Anterior Cruciate Ligament Reconstruction Using a Bone–Patellar Tendon–Bone Autograft to Avoid Harvest-Site Morbidity in Knee Arthroscopy

Abstract

Although anterior cruciate ligament reconstruction using a boneepatellar tendonebone (BPTB) autograft has many advantages (e.g., high strength and solid fixation), there are also several complications (e.g., anterior knee pain or kneeling pain) due to harvest-site morbidity associated with the use of this graft type compared with the use of hamstring tendon. Therefore the ultimate goal of anterior cruciate ligament reconstruction using a BPTB graft is to minimize harvestsite morbidity. We have used a technique for harvesting central-third BPTB grafts that involves only a 3-cm-long, longitudinal, curved incision in the medial tibial tuberosity for both graft harvesting and fixation. The purpose of this report is to describe the technique, which can avoid the harvest-site morbidities associated with BPTB autografts during knee arthroscopy. We believe that this less invasive reconstruction may reduce the harvest-site morbidities associated with BPTB grafts because it allows for BPTB graft harvesting without incising the synovial bursa or paratenon and mitigates scarring and adhesion formation.A nterior cruciate ligament (ACL) ruptures are among the most frequent ligament injuries. Given that obtaining sufficient regeneration is difficult in cases of a torn ACL because of its poor healing potential, reconstruction surgery is the first choice for treatment of ACL ruptures. Thus boneepatellar tendonebone (BPTB) and hamstring tendon (HS) autografts are the 2 most commonly used reconstruction techniques. In 1963 Jones 1 pioneered the use of BPTB grafts, and this technique has since been considered the gold-standard technique. The BPTB graft is most frequently used because it provides high strength and stiffness, graft size consistency, harvesting ease, early graft incorporation, and solid fixation. However, reconstruction using a BPTB graft is not a perfect solution and may result in harvest-site morbidities, including anterior knee pain or kneeling pain. To avoid the harvest-site morbidities associated with BPTB grafts, HS grafts have recently been used for ACL reconstruction 2 ; however, they are associated with graft loosening, require more expensive implants, and have the potential for knee flexion weakness. In fact, many surgeons who regularly use HS grafts advocate the use of BPTB grafts in athletes and heavy laborers. 3 We believe that the ultimate goal of ACL reconstruction, using a BPTB graft, is to minimize harvest-site morbidity.We have successfully used a technique for harvesting central-third BPTB grafts that involves only 1 longitudinal, curved incision, approximately 3 cm in length, in the medial tibial tuberosity for both graft harvesting and fixation. This technique, performed using devices previously developed by us, not only involves a small skin incision but also allows for BPTB graft harvesting without incising the synovial bursa or paratenon. Subsequently, the BPTB graft can be fixed through the same incision using an all-inside technique. In this report we describe our technique, which m...

All-Inside Single-Bundle Reconstruction of the Anterior Cruciate Ligament with the Anterior Half of the Peroneus Longus Tendon Compared to the Semitendinosus Tendon: A Two-Year Follow-Up Study

“…Hamstring tendons, patellar tendons, and quadriceps tendons have been widely used in knee ligament reconstruction. 10,44,46,[51][52][53] The hamstring tendons that are harvested on the same leg are the primary choice for cruciate ligament reconstruction. Generally, they are sufficient for SB cruciate ligament reconstruction; however, in clinical practice, shortages in supplies of harvested hamstring tendons are sometimes encountered.…”

“…Although, in theory, quadricep tendons or patellar tendons can be harvested as an additional or alterative graft, in clinical practice, we seldom chose them as optimal donor sites considering the potential morbidities of extension mechanism or complications after harvesting. 52,54 Allografts may have been a good choice over the past few decades, 55,56 but it is limited in use due to the possible immunological rejection, 57,58 scarcity of resources, or relevant ethical issues. From our perspective, the PLT may be an ideal alternative for cruciate ligament reconstructive procedures as it can be easily and safely harvested.…”

A cadaveric study of the location and morphology of the central patellar ridge for bone-patellar tendon-bone graft

“…Kirti et al advocated to harvest the BPTB at the sharp corner instead of at the round corner which has a higher chance of failure after the procedure [11]. The common BPTB harvesting technique uses patella bone graft that is 10 mm in width, 20-30 mm in length and thickness usually less than 10 mm [8,[12][13]. Some surgeons use the medial third BPTB harvesting technique based on Wiberg's theory that the thickest central ridge was commonly located at the medial side of the patella.…”

Trends in Anterior Cruciate Ligament Reconstruction in the Last Decade: A Web-Based Analysis

“…22 Hamstring graft was found to be preferred over patellar graft, and there has been increased use of hamstring grafts to avoid the harvest-site morbidity associated with patellar grafts used for ACL reconstruction. 23 For tendon-bone healing, many biological strategies, including active substances such as platelet-rich plasma and growth factors, gene transfer, tissue engineering, and stem cell therapy, have been introduced and aggressively developed in recent years. 11 Another issue in ACL reconstruction is simultaneous intra-articular injections.…”