Abstract
Anterior cruciate ligament reconstruction using a bone–patellar tendon–bone autograft is widely regarded as the graft of choice for many sports medicine surgeons for young, active patients with anterior cruciate ligament injuries. It is favored for use in athletes because of its high return-to-play rates and low re-rupture rates. Despite its benefits, there are many pitfalls in the surgical technique, and the use of a careful surgical technique can avoid them. This article describes our preferred technique.
Technique Video
The bone–patellar tendon–bone (BPTB) autograft technique has become the most widely adopted approach for anterior cruciate ligament reconstruction (ACLR) and is now considered by many surgeons to be the gold standard.1,2 The principal limitations associated with using BPTB autografts in ACLR include the risk of donor-site morbidity, particularly perioperative patellar fractures and postoperative pain when kneeling.1,3 Anatomical variations in patellar tendon length can cause graft-tunnel mismatch, presenting challenges in securing adequate tibial fixation. These concerns can affect patient comfort and recovery outcomes and can be obviated or minimized by a meticulous surgical technique.1,3 The purpose of this Technical Note and the accompanying video is to highlight the key steps to maximize the chances for a successful outcome and to minimize the risk of intra- and postoperative complications.
Surgical Technique
We describe the senior author’s preferred surgical technique for ACLR using a BPTB autograft with an inside-out, medial portal femoral drilling technique with femoral and tibial fixation using cannulated interference screw fixation, as outlined in Video 1.
Patient Positioning and Preparation for Surgery
The procedure is performed with the patient under general anesthesia and in a supine position. Prior to graft harvest, the affected knee undergoes a thorough examination under anesthesia. We prefer to harvest the graft first if the examination under anesthesia confirms the diagnosis. In cases in where diagnostic uncertainty remains, a diagnostic arthroscopy may be performed prior to graft harvest. The operative leg is then prepared and draped. An Esmarch bandage is wrapped tightly around the limb from distal to proximal to exsanguinate it before inflating the pneumatic tourniquet to 250 mm Hg.
Graft Harvest and Preparation
The knee is fully extended. The anatomical landmarks are palpated, including the patellar tendon, poles, and the tibial tuberosity. The incision is marked longitudinally beginning at the inferior pole of the patella and extending to about 1 to 2 cm distal to the tibial tubercle (Fig 1). The midportion of the patella should be reached with the incision. The incision is created using a No. 10 blade scalpel and is taken sharply to the level of the patellar tendon peritenon. It should be made slightly medial to better facilitate access for tibial tunnel drilling requiring additional extension of the incision. The peritenon is elevated and preserved. Small skin flaps are created to properly visualize the medial and lateral borders of the patellar tendon. The width of the tendon is measured and the central third is harvested for a 10-mm graft. The tendon is incised sharply using a No. 10 blade scalpel. We prefer to harvest the tibial bone plug first so the patella can be pulled into the incision to be harvested next. The periosteum is incised over the tibial tubercle to 28 mm length using electrocautery. A rectangular tibial tubercle bone plug is excised using a 10-mm oscillating saw. A 6-mm blade is used at the distal aspect. The central inferior patella is marked for a 22-mm-long bone plug. The oscillating saw is angled at roughly 45° in a trapezoidal orientation to avoid intra-articular penetration (Fig 2). The proximal cut is completed with a small 6-mm saw to avoid overcutting stress risers. Care is taken to avoid excessively impacting the patella. The patellar bone block is freed and the graft is given to the surgical assistant to be prepared at the back table.
Fig 1.
The patient is positioned supine and the operative left knee is placed fully extended after being prepared and draped. A pneumatic tourniquet is placed on the left thigh and is inflated to 250 mm Hg. The planned incision to harvest the bone–patellar tendon–bone autograft is marked from the inferior pole of the patella to the superior aspect of the tibial tubercle.
Fig 2.
Harvesting the bone–patellar tendon–bone autograft for anterior cruciate ligament reconstruction with the patient in a supine position and the left operative knee fully extended. (A) Measurement of the graft width of 10 mm before graft incision. (B) The sides of the tibial bone plug are cut with a 10-mm scalpel and the lateral/medial sides with a 10-mm oscillating saw. A 6-mm small blade is then used at the distal aspect. (C) While harvesting the patellar bone plug, the 10-mm oscillating saw should be angled at roughly 45° in a trapezoidal orientation to avoid intra-articular penetration. (D) Shown is the trapezoidal shape of the patellar bone plug. (E) Shown is the square shape of the tibial bone plug.
Graft Preparation
Autograft preparation begins by gently removing any adherent fat pad from the deep side of the patellar tendon segment. The bone plug is then contoured to approximately 10 mm in diameter using a rongeur and a 10-mm sizing tube. The lengths are 22 and 28 mm for the patellar and tibial bone plugs, respectively. A patellar bone plug longer than 22 mm can be difficult to pass intra-articularly across the knee when using a medial portal technique. In small knees, a shorter 20-mm plug may even be desirable. Afterwards, two 2.0-mm holes are drilled through the cortical portion of the tibial and femoral bone plugs. Two No. 2 strong sutures (FiberWire, Arthrex, Naples, FL) are then passed through each of these drill holes in the patella and two No. 5 ETHIBOND (Ethicon, Raritan, NJ) sutures are passed through the 2 holes in the tibial bone plug (Fig 3). The “desired side” for screw insertion on the patella bone plug—which is the side that will face anterior when the bone plug is inserted in the femur such that the patella tendon is placed low and lateral—is marked. The “safe sides” for screw insertion (sides away from the sutures) of the tibial bone plug are also marked.
Fig 3.
Measurement the bone–patellar tendon–bone (BPTB) autograft after being prepared and contoured by the assistant on the back table. (A) BPTB autograft measuring at 10+ cm in length. (B) Two 2.0-mm holes are drilled through the cortical portion of the tibial and femoral bone plug. Two No. 2 permanent suture (FiberWire; Arthrex, Naples, FL) and two No. 5 ETHIBOND (Ethicon, Raritan, NJ) are passed through each of the drill holes in the patella and tibial bone plugs, respectively.
Portal Placement and Femoral Tunnel Preparation
The lateral portal is created within the harvest site lateral to the patella tendon. The medial portal is placed just medial to the fat pad and angled from inferior to superior, entering just above the medial meniscus to allow for optimal femoral screw placement. Portal positioning is confirmed with a spinal needle. A diagnostic arthroscopy is then performed, and any concomitant injuries are addressed at this time.
The remnant ACL is debrided using a shaver (Arthrex). The backwall of the lateral femoral condyle is cleared. A notchplasty is typically performed. An open pituitary rongeur (Millennium Surgical Corp., Bala Cynwyd, PA) measuring 15 mm in width is used intra-articularly to confirm adequate width of the intercondylar notch. If it cannot be completely opened in the notch, an additional notchplasty should be performed.
The desired center of the femoral tunnel is marked at the lateral femoral condyle using 45° microfracture awl. The goal is to have 1 to 2 mm of a proximal/posterior backwall and to have approximately a 10:30-o’clock position (1:30 for the left knee) of entry. A 70° scope is then introduced from the lateral portal and again the desired femoral tunnel position is confirmed. A Beath pin (Arthrex) is placed using a 6-mm over-the-top guide (Arthrex) into the desired center of the femoral tunnel, as the knee is carefully hyperflexed by an assistant. The Beath pin is drilled through the femur and out of the lateral skin of the knee. The femoral tunnel is created using a 10-mm low-profile reamer. The reamer is carefully inserted by hand and is oriented away from the medical femoral condyle. The femoral tunnel is then created. The length of the tunnel is typically 25 mm to accommodate the 22-mm patella bone plug. If the graft is long (>90-100 mm), a longer femoral tunnel can be used recess the graft and help decrease the risk of graft tunnel mismatch at the tibia. Tunnel position and backwall preservation are confirmed under direct vision and all bone debris should be removed so graft insertion is not hindered. A No. 5 ETHIBOND suture (Ethicon) is then shuttled through the tunnel using the Beath pin. The anterior aspect of the tunnel is notched using curette as a reference and to aid in starting the interference screw.
Tibial Tunnel Preparation
The desired tibial tunnel site is identified in the central portion of the ACL remnant and on the downslope of the medial tibial spine. The desired length of the tibial tunnel is calculated as the total graft length minus the patellar bone plug (22 mm) and intra-articular graft length (typically 20-25 mm). In the presented case, the desired tibial tunnel length is 50 mm (graft length of 97 mm minus 47 mm (25 mm intra-articular graft + 22 patella plug = 50 mm). The tibial drill guide (Smith & Nephew, Andover, MA) is placed and the desired length of the tunnel is set on the bullet insert which is then placed firmly on the anterior tibia.
The tibial drill guide is then placed at the desired location on the downslope of the medial tibial spine just in line with the midportion of the anterior horn of the lateral meniscus, and approximately 12 mm anterior to the posterior cruciate ligament (Fig 4). A breakaway guide pin is then drilled. The pin is clamped with a Kocher clamp to protect the condyles. The tibial tunnel is then created using a solid 10-mm reamer with a matched sizing guide as a soft tissue protector. Bone debris from drilling is collected to use as a graft for the patella harvest site. Russian forceps and a sterile cup are used in combination to collect the reamings. A chamfer reamer is then used on posterior intra-articular aperture of the tibial tunnel to ensure smooth edges. The ETHIBOND shuttling suture is then retrieved through the tibial tunnel.
Fig 4.
Patient lying supine with the left knee flexed down the operating table. Positioning of the tibial tunnel for the anterior cruciate ligament using a tibial guide hook (green square) at the anatomic tibial footprint via the anteromedial portal. Arthroscopic vision is established through the lateral portal. (A and B) The tibial drill guide is placed at the desired location on the downslope of the medial tibial spine in line with the midportion of the anterior horn of the lateral meniscus and approximately 12 mm anterior to the posterior cruciate ligament. (C-D) The tibial guide is held firmly and a breakaway guide pin is drilled. Violet star: Lateral meniscus. (MTS, medial tibial spine.)
Graft insertion and Interference Screw Fixation
The graft is then passed with the patellar bone plug into the femoral tunnel (blue sutures go towards the sky, green towards the ground). The knee should be in a hyperflexed position while passing the graft and inserting the femoral interference screw (Fig 5). We prefer to view through the lateral portal and use a pituitary rongeur from the medial portal to manipulate the patellar bone plug into the femoral tunnel. Care should be taken to avoid fully seating the bone plug so the guidewire for the cannulated screw can be placed. The guidewire is placed anterosuperior in the tunnel to ensure that the screw will be anterior and parallel to the bone plug. It should not be fully inserted before the bone plug is aligned because the wire can prevent the bone plug from fully seating. The bone plug and graft can then be fully seated in the femoral tunnel. With the knee in hyperflexion, a cannulated interference screw (Cannulated Interference, Full Thread; Arthrex) is then placed over the wire and inserted through the medial portal. While the screw is inserted, the graft is carefully protected using a plastic sheath (Fig 6). Typically, a 7 × 20-mm screw is used. The knee is fully extended to test for graft impingement, and the knee is cycled to remove graft creep. The arthroscope is then removed.
Fig 5.
Patellar bone plug (violet star) insertion into the femoral tunnel for anterior cruciate ligament reconstruction. The patient is lying supine with the left knee flexed down the operating table. Arthroscopic vision is established through the lateral portal. (A) Before insertion, the graft is oriented anteriorly with the markings of the bone plugs with the patellar bone plug and FiberWire fixation to the femoral side and the tibial bone plug with the ETHIBOND suture to the tibial side “blue sutures go toward the sky, green toward the ground.” (B) The graft is carefully pulled intra-articularly by the assistant under arthroscopic vision. (C) A pituitary rongeur is used to orient the graft appropriately while entering the femoral tunnel. (LFC, lateral femoral condyle.)
Fig 6.
Patellar bone plug seating and fixation in the femoral tunnel for anterior cruciate ligament reconstruction using a bone-patellar tendon-bone autograft. The patient is lying supine with the left knee hyperflexed down the operating table. Arthroscopic vision is shown through the lateral portal. (A) The guidewire for interference screw is then placed anterosuperior in the femoral tunnel while inserting the femoral bone plug. It should not be fully inserted before the bone plug is aligned because it can prevent the bone plug from fully seating. (B) A cannulated interference screw (Cannulated Interference, Full Thread; Arthrex, Naples, FL) is placed over the wire while the graft is carefully protected using a plastic sheath. This is typically a 7 × 20 mm screw. Violet star: interference screw. Green square: patellar bone plug. (LFC, lateral femoral condyle.)
The knee is positioned in approximately 20° of flexion with a posterior drawer. The guidewire for the tibial interference screw is then placed proximally and medially, with care taken to identify the “safe sides” of the tibial bone plug to avoid inadvertently cutting the green tensioning sutures (Fig 7). A cannulated interference screw (Cannulated Interference, Full Thread; Arthrex) is inserted over the wire while the surgical assistant maintains tension on the graft and a posterior drawer. This is typically an 8 × 25-mm screw. The screw is placed in a parallel orientation to the tibial bone plug and tibial tunnel. Figure 8 illustrates the final reconstruction fixated with interference screws.
Fig 7.
Tibial tunnel fixation of the bone plug for bone−patellar tendon−bone autograft for anterior cruciate ligament reconstruction using an interference screw. The patient is lying supine with the left knee placed in approximately 20° of flexion with a posterior drawer. (A) The guidewire for the tibial interference screw is then placed proximal and medial. (B) A cannulated interference screw (Cannulated Interference, Full Thread, Arthrex, Naples, FL) is placed over the wire and brought in with the surgical assistant holding tension on the graft and a posterior drawer. (C) Final position after insertion of the interference screw.
Fig 8.
Radiographs of the left knee after anterior cruciate ligament reconstruction using a bone−patellar tendon−bone autograft on the first postoperative day showing appropriate positions of the femoral and tibial interference screws on anteroposterior (A) and lateral (B) views.
Closure
The wounds are irrigated, and the medial periosteum is closed over the tibial tunnel using No. 1 VICRYL suture in a figure-of-eight configuration. The patellar tendon is closed with No. 1 VICRYL while the knee is held in flexion to avoid creating patella baja. Bone from the tibial tunnel reamings is placed into the patellar harvest site. The peritenon is closed over the patella and patellar tendon also using a No. 1 VICRYL in running configuration to the level of the tibial tubercle harvest site, where the remaining autograft bone from the graft preparation is placed. The peritenon is then completely closed. Sutures from the femoral tunnel are cut and removed. The subcuticular tissues and skin are closed in layered fashion. The medial portal is closed using a buried 3-0 MONOCRYL suture. The knee is injected with platelet-rich plasma, the skin and harvest site are injected with liposomal bupivacaine local anesthetic. The incisions are dressed, and a hinged knee brace is applied.
Postoperative Rehabilitation Protocol
Postoperative rehabilitation begins with a hinged knee brace, allowing full weight-bearing and free range-of-motion exercises. Early rehabilitation focuses on maintaining full extension and performing quadriceps activation exercises. The knee brace is locked until good quadriceps control and terminal knee extension is achieved, after which it is used for ambulation, with a total duration of 6 weeks postoperatively. Gradual strengthening begins 3 weeks postoperatively. Running may be started 13 weeks postoperatively. Return to sport (RTS) is allowed at 4 months for nonpivoting sport and at least 6 months for pivoting sport after passing strength tests.4
Discussion
The ACLR procedure using BPTB autograft is a reliable and efficient method with high levels of satisfaction and functional outcomes on long-term follow-up.5 Studies have reported its superior rotational stability and lower rates of failure compared with hamstring tendon autografts.6 Several studies have demonstrated that BPTB autografts are associated with a higher and earlier RTS compared to hamstring tendon autografts. A study by Gupta et al.7 reported that 74.1% of athletes who underwent ACLR with a BPTB graft returned to sports compared with 53.4% for those with hamstring tendon grafts. Tomihara et al. 8 found that 74.6% of high-level athletes returned to their preinjury levels of performance with BPTB grafts compared with 53.5% with hamstring tendon grafts. The RTS rate is also generally greater or comparable with that using a quadriceps tendon autograft, with some studies indicating slightly better outcomes for BPTB in terms of RTS.1,2,5 Advantages and disadvantages of the technique are outlined in Table 1.
Table 1.
Advantages and Disadvantages of Using a Bone–Patellar Tendon–Bone Autograft While Performing an Anterior Cruciate Ligament Reconstruction
| Advantages | Disadvantages |
|---|---|
| Ease of technique reproducibility Fast bone-to-bone healing Precise tendon autograft size Low re-rupture rate and high return to sport rate No risk of disease transmission Less cost |
Risk of donor-site morbidity Risk of patellar fracture Potential graft-tunnel mismatch Potential knee extensor mechanism disruption |
Despite offering a low-cost alternative to ACL using an allograft, the incidence of anterior knee pain is a concern in this technique and can be attributed to several factors, including donor-site morbidity, patellar tendonitis, and sensory disturbances due to injury to the infrapatellar branch of the saphenous nerve during graft harvest.9 Careful dissection to avoid injury to the infrapatellar branch of the saphenous nerve and refilling the patellar bony defect with bone graft from the tunnels as demonstrated in the present technique has been shown to significantly reduce the prevalence and severity of anterior knee pain.10
Graft tunnel mismatch is uncommon during BPTB autograft ACLR when care is taken, as described in this Technical Note, to appropriately match the tibial and femoral tunnels to the length of the graft.11 Avoiding this issue begins preoperatively by measuring the patellar tendon and planning tunnel lengths. Boddu et al.12 describe a method to calculate the ideal length of bone plugs required to avoid graft tunnel mismatch during anatomical ACLR using a far medial portal technique. In cases in which graft tunnel mismatch is anticipated, alternative graft choices may be considered.13 If graft tunnel mismatch is identified intraoperatively after harvesting the autograft, for minor mismatches (5-10 mm), the femoral bone plug can be recessed. A cortical suspensory device or outside-in fixation could be used.14 Experienced surgeons also could use a transtibial femoral drilling technique with lower tibial tunnel angulation to make a longer tibial tunnel to reduce the incidence of graft tunnel mismatch, but this can limit the femoral tunnel orientation. If graft tunnel mismatch does occur, the senior author prefers to push the tibial plug into the tibial tunnel and then create a trough in the anterior tibia. The graft is then tensioned. A bioabsorbable screw (usually 9 or 10 mm) is inserted into the tibial tunnel and a size large Richard’s staple (Smith & Nephew) is used to secure the bone plug into tibia, tying the No. 5 ETHIBOND sutures over the staple. Pearls and pitfalls of the technique are outlined in Table 2.
Table 2.
Pearls and pitfalls of Using a Bone–Patellar Tendon–Bone Autograft While Performing an Anterior Cruciate Ligament Reconstruction
| Pearls | Pitfalls |
|---|---|
| Evaluate the patellar tendon length preoperatively and carefully harvest the graft and bone plugs with precise measurements. Meticulous dissection around the patellar tendon is crucial to avoid damage the infrapatellar branch of the saphenous nerve and to minimize sensory disturbances. A notchplasty should be performed and the space evaluated with an opened pituitary rongeur to confirm adequate width. An additional notchplasty should be performed as needed. The femoral tunnel should be oriented at approximately the 10:30-clock face position for the right knee (1:30 for the left knee) to ensure it overlaps both the anteromedial and posterolateral bundle origins. The length of the tunnel is typically 25 mm to accommodate the patellar bone plug. If the graft is long (>100 mm), a longer femoral tunnel can be used recess the graft and help decrease the risk of graft tunnel mismatch at the tibia. The knee should be in a hyperflexed position while passing the graft and inserting the femoral interference screw after the guidewire is placed anteriorly. Place the knee in 20° of flexion with a posterior drawer for tibial interference screw insertion. The guidewire is then placed proximal and medial identifying the “safe sides” of the tibial bone plug to avoid inadvertently cutting the green tensioning sutures. Maintain appropriate tension on the graft during screw fixation. |
Posterior position of the interference screw can lead to inadequate fixation Disengagement of the interference screw from the screw driver can lead to inadequate fixation and intra-articular screw prominence. Do not pull on the screwdriver to avoid disengagement. Large mismatches that do not adequately recess through the femoral tunnel can occur. Use a transtibial femoral drilling technique with lower tibial tunnel angulation to make a longer tibial tunnel. If graft tunnel mismatch persists, push the tibial plug into the tibial tunnel and create a trough. The graft is then tensioned. A bioabsorbable screw is inserted into the tibial tunnel and a Richard’s staple is used to secure the bone plug into tibia tying the ETHIBOND sutures over the staple. |
In summary, ACLR using a BPTB autograft remains the gold standard, offering excellent stability and high patient satisfaction. The technique is associated with high RTS and low re-rupture rates. Attention to detail and meticulous surgical technique are essential to achieving optimal outcomes and minimizing the risk of donor-site morbidity and graft tunnel mismatch. This Technical note describes a reproducible and reliable technique for performing ACLR with a BPTB autograft.
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: A.J. reports financial support, administrative support, article publishing charges, and statistical analysis were provided by Steadman Philippon Research Institute (SPRI); is employed as a research fellow at SPRI. SPRI receives support from Arthrex, Department of Defense Office of Naval Research, DJO, MIB, Ossur, Siemens, Smith & Nephew, and XTRE. C.J.H. reports financial support, administrative support, article publishing charges, and statistical analysis were provided by SPRI; is employed as a research assistant at SPRI. SPRI receives support from Arthrex, Department of Defense Office of Naval Research, DJO, MIB, Ossur, Siemens, Smith & Nephew, and XTRE. C.M. reports financial support, administrative support, article publishing charges, and statistical analysis were provided by SPRI; is employed as a sports medicine fellow in the Steadman Clinic (TSC) and SPRI. TSC and SPRI receive support from Arthrex, Department of Defense Office of Naval Research, DJO, MIB, Ossur, Siemens, Smith & Nephew, and XTRE. N.C. reports financial support, administrative support, article publishing charges, and statistical analysis were provided by SPRI; is employed at SPRI. SPRI receives support from Arthrex, Department of Defense Office of Naval Research, DJO, MIB, Ossur, Siemens, Smith & Nephew, and XTRE.
P.J.M. reports financial support, administrative support, article publishing charges, and statistical analysis were provided by SPRI; is a sports medicine physician at TSC and SPRI. TSC and SPRI receive support from Arthrex, Department of Defense Office of Naval Research, DJO, MIB, Ossur, Siemens, Smith & Nephew, and XTRE. All other authors (L.A., M.H.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Supplementary Data
Video depicting our preferred surgical technique for anterior cruciate ligament reconstruction using a bone−patellar tendon−bone autograft with inside-out, medial portal femoral drilling technique with femoral and tibial fixation using cannulated interference screw fixation. The patient is positioned supine and the left knee is prepared and draped for the procedure.
References
- 1.Barié A., Sprinckstub T., Huber J., Jaber A. Quadriceps tendon vs. patellar tendon autograft for ACL reconstruction using a hardware-free press-fit fixation technique: Comparable stability, function and return-to-sport level but less donor site morbidity in athletes after 10 years. Arch Orthop Trauma Surg. 2020;140:1465–1474. doi: 10.1007/s00402-020-03508-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Dave U., Ofa S.A., Ierulli V.K., Perez-Chaumont A., Mulcahey M.K. Both quadriceps and bone–patellar tendon–bone autografts improve postoperative stability and functional outcomes after anterior cruciate ligament reconstruction: A systematic review. Arthrosc Sports Med Rehabil. 2024;6 doi: 10.1016/j.asmr.2024.100919. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Sgardelis P., Naqvi G., Servant C. Minimally invasive bone-patellar tendon-bone graft harvest is associated with less frequent anterior knee pain at rest than hamstring graft harvest after anterior cruciate ligament reconstruction at the 1-year follow-up. Arthrosc Sports Med Rehabil. 2023;5 doi: 10.1016/j.asmr.2023.100766. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Gill V.S., Tummala S.V., Sullivan G., et al. Functional return-to-sport testing demonstrates inconsistency in predicting short-term outcomes following anterior cruciate ligament reconstruction: A systematic review. Arthroscopy. 2024;40:2135–2151.e2. doi: 10.1016/j.arthro.2023.12.032. [DOI] [PubMed] [Google Scholar]
- 5.Zhou Y., Fuimaono-Asafo A., Frampton C., van Niekerk M., Hirner M. Quadriceps tendon autograft is comparable to hamstring tendon and bone−patella-tendon−bone up to 2 years after isolated primary anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2023;31:3268–3276. doi: 10.1007/s00167-023-07370-7. [DOI] [PubMed] [Google Scholar]
- 6.Lindskog J, Högberg J, Hamrin Senorski R, et al. Primary anterior cruciate ligament reconstruction performed with hamstring tendon autograft leads to an over 4 times greater rate of second anterior cruciate ligament rupture after return to sport in patients with generalized joint hypermobility compared with bone–patellar tendon–bone autograft. [published online January 30, 2025]. Arthroscopy. 10.1016/j.arthro.2025.01.028. [DOI] [PubMed]
- 7.Gupta R., Kapoor A., Soni A., Khatri S., Masih G.D. Anterior cruciate ligament reconstruction with bone−patellar tendon−bone graft is associated with higher and earlier return to sports as compared to hamstring tendon graft. Knee Surg Sports Traumatol Arthrosc. 2020;28:3659–3665. doi: 10.1007/s00167-020-06074-6. [DOI] [PubMed] [Google Scholar]
- 8.Tomihara T., Hashimoto Y., Okazaki S., et al. Bone−patellar tendon−bone autograft is associated with a higher rate of return to preinjury levels of performance in high-level athletes than anterior cruciate ligament reconstruction using hamstring autograft. Knee Surg Sports Traumatol Arthrosc. 2024;32:1384–1395. doi: 10.1002/ksa.12144. [DOI] [PubMed] [Google Scholar]
- 9.Vinagre G., Saraiva J. Anterior cruciate ligament reconstruction graft options. Orthop J Sports Med. 2018;6(6_suppl 3) [Google Scholar]
- 10.Shichman I., Baruchi D., Rachevsky G., et al. Bone filling decreases donor site morbidity after anterior cruciate ligament reconstruction with bone−patellar tendon−bone autografts. Arch Orthop Trauma Surg. 2023;143:2565–2572. doi: 10.1007/s00402-022-04572-5. [DOI] [PubMed] [Google Scholar]
- 11.Graf R.M., Dart S.E., MacLean I.S., et al. The “N+10 rule” to avoid graft-tunnel mismatch in bone−patellar tendon−bone ACL reconstruction using independent femoral tunnel drilling. Orthop J Sports Med. 2023;11 doi: 10.1177/23259671231168885. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Boddu C.K., Arif S.K., Hussain M.M., Sankaranarayanan S., Hameed S., Sujir P.R. Prevention of graft-tunnel mismatch during anatomical anterior cruciate ligament reconstruction using a bone−patellar tendon−bone graft. Bone Joint J. 2015;97-B:324–328. doi: 10.1302/0301-620X.97B3.34653. [DOI] [PubMed] [Google Scholar]
- 13.Lin T.J. Editorial Commentary: Quadrupled semitendinosus autograft is a suitable graft choice for anterior cruciate reconstruction, regardless of diameter, in patients with lower risk for rerupture. Arthroscopy. 2024;41:246–247. doi: 10.1016/j.arthro.2024.09.031. [DOI] [PubMed] [Google Scholar]
- 14.Saltzman B.M., Varkey D.T., Trofa D.P., et al. An update on graft-tunnel mismatch in anterior cruciate ligament reconstruction: A survey of the experts in the field of orthopedic sports medicine demonstrates no clear consensus in management. Knee. 2020;27:1525–1533. doi: 10.1016/j.knee.2020.08.003. [DOI] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Video depicting our preferred surgical technique for anterior cruciate ligament reconstruction using a bone−patellar tendon−bone autograft with inside-out, medial portal femoral drilling technique with femoral and tibial fixation using cannulated interference screw fixation. The patient is positioned supine and the left knee is prepared and draped for the procedure.