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. 2020 Dec 4;8(12):2325967120970224.
doi: 10.1177/2325967120970224. eCollection 2020 Dec.

Comparing Bone-Tendon Autograft With Bone-Tendon-Bone Autograft for ACL Reconstruction: A Matched-Cohort Analysis

Christian A Cruz  1 , Daniel Goldberg  2 , Jeffrey Wake  1 , Joshua Sy  1 , Brian J Mannino  1 , Kyong S Min  1 , Craig R Bottoni  1
Affiliations

Comparing Bone-Tendon Autograft With Bone-Tendon-Bone Autograft for ACL Reconstruction: A Matched-Cohort Analysis

Christian A Cruz et al. Orthop J Sports Med. .

Abstract

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) using bone-tendon-bone (BTB) autograft is associated with increased postoperative anterior knee pain and pain with kneeling and has the risk of intra- and postoperative patellar fracture. Additionally, graft-tunnel mismatch is problematic, often leading to inadequate osseous fixation. Given the disadvantages of BTB, an alternative is a bone-tendon autograft (BTA) procedure that has been developed at our institution. BTA is a patellar tendon autograft with the single bone plug taken from the tibia.

Purpose/hypothesis: The purpose of this study was to evaluate the short-term outcomes of BTA ACLR. We hypothesized that this procedure will provide noninferior failure rates and clinical outcomes when compared with a BTB autograft, as well as a lower incidence of anterior knee pain, pain with kneeling, and patellar fracture.

Methods: A consecutive series of 52 patients treated with BTA ACLR were retrospectively identified and compared with 50 age-matched patients who underwent BTB ACLR. The primary outcome was ACL graft failure, while secondary outcomes included subjective instability, anterior knee pain, kneeling pain, and functional outcome scores (Single Assessment Numeric Evaluation, Lysholm, and International Knee Documentation Committee subjective knee form).

Results: At a mean follow-up of 29.3 months after surgery, there were 2 reruptures in the BTA cohort (4.0%) and 2 in the BTB cohort (4.0%). In the BTA group, 18% of patients reported anterior knee pain versus 36% of the BTB group (P = .04). A total of 22% of patients noted pain or pressure with kneeling in the BTA cohort, as opposed to 48% in the BTB cohort (P = .006). There were no differences in functional scores. In the BTA group, 94.2% of patients reported that their knees subjectively felt stable, as compared with 86% in the BTB group (P = .18).

Conclusion: This study demonstrated that the BTA ACLR leads to similarly low rates of ACL graft failure requiring revision surgery, with significantly decreased anterior knee pain and kneeling pain when compared with a BTB. Additionally, the potential complications of graft-tunnel mismatch and patellar fracture are eliminated with the BTA ACLR technique.

Keywords: ACL; graft; knee; reconstruction.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: K.S.M. has received grant support from Arthrex and Zimmer Biomet and education payments from Smith & Nephew. C.R.B. has received education payments, consulting fees, and nonconsulting fees from Arthrex and honoraria from the Musculoskeletal Transplant Foundation. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
The paratenon is split and carefully reflected off 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.
Figure 2.
Figure 2.
At the inferior pole of the patella, electrocautery is used to harvest the tendon. Typically, an additional 5 to 10 mm of tendon can be obtained from the inferior pole.
Figure 3.
Figure 3.
A standard BTA graft. The tendinous end of the BTA graft is prepared with a locking-loop suture passed through the tendon. The bone plug is secured by passing a suture through two 2.0-mm drill holes. The cancellous portion of the bone plug is colored purple, and the graft is placed on 15 to 20 lb (7-9 kg) of tension. BTA, bone-tendon autograft.
Figure 4.
Figure 4.
While tension is maintained on the graft and a large curette is used to provide downward pressure, a RetroScrew is secured into the tibia, obtaining interference fixation against the tendinous portion of the graft.
Figure 5.
Figure 5.
Comparison of anterior knee pain and kneeling pain between bone-tendon autograft (BTA) and bone-tendon-bone (BTB) autograft. A significantly higher percentage of BTB patients reported anterior knee pain (P = .04) and kneeling pain (P = .006) compared with BTA patients. Error bars represent SE.
See this image and copyright information in PMC

References

    1. Almazán A, Miguel A, Odor A, Ibarra JC. Intraoperative incidents and complications in primary arthroscopic anterior cruciate ligament reconstruction. Arthroscopy. 2006;22(11):1211–1217. - PubMed
    1. Biau DJ, Katsahian S, Kartus J, et al. Patellar tendon versus hamstring tendon autografts for reconstructing the anterior cruciate ligament: a meta-analysis based on individual patient data. Am J Sports Med. 2009;37(12):2470–2478. - PubMed
    1. Brown JA, Brophy FH, Fanco J. Avoiding allograft length mismatch during anterior cruciate ligament reconstruction: patient height as an indicator of appropriate graft length. Am J Sports Med. 2007;35:986–989. - PubMed
    1. Fowler BL, Distefano VJ. Tibial tunnel bone grafting: a new technique for dealing with graft-tunnel mismatch in endoscopic anterior cruciate ligament reconstruction. Arthroscopy. 1998;14:224–228. - PubMed
    1. Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BR. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med. 2003;31(1):2–11. - PubMed

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