Pitfalls and Risks of Tendon Harvest About the Knee

Fig. 31.1

AP radiograph of a metaphyseal fracture of the proximal tibia after ACL reconstruction (Voos et al. HSSJ, 2008) (Voos et al. 2008)

31.2.2 Patellar Fracture

Studies infrequently report on patellar fractures as a potential complication of BTB autograft: the incidence of such fractures has been reported to be between 0.23 and 2.3% (Wilson et al. 2006). Possible reasons for these fractures include a large patellar bone plug harvest (greater than 11–12 mm) or a stress riser caused by an aggressive saw cut (Christen and Jakob 1992; Stein et al. 2002).

Intraoperative patellar fractures occur due to aggressive bony resection, while postoperative patellar fractures usually occur from direct trauma to the patella in the setting of a stress riser. Intraoperative fractures tend to be longitudinal fissure fractures, with the most common being a nondisplaced vertical fissure fracture. Postoperative patella fractures are typically transverse-shaped injuries that result from an aggressive contraction of the quadriceps or direct trauma (Wilson et al. 2006).

Displaced fractures require surgical intervention, but nondisplaced fractures can typically be treated nonoperatively with rigid knee immobilization (Wilson et al. 2006).

31.2.3 Patellar Tendon Ruptures

Though uncommon, reports of patellar tendon rupture following ACL reconstruction do exist—with most describing injuries in the early postoperative period and others describing injury up to 3 years after surgery (Shelbourne et al. 2006). Most studies report only one or two cases—for instance, Lee et al. reported one rupture among 1725 BTPB reconstructions (Lee et al. 2008).

A study by Benner et al. described a subset of patients presenting with postoperative patellar tendon rupture (Benner et al. 2012). These patients all experienced an acute onset of pain and weakness after an injury to their graft knee. Injury was typically due to a “slip and fall” mechanism of injury. Patients also observed swelling around their injured knees. As well, patellar tendon ruptures result in patella alta and an inability to extend the knee. Physical examination typically reveals a palpable tendon defect (Fig. 31.2) (Benner et al. 2012).

Fig. 31.2

Posteroanterior (a) and lateral radiographs (b) after repair of a proximal–medial/distal–lateral Z-type patellar tendon rupture after bone–patellar tendon–bone autograft harvest for anterior cruciate ligament reconstruction (Benner et al. AJSM, 2012) (Benner et al. 2012)

31.2.4 Patellar Tendinitis

Shelbourne et al. reported patellar tendinitis in 21% of patients who received a BTB graft (Mastrokalos 2005; Shelbourne et al. 1994). They defined patellar tendinitis as soreness in the patellar tendon region.

31.2.5 Secondary Complications

One of the primary secondary complications following BTB graft harvest is increased anterior knee pain. Specifically, kneeling is more difficult up to 7 years postoperatively for BTB graft patients (Riaz et al. 2015).

31.3 Complications Specific to Hamstring Autografts

Most of the complications specific to harvesting the semitendinosus and gracilis tendons are technical problems that are avoidable with good surgical technique (Williams et al. 2005).

31.3.1 Incomplete Tendon Harvest

The most common problem harvesting the semitendinosus and gracilis tendons occurs due to tendon amputation leading to inadequate graft issue. The tendons lie deep to the sartorius fascia and superficial to the medial collateral ligament. There are bands of tissue that must be released, including usually a very thick band running from the semitendinosus to the gastrocnemius, which can cause the tendon stripper to deviate and prematurely amputate the tendon tissue (Williams et al. 2005). With good surgical technique, it is extremely rare for the surgeon to be unable to harvest adequate graft issue for ACL reconstruction.

31.3.2 MCL Injury

The medial collateral ligament is located just deep to the insertion of the gracilis and semitendinosus tendons. Care must be taken to avoid this tissue when dividing the sartorius fascia and when releasing the gracilis semitendinosus tendons from their insertion (Wittstein et al. 2006).

31.3.3 Secondary Complications

Secondary complications of hamstring harvest typically resolve about 3 months post-op and do not require surgical intervention (Wittstein et al. 2006). Such complications include persistent weakness of the hamstrings and surrounding muscle (which compensates for the lack of hamstring tissue), as well as donor site pain. However, donor site pain appears to be temporary (Yasuda et al. 1995).

Hamstring autografts have several pros compared to BTB autografts. These include preserved quadriceps, decreased anterior knee pain, and reduced risk of patellar tendon rupture or patellar fracture. However, BTB autografts have a lower rate of re-rupture (Freedman et al. 2003).

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