Author's Accepted Manuscript

Managing Perioperative Extensor Mechanism Inju-

ries and the Patellar Defect after ACL Reconstruction
Rachel M. Frank MD, Annemarie K. Tilton BS, Kirk A.
Campbell M.D., Bernard R. Bach Jr. MD

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PII: S1060-1872(15)00113-6
DOI: http://dx.doi.org/10.1053/j.otsm.2015.08.006
Reference: YOTSM50529

To appear in:
Oper Tech Sports Med

Cite this article as: Rachel M. Frank MD, Annemarie K. Tilton BS, Kirk A. Campbell M.D.,
Bernard R. Bach Jr. MD, Managing Perioperative Extensor Mechanism Injuries and the
Patellar Defect after ACL Reconstruction,
Oper Tech Sports Med , http://dx.doi.org/10.1053/j.otsm.2015.08.006

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Title: Managing Perioperative Extensor Mechanism Injuries and the Patellar Defect after ACL
Reconstruction
Corresponding Author: Dr. Kirk A. Campbell, M.D.
Corresponding Author's Institution: New York University Hospital for Joint Diseases

First Author: Rachel M Frank, MD

Order of Authors: Rachel M Frank, MD; Annemarie K Tilton, BS; Kirk A. Campbell, M.D.; Bernard R
Bach, Jr., MD

Managing Perioperative Extensor Mechanism Injuries and the Patellar Defect after ACL

Reconstruction

Abstract:

Anterior cruciate ligament (ACL) tears are a common and potentially devastating injury for an

athlete. ACL reconstruction is a safe, highly effective procedure that has been shown to result in

excellent clinical and functional outcomes, but complications still do arise. Although extremely

unusual, perioperative extensor mechanism injuries after ACL reconstruction are a serious and

potentially complex complication. An overview of some of the technical aspects of managing the

extensor mechanism in ACL reconstructions, types of injuries and their management, as well as a

comprehensive review of the literature on the management of the patellar defect following ACL

reconstruction with BPTB autograft will be explored.

Key words: ACL reconstruction, patellar defect, extensor mechanism

1
Introduction:

Anterior cruciate ligament (ACL) tears are the most common ligamentous injury of the knee,

often requiring reconstruction in order to restore knee stability, function and prevent cartilage

damage.1-34 When performing ACL reconstruction (ACLR), surgeons face several graft and

technique options, such as autograft versus allograft or the transtibial versus the medial portal

technique.5 The most common autograft choices include bone-patellar-tendon-bone (BPTB),

hamstring, and quadriceps tendon. Allograft options include BPTP, hamstring tendon, Achilles

tendon, and tibialis tendon.5

BPTB autograft is the most common graft used in the young, athletic patient population.6-89

Tissue strength, ease of graft harvest, bone-to-bone healing and lower rates of retear compared to

allograft in young patients have contributed to the popularity of BPTB grafts for ACLR.5, 10

Subjective and objective outcomes are excellent with BPTB autograft with high return to play

rates, low overall failure rates, and low complication rates.9, 11-15 Nevertheless, concerns over

BPTB autograft remain, including anterior knee pain, and the potential for extensor mechanism

disruption or patella fracture. While reported rates of intraoperative and post-operative patellar

fractures are relatively unusual, ranging from 0.2 to 3%,16, 17 they can be a devastating

complication.

In this review article, some of the technical aspects of ACLR with BPTB autograft that may be

associated with postoperative extensor mechanism injuries and pearls for avoiding these

potential complications will be discussed. A comprehensive review of all available literature

2
discussing management of the patellar defect following ACLR with BPTB autograft will be

provided.

Technical Considerations

While there are several techniques available for performing ACLR with BTPB, classically, the

central one-third of the ipsilateral patellar tendon (Figure 1) is harvested with approximately

10mm tendon width and 10mm width of bone plugs from the patella and the tibia.8, 18 Upon

exposing the patellar tendon, the paratenon is sharply incised in line with its fibers to allow full

exposure of the patellar tendon, and to allow for subsequent defect closure (Figures 2-3). The

central one-third of the tendon is harvested sharply (Figure 4), while bone plugs from the patella

and the tibia are harvested with the combination of a sagittal saw and a ¼ and 3/8” curved

osteotomes (Figure 5). Care must be taken while performing the bone plug harvest, particularly

along the patella, in order to avoid intraoperative patella fracture and/or penetration of the

saw/osteotome through the articular surface of the patella. It is critical to avoid creating extra

cortical disruptions, even micro-perforations, as such disruptions can create stress risers in the

patella that may result in a postoperative fracture. Initiating the saw penetration into the

cancellous bone is best done started at the respective tendo-osseous junctions of the graft.

Intraoperatively, if concerned for even the possibility of a fracture, intraoperative radiographs

should be performed, as the presence of a fracture is likely to change the immediate

intraoperative as well as postoperative management of the patient. While unusual, several

authors have described the intraoperative management of patella fractures in the setting of

ACLR.15, 19 There are generally two types of patella fractures associated with BPTB ACLR: a

vertically-oriented fracture (typically occurs intraoperatively) and a transverse-oriented fracture,

3
resulting from post-operative trauma.19 Vertical patella fractures can be recognized on

arthroscopy by the appearance of creased cartilage.19 Options for patella fracture repair include

tension band wiring, large fragment screw fixation, or cannulated screw fixation with or without

tension band augmentation.15 Regardless of preferred method, patella fractures must be rigidly

fixed to result in stability through full range of motion.15

Following appropriate BPTB harvest for ACLR, there is an approximately 9-10mm defect in the

middle third of the native patellar tendon, as well as bone defects in the proximal anterior tibia

and distal anterior patella.20 The bone defects are typically 20 to 25mm in length and

approximately 10mm in width and depth (Figure 6). The patella plug is smaller and is typically

cut such that a trapezoidal bone graft is produced.. Following ACLR per surgeon preference,

various closure techniques for both the patellar tendon defect as well as the bone defects can be

employed, and no one single technique has been proven to be superior. With respect to the soft

tissue defect, options include repairing both the patellar tendon and paratenon defects, repairing

only the patellar tendon defect, repairing only the paratenon defect, or leaving both the patellar

tendon and paratenon unclosed. Although unusual, an intra-operative or post-operative patellar

tendon rupture is another devastating complication, and Milankov et al showed that it occurred in

0.18% of their 2215 ACLR at a mean of 8 months post-operatively.21 Great care should be taken

when harvesting the patella tendon to ensure that there is adequate patella tendon width, typically

a width of 30mm is desired prior to harvesting a 10mm tendon width, so that a sufficient amount

of tendon remains both medially and laterally. If the patella tendon is found to be less than

30mm then consideration should be given for an alternate graft source, such as hamstring or

quadriceps autograft, or an allograft. Leaving behind a thin strip of tendon medially or laterally

4
could potentially result in a patella tendon rupture. Alternatively, the patient may sustain an

injury during the post-operative period that could result in a patella tendon rupture. In terms of

repairing the patella tendon rupture, there are a variety of different techniques that could be used

and are generally based on the location of the tear (proximal, intra-substance or distal); these

include the use of drill holes and suture repair and/or suture anchor repair based on the surgeon’s

preference. In terms of the bony defects, both the patellar and tibial defects can be grafted, either

defect can be grafted in isolated, or the surgeon can choose to not graft the defects.

Our preference is as follows: 1) to loosely approximate the patellar tendon defect with the knee

in 70 to 90 degrees of flexion with interrupted 0-vicryl sutures (Figure 7); 2) to graft both the

patellar and tibial defects with autograft, utilizing bone collected during tibial and femoral tunnel

reaming as well as any extra bone saved during the graft preparation (Figures 8-9); and 3) to

close the paratenon defect with a running 2-0 vicryl suture (Figure 10). Closing the soft tissue

defect with the knee in flexion reduces the potential for overconstraining or shortening the

extensor mechanism. If there is insufficient bone to fill both the patellar and the tibial defects, we

recommend prioritizing grafting of the patella defect to minimize the risk of fracture; the tibial

defect is much less likely to fracture given the surrounding bone stock.

5
Evidence Based Decision-Making:

Clinical Evidence

While the authors prefer to repair the patellar tendon defect, close the paratenon, and graft the

bony defects following patellar tendon harvest for ACLR, there is substantial controversy in the

literature over the clinical implications of closing, or not closing, the patellar tendon defect. The

impact of the patellar tendon defect on the extensor mechanism function following BPTB harvest

is unclear. Adriani et al evaluated the intrinsic healing potential of the patellar tendon and the

incidence of patellofemoral symptoms following harvest of the middle-third of the patellar

tendon for ACLR in patients who underwent closure (n=25) versus those who did not undergo

closure of the tendon defect site (n=36).22 On ultrasound evaluation one year after surgery, the

open group had more scar tissue in the defect site compared to the closed group, which had

normal appearing tendon tissue in the defect site. Interestingly, the clinical, radiographic and

isokinetic findings did not differ between the open and closed groups at six months after surgery.

The authors concluded that the extensor mechanism is not significantly affected by defect

closure.22 Similar results were reported in a study of 50 patients by Brandsson et al following

BPTB graft harvest for ACLR. Two-year follow-up results demonstrated no difference between

groups in functional outcomes, pain, healing on ultrasound, or joint stability. Together, these

results suggest that the extensor mechanism is not necessarily compromised after patellar tendon

harvest without defect closure, and closing of the defect does not improve outcomes.23 In another

randomized controlled trial conducted by Cerullo et al, 50 patients were randomly assigned to

undergo defect closure or no closure following ACLR with BPTB autograft. At final follow-up,

the authors reported no clinically significant differences between the two groups. However, they

did report increased patellar tendon scar formation in the closure group on follow-up computed

6
tomography (CT) imaging, and ultimately, the authors recommended leaving the defect open.24

The clinical implications of the CT study findings are unclear, and certainly additional research

is necessary to correlate the imaging findings with clinical outcomes.

In 1993, Shaffer and Tibone conducted a prospective clinical study of 36 patients undergoing

ACLR with BPTB autograft in order to assess the impact of graft closure on patellar tendon

length. The graft harvest site defect was closed in half the patients and left open in the other half

of the patients. Results on intraoperative measurements and postoperative radiographs showed no

negligible tendon shortening in the closure group, and further, no patients in either group

developed patella baja postoperatively.25 In a separate study, Krosser et al prospectively

evaluated the radiographic appearance of 114 patients after undergoing ACLR with BPTB

autograft and patellar tendon closure. The patellar tendon defect was left open in 59 patients, and

the defect was sutured closed in the remaining 55 patients. In all patients, the paratenon was

approximated. Pre- and postoperative lateral knee radiographs were taken in all patients, and pre-

and postoperative patellar tendon lengths were measured. The authors found no significant

shortening in the tendon length in the closed versus open groups.26 A study by Hantes et al also

investigated patellar tendon shortening following BPTB autograft with defect closure in 16

patients, and compared their findings to 32 patients who underwent ACLR with hamstring

tendon autograft. The authors found that there was approximately 10% shortening of the patellar

tendon and 6% incidence of patella baja following BPTB autograft with defect closure.

Interestingly, the functional outcomes in the BPTB group were not significantly different from

those in the hamstring autograft group, which experienced minor tendon shortening and 0%

incidence of patella baja.27

7
Certainly, closure of the defect in the native patellar tendon can potentially lead to complications,

including patella baja, decreased patellar tendon length, suture irritation, and/or increased

operative time.28-30 However, there are also potential benefits of closure of the graft harvest site,

including biological graft coverage of the void from graft harvest, possible increased strength of

the remaining patellar tendon, and decreased risk of post-operative patellar tendon rupture or

extensor lag.20 Further, complications resulting from bone defect sites left un-grafted have been

reported, including anterior knee pain especially while kneeling, as well as patella fracture.31

The potential relationship between defect closure, functional outcomes and postoperative pain

are unclear. A recent systematic review by Frank et al evaluated 4 studies with a total of 221

patients following ACLR with BPTB autograft with or without defect closure. Results showed

no differences in clinical outcomes or pain scores between patients whose defects were closed

versus those who were left open. Imaging findings were variable with 2 studies showing no

difference between groups, one showing improved quality of the patellar tendon defect tissue

following repair, and one study showing excessive scar formation with defect repair.32

Cadaveric Evidence

Several cadaveric studies have attempted to look at the impact of patellar tendon defect closure

following patellar tendon harvest. Eilerman et al assessed changes in patellofemoral pressure

between cadaveric knees with or without side-to-side repair of the patellar defect after graft

harvest. Patellofemoral joint pressures were compared at 30, 60 and 90 degrees of knee flexion

with loads varying from 647 to 1923 N. The authors found no statistically significant differences

in patellofemoral joint pressures with and without defect closure after graft harvest for BPTB

8
graft. This suggests that both closure or nonclosure of the patellar tendon defect site is likely

appropriate, as neither strategy appears to alter patellofemoral pressure.33 A more recent

cadaveric study by Sobieraj et al investigated the effects of defect closure on the strength and

stiffness of the remaining donor patellar tendon. BPTB grafts were harvested from 7 matched-

pairs of fresh frozen cadaver patellar tendons from human cadaveric knee specimens from

donors under 50 years of age with no prior history of surgery or fracture. Half of the specimens

underwent defect closure prior to biomechanical testing. The authors found no differences in the

mechanical properties between tendons that underwent defect closure and those that were left

open.20

Imaging Evidence

Patellar tendon reconstitution over time following graft harvest has been shown in several

magnetic resonance imaging (MRI) studies, indicating that the patellar tendon potentially can

regenerate and remodel following graft harvest.34, 35 Coupens et al evaluated MRIs of 20 patients

at variable follow-up intervals (6 weeks to 18 months) after undergoing ACLR with BPTB

autograft. All patients underwent defect closure at the time of surgery. At all time points,

imaging showed a significant increase in tendon thickness without an increase in tendon width.

Interestingly, MRI signal intensity was high during the early follow-up period, indicating scar

tissue, and signal intensity decreased at later follow-up, suggesting more normal patellar tendon

tissue at minimum 18 months post-operatively. Similar results were reported by Nixon et al, who

showed that defect tissue returned to the appearance of normal patellar tendon tissue on MRI at 2

years following ACLR with BPTB autograft. In addition, in their study, patellar tendon biopsies

were taken from 8 patients who underwent second-look arthroscopy. Compared to the time of the

9
index ACLR, both the size of the defect on histology and signal intensity on MRI in the graft site

were decreased and nearly identical to normal tendon tissue.35

Summary

BPTB autograft provides a commonly used and highly effective graft choice for ACLR.

Unfortunately, there is no consensus on the best patellar tendon defect closure technique or the

effect of closure on the extensor mechanism. Further, currently available data is inconsistent on

the impact of defect closure on scar formation. Results suggest clinically favorable results from

either technique. It is our preference to perform closure of the patellar tendon defect and the

paratenon, as well as perform bone grafting of the patellar and tibial defects with autograft at the

time of surgery, in order to preserve biology, and potentially reduce the incidence of post-

operative anterior knee pain (especially with kneeling) and patella fracture. Bone graft comes

from the bone collected at the time of tibial and femoral tunnel reaming. We then prefer to

loosely reapproximate the patellar tendon with the knee flexed to 80 degrees, in order to reduce

the likelihood of overconstraining the patella. Finally, we advocate for closing the patellar

tendon defect with vicryl suture, in order to preserve biology to the tendon itself. These

preferences are based on the experience of the senior author, who has performed over 2300

ACLR procedures with BPTB grafts, and who has noticed subjectively inferior outcomes in

patients in whom the patellar tendon defect is left unrepaired. To protect the donor site (ie, the

patella), we advocate for using a long-leg hinged knee brace locked in extension for 6 weeks,

while allowing full active and passive range-of-motion, and without weight-bearing restrictions.

10
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17. Lee GH, McCulloch P, Cole BJ, Bush-Joseph CA, Bach BR: The incidence of acute
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34. Coupens SD, Yates CK, Sheldon C, Ward C: Magnetic resonance imaging evaluation of
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Figure/Table Legend:

Figure 1 – Intraoperative photograph of a right knee undergoing ACLR with a BPTB autograft,

demonstrating the incision from the distal aspect of the patella to the level of the tibial tubercle

Figure 2 - Intraoperative photograph of a right knee undergoing ACLR with a BPTB autograft,

demonstrating identification and incision of the paratenon in line with its fibers

Figure 3 - Intraoperative photograph of a right knee undergoing ACLR with a BPTB autograft,

demonstrating the appearance of the patellar tendon after the paratenon has been incised

Figure 4 - Intraoperative photograph of a right knee undergoing ACLR with a BPTB autograft,

demonstrating harvesting of the central third of the patellar tendon sharply with a knife, in line

with its fibers

Figure 5 - Intraoperative photograph of a right knee undergoing ACLR with a BPTB autograft,

demonstrating the harvested graft with bone plugs from the patella and tibia

Figure 6 - Intraoperative photograph of a right knee undergoing ACLR with a BPTB autograft,

demonstrating the defect sites at the patella and the tibia prior to bone grafting

Figure 7 - Intraoperative photograph of a right knee undergoing ACLR with a BPTB autograft,

demonstrating loose approximation of the patellar tendon defect with interrupted vicryl sutures

Figure 8 - Intraoperative photograph of a right knee undergoing ACLR with a BPTB autograft,

demonstrating grafting of the patellar defect with autograft harvested during the procedure

13
Figure 9 - Intraoperative photograph of a right knee undergoing ACLR with a BPTB autograft,

demonstrating grafting of the patellar and tibial defects with autograft harvested during the

procedure

Figure 10 - Intraoperative photograph of a right knee undergoing ACLR with a BPTB autograft,

demonstrating closure of the paratenon defect with a running vicryl suture

14
Figure 1
Figure 2a
Figure 2B
Figure 3
Figure 4
Figure 5
Figure 6
Figure 7
Figure 8
Figure 9
Figure 10a
Figure 10B