AANA Lab Course 1002 -3rd Annual Fellows/Chief Residents-ACL Reconstruction Bone Tendon Bone Autograft-Christopher Y. Kweon, M.D.

ACL Reconstruction Bone Tendon Bone Autograft-Christopher Y. Kweon, M.D.

Pdf Summary

This presentation by Dr. Christopher Kweon focuses on anterior cruciate ligament (ACL) reconstruction using bone-tendon-bone (BTB) autograft, delivered at the AANA 3rd Annual Fellows and Chief Residents Arthroscopy Course. Key points include:

<strong>Background & Indications:</strong>  
BTB autografts have similar patient outcomes compared to other graft types in terms of return to play, failure rates, revisions, and complications. However, they may cause more anterior or kneeling pain, exhibit less laxity on instrumented testing, and have a lower revision risk in younger patients (under 25). BTB grafts may be especially suitable for younger, competitive, or contact athletes, potentially benefiting from bone-to-bone healing while requiring cautious progression postoperatively to manage pain.

<strong>Contraindications:</strong>  
Avoid BTB autografts in patients with compromised patella or patellar tendon, active tubercle apophysitis, heavy kneeling demands (wrestlers, catchers, laborers), or those with open growth plates.

<strong>Harvesting Technique:</strong>  
Harvest involves a central third patellar tendon graft including the inferior pole of the patella with careful preservation of the peritenon and deep bursa for closure. Bone plugs are harvested with shallow cuts on the patella and deeper cuts on the tibia, limiting plugs to a maximum of 20 mm.

<strong>Graft Preparation:</strong>  
The graft must pass through sizing guides easily, with femoral bone plugs bullet-shaped and suture holes drilled through the cortical bone for fixation.

<strong>Tunnel Drilling & Fixation:</strong>  
Femoral tunnels should be drilled as posterior as possible; tibial tunnel placement is adjusted to address graft-tunnel mismatch, favoring more vertical orientation. Interference fixation on the femoral side requires cancellous bone facing up, with careful tibial fixation avoiding sutures on bone edges to prevent cutout.

<strong>Troubleshooting:</strong>  
In cases where the graft does not pass, strategies include “bulletizing” the bone plug, removing soft tissue, or adjusting tunnel sizing and orientation. Graft-tunnel mismatch may require switching fixation techniques or outside-in drilling to position the graft adequately.

This comprehensive overview integrates surgical pearls to optimize BTB ACL reconstructions, emphasizing patient selection, surgical technique, and problem-solving intraoperatively.

Keywords

Anterior Cruciate Ligament Reconstruction

Bone-Tendon-Bone Autograft

ACL Surgery

Patellar Tendon Harvesting

Graft Preparation

Tunnel Drilling Techniques

Interference Fixation

Graft-Tunnel Mismatch

Postoperative Pain Management

Athlete Patient Selection