Welcome to our ACL Toolkit where we're going to share our technique for bone patellar tendon bone graft harvest. Our disclosures can be found in the Academy website. Today we're going to discuss current indications for utilizing bone patellar tendon bone for your source of autograft during ACL reconstruction, we're going to outline advantages and disadvantages of utilizing the graft, our preferred surgical technique, and a brief summary of clinical outcomes. Bone patellar tendon bone autograft is often referred to as the gold standard for ACL reconstruction. It has a lengthy track record with multiple studies demonstrating excellent clinical outcomes and very high rates of return to support. The graft possesses the necessary structural and biological components for reliable healing and incorporation and multiple trials have demonstrated success in the highest demand contact and non-contact athletes. Strengths of the graft include bone-to-bone fixation on the femur and the tibia as well as high load-to-failure in biomechanical testing. However, there have been reports of anterior knee pain and the graft does carry a risk of patellar fracture postoperatively. Signs for bone patellar tendon bone autograft include younger, higher demand athletes less than 25 years old. These athletes should be approaching skeletal maturity or currently skeletally mature. Preoperative advanced imaging can help evaluate for adequate tendon length prior to your reconstruction and the graft is also useful in revision settings of prior ACL failures that have utilized all soft tissue autograft or autograft. Our preferred surgical technique begins with an incision medial to the midline so that the resulting patellar tendon defect does not end up directly beneath the surgical incision. The peritoneum is incised sharply and metabalm scissors are used to extend the incision proximally and distantly. Great care is taken to preserve and dissect out the peritoneum layers for closure later on during the case. The desired tendon width is measured. The authors prefer to harvest one additional millimeter compared to the bone block in order to increase the amount of collagen in the graft. A double blade is used. An incision carried distantly, metabalm scissors are used to isolate the tendon and the incision is carried down sharply with a 15 blade. A 10 millimeter sagittal saw is used to harvest the tibial bone block. Cuts are made on the medial, lateral, and distal aspects creating the block and the cuts are finished with sharp osteotomes. Additional bone can be harvested from the tibia at this time for later bone grafting of the patella. Our attention is turned to the patella with the desired width that the bone block is measured and outlined with a knife. A 10 millimeter sagittal saw is used to create the cuts for the bone block. It is essential to minimize the amount of resection taken here in order to reduce the risk of patella fracture post-operative. The graft is then taken to the back table to be prepared. Metabalm scissors are used to remove any adipose tissue left on the tendon. A scissor can also be used to trim soft tissues around the bone blocks on both the febrile and tibial sides. The grafts are sized appropriately on the back table using the sizing block on both the femoral side and the tibial side. Ensuring proper sizing is critical to subsequent graft passage. The sagittal saw can be used to trim the bone block to reach appropriate size and aid in graft passage. K-wires are then used and taken to the tibial side of the bone block first, drilling three holes on the tibial bone block as shown. Two holes are then drilled with the K-wire on the femoral side. Fiber wire sutures are passed on a needle by hand through the bone block. These are then snapped and set aside. A Keith needle can be used to pass passing sutures through the tibial bone block as shown here. These are also snapped and set aside. At this point the graft is thoroughly examined and any additional adipose tissue or soft tissue remaining on the bone blocks are removed. The bone blocks are marked with a marking pen in order to aid in arthroscopic visualization when the graft is being passed later in the case. The graft is then taken through the sizing block once again in order to ensure that the graft will pass easily through the appropriately sized tunnels. At the end of the case the patellar defect can be bone grafted from what was harvested from the tibia and the defect closed with interrupted 0-micro figure A sutures. The patellar tendon is also closed in interrupted simple suture fashion running from proximal to distal as seen here. The peritoneum is closed as a separate layer with a running 3-O monocle. The subcutaneous tissue and skin are then closed afterwards. Kirtler et al. from the University of Colorado looked at a cohort of over 5,000 patients with ACL reconstruction performed with BTB autograft versus allograft and found improved patient-reported outcomes as well as clinical outcomes for autograft compared to allograft. In addition, they also found a three-fold increase in the re-rupture rates for allograft 12 versus 4%. Kane et al. out of Rothman looked at a BTB autograft versus allograft cohort for ACL reconstruction and minimal two-year follow-up and didn't find any difference in patient-reported outcome measures but found a significantly higher rate of revision for allograft compared to autograft. Rauch et al. out of the Hospital for Special Surgery examined a high school ethnic cohort of 53 patients with an average age of 16.6 years. They reported an ACL re-tear rate of 7.5% of 4 patients. 83% of their patients returned to their prior level of support at an average time of 10.5 months. Over 90% were very satisfied with their overall outcome. In conclusion, while BTB autograft remains the dependable gold standard for ACL reconstruction, it always comes down to a patient-centered, individualized approach when considering graft choice for ACL reconstruction. Learning and practicing a reproducible technique can help increase efficiency and avoid technical errors in the operating room.

ACL reconstruction

bone patellar tendon graft

surgical procedure

patient outcomes

autografts

BTB autograft

surgical technique

clinical outcomes

patient-specific