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Bone Patellar Tendon Bone GraftEdit

Bone Patellar Tendon Bone Graft (Bone Patellar Tendon Bone Graft) is a surgical autograft widely used in the reconstruction of the anterior cruciate ligament (ACL reconstruction). The graft uses a central portion of the patellar tendon with bone blocks affixed at each end, typically harvested from the front of the knee. The bone-to-bone interfaces at the femoral and tibial attachments are designed to promote solid fixation and relatively rapid incorporation into the bone tunnels created during ACL reconstruction. This approach has a long track record and remains a common choice for athletes and active individuals who require a dependable, durable graft.

The concept of a bone-to-bone graft was developed to improve initial stability and speed of graft incorporation, leveraging the healing advantages of bone plugs rather than soft-tissue interfaces alone. In practice, the bone-patellar-tendon-bone graft is harvested from the middle third of the patellar tendon, with bone blocks taken from the inferior pole of the patella and the tibial tubercle. The resulting graft is then threaded into the prepared bone tunnels in the femur and tibia and fixed with a combination of hardware such as screws or buttons, depending on surgeon preference and patient anatomy.

Overview

  • Anatomy and components: The graft comprises a central tendon portion flanked by small bone plugs on both ends, enabling bone-to-bone healing within the tunnels. This contrasts with soft-tissue grafts that rely on tendon-to-bone healing. See patellar tendon for context and bone graft interfaces for healing principles.
  • Historical usage: The BPTB autograft has been a mainstay in ACL surgery for decades, favored for its robust initial fixation and high reported success rates in athletic populations.
  • Core rationale: Bone plugs at each end facilitate rapid graft incorporation and can offer precise graft length and tensioning during reconstruction. See ACL reconstruction for broader context on graft choices in ACL surgery.

Surgical Technique

  • Harvest: A curved incision is placed over the patellar tendon to access the central third of the tendon. Bone plugs are harvested from the inferior pole of the patella and the tibial tubercle. See bone-patellar-tendon-bone graft for a procedural description.
  • Tunnel preparation: Precise drilling creates femoral and tibial tunnels sized to accommodate the graft’s bone plugs.
  • Graft passage and fixation: The graft is threaded through the tunnels and fixed with screws, buttons, or other devices designed to secure the graft during the healing period.
  • Postoperative considerations: Rehabilitation emphasizes controlled range of motion, progressive loading, and gradual return to activity, with attention to quadriceps strength and patellofemoral joint symptoms.

Indications and Patient Selection

  • Ideal candidates: Active individuals and athletes who require a stable, durable graft with predictable fixation. The graft is often chosen for younger patients with high functional demands and for primary ACL reconstructions where bone-to-bone healing is advantageous.
  • Considerations and contraindications: Patellofemoral pain history, patellar maltracking, significant pre-existing anterior knee pain, or concerns about kneeling-related discomfort may push surgeons to consider alternative grafts. See autograft vs allograft discussions for broader graft selection considerations.

Advantages and Disadvantages

  • Advantages:
    • Strong initial fixation due to bone plugs, which can translate into firm graft incorporation.
    • Robust stability suitable for high-demand activities and young athletes.
    • Bone-to-bone healing may provide reliable tunnel integration and potentially shorter time to secure graft incorporation.
  • Disadvantages:
    • Donor-site morbidity, including anterior knee pain and kneeling discomfort, is more common than with some other graft types.
    • Risk of patellar fracture or tendon-related complications, particularly in patients with risk factors or those who undergo aggressive rehabilitation early.
    • Recruitment of the central patellar tendon portion may lead to quadriceps and patellar tendon-related weakness or discomfort in some patients.
  • See also discussions of hamstring graft and quadriceps tendon graft as alternatives that balance these trade-offs.

Outcomes and Complications

  • Graft success: In many series, BPTB autografts demonstrate durable long-term stability with favorable return-to-sport rates, especially in pivoting sports requiring strong knee landmarks and fixation.
  • Donor-site issues: Anterior knee pain, kneeling discomfort, and, less commonly, fracture or tendon irritation at the harvest site can occur.
  • Complications: Infection, graft malposition, tunnel widening, and stiffness are potential, though not universal, complications. Revision ACL procedures may be approached with alternative graft choices depending on patient factors and prior graft performance.
  • Comparative context: When compared with other autografts like the hamstring graft, differences in donor-site morbidity and kneeling pain are commonly discussed among surgeons and patients.

Variants and Alternatives

  • Hamstring tendon graft (semitendinosus-gracilis autograft): Often chosen to minimize anterior knee pain and kneeling discomfort, at the possible expense of different fixation dynamics and tendon-only healing considerations.
  • Quadriceps tendon graft: A growing alternative that may offer robust graft size with potentially different donor-site profiles.
  • Allograft options: Bone-tendon-bone allografts or other allograft tissues may be used in certain scenarios (e.g., revisions or specific patient populations), with considerations about disease transmission risk, incorporation rates, and cost.
  • See ACL reconstruction for broader comparisons among graft options.

Controversies and Debates

  • Graft choice and patient factors: The decision between BPTB autograft and alternatives like the hamstring graft often hinges on activity level, age, patellofemoral health, and patient preferences about kneeling discomfort. Proponents of BPTB emphasize the strength and bone-to-bone healing advantages, while critics highlight anterior knee pain and donor-site morbidity as meaningful downsides.
  • Autograft versus allograft in younger patients: Many surgeons favor autografts in younger, active patients due to concerns about allograft failure and slower incorporation, particularly with certain processing methods. Others argue allografts can shorten operative time and reduce donor-site morbidity, though with trade-offs in durability.
  • Revision and complex cases: In revision ACL reconstructions or in cases with prior graft failure, graft choice may shift toward alternatives that optimize fixation or minimize prior donor-site complications. See revision ACL reconstruction for related considerations.
  • Economic and access considerations: Discussions about resource use, insurance coverage, and cost-effectiveness influence graft selection in some healthcare systems, with conservative or cost-conscious framing sometimes invoked by commentators who emphasize value-based care.

See also