BPTB Autograft

Harvest graft

 

BPTB IncisionBPTB ParatenonBPTB Expose TendonBPTB Measure Central Third

 

Midline incision over patella tendon

- from lower pole of patella to tibial tuberosity

- dissect fascia off tendon carefully without injuring tendon

- identify medial and lateral margins and assess tendon width

 

BPTB Central ThirdBPTB Medial CutBPTB Medial Cut 2BPTB Lateral Cut

 

Use marking pen to mark central 1 cm of tendon at distal pole patella

- can increase this to 12 - 14 mm in large male if sufficient tendon width

- use knife to cut from 2 cm on patella down medial side

- ensure leave 5 mm tendon medially

- extend 2cm down tibial tuberosity

- remeasure and cut laterally

 

BPTB Tibial Incision 2 cm longBPTB Saw CutBPTB Elevated Bone Block

 

Bone blocks

- measure 2 x 1 cm bone block on tibial tuberosity

- cut each side at 45o with saw

- 1cm deep with each saw cut meeting as triangle

- distal transverse cut 1cm deep

- lever out with curved ostetome

- make 2 x 1.5 cm drill holes with piece in situ, mark with pen

 

BPTB Patella BoneBPTB Patella SawBPTB Patella ElevationBPTB Drill in Situ

 

Repeat on patella side, can push patella down for exposure

- use smaller lever on patella side and be more delicate

- remove graft carefully, have to dissect off the fat pad

 

BPTB Graft

 

Graft preparation

 

ACL BPTB GraftACL BPTB Graft 2

 

Clean tendon of soft tissue

- decide which end will pass into femur

- usually the smaller piece

- nibble any sharp edges off especially on leading edge

- ensure whole graft will pass through 10 mm tube

- decide which end will be tibial or femoral

- mark femoral end with blue pen

- put 2 x 1 non absorbable sutures through drill holes

- probably don't need to tension BPTB

 

Knee arthroscopy

 

Medial portal

- soft spot

- make larger as need to insert 7 mm screw through here

- clean thoroughly with shaver

 

Prepare LFC

- notchplasty often required

- graft is significantly larger than HS

 

Tunnels

 

Tibial tunnel

- tibial jig / beath pin / 10 mm reamer

- need to ensure sufficient distance anterior to PCL

- use shaver to clean tunnel, especially entrance

 

ACL Tibial GuideTibial Beath Pin

 

Transtibial femoral tunnel

- need to use 7 mm offset jig to prevent posterior wall blowout

- pass femoral beath pin at 90o

- drill femoral tunnel 10 mm wide

- 5mm deeper than bone graft length

- if bone plug 20 mm long, drill 25 mm

- if bone plug 25 mm long, drill 30 mm

- need to thoroughly clean tunnel of bone debris

- can help to pass acorn reamer twice

 

ACL Femoral Offset GuideACL Transtibial Beath Pin 1ACL Transtibial Beath Pin 2ACL Femoral Acorn Drill

Graft

 

Pass loop 1 PDS though tip of beath pin

- pull 4 sutures of lead bone plug through

- advance the beath pin out of the femur

- secure sutures

 

Pass graft

- ensure bone plug passes easily into tibial tunnel

- pull up gently on sutures and advance the bone plug into knee

- use grasper to align the bone plug with the femoral tunnel

- then pull on sutures and advance the plug into the tennel

- pull femoral bone plug deep into tunnel and tension

 

Screw Fixation

 

Femoral screw

- need to be careful ans can blowout back wall or create divergent screw

- hyperflex knee +++

- this step is very important to prevent divergent screw

- expose femoral tunnel with good vision

- pass screw guide wire anterior to bone graft so as not to blow out tunnel

- insert 7 x 25 mm screw ensuring that the screw threads engage the tunnel

 

ACl Femoral Screw Guide WireACL Femoral ScrewACL BPTB in situ

 

Trial

- check no impingement

- tension tibial side at 30o

- insert 9 x 25 mm screw

 

ACL No Impingment full extension

 

Post Op xrays

 

ACL BPTB Autograft LateralACL BPTP Autograft APACL BPTP Autograft Skyling