Bone-Tendon-Autograft Anterior Cruciate Ligament Reconstruction: A New Anterior Cruciate Ligament Graft Option

Abstract

The bone-tendon-bone (BTB) autograft is widely used for anterior cruciate ligament (ACL) reconstruction. However, the primary disadvantages of this technique include postoperative kneeling pain, the risk of perioperative patellar fracture, and graft-tunnel mismatch. Therefore, a single bone plug technique for ACL reconstructions was developed to mitigate the disadvantages of the BTB technique. To differentiate this graft, we have coined the term BTA, for bone-tendon-autograft. The middle third of the patellar tendon is used with a typical width of 10 to 11 mm. A standard tibial tubercle bone plug is harvested. The length of the patellar tendon and graft construct is then measured. If the tendon is >45 mm and the construct at least 70 mm, then we proceed with the BTA technique. At the inferior pole of the patella, electrocautery is used to harvest the tendon from the patella. The advantages of this technique include faster graft harvest and preparation. Obviating the patellar bone plug harvest should eliminate the risk of perioperative patellar fracture and theoretically will mitigate donor site morbidity and kneeling pain, 2 of the most commonly cited complications of the use of BTB autografts for ACL reconstruction. In conclusion, the BTA technique is a reliable technique for ACL reconstruction.

Fig 1

With the patient positioned supine, the knee is flexed to 90°. A midline incision is used from the inferior pole of the patella to the superior aspect of the tibial tubercle. The medial aspect of the knee is located on the left of the figure, with the lateral knee of the right of the figure. The head of the patient is at the top of the figure.

Fig 2

With the patient positioned supine, the knee is flexed to 90°. The paratenon is split and carefully reflected off of the underlying tendon. The middle third of the patellar tendon is used with a typical width of 10 to 11 mm. A full-thickness longitudinal incision of the patellar tendon is made from the inferior pole of the patella to the tibial tubercle. The medial aspect of the knee is located on the left of the figure with the lateral knee of the right of the figure. The head of the patient is at the top of the figure.

Fig 3

With the patient positioned supine, the knee is flexed to 90°. At the inferior pole of the patella, electrocautery is used to harvest the tendon. Electrocautery is used to elevate the tendon off of the patella in a subperiosteal fashion. Typically, an additional 5 to 10 mm of tendon can be obtained from the inferior pole. The proximal aspect of the patella is located on the right of the figure. Retractors are located within the medial and lateral skin flaps of the incision. The foot is at the left of the figure.

Fig 4

The tendinous end of the bone-tendon-autograft is prepared with a locking No. 2 FiberWire looped suture passed through the tendon. The bone plug is secured by passing a No. 2 FiberWire is then passed through 2 2.0-mm the drill holes. The cancellous portion of the bone plug is colored purple and the graft is placed on 15 to 20 pounds of tension.

Fig 5

Viewing from the anterolateral portal, the tibial footprint of the native anterior cruciate ligament is used for accurate placement of the tibial tunnel. The tibial tunnel location is established with a standard tibial guide. On the right of the figure is the LFC; the MFC is on the left of the screen and the anterior aspect of the tibia is at the inferior portion of the figure. (LFC, lateral femoral condyle; MFC, medial femoral condyle.)

Fig 6

Viewing from the anterolateral portal, after the guide pin has been placed in the accurate location and confirmed, the tibial tunnel is drilled. The guide pin position is verified using the remnant anterior cruciate ligament to ensure anatomic position of the tibial tunnel. On the right of the figure is the LFC; the MFC is on the left of the screen and the anterior aspect of the tibia is at the inferior portion of the figure. (LFC, lateral femoral condyle; MFC, medial femoral condyle.)

Fig 7

Viewing from the anterolateral portal, the knee is flexed to 90°, a Beath pin is placed through the medial portal into the femoral tunnel start point. On the right of the figure is the LFC; the MFC is on the left of the screen and the anterior aspect of the tibia is at the inferior portion of the figure. (LFC, lateral femoral condyle; MFC, medial femoral condyle.)

Fig 8

Viewing from the anterolateral portal, the knee is hyperflexed for interference screw fixation. A biocomposite or metal interference screw is used for femoral fixation. The graft is protected using an arthroscopic sled. The interference screw on the right of the figure is inserted into the femoral tunnel. (LFC, lateral femoral condyle; MFC, medial femoral condyle.)

Fig 9

Viewing from the anterolateral portal, tension is maintained on the graft, and a large curette used to provide downward pressure; a RetroScrew is secured into the tibia obtaining interference fixation against the tendinous portion of the graft. The screwdriver within the RetroScrew is inserted anterior to the BTA graft through the tibial tunnel. On the right of the figure is the BTA exiting the lateral femoral condyle. The anterior aspect of the tibia is at the inferior aspect of the figure. (BTA, bone-tendon-autograft; LFC, lateral femoral condyle; MFC, medial femoral condyle.)