Patellar Tendon Graft Harvest: The Bone Transfer Technique

Bone-patellar tendon-bone (BPTB) autograft for anterior cruciate ligament (ACL) reconstruction (ACLR) is strong and has a low failure rate. However, postoperative anterior knee pain remains a concern because of bony defects at the harvest site, which can be reduced with proper bone grafting.

BPTB autograft for ACLR is indicated for professional athletes, patients returning to pivoting sports, patients undergoing revision surgery, and patients with hyperlaxity, increased recurvatum, or increased posterior tibial slope. This technique is indicated for all these patients, except for revision ACLR, as the bone transfer from the tibial tunnel is not recommended because of the previous ACL tunnel.

A 4-cm vertical anteromedial proximal tibial incision is made medial to the patellar tendon. The skin is mobilized using full-thickness skin flaps, and the paratenon is split longitudinally to expose the patellar tendon. The mid-third of the tendon is harvested, and bone blocks are taken from both ends of the graft, with special consideration taken to harvest a deep tibial bone block to be able to use the deep portion of the tibial bone block to bone graft the patellar defect. A coring reamer is used to create the tibial ACL tunnel, resulting in a bone cylinder to be used to bone graft the tibial tuberosity defect. Finally, the superficial portion of the tendon and the paratenon are closed, and finally, the skin incision is closed in layers.

As previously shown, BPTB autograft for ACLR has a low failure rate and a high return to sports rate, especially in young individuals.

Multiple techniques for BPTB harvest have been described, but we believe this technique addresses the major concern of postoperative anterior knee pain. A bony defect from bone block harvest is a crucial cause of postoperative anterior knee pain, but anatomical bone grafting reduces the risk of harvest-site pain. Furthermore, autologous bone graft heals faster than other grafts, and our technique is designed to address all of these factors by using an autologous bone prism for the patella and a bone cylinder for the tibial tuberosity to avoid defects and restore anatomy.

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