17.1 Introduction

Anterior cruciate ligament tear and subsequent reconstruction (ACL-R) is exceedingly common in the United States, with an estimated 100,000 to 300,000 performed annually. ¹ Reconstruction can be performed with autograft (patellar tendon, hamstring, and quadriceps) or allograft. Graft selection is typically based on surgeon and patient preference, and can also be influenced by the patients’ age, and activity level. ² Here, we describe the authors preferred technique for ACL-R with BTB autograft. ³

17.2 Preop

• 
  

  Review MRI for any concomitant pathology (meniscus, medial collateral ligament [MCL], etc.).

  
  
• 
  

  Measure patellar tendon length on mid-sagittal MRI. Desire tendon to be between 40 and 50 mm to avoid the graft being too short or too long and causing graft-tunnel mismatch. This is beyond the scope of this chapter.

  
  
• 
  

  Examine patient under anesthesia preoperatively.

17.3 Position

• 
  

  Supine, take the foot of bed off and place the well leg in a leg holder with minimal hip flexion and abduction.

  
  
• 
  

  Place rolled towel bump in the cut out of bed, under the thighs once foot of bed is removed.

  
  
• 
  

  Patients operative leg should be off the bed distal to thigh.

  
  
• 
  

  Post against the operative thigh.

  
  
• 
  

  Place a tourniquet around the operative thigh as high as possible, only inflate if necessary.

17.4 Approach

Draw landmarks. Inferior pole, standard lateral and medial portals, low anteromedial portal, anteromedial outflow (optional based on preference and tibial tunnel incision 3 finger breadths below medial joint line and mid-way between the tibial crest and posteriomedial border of the tibia).

17.5 Bone–Patellar Tendon–Bone Harvest

• 
  

  Perform harvest first, goal should be for 9 × 25 mm bone plugs from both the patella and tibial.

  
  
• 
  

  Midline incision, approximately 5 cm, from the inferior pole of patella to tibial tuberosity.

  
  
• 
  

  Cauterize any subcutaneous vessels.

  
  
• 
  

  Assistance use skin rakes to provide tension for dissection.

  
  
• 
  

  Use bovie electro cautery and blunt with finger or scissors until the paratenon is reached. Ensure that the whole incision is used. This is facilitated by the assistant providing ample retraction.

  
  
• 
  

  Make approximately 1-cm incision in the paratenon, and then use Metzenbaum dissecting scissors to complete the layer proximal and distal.

  
  
• 
  

  Use scissors and a finger to elevate paratenon to expose the edges of the patellar tendon. Continued retraction will aid in proper visualization. Care should be taken to elevate paratenon as a discrete flap on either side of paratenon incision. Paratenon will be less robust distally by the tibial tubercle.

  
  
• 
  

  Pass a Kelly clamp under middle of tendon and hold out to flatten tendon.

  
  
• 
  

  Use surgical ruler to measure middle 10 mm of patellar tendon. Mark using surgical marker.

  
  
• 
  

  Extend incision in tendon proximally with #10 blade, on both sides, going up to patella but not through. Rotate blade onto the top of patella to get full length.

  
  
• 
  

  Place patients foot on chest and extend leg, assistant should move to position to retract patella.

  
  
• 
  

  Place spiked patellar retractor to deliver patella out of wound.

  
  
• 
  

  Use bovie to extend tendon harvest up to 20 mm on either side, and then come transverse with bovie to complete the box.

  
  
• 
  

  Use 10-mm straight sagittal saw to cut patellar bone block along the box made by bovie. Cut bone block in a triangular shape.

  
  
• 
  

  Use curved ½ inch osteotome to complete osteotomy.

  
  
• 
  

  Relax leg, use pick up or freer to spread and expose tendon to allow distal extension of the incision on both sides down to the tibial tubercle.

  
  
• 
  

  Use bovie to make a 30 mm box extending distal from patellar tendon cuts similar to patellar side. Assistant should retract with army navy retractors to aid exposure as distal as possible.

  
  
• 
  

  Use sagittal saw to make tibial osteotomy, should get as distal as possible. Shape should be more rectangular.

  
  
• 
  

  Complete with osteotome as needed.

  
  
• 
  

  Grab patellar bone block with moist sponge, use Mayo scissors to remove soft tissue and take graft to back table.