Bone-Patella Tendon-Bone Autograft Anterior Cruciate Ligament Reconstruction

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The anterior cruciate ligament (ACL) serves an important stabilizing and biomechanical function for the knee. Reconstruction of the ACL remains one of the most commonly performed procedures in the field of sports medicine. Reconstruction of the ACL with bone-patella tendon-bone (BPTB) autograft secured with interference screw fixation has been the historical reference standard and remains the benchmark against which other methods are gauged. This article reviews the reconstruction of the ACL with BPTB autograft including the surgical technique, rationale for BTPB use, and outcomes.

Section snippets

Preoperative Evaluation

Assessment of the knee joint before surgical intervention is critical to perform a successful procedure and is vital for a good result. Poor outcomes are associated with poor range of motion, weak quadriceps function, and excessive swelling. Before surgical intervention it is important to obtain a history of previous surgery or trauma to determine the best reconstructive technique for each specific patient.

After the decision has been made to proceed with surgery, care should be taken to

Tunnel Placement

Proper placement and reaming of the tibial and femoral tunnels is paramount to achieve a graft that is isometric through a full range of motion and to control anterior translation and rotational stability of the knee. Recognition of pivot control as the main goal of ACL reconstruction and improved knowledge of the true anatomic insertion of the ACL on the femur has led to the placement of the femoral tunnel farther down the face of the intercondylar notch than previously described [3], [17].

Fixation

The primary advantage of BPTB graft has long been the ability to secure the graft with excellent initial strength and stiffness and the resultant bone-to-bone healing. Many methods of femoral fixation have been used over time, including extracortical suspensory systems, screw and washer constructs, and interference screws. Interference screw fixation has greater initial fixation strength than other fixation techniques and allows the desired bone-to-bone healing [1], [28], [29], [30]. Both metal

Rehabilitation

The first and most important step in rehabilitation of an ACL reconstruction is avoiding preoperative stiffness. Patients should be evaluated for range of motion at the time of the initial visit with particular attention paid to the ability to achieve full extension. Any concern by the physician regarding the patient's preoperative motion should be addressed by a referral to a physical therapist for aggressive therapy for knee range of motion and a repeat clinical evaluation before the surgery.

Complications

Despite the biomechanical strength and stiffness that this graft provides for ACL reconstruction, it can have complications. Most of the attention has focused on graft harvest morbidity. Kneeling pain is the one complaint that is unique to patella tendon reconstruction and frequently persists [1], [26], [47], [48], [49], [50], [51], [52]. It is important that the patients be informed of this possibility before surgical intervention. Patellofemoral pain (anterior knee pain) continues to be an

Outcomes

Rupture of the ACL leads to abnormal knee kinematics and predisposes the joint to degenerative changes. Activities that demand cutting, pivoting, and quick changes in direction can be difficult and lead to instability with a knee that is ACL deficient. Arthroscopically assisted ACL reconstruction facilitates early recovery and rehabilitation, allows an early return to preinjury activity, improves patient discomfort, and diminishes the chances of osteoarthritic changes in the knee. The ideal

Summary

Clearly, the controversy over the best graft choice for ACL reconstruction is not over. Additionally, despite the recent increase in the use of various soft tissue graft sources, BPTB autograft has not been displaced as the reconstruction graft option against which all others are measured. No choice of graft is ideal for all patients, and the modern surgeon should be skillful in using more than one type of graft to allow the surgeon and the patient the opportunity to make an educated decision

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