducing anterior knee pain by nearly half compared to BPTB grafts (33% vs. 64%), with encouraging return to sports rates (64-75%), similar to BPTB (81%). Ultimately, they concluded that the QT and BPTB offer the optimal combination of graft survivorship and functional outcomes for high-demand patients [27]. A systematic review of 1,398 patients by Ajrawat et al. confirmed that clinical outcomes for the QT are at least comparable to traditional grafts, with a significant reduction in anterior knee pain [16]. When contrasted with hamstring autografts, the QT avoids the risks of iatrogenic saphenous nerve injuries and permanent flexor muscle weakness. While HT grafts are known for their extreme variability in volume and the lack of a reproducible preoperative prediction method, the QT provides a predictable donor site. Our data confirms that with a mean length of 70 mm, surgeons can confidently perform "all-inside" techniques, which generally require a minimum graft length of 65–70 mm [28-30]. A critical methodological takeaway is the role of specialized imaging in preoperative planning. While international studies report that a standard MRI may be sufficient, the FOV is a major technical hurdle. Standard knee MRI protocols frequently fail to capture the full proximal extent of the QT musculotendinous junction. Our use of a dedicated thigh MRI protocol allowed for the visualization of at least 10 cm proximal to the patella, ensuring that the measurement from the superior pole to the rectus femoris junction was accurate. The high inter-observer reliability (ICC = 0.83) in our study demonstrates that MRI-based QT measurement is a highly reproducible tool, even among evaluators with varying levels of experience. This is crucial for preventing intraoperative "graft-tunnel mismatch." As Yamasaki et al. highlighted, if a tendon is shorter than 60 mm on MRI, surgeons should consider including a bone block during harvesting to ensure adequate length for fixation. Given that height is a poor predictor (r² = 0.06), we argue that preoperative MRI assessment is suggested for any surgeon planning a QT autograft, especially in female patients shorter than 1.60 m. This study serves as a foundational morphometric reference for the Chilean and Latin American populations, filling a significant void in the international literature. We have demonstrated that the Latin American quadriceps tendon is a structurally robust, biomechanically superior, and morphologically predictable autograft choice. The independence of its length from the patient’s anthropometric profile challenges current clinical assumptions and elevates the importance of individualized radiological assessment. Future research must focus on correlating these morphometric findings with Patient-Reported Outcome Measures (PROMs) and long-term functional stability in our population. However, based on the current radiological and biomechanical evidence, the QT is at least equivalent, and in several key aspects superior, to traditional autografts. Its combination of predictable volume, high collagen content, and reduced morbidity profile positions it as an optimal first-line choice for primary ACL reconstruction. Limitations This study has several limitations that must be acknowledged. First, its retrospective, single-center design may limit the generalizability of the findings to the entire Chilean population and broader Latin American population. While a sample of 78 patients provides valuable pioneer data for the region, future multicenter studies with larger cohorts are warranted to confirm these morphometric trends across different regional phenotypes. Second, this is a radiological morphometric study and does not include direct intraoperative measurements or postoperative clinical outcomes. Although previous research has demonstrated a high correlation between MRI-based measurements and intraoperative findings [20, 21], direct surgical verification would further strengthen the clinical applicability of our results. Third, the analysis focused primarily on longitudinal tendon length. While thickness and CSA are critical determinants of total graft volume—and the QT is recognized for its superior CSA compared to the patellar tendon—these specific parameters were not the primary focus of the current study. Furthermore, while the literature supports a reduction in donor-site morbidity, such as anterior knee pain, compared to BPTB grafts, prospective longitudinal studies are required to evaluate the long-term functional recovery of quadriceps peak torque and PROMs within this specific demographic. Conclusion This study confirms that the QT in the Latin American population is a highly feasible and reliable autograft for ACL reconstruction, with a mean length of 70.82 mm. This dimension consistently meets the requirements for modern surgical techniques. The most critical clinical takeaway is that patient height is an unreliable predictor of QT length, explaining only 6.5% of its variance. This finding is particularly relevant for female patients, who constitute the vast majority of those with critical tendon lengths (<60 mm). Consequently, we strongly recommend the routine use of preoperative MRI with a dedicated thigh protocol to ensure a full field of view and accurate graft planning, thereby avoiding intraoperative graft-tunnel mismatch. Given its superior biomechanical profile and its significantly lower incidence of donor-site morbidity and kneeling pain compared to traditional autografts, the QT should be considered a first-line autograft choice in the Latin American population, offering a predictable and robust alternative to hamstring and BPTB grafts. Abbreviations ACL (Anterior cruciate ligament), QT (Quadriceps tendon), BPTB Bone-patellar tendon-bone, HT (Hamstring tendon), ICC (Intraclass correlation coefficient), CSA (Cross-sectional area), FOV (Field of view), SD (Standard deviations), BMI (Body mass index), PROMs (Patient-Reported Outcome Measures) Declarations Ethics approval and consent to participate: This study was approved by the Institutional Ethics Committee of Clínica Dávila Recoleta (Santiago, Chile), IORG0004449 and conducted in accordance with the Declaration of Helsinki and Chilean Law No. 20,584 regarding patients’ rights and healthcare standards. Informed consent was waived by the Institutional Ethics Committee due to the retrospective, anonymized nature of the study. Consent for publication (if applicable): Not applicable. Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing interests: the authors declare that they have no competing interests or other interests that might be perceived to influence the results and/or discussion reported in this paper. Availability of data and materials: The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. References Mouarbes D, Menetrey J, Marot V, Courtot L, Berard E, Cavaignac E. Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Outcomes for Quadriceps Tendon Autograft Versus Bone-Patellar Tendon-Bone and Hamstring-Tendon Autografts. Am J Sports Med. 2019;47:3531–40. 10.1177/0363546518825340 . Belk JW, Kraeutler MJ, Marshall HA, Goodrich JA, McCarty EC. Quadriceps Tendon Autograft for Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review of ComparativeStudies With Minimum 2-Year Follow-Up. Arthroscopy. 2018;34:1699–707. 10.1016/j.arthro.2018.01.047 . 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J Clin Med. 2023;12:5793. 10.3390/jcm12185793 . ANEXES. Tables Table 1 Demographic and anthropometric characteristics of the patients Variable Male (n = 34) Female (n = 44) Total p value Age (years) 52.2 +- 14.7 53.3 +- 19.1 52.8 +- 17.3 0.78 Height (cm) 173.9 +- 5.7 158.1 +- 5.2 165 +- 9.57 < 0.0001 Weight (kg) 91.9 +- 21.1 72.1 +- 14.6 80.7 +- 20.2 < 0.0001 BMI (kg/m^2) 30.2 +- 6.1 28.8 +- 5.5 29.4 +- 5.8 0.29 QT total length (mm) 74.4 +- 10.5 68.0 +- 10.7 70.8 +- 11.1 0.01 Table 2 Female percentage and mean height comparison and between insufficient and sufficient quadriceps tendon length groups QT length Insufficient tendon Sufficient tendon ≤ 60 mm (n = 13) ≤ 70mm (n = 36) > 70mm (n = 42) Female (%) 92.3 69.4 45.2 Height (cm) 160.5 +- 7.2* 163.0 +- 9.5* 166.7 +- 9.4 *p value 0.03 0.08 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9224492","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":618968089,"identity":"aa7eb70f-8ed1-429b-87f7-1a2c12bee677","order_by":0,"name":"Jose Miguel Luarte Espinosa","email":"","orcid":"","institution":"Clínica Dávila","correspondingAuthor":false,"prefix":"","firstName":"Jose","middleName":"Miguel Luarte","lastName":"Espinosa","suffix":""},{"id":618968092,"identity":"76bddd17-2024-4ad8-a372-291a15fc572f","order_by":1,"name":"Gonzalo Marambio Santana","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYBCDBDYG5gMMCSDmARBRQJQWtgQkLQZEaGFg4IEqI6RF3v104ueKmm15fOw9Xzc8bLPL4zve/oDhBx4thmdyN0ueOXa7mI3n7LYbiW3JxZJnzhgw9uDT0pC7QbKB7XZim0QuSAtz4oYbOQzM+Bxm2P9288+GfyAtOc+AWuoTN9x//gCvFnmg4ZKNbWAtbEAth4G2MBjg1WIg8XabZWMfyC/HzG4knDueOPNMjsFBfH6R78/dfLPh2+08+fbmZzd/lFUn9h0//vDBjwo8thzAJopVEG5LAz7ZUTAKRsEoGAUgAADp+F58rsFhrgAAAABJRU5ErkJggg==","orcid":"","institution":"Universidad de Los Andes, Chile","correspondingAuthor":true,"prefix":"","firstName":"Gonzalo","middleName":"Marambio","lastName":"Santana","suffix":""},{"id":618968095,"identity":"a896303d-3d69-4a3b-bc57-187170b7a0b7","order_by":2,"name":"Diego Munita Benavides","email":"","orcid":"","institution":"Clínica Dávila","correspondingAuthor":false,"prefix":"","firstName":"Diego","middleName":"Munita","lastName":"Benavides","suffix":""},{"id":618968097,"identity":"4c4f83c1-4cc0-420d-9bce-867026fc2b0c","order_by":3,"name":"José Miguel Castellón Valdivieso","email":"","orcid":"","institution":"Clínica Dávila","correspondingAuthor":false,"prefix":"","firstName":"José","middleName":"Miguel Castellón","lastName":"Valdivieso","suffix":""},{"id":618968099,"identity":"3ca0fd4b-43a3-46b9-b2a0-aba3e63e45f7","order_by":4,"name":"Luis Lira Steembecker","email":"","orcid":"","institution":"Clínica Dávila","correspondingAuthor":false,"prefix":"","firstName":"Luis","middleName":"Lira","lastName":"Steembecker","suffix":""},{"id":618968101,"identity":"a0a70fd9-3a80-45ae-b862-8c5a857372cf","order_by":5,"name":"Alberto Esteban Stocker Zegers","email":"","orcid":"","institution":"Universidad de Los Andes, Chile","correspondingAuthor":false,"prefix":"","firstName":"Alberto","middleName":"Esteban Stocker","lastName":"Zegers","suffix":""}],"badges":[],"createdAt":"2026-03-25 14:38:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9224492/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9224492/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106877887,"identity":"d87e9d4b-58c3-45f7-838b-cfc901354632","added_by":"auto","created_at":"2026-04-14 10:42:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":115349,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMRI measurement of quadriceps tendon length. \u003c/strong\u003eBoth axial (right) and sagittal (left) planes were utilized to measure the distance from the superior pole of the patella to the musculotendinous junction\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9224492/v1/e66140f046b44099f64186c9.png"},{"id":106994415,"identity":"6211ee1e-9ceb-47f8-9c60-a992f39c9b88","added_by":"auto","created_at":"2026-04-15 15:08:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":788571,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9224492/v1/37ff16ee-996d-47cf-947b-742dc6d9a231.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eQuadriceps Tendon Morphometry in Latin American Population and its feasibility as an autograft for Anterior Cruciate Ligament Reconstruction: An Observational Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eclinical outcomes and graft failure rates. Although quadruple HT and BPTB grafts have traditionally been the most utilized autografts, both present well-documented disadvantages. BPTB grafts are associated with an increased risk of patellar fracture, patellar tendon rupture, residual anterior knee pain, and difficulty kneeling [1-3]. Conversely, HT harvesting may result in greater residual instability, delayed graft incorporation, iatrogenic saphenous nerve injuries, hamstring strength deficits, and significant length variability during graft harvesting [1, 2, 4]. Despite extensive study, the selection of the most appropriate autograft remains a subject of ongoing controversy.\u003c/p\u003e\n\u003cp\u003eThe historical foundation of the QT as a graft choice dates back to Marshall (1979) and Blauth (1984), who were the first to describe its use in ACL reconstruction [5, 6]. Subsequently, Staubli and Jakob characterized its anatomical and biomechanical properties as suitable for autograft use [7]. Fulkerson et al. further advanced the technique by describing the use of the autograft without the need for a bone plug, establishing the versatility of the central QT as a \"free graft\" [8].\u003c/p\u003e\n\u003cp\u003eIn this context, the QT has emerged as a reliable and biomechanically superior alternative, demonstrating a higher failure load than BPTB grafts and greater residual quadriceps strength following harvest compared to the patellar tendon [3, 9, 10]. Evidence suggests that the QT autograft offers a significantly larger cross-sectional area (CSA) and structural properties comparable or superior to the native ACL, containing approximately 20% more collagen than a BPTB graft of the same thickness [11]. Furthermore, recent literature has established the QT as a robust option for both primary and revision surgeries, showing postoperative stability and functional outcomes equivalent to traditional grafts while significantly reducing donor-site morbidity [1, 2, 12-18].\u003c/p\u003e\n\u003cp\u003eSuccessful ACL reconstruction requires grafts with predictable and reproducible morphometry to optimize surgical planning and avoid graft-tunnel mismatch. Preoperative MRI is essential for evaluating QT length and thickness. While Ugwuoke et al. demonstrated the intraoperative suitability of QT length in Caucasian patients without finding a correlation with weight or height [19], other authors like Yamasaki et al. and Xerogeanes et al. found strong correlations between MRI-based measurements and intraoperative findings [20, 21]. Studies by Xerogeanes, Yuksel, and Yamasaki in North American, European, and Asian populations, respectively, collectively show that their respective populations are suitable for QT grafting [4, 20, 21]. Notably, Yamasaki suggested that patients with a tendon length shorter than 60 mm require the inclusion of a bone block during harvesting to ensure adequate fixation [20]. Furthermore, Xerogeanes and Yuksel reported a significant positive correlation between patient height and QT length in North American and European populations, respectively [4, 21]. Conversely, Goto et al. demonstrated that in small-statured (\u0026lt; 163 cm), female patients series of 73 patients, the use of QT autografts yielded excellent clinical outcomes, including muscle strength recovery, donor-site morbidity, and time to return to sports, despite their smaller physical profile [22].\u003c/p\u003e\n\u003cp\u003ePhenotypic and anthropometric variations between different ethnicities suggest that international predictive models may not be universally applicable. Therefore, characterizing QT morphometry in a local cohort is vital for validating the QT as a viable alternative in this region and addressing the existing gap in morphometric studies within Latin American populations.\u003c/p\u003e\n\u003cp\u003eGiven that the anthropometric dependencies observed in other populations may not be as robust in our setting, it is necessary to determine whether these variables serve as reliable clinical predictors.\u003c/p\u003e\n\u003cp\u003eThe purpose of this study was to evaluate QT morphometry in a Latin American population using MRI and to determine the strength of its correlation with individual anthropometric variables. We hypothesized that QT morphometric parameters in this population would allow for its reliable use as an autograft and that these measurements would correlate significantly with the individuals' anthropometric profiles.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eEthics and Patient Selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective case series was approved by the Institutional Ethics Committee of Clínica Dávila (Santiago, Chile) and conducted in accordance with the Declaration of Helsinki and Chilean Law No. 20,584 regarding patients’ rights and healthcare standards.\u003c/p\u003e\n\u003cp\u003eThe study was a collaborative effort between the Departments of Orthopedics and Musculoskeletal Radiology. An anonymized review of the institutional radiology database was conducted, screening thigh magnetic resonance imaging (MRI) examinations performed between January 2023 and October 2025.\u003c/p\u003e\n\u003cp\u003eEligible participants included patients older than 18 years with complete electronic medical records. Exclusion criteria were defined as: (1) a history of patellar or quadriceps tendon rupture, (2) prior patellar fractures, (3) known musculoskeletal comorbidities, (4) significant imaging artifacts that precluded precise morphometric assessment, or (5) studies deemed technically inadequate according to institutional imaging protocols.\u003c/p\u003e\n\u003cp\u003eOut of 247 initially screened patients, 78 non-contrast thigh MRI examinations met all inclusion criteria and were included in the final analysis. Demographic and anthropometric variables—including sex, age, height, weight, and body mass index (BMI)—were retrieved from the electronic medical records.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMRI Protocol and Measurements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll thigh MRI examinations were performed using a standard institutional protocol on a 1.5 Tesla clinical MRI scanner (Siemens MAGNETOM Essenza 1.5T, Shenzhen, China or Philips Achieva 1.5T Best, Netherlands), with an average acquisition time of 10 minutes. The use of a dedicated thigh protocol was prioritized over standard knee imaging to ensure a complete field of view (FOV) of the QT, addressing the common limitation of standard knee scans that often fail to capture the full proximal extent of the donor site.\u003c/p\u003e\n\u003cp\u003eQT length was measured primarily using sagittal T2-weighted short-tau inversion recovery (STIR) sequences, which provided optimal contrast to identify the musculotendinous junction. The sagittal plane was utilized to measure the distance from the superior pole of the patella to the most distal aspect of the musculotendinous junction of the rectus femoris, following established morphometric protocols. (Figure 1).\u003c/p\u003e\n\u003cp\u003eMeasurements were independently performed by three evaluators to assess inter-observer reliability: a first-year orthopedic surgery resident, a knee surgery fellow, and a musculoskeletal radiology fellow. All assessments were conducted directly on the XERO® universal viewer platform (Agfa Healthcare, Mortsel, Belgium). To ensure objectivity, evaluators were blinded to the patients’ anthropometric data and to each other's measurements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were expressed as means and standard deviations (SD) for continuous variables and as frequencies/percentages for categorical variables. The normality of data distribution was verified using the Shapiro-Wilk test to ensure the appropriateness of subsequent parametric testing. Inter-observer reliability for all radiological measurements was assessed using the ICC, interpreted according to Koo and Li’s guidelines (values \u0026gt;0.75 indicating excellent reliability).\u003c/p\u003e\n\u003cp\u003eComparisons of QT length between sexes were performed using independent-samples Student’s t-tests. To evaluate the associations between the primary outcome (QT length) and anthropometric variables (weight, height, and BMI), Pearson correlation coefficients were initially calculated. Subsequently, simple and multiple linear regression models were constructed to determine the predictive capacity of these variables. The coefficient of determination (R²) was used to quantify the proportion of variance in QT length explained by the anthropometric predictors.\u003c/p\u003e\n\u003cp\u003eStatistical analyses were conducted using STATA version 19.0 (StataCorp, College Station, TX, USA). A 95% confidence level and 80% statistical power were adopted. Statistical significance was set at p \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 78 subjects were included, comprising 44 females (56.4%) and 34 males (43.6%). The mean of the three independent measurements per participant was used for statistical evaluation, as inter-observer reliability demonstrated excellent agreement with an ICC of 0.83.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic and Anthropometric Profile\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSignificant sexual differences were observed in anthropometric variables. Males exhibited significantly greater body weight (91.9 ± 21.2 vs. 72.2 ± 14.7 kg p\u0026lt;0.0001) and height (173.9 ± 5.7 vs. 158.1 ± 5.3 cm p\u0026lt;0.0001) compared with females. No significant differences in BMI were observed between sexes (30.3 ± 6.1 vs. 28.8 ± 5.5 kg/m² p=0.29). Regarding QT morphometry, males also demonstrated significantly greater QT length than females (74.45 ± 9.88 vs. 68.02 ± 10.16 mm p=0.01). (Table 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStratification by Tendon Length\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen patients were stratified according to QT length, shorter tendons were predominantly found in females. In the QT ≤ 60 mm \u0026nbsp;group (n = 13), which represents the critical threshold for potential bone-block requirement, 92.3% were female, with a mean height of 160.5 ± 7.2 cm.\u003c/p\u003e\n\u003cp\u003eIn the QT ≤ 70 mm (n = 36), 69.4% were female, with a mean height of 163.0 ± 9.5 cm. Conversely, in the sufficient tendon length group (QT \u0026gt; 70 mm; n = 42), only 45.2% were female, and the mean height was higher (166.7 ± 9.4 cm).\u003c/p\u003e\n\u003cp\u003eWhile a progressive increase in mean height was observed across increasing QT length categories, this correlation only reached statistical significance when comparing the QT ≤ 60mm and QT \u0026gt;70mm groups. (Table 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelation and Predictive Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBivariate comparisons showed statistically significant sex-related differences for weight (Δ = 19.7 kg; p \u0026lt; 0.001), height (Δ = 15.8 cm; p \u0026lt; 0.001), and QT length (Δ = 6.43 mm; p = 0.006), but not for BMI (p = 0.28).\u003c/p\u003e\n\u003cp\u003eCorrelation analysis revealed only weak positive associations between QT length and height (r = 0.26) and weight (r = 0.24). While simple linear regression identified a statistically significant association between height and QT length (β = 0.28; p = 0.024), the clinical predictive value was markedly limited. The coefficient of determination (R²) was 0.065, indicating that height explains only 6.5% of the total variance in tendon length in this cohort.\u003c/p\u003e\n\u003cp\u003eNeither weight nor BMI demonstrated significant associations with QT length. In multivariable models adjusted for sex, weight, and height, no single variable remained independently associated with QT length, reinforcing the high inter-individual variability of the donor site.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe primary finding of this study is that the studied Latin American population possesses a mean QT length of 70.82 ± 11.09 mm, establishing it as a highly feasible autograft for ACL reconstruction regardless of patient height. Our data demonstrates that height, while statistically significant, is a clinically weak predictor of tendon length, accounting for only 6.5% of its variance (r² = 0.06). This aligns with the findings of Yuksel et al., who also noted that despite a positive correlation, the discriminatory capacity of height was too weak to serve as a reliable diagnostic tool for identifying inadequate graft length [4].\u003c/p\u003e\n\u003cp\u003eThe relationship between patient height and graft dimensions has been a subject of intense debate. Early studies, such as those by Xerogeanes et al., suggested that height was a robust predictor, reporting that in North American cohorts, no patient taller than 167 cm had a free QT graft shorter than 60 mm [21]. However, our results align more closely with the recent observations of Yuksel et al., who noted that the discriminatory capacity of height was too weak to serve as a reliable diagnostic tool, in their series, nearly one-third of subjects had an insufficient free QT length, including many patients taller than 167 cm [4].\u003c/p\u003e\n\u003cp\u003eIn the studied cohort, this independence of QT length from stature is even more pronounced. This phenotypic variation may be attributed to ethnic differences; while Yamasaki et al. found shorter mean lengths (60.9 mm) in Asian populations—partially explained by shorter average patient height (169.3 cm) [20]—our cohort maintained a mean length of 70.82 mm despite a lower average height (165 cm). This suggests that the \"70 mm rule\" is a stable morphometric trait in our population, reinforcing the feasibility of the QT autograft even for shorter individuals.\u003c/p\u003e\n\u003cp\u003eA pivotal aspect of our study is the stratification by tendon length (Table 2), which reveals a critical gender-based distribution. The majority (92.3%) of patients with a \"critical\" tendon length (\u0026lt; 60mm) were female. This finding has profound clinical implications: while Goto et al. demonstrated that small-statured female patients (\u0026lt; 163 cm) achieve excellent clinical outcomes with QT autografts [22], our data warns that this specific subgroup is at the highest risk for graft-tunnel mismatch. As Yamasaki et al. suggested, identifying a tendon shorter than 60 mm on preoperative MRI should alert the surgeon to include a bone block during harvest to ensure sufficient length for stable fixation [20]. The fact that height only became a significant predictor when comparing the extremes of our cohort (\u0026lt; 60 mm vs. \u0026gt; 70 mm) further underscores that anthropometric estimates are insufficient for the individual patient.\u003c/p\u003e\n\u003cp\u003eThe decision to utilize the QT over traditional BPTB or HT grafts is increasingly supported by its superior biological and biomechanical profile. Histological examinations show that the QT contains approximately 20% more collagen than a patellar tendon graft of the same thickness [11]. This higher collagen density translates into a significantly greater ultimate load to failure and increased stiffness, which are critical for early postoperative stability.\u003c/p\u003e\n\u003cp\u003eFurthermore, the cross-sectional area and volume are vastly superior to the patellar tendon. Research by Xerogeanes et al. demonstrated that the distal 6 cm of the QT has a mean volume 275% larger than the entire patellar tendon, The mean thickness and width of the QT allow for a graft whose volume is approximately 88% greater than an equivalent BPTB graft [3, 21]. This structural robustness is vital, as HT grafts with diameters less than 7-8 mm are associated with higher revision rates. The QT effectively eliminates this concern by providing a consistent and ample donor tissue volume. Additionally, Kanakamedala et al. demonstrated in a systematic review that there are no significant differences in stability or functional outcomes between full-thickness and partial-thickness QT autografts, offering further technical flexibility [23].\u003c/p\u003e\n\u003cp\u003eRegarding morbidity, BPTB grafts frequently report residual anterior knee pain, kneeling difficulty and risk of patellar fracture [24-26]. Our study supports the growing consensus that the QT offers the mechanical strength of the BPTB [10, 11] with a morbidity profile comparable to, or better than, the HT [1, 13, 16]. Furthermore, a recent systematic review of Level I-II evidence by Hasan et al. corroborated this consensus, demonstrating that QT autografts exhibit failure rates as low as 2–3%—vastly superior to HT grafts (11–17%)—while reducing anterior knee pain by nearly half compared to BPTB grafts (33% vs. 64%), with encouraging return to sports rates (64-75%), similar to BPTB (81%). Ultimately, they concluded that the QT and BPTB offer the optimal combination of graft survivorship and functional outcomes for high-demand patients [27]. A systematic review of 1,398 patients by Ajrawat et al. confirmed that clinical outcomes for the QT are at least comparable to traditional grafts, with a significant reduction in anterior knee pain [16].\u003c/p\u003e\n\u003cp\u003eWhen contrasted with hamstring autografts, the QT avoids the risks of iatrogenic saphenous nerve injuries and permanent flexor muscle weakness. While HT grafts are known for their extreme variability in volume and the lack of a reproducible preoperative prediction method, the QT provides a predictable donor site. Our data confirms that with a mean length of 70 mm, surgeons can confidently perform \"all-inside\" techniques, which generally require a minimum graft length of 65–70 mm [28-30].\u003c/p\u003e\n\u003cp\u003eA critical methodological takeaway is the role of specialized imaging in preoperative planning. While international studies report that a standard MRI may be sufficient, the FOV is a major technical hurdle. Standard knee MRI protocols frequently fail to capture the full proximal extent of the QT musculotendinous junction. Our use of a dedicated thigh MRI protocol allowed for the visualization of at least 10 cm proximal to the patella, ensuring that the measurement from the superior pole to the rectus femoris junction was accurate.\u003c/p\u003e\n\u003cp\u003eThe high inter-observer reliability (ICC = 0.83) in our study demonstrates that MRI-based QT measurement is a highly reproducible tool, even among evaluators with varying levels of experience. This is crucial for preventing intraoperative \"graft-tunnel mismatch.\" As Yamasaki et al. highlighted, if a tendon is shorter than 60 mm on MRI, surgeons should consider including a bone block during harvesting to ensure adequate length for fixation. Given that height is a poor predictor (r² = 0.06), we argue that preoperative MRI assessment is suggested for any surgeon planning a QT autograft, especially in female patients shorter than 1.60 m.\u003c/p\u003e\n\u003cp\u003eThis study serves as a foundational morphometric reference for the Chilean and Latin American populations, filling a significant void in the international literature. We have demonstrated that the Latin American quadriceps tendon is a structurally robust, biomechanically superior, and morphologically predictable autograft choice. The independence of its length from the patient’s anthropometric profile challenges current clinical assumptions and elevates the importance of individualized radiological assessment.\u003c/p\u003e\n\u003cp\u003eFuture research must focus on correlating these morphometric findings with Patient-Reported Outcome Measures (PROMs) and long-term functional stability in our population. However, based on the current radiological and biomechanical evidence, the QT is at least equivalent, and in several key aspects superior, to traditional autografts. Its combination of predictable volume, high collagen content, and reduced morbidity profile positions it as an optimal first-line choice for primary ACL reconstruction.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis study has several limitations that must be acknowledged. First, its retrospective, single-center design may limit the generalizability of the findings to the entire Chilean population and broader Latin American population. While a sample of 78 patients provides valuable pioneer data for the region, future multicenter studies with larger cohorts are warranted to confirm these morphometric trends across different regional phenotypes.\u003c/p\u003e\n\u003cp\u003eSecond, this is a radiological morphometric study and does not include direct intraoperative measurements or postoperative clinical outcomes. Although previous research has demonstrated a high correlation between MRI-based measurements and intraoperative findings [20, 21], direct surgical verification would further strengthen the clinical applicability of our results.\u003c/p\u003e\n\u003cp\u003eThird, the analysis focused primarily on longitudinal tendon length. While thickness and CSA are critical determinants of total graft volume—and the QT is recognized for its superior CSA compared to the patellar tendon—these specific parameters were not the primary focus of the current study. Furthermore, while the literature supports a reduction in donor-site morbidity, such as anterior knee pain, compared to BPTB grafts, prospective longitudinal studies are required to evaluate the long-term functional recovery of quadriceps peak torque and PROMs within this specific demographic.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study confirms that the QT in the Latin American population is a highly feasible and reliable autograft for ACL reconstruction, with a mean length of 70.82 mm. This dimension consistently meets the requirements for modern surgical techniques.\u003c/p\u003e\n\u003cp\u003eThe most critical clinical takeaway is that patient height is an unreliable predictor of QT length, explaining only 6.5% of its variance. This finding is particularly relevant for female patients, who constitute the vast majority of those with critical tendon lengths (\u0026lt;60 mm). Consequently, we strongly recommend the routine use of preoperative MRI with a dedicated thigh protocol to ensure a full field of view and accurate graft planning, thereby avoiding intraoperative graft-tunnel mismatch.\u003c/p\u003e\n\u003cp\u003eGiven its superior biomechanical profile and its significantly lower incidence of donor-site morbidity and kneeling pain compared to traditional autografts, the QT should be considered a first-line autograft choice in the Latin American population, offering a predictable and robust alternative to hamstring and BPTB grafts.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eACL\u003c/strong\u003e (Anterior cruciate ligament), \u003cstrong\u003eQT\u003c/strong\u003e (Quadriceps tendon), \u003cstrong\u003eBPTB\u003c/strong\u003e Bone-patellar tendon-bone, \u003cstrong\u003eHT\u003c/strong\u003e (Hamstring tendon), \u003cstrong\u003eICC\u003c/strong\u003e (Intraclass correlation coefficient), \u003cstrong\u003eCSA\u003c/strong\u003e (Cross-sectional area), \u003cstrong\u003eFOV\u003c/strong\u003e (Field of view),\u003cstrong\u003e\u0026nbsp;SD\u003c/strong\u003e (Standard deviations), \u003cstrong\u003eBMI\u0026nbsp;\u003c/strong\u003e(Body mass index),\u0026nbsp;\u003cstrong\u003ePROMs\u003c/strong\u003e (Patient-Reported Outcome Measures)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis study was approved by the Institutional Ethics Committee of Clínica Dávila Recoleta (Santiago, Chile), IORG0004449\u0026nbsp;and conducted in accordance with the Declaration of Helsinki and Chilean Law No. 20,584 regarding patients’ rights and healthcare standards. Informed consent was waived by the Institutional Ethics Committee due to the retrospective, anonymized nature of the study.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e(if applicable): Not applicable.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e the authors declare that they have no competing interests or other interests that might be perceived to influence the results and/or discussion reported in this paper.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMouarbes D, Menetrey J, Marot V, Courtot L, Berard E, Cavaignac E. 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J Clin Med. 2023;12:5793. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/jcm12185793\u003c/span\u003e\u003cspan address=\"10.3390/jcm12185793\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eANEXES.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":" \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eDemographic and anthropometric characteristics of the patients\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eVariable\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMale (n\u0026thinsp;=\u0026thinsp;34)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eFemale (n\u0026thinsp;=\u0026thinsp;44)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eTotal\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003ep value\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eAge (years)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e52.2 +- 14.7\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e53.3 +- 19.1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e52.8 +- 17.3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.78\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eHeight (cm)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e173.9 +- 5.7\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e158.1 +- 5.2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e165 +- 9.57\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.0001\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eWeight (kg)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e91.9 +- 21.1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e72.1 +- 14.6\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e80.7 +- 20.2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.0001\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eBMI (kg/m^2)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e30.2 +- 6.1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e28.8 +- 5.5\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e29.4 +- 5.8\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.29\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eQT total length (mm)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e74.4 +- 10.5\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e68.0 +- 10.7\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e70.8 +- 11.1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e0.01\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eFemale percentage and mean height comparison and between insufficient and sufficient quadriceps tendon length groups\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003eQT length\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eInsufficient tendon\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eSufficient tendon\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026le;\u0026thinsp;60 mm (n\u0026thinsp;=\u0026thinsp;13)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026le;\u0026thinsp;70mm (n\u0026thinsp;=\u0026thinsp;36)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026gt;\u0026thinsp;70mm (n\u0026thinsp;=\u0026thinsp;42)\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eFemale (%)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e92.3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e69.4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e45.2\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eHeight (cm)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e160.5 +- 7.2*\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e163.0 +- 9.5*\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e166.7 +- 9.4\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e*p value\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e0.03\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.08\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"ACL reconstruction, MRI, Quadriceps tendon autograft, Anthropometrics, Graft length","lastPublishedDoi":"10.21203/rs.3.rs-9224492/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9224492/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Anterior cruciate ligament (ACL) reconstruction requires grafts with predictable morphometry to optimize surgical outcomes and avoid graft-tunnel mismatch. While the quadriceps tendon (QT) has emerged as a reliable alternative globally, high-quality morphometric data for Latin American populations is scarce, potentially limiting its adoption over traditional bone-patellar tendon-bone (BPTB) or hamstring tendon (HT) grafts. This study aims to characterize QT morphometry in a Latin American population using MRI to assess its clinical feasibility.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A retrospective case series was conducted on 78 adults. Morphometric assessment of the QT was performed using Xero software, adapting established measurement protocols. Three independent observers performed the measurements to evaluate reliability. Inter-observer reliability was assessed via the intraclass correlation coefficient (ICC). Anthropometric correlations were analyzed using linear regression models.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The cohort included 34 males and 44 females (mean age 52 years; mean height 165 cm). The mean QT length was 70.82 ± 11.09 mm. Although a statistically significant relationship was found between patient height and tendon length (p \u0026lt; 0.05), the correlation was too weak to serve as a robust predictor for graft sizing. Inter-observer reliability for QT measurements was high (ICC = 0.83).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Latin American QT morphometry is predictable and reproducible, supporting its feasibility for primary ACL reconstruction. The reliability of MRI measurements validates its utility for preoperative planning. However, the weak correlation with anthropometric variables suggests that preoperative MRI planning is essential, as height alone is an unreliable predictor of graft dimensions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of evidence: \u003c/strong\u003eIV, retrospective case series.\u003c/p\u003e","manuscriptTitle":"Quadriceps Tendon Morphometry in Latin American Population and its feasibility as an autograft for Anterior Cruciate Ligament Reconstruction: An Observational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-14 10:42:27","doi":"10.21203/rs.3.rs-9224492/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2e17cfb5-ad50-4622-a447-d316794c9bb4","owner":[],"postedDate":"April 14th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-14T22:24:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-14 10:42:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9224492","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9224492","identity":"rs-9224492","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}