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Complications and Pitfalls in Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft

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Knee Surgery

Abstract

Bone—patellar tendon—bone autograft (BPTB) has served as the gold standard for anterior cruciate ligament (ACL) reconstruction. Although alternate graft options have recently gained popularity, BPTB autograft is by far the most common technique employed for ACL reconstruction.1 With an estimated 150,000 ACL reconstructions performed annually, this graft choice may account for up to 80% of all such procedures. With follow-up studies evaluating patients for up to 10 years, the complication profile of this technique has been well documented. While the overall serious complication rate is low, there are potential risks that the orthopedic surgeon must be cognizant of in order to minimize their occurrence and optimize patient outcome.

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References

  1. Garth WPJ. Current concepts regarding the anterior cruciate ligament. Orthop feu 1992; 21: 565–575.

    Google Scholar 

  2. Benson ER, Barnett PR. A delayed transverse avulsion fracture of the superior pole of the patella after anterior cruciate ligament reconstruction. Arthroscopy 1998; 14: 85–88.

    Article  PubMed  CAS  Google Scholar 

  3. Brownstein B, Bronner S. Patella fractures associated with accelerated ACL rehabilitation in patients with autogenous patella tendon reconstructions. J Orthop Sports Phys Ther 1997;26:.168–172.

    Google Scholar 

  4. Berg EE. Management of patella fractures associated with central third bone-patella tendon-bone autograft ACL reconstructions. Arthroscopy 1996; 12: 756–759.

    Article  PubMed  CAS  Google Scholar 

  5. Bonatus TJ, Alexander AH. Patellar fracture and avulsion of the patellar ligament complicating arthroscopic anterior cruciate ligament reconstruction. Orthop feu 1991; 20: 770–774.

    CAS  Google Scholar 

  6. Delzell PB, Schils JP, Recht MP. Subtle fractures about the knee: innocuous-appearing yet indicative of significant internal derangement. AJR 1996; 167: 699–703.

    PubMed  CAS  Google Scholar 

  7. Delee JC, Craviotto DF. Rupture of the quadriceps tendon after a central third patellar tendon anterior cruciate ligament reconstruction. Am J Sports Med 1991; 19: 415–416.

    Article  PubMed  CAS  Google Scholar 

  8. Daluga D, Johnson C, Bach BR, Jr. Primary bone grafting following graft procurement for anterior cruciate ligament insufficiency. Arthroscopy 1990; 6: 205–208.

    Article  PubMed  CAS  Google Scholar 

  9. Small NC. Complications in arthroscopic surgery of the knee and shoulder. Orthopedics 1993; 16: 985–988.

    PubMed  CAS  Google Scholar 

  10. Christen B, Jakob RP. Fractures associated with patellar ligament grafts in cruciate ligament surgery [see comments]. J Bone Joint Surg 1992; 74B: 617–619.

    CAS  Google Scholar 

  11. Graf B, Uhr F. Complications of intra-articular anterior cruciate reconstruction. Clin Sports Med 1988; 7: 835–848.

    PubMed  CAS  Google Scholar 

  12. Friis EA, Cooke FW, McQueen DA, Henning CE. Effect of bone block removal and patellar prosthesis on stresses in the human patella. Am J Sports Med 1994; 22: 696–701.

    Article  PubMed  CAS  Google Scholar 

  13. McCarroll JR, Shelbourne KD, Porter DA, Rettig AC, Murray S. Patellar tendon graft reconstruction for mid-substance anterior cruciate ligament rupture in junior high school athletes. An algorithm for management. Am J Sports Med 1994; 22: 478–484.

    Article  PubMed  CAS  Google Scholar 

  14. Blevins FT, Hecker AT, Bigler GT, Boland AL, Hayes WC. The effects of donor age and strain rate on the biomechanical properties of bone-patellar tendon-bone allografts. Am J Sports Med 1994; 22: 328–333.

    Article  PubMed  CAS  Google Scholar 

  15. Marumoto JM, Mitsunaga MM, Richardson AB, Medoff RJ, Mayfield GW. Late patellar tendon ruptures after removal of the central third for anterior cruciate ligament reconstruction. A report of two cases. Am J Sports Med 1996; 24: 698–701.

    Article  PubMed  CAS  Google Scholar 

  16. Wallenbock E. [Rupture of the patellar ligament-a late complication after removal of a bone-tendon-bone transplant as cruciate ligament replacement]. Langenbecks Arch Chir 1993; 378: 339–340.

    Article  PubMed  CAS  Google Scholar 

  17. Bonamo JJ, Krinick RM, Sporn AA. Rupture of the patellar ligament after use of its central third for anterior cruciate reconstruction. A report of two cases. J Bone Joint Surg 1984; 66A: 1294–1297.

    PubMed  CAS  Google Scholar 

  18. Langan P, Fontanetta AP. Rupture of the patellar tendon after use of its central third. Orthop Rev 1987; 16: 317–321.

    PubMed  CAS  Google Scholar 

  19. Daniel DM, Woodward EP, Loose G. The Marshall/MacIntosh anterior cruciate ligament reconstruction with the Kennedy ligament augmentation device: Report of the United States clinical trials. Philadelphia: WB Saunders Co, 1988.

    Google Scholar 

  20. Hardin GT, Bach BRJ. Distal rupture of the infrapatellar tendon after use of its central third for anterior cruciate ligament reconstruction. Am J Knee Surg 1992; 5: 140–143.

    Google Scholar 

  21. McMaster PE. Tendon and muscle ruptures: clinical and experimental studies on the causes and location of ruptures. J Bone Joint Surg 1933; 15A: 705–722.

    Google Scholar 

  22. Burks RT, Haut RC, Lancaster RL. Biomechanical and histological observations of the dog patellar tendon after removal of its central one-third. Am J Sports Med 1990; 18: 146–153.

    Article  PubMed  CAS  Google Scholar 

  23. Kamps BS, Linder LH, DeCamp CE, Haut RC. The influence of immobilization versus exercise on scar formation in the rabbit patellar tendon after excision of the central third. Am J Sports Med 1994; 22: 803–811.

    Article  PubMed  CAS  Google Scholar 

  24. Jackson DW, Grood ES, Goldstein JD, et al. A comparison of patellar tendon autograft and allograft used for anterior cruciate ligament reconstruction in the goat model. Am J Sports Med 1993; 21: 176–185.

    Article  PubMed  CAS  Google Scholar 

  25. O’Brien SJ, Warren RF, Pavlov H, Panariello R, Wickiewicz TL. Reconstruction of the chronically insufficient anterior cruciate ligament with the central third of the patellar ligament. J Bone Joint Surg 1991; 73A: 278–286.

    PubMed  Google Scholar 

  26. Paulos LE, Rosenberg TD, Drawbert J, Manning J, Abbott P. Infrapatellar contracture syndrome. An unrecognized cause of knee stiffness with patella entrapment and patella infera. Am J Sports Med 1987; 15: 331–341.

    Article  PubMed  CAS  Google Scholar 

  27. van Eijden TM, Kouwenhoven E, Weijs WA. Mechanics of the patellar articulation. Effects of patellar ligament length studied with a mathematical model. Acta Orthop Scand 1987; 58: 560–566.

    Article  PubMed  Google Scholar 

  28. Brandsson S, Faxen E, Eriksson BI, Kalebo P, et al. Closing patellar tendon defects after anterior cruciate ligament reconstruction: absence of any benefit. Knee Surg Sports Traumatol Arthrosc 1998; 6: 82–87.

    Article  PubMed  CAS  Google Scholar 

  29. Cooper DE, Arnoczky SP, Warren RF. Contaminated patellar tendon grafts: incidence of positive cultures and efficacy of an antibiotic solution soak-an in vitro study. Arthroscopy 1991; 7: 272–274.

    Article  PubMed  CAS  Google Scholar 

  30. Malek MM, Kunkle KL, Knable KR. Intraoperative complications of arthroscopically assisted ACL reconstruction using patellar tendon autograft. Instr Course Lect 1996; 45: 297–302.

    PubMed  CAS  Google Scholar 

  31. Berg EE. Lateral femoral condyle fracture after endoscopic anterior cruciate ligament reconstruction. Arthroscopy 1994; 10: 693–695.

    Article  PubMed  CAS  Google Scholar 

  32. Berg EE. Autograft bone-patella tendon-bone plug comminution with loss of ligament fixation and stability [see comments]. Arthroscopy 1996; 12: 232–235.

    Article  PubMed  CAS  Google Scholar 

  33. Matthews LS, Soffer SR. Pitfalls in the use of interference screws for anterior cruciate ligament reconstruction: brief report. Arthroscopy 1989; 5: 225–226.

    Article  PubMed  CAS  Google Scholar 

  34. Butler JC, Branch TP, Hutton WC. Optimal graft fixation-the effect of gap size and screw size on bone plug fixation in ACL reconstruction. Arthroscopy 1994; 10: 524–529.

    Article  PubMed  CAS  Google Scholar 

  35. Lemos MJ, Albert J, Simon T, Jackson DW. Radiographic analysis of femoral interference screw placement during ACL reconstruction: endoscopic versus open technique. Arthroscopy 1993; 9: 154–158.

    Article  PubMed  CAS  Google Scholar 

  36. Lemos MJ, Jackson DW, Lee TQ, Simon TM. Assessment of initial fixation of endoscopic interference femoral screws with divergent and parallel placement. Arthroscopy 1995; 11: 37–41.

    Article  PubMed  CAS  Google Scholar 

  37. Jomha NM, Raso VJ, Leung P. Effect of varying angles on the pullout strength of interference screw fixation. Arthroscopy 1993; 9: 580–583.

    Article  PubMed  CAS  Google Scholar 

  38. Jackson DW, Jennings LD. Arthroscopically assisted reconstruction of the anterior cruciate ligament using a patella tendon bone autograft. Clin Sports Med 1988; 7: 785–800.

    PubMed  CAS  Google Scholar 

  39. Ray JM. A proposed natural history of symptomatic anterior cruciate ligament injuries of the knee. Clin Sports Med 1988; 7: 697–713.

    PubMed  CAS  Google Scholar 

  40. Wainer RA, Clarke TJ, Poehling GG. Arthroscopic reconstruction of the anterior cruciate ligament using allograft tendon. Arthroscopy 1988; 4: 199–205.

    Article  PubMed  CAS  Google Scholar 

  41. Clancy WG, Jr., Nelson DA, Reider B, Narechania RG. Anterior cruciate ligament reconstruction using one-third of the patellar ligament, augmented by extra-articular tendon transfers. J Bone Joint Surg 1982; 64A: 352–359.

    PubMed  Google Scholar 

  42. Rubinstein RA, Jr., Shelbourne KD, VanMeter CD, Mc-Carroll JC, Rettig AC. Isolated autogenous bone-patellar tendon-bone graft site morbidity. Am J Sports Med 1994; 22: 324–327.

    Article  PubMed  Google Scholar 

  43. Arendt EA, Hunter RE, Schneider WT. Vascularized patella tendon anterior cruciate ligament reconstruction. Clin Orthop 1989; 222–232.

    Google Scholar 

  44. Kaplan N, Wickiewicz TL, Warren RF. Primary surgical treatment of anterior cruciate ligament ruptures. A longterm follow-up study. Am J Sports Med 1990; 18: 354–358.

    Article  PubMed  CAS  Google Scholar 

  45. Aglietti P, Insall JN, Cerulli G. Patellar pain and incongruence. I: Measurements of incongruence. Clin Orthop 1983; 176: 217–224.

    PubMed  Google Scholar 

  46. Insall JN, Aglietti P, Tria AJJ. Patellar pain and incongruence. II: Clinical application. Clin Orthop. 1983; 176: 225–232.

    PubMed  Google Scholar 

  47. Laurin CA, Dussault R, Levesque HP. The tangential x-ray investigation of the patellofemoral joint: x-ray technique, diagnostic criteria and their interpretation. Clin Orthop 1979; 144: 16–26.

    PubMed  Google Scholar 

  48. Aglietti P, Buzzi R, D’Andria S, Zaccherotti G. Patellofemoral problems after intraarticular anterior cruciate ligament reconstruction. Clin Orthop 1993; 288: 195–204.

    PubMed  Google Scholar 

  49. Shelbourne KD, Gray T. Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two-to nine-year followup. Am J Sports Med 1997; 25: 786–795.

    Article  PubMed  CAS  Google Scholar 

  50. Shelbourne KD, Patel DV. Prevention of complications after autogenous bone-patellar tendon-bone ACL reconstruction. Instr Course Lect 1996; 45: 253–262.

    PubMed  CAS  Google Scholar 

  51. Shelbourne KD, Wilckens JH, Mollabashy A, DeCarlo M. Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation. Am J Sports Med 1991; 19: 332–336.

    Article  PubMed  CAS  Google Scholar 

  52. Wasilewski SA, Covall DJ, Cohen S. Effect of surgical timing on recovery and associated injuries after anterior cruciate ligament reconstruction. Am J Sports Med 1993; 21: 338–342.

    Article  PubMed  CAS  Google Scholar 

  53. Fisher SE, Shelbourne KD. Arthroscopic treatment of symptomatic extension block complicating anterior cruciate ligament reconstruction. Am J Sports Med 1993; 21: 558–564.

    Article  PubMed  CAS  Google Scholar 

  54. Cosgarea AJ, DeHaven KE, Lovelock JE. The surgical treatment of arthrofibrosis of the knee. Am J Sports Med 1994; 22: 184–191.

    Article  PubMed  CAS  Google Scholar 

  55. Cosgarea AJ, Sebastianelli WJ, DeHaven KE. Prevention of arthrofibrosis after anterior cruciate ligament reconstruction using the central third patellar tendon autograft. Am J Sports Med 1995; 23: 87–92.

    Article  PubMed  CAS  Google Scholar 

  56. Aglietti P, Buzzi R, D’Andria S, Zaccherotti G. Long-term study of anterior cruciate ligament reconstruction for chronic instability using the central one-third patellar tendon and a lateral extraarticular tenodesis. Am J Sports Med 1992; 20: 38–45.

    Article  PubMed  CAS  Google Scholar 

  57. Engebretsen L, Benum P, Fasting O, Moister A, Strand T. A prospective, randomized study of three surgical techniques for treatment of acute ruptures of the anterior cruciate ligament. Am J Sports Med 1990; 18: 585–590.

    Article  PubMed  CAS  Google Scholar 

  58. Sachs RA, Daniel DM, Stone ML, Garfein RF. Patellofemoral problems after anterior cruciate ligament reconstruction. Am J Sports Med 1989; 17: 760–765.

    Article  PubMed  CAS  Google Scholar 

  59. Mohtadi NG, Webster-Bogaert S, Fowler PJ. Limitation of motion following anterior cruciate ligament reconstruction. A case-control study. Am J Sports Med 1991; 19: 620–624.

    Article  PubMed  CAS  Google Scholar 

  60. Dodds JA, Keene JS, Graf BK, Lange RH. Results of knee manipulations after anterior cruciate ligament reconstructions. Am J Sports Med 1991; 19: 283–287.

    Article  PubMed  CAS  Google Scholar 

  61. Meyers JF, St.Pierre RK, Sutter JS, Caspari RB, Whipple TL. Arthroscopic evaluation of anterior cruciate ligament reconstructions. Arthroscopy 1986; 2: 155–161.

    Article  PubMed  CAS  Google Scholar 

  62. Jackson DW, Schaefer RK. Cyclops syndrome: loss of extension following intra-articular anterior cruciate ligament reconstruction. Arthroscopy 1990; 6: 171–178.

    Article  PubMed  CAS  Google Scholar 

  63. Marder RA, Raskind JR, Carroll M. Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstruction. Patellar tendon versus semitendinosus and gracilis tendons. Am J Sports Med 1991; 19: 478–484.

    Article  PubMed  CAS  Google Scholar 

  64. Rosenberg TD, Franklin JL, Baldwin GN, Nelson KA. Extensor mechanism function after patellar tendon graft harvest for anterior cruciate ligament reconstruction. Am J Sports Med 1992; 20: 519–525.

    Article  PubMed  CAS  Google Scholar 

  65. Yasuda K, Ohkoshi Y, Tanabe Y, Kaneda K. Quantitative evaluation of knee instability and muscle strength after anterior cruciate ligament reconstruction using patellar and quadriceps tendon. Am J Sports Med 1992; 20: 471–475.

    Article  PubMed  CAS  Google Scholar 

  66. Tibone JE, Antich TJ. A biomechanical analysis of anterior cruciate ligament reconstruction with the patellar tendon. A two year followup [see comments]. Am J Sports Med 1988; 16: 332–335.

    Article  PubMed  CAS  Google Scholar 

  67. Gerber C, Hoppeler H, Claassen H, Robotti G, Zehnder R, Jakob RP. The lower-extremity musculature in chronic symptomatic instability of the anterior cruciate ligament. J Bone Joint Surg 1985; 67A: 1034–1043.

    PubMed  CAS  Google Scholar 

  68. Seto JL, Orofino AS, Morrissey MC, Medeiros JM, Mason WJ. Assessment of quadriceps/hamstring strength, knee ligament stability, functional and sports activity levels five years after anterior cruciate ligament reconstruction. Am J Sports Med 1988; 16: 170–180.

    Article  PubMed  CAS  Google Scholar 

  69. Shelbourne KD, Rubinstein RAJ, VanMeter CD, McCarroll JR, Rettig AC. Correlation of remaining patellar tendon width with quadriceps strength after autogenous bone-patellar tendon-bone anterior cruciate ligament reconstruction. Am J Sports Med 1994; 22: 774–777.

    Article  PubMed  CAS  Google Scholar 

  70. Lephart SM, Kocher MS, Harner CD, Fu FH. Quadriceps strength and functional capacity after anterior cruciate ligament reconstruction. Patellar tendon autograft versus allograft. Am J Sports Med 1993; 21: 738–743.

    Article  PubMed  CAS  Google Scholar 

  71. Stringham DR, Pelmas CJ, Burks RT, Newman AP, Marcus RL. Comparison of anterior cruciate ligament reconstructions using patellar tendon autograft or allograft. Arthroscopy 1996; 12: 414–421.

    Article  PubMed  CAS  Google Scholar 

  72. Saddemi SR, Frogameni AD, Fenton PJ, Hartman J, Hartman W. Comparison of perioperative morbidity of anterior cruciate ligament autografts versus allografts. Arthroscopy 1993; 9: 519–524.

    Article  PubMed  CAS  Google Scholar 

  73. Clatworthy, M. G Annear P, Blow J-U, and Bartlett RJ. Isokinetic muscle strength following ACL reconstruction: Hamstrings vs patella tendon grafts. 1998. ( GENERIC) (Unpublished Work )

    Google Scholar 

  74. Wojtys EM, Huston U. Neuromuscular performance in normal and anterior cruciate ligament-deficient lower extremities. Am J Sports Med 1994; 22: 89–104.

    Article  PubMed  CAS  Google Scholar 

  75. Lorentzon R, Elmqvist LG, Sjostrom M, Fagerlund M, Fuglmeyer AR. Thigh musculature in relation to chronic anterior cruciate ligament tear: muscle size, morphology, and mechanical output before reconstruction. Am J Sports Med 1989; 17: 423–429.

    Article  PubMed  CAS  Google Scholar 

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Higgins, L.D., Clatworthy, M., Harner, C.D. (2001). Complications and Pitfalls in Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft. In: Malek, M.M. (eds) Knee Surgery. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-87202-0_9

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  • DOI: https://doi.org/10.1007/978-3-642-87202-0_9

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