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Patellar tendon autograft harvesting using a mini vertical incision
Technical Note
Patellar Tendon Autograft Harvesting Using a Mini Vertical Incision Howard J. Levy, M.D., and Dann C. Byck, M.D.
Summary: Patellar tendon autograft is a commonly used graft for anterior cruciate ligament reconstruction. Harvesting the patellar tendon graft typically entails using a longer incision than other graft options. We describe a technique for harvesting bone–patellar tendon–bone autograft using a smaller more cosmetic incision. Key Words: ACL—Patellar tendon autograft—Mini-incision.
A
nterior cruciate ligament (ACL) reconstruction has become the standard of care for active patients with a functionally unstable knee. With the evolution of endoscopic techniques, ACL surgery can typically be preformed through a single incision. Several graft options are currently available, including bone–patellar tendon–bone, hamstring, quadriceps tendon, and allograft. Surgeons who advocate the use of patellar tendon autograft believe that it provides superior strength with early rigid fixation. However, patellar tendon autograft has been associated with increased incidence of patellofemoral pain and typically needs a larger incision for harvesting. Incisions as long as 4 inches have been described. This incision can hypertrophy and produce an unsightly scar, as well as cause pain and discomfort while the patient is kneeling.1-11 The use of 2 horizontal incisions has been described but this does not allow for complete visualization of the tendon and bone plugs.12 With all other factors held constant, cosmesis of the incision should be taken into account. The purpose of this article is to describe a surgical technique for harvesting patellar tendon autoFrom the Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York (H.J.L.); and Yakima Orthopaedic and Fracture Clinic, Yakima, Washington (D.C.B.), U.S.A. Address correspondence and reprint requests to Howard J. Levy, M.D., Lenox Hill Hospital, 130 East 77 St, New York, NY 10021, U.S.A. r 2000 by the Arthroscopy Association of North America 0749-8063/00/1605-2124$3.00/0 doi:10.1053/jars.2000.6768
558
FIGURE 1. Transverse line marking distal pole of the patella with the skin shifted proximally.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 5 (July-August), 2000: pp 558–562
PATELLAR TENDON AUTOGRAFT HARVESTING
FIGURE 2. Skin incision is made from 2 cm proximal to the distal pole of the patella to the tibial tubercle.
grafts that consistently uses a smaller incision, measuring 3 to 4 cm. SURGICAL TECHNIQUE The patient is placed on the operating table in the supine position and the operative limb placed in a tourniquet and a leg holder. The leg holder should
FIGURE 3. Metzenbaum scissors are used to split the paratenon proximally.
559
allow for 0° to 110° range of motion. The leg is prepped and draped and the table is raised to a comfortable height. With the foot resting on the surgeon’s thigh, the knee is flexed to 30° and a methylene blue mark is made at the distal pole of the patella. A second mark is made at the tibial tubercle. The knee is now brought into full extension and the skin is pulled proximally over the patella (Fig 1). With the skin shifted proximally, another mark is now made 20-mm proximal to the distal pole of the patella, indicating the length of the patellar bone plug (Fig 2). The incision is made from the distal mark to the tibial tubercle. The extremity is exsanguinated and the tourniquet is inflated. A No. 15 scalpel is used to make the incision. A second scalpel blade is used to sharply divide the subcutaneous tissue and the peritenon. The peritenon is elevated to expose the patellar tendon. Metzenbaum scissors are now used to clear the peritenon layer over the entire length of the patellar proximally. This is best accomplished with the knee in extension (Fig 3). This allows placement of an army-navy retractor into the proximal portion of the incision. The patella is now shifted distally into the wound by levering on the long end of the army-navy retractor. This maneuver allows for full exposure of the distal pole of the patella using minimal skin incision proximally (Fig 4A). Mark the desired length of the patellar tendon bone plug with a ruler. The use of 20-mm bone plugs allows for adequate interference screw fixation, minimizes the risk of postoperative patella fracture, and also allows for a shorter skin incision. A catamaran scalpel blade is now used to harvest the graft (Fig 4B). We typically use 9- or 10-mm wide grafts depending on the size of
560
H. J. LEVY AND D. C. BYCK
FIGURE 4.
(A) An army-navy retractor feeds the patella into the wound. (B) A catamaran blade is used to harvest the graft.
the patient. With the limb in extension, the catamaran blade demarcates the width of the tendon graft at the distal pole of the patella. Once the dual scalpel reaches the distal pole, the army-navy retractor is removed and
the knee is flexed to 100° to tension the tendon. If the tendon is not under tension, the catamaran scalpel blade may not provide a straight longitudinal cut, which would result in variability of the tendon width.
FIGURE 5.
Distal exposure is achieved using smooth retractor.
FIGURE 6. Harvesting of a 90-mm bone–patellar tendon–bone autograft is performed through a 3.5-cm incision.
FIGURE 7.
Subcuticular closure results in a cosmetic scar.
562
H. J. LEVY AND D. C. BYCK
Try not to violate the joint capsule as this will allow for fluid extravasation during the remainder of the procedure. Continue distally with the catamaran blade parallel to the tendon fibers down to the tibial tubercle. Use of smooth retractors allows for distal skin retraction and also protects the skin from the scalpel blade (Fig 5). The desired length of tibial bone plug is now measured and demarcated. The limb is again placed in full extension and the army-navy retractor is replaced, forcing the patella distally into the field. Use a sagittal saw angled at 45° to obtain a wedge-shaped plug. Placing the nondominant index finger around the tendon aids in stabilizing the patella while using the oscillating saw. The plug is then removed by using an osteotome. The army-navy retractor is now removed and smooth retractors are placed distally. The tibial bone plug is removed in similar fashion. Metzenbaum scissors are now used to free the graft of its soft tissue attachment (Fig 6). Proceed in the usual fashion with the arthroscopic part of the procedure while a surgical assistant prepares the graft. Use separate arthroscopic portal sites to avoid tension on the incision during placement of the tibial guide. Subcuticular wound closure is performed at the end of the procedure (Fig 7). DISCUSSION We have described a technique of harvesting a central third patellar tendon autograft using a smaller, single vertical incision. Typically, these incisions are 3 to 4 cm. Female patients with lax skin provide for the best candidates. This technique provides a cosmetic scar without compromising harvesting of the graft.
REFERENCES 1. Harner CD, Marks PH, Fu FH, Irrgang JJ, Silby MB, Mengato R. Anterior cruciate ligament reconstruction: Endoscopic versus two incision technique. Arthroscopy 1994;10:502-512. 2. Buss D, Warren R, Wickiewicz T, Galinat BJ, Panariello R. Arthroscopically assisted reconstruction of the anterior cruciate ligament with use of autogenous patellar-ligament grafts. J Bone Joint Surg Am 1993;75:1346-1355. 3. Paulos L, Cherf J, Rosenberg T, Beck CL. Anterior cruciate ligament reconstruction with autografts. Clin Sports Med 1991;10:469-485. 4. Shelbourne K, Rettig A, Hardin G, William RI. Miniarthrotomy versus arthroscopically assisted anterior cruciate ligament reconstructions with autogenous patellar tendon graft. Arthroscopy 1993;9:72-75. 5. Sgaglione N, Schwartz R. Arthroscopically assisted reconstruction of the anterior cruciate ligament: Initial clinical experience and minimal 2-year follow-up comparing endoscopic transtibial and two-incision techniques. Arthroscopy 1997;13:156165. 6. Barrett G, Richardson K. Comparison of rear-entry (twoincision) and endoscopic techniques for reconstruction of the anterior cruciate ligament. J South Orthop Assoc 1996;5:87-95. 7. O’Neill D. Arthroscopically assisted reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am 1996;78:803813. 8. Al-Zarahini S, Franceschi J. Anterior cruciate ligament reconstruction by mini-arthrotomy. Int Orthop (SICOT) 1997;21:161163. 9. Arciero RA, Scoville CR, Snyder RJ, Uhorchak JM, Taylor DC, Huggard DJ. Single versus two-incision arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 1996;12: 462-469. 10. Struab T, Hunter R. Acute anterior cruciate ligament repair. Clin Orthop Rel Res 1988;227:238-250. 11. O’Donnell J, Scerpella T. Endoscopic anterior cruciate ligament reconstruction: Modified technique and radiographic review. Arthroscopy 1995;11:577-584. 12. Mishra A, Fanton G, Dillingham MF, Carver TJ. Patellar tendon graft harvesting using horizontal incisions for anterior cruciate ligament reconstruction. Arthroscopy 1995;11:749752.
Patellar Tendon Autograft Harvesting Using a Mini Vertical Incision Howard J. Levy, M.D., and Dann C. Byck, M.D.
Summary: Patellar tendon autograft is a commonly used graft for anterior cruciate ligament reconstruction. Harvesting the patellar tendon graft typically entails using a longer incision than other graft options. We describe a technique for harvesting bone–patellar tendon–bone autograft using a smaller more cosmetic incision. Key Words: ACL—Patellar tendon autograft—Mini-incision.
A
nterior cruciate ligament (ACL) reconstruction has become the standard of care for active patients with a functionally unstable knee. With the evolution of endoscopic techniques, ACL surgery can typically be preformed through a single incision. Several graft options are currently available, including bone–patellar tendon–bone, hamstring, quadriceps tendon, and allograft. Surgeons who advocate the use of patellar tendon autograft believe that it provides superior strength with early rigid fixation. However, patellar tendon autograft has been associated with increased incidence of patellofemoral pain and typically needs a larger incision for harvesting. Incisions as long as 4 inches have been described. This incision can hypertrophy and produce an unsightly scar, as well as cause pain and discomfort while the patient is kneeling.1-11 The use of 2 horizontal incisions has been described but this does not allow for complete visualization of the tendon and bone plugs.12 With all other factors held constant, cosmesis of the incision should be taken into account. The purpose of this article is to describe a surgical technique for harvesting patellar tendon autoFrom the Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York (H.J.L.); and Yakima Orthopaedic and Fracture Clinic, Yakima, Washington (D.C.B.), U.S.A. Address correspondence and reprint requests to Howard J. Levy, M.D., Lenox Hill Hospital, 130 East 77 St, New York, NY 10021, U.S.A. r 2000 by the Arthroscopy Association of North America 0749-8063/00/1605-2124$3.00/0 doi:10.1053/jars.2000.6768
558
FIGURE 1. Transverse line marking distal pole of the patella with the skin shifted proximally.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 5 (July-August), 2000: pp 558–562
PATELLAR TENDON AUTOGRAFT HARVESTING
FIGURE 2. Skin incision is made from 2 cm proximal to the distal pole of the patella to the tibial tubercle.
grafts that consistently uses a smaller incision, measuring 3 to 4 cm. SURGICAL TECHNIQUE The patient is placed on the operating table in the supine position and the operative limb placed in a tourniquet and a leg holder. The leg holder should
FIGURE 3. Metzenbaum scissors are used to split the paratenon proximally.
559
allow for 0° to 110° range of motion. The leg is prepped and draped and the table is raised to a comfortable height. With the foot resting on the surgeon’s thigh, the knee is flexed to 30° and a methylene blue mark is made at the distal pole of the patella. A second mark is made at the tibial tubercle. The knee is now brought into full extension and the skin is pulled proximally over the patella (Fig 1). With the skin shifted proximally, another mark is now made 20-mm proximal to the distal pole of the patella, indicating the length of the patellar bone plug (Fig 2). The incision is made from the distal mark to the tibial tubercle. The extremity is exsanguinated and the tourniquet is inflated. A No. 15 scalpel is used to make the incision. A second scalpel blade is used to sharply divide the subcutaneous tissue and the peritenon. The peritenon is elevated to expose the patellar tendon. Metzenbaum scissors are now used to clear the peritenon layer over the entire length of the patellar proximally. This is best accomplished with the knee in extension (Fig 3). This allows placement of an army-navy retractor into the proximal portion of the incision. The patella is now shifted distally into the wound by levering on the long end of the army-navy retractor. This maneuver allows for full exposure of the distal pole of the patella using minimal skin incision proximally (Fig 4A). Mark the desired length of the patellar tendon bone plug with a ruler. The use of 20-mm bone plugs allows for adequate interference screw fixation, minimizes the risk of postoperative patella fracture, and also allows for a shorter skin incision. A catamaran scalpel blade is now used to harvest the graft (Fig 4B). We typically use 9- or 10-mm wide grafts depending on the size of
560
H. J. LEVY AND D. C. BYCK
FIGURE 4.
(A) An army-navy retractor feeds the patella into the wound. (B) A catamaran blade is used to harvest the graft.
the patient. With the limb in extension, the catamaran blade demarcates the width of the tendon graft at the distal pole of the patella. Once the dual scalpel reaches the distal pole, the army-navy retractor is removed and
the knee is flexed to 100° to tension the tendon. If the tendon is not under tension, the catamaran scalpel blade may not provide a straight longitudinal cut, which would result in variability of the tendon width.
FIGURE 5.
Distal exposure is achieved using smooth retractor.
FIGURE 6. Harvesting of a 90-mm bone–patellar tendon–bone autograft is performed through a 3.5-cm incision.
FIGURE 7.
Subcuticular closure results in a cosmetic scar.
562
H. J. LEVY AND D. C. BYCK
Try not to violate the joint capsule as this will allow for fluid extravasation during the remainder of the procedure. Continue distally with the catamaran blade parallel to the tendon fibers down to the tibial tubercle. Use of smooth retractors allows for distal skin retraction and also protects the skin from the scalpel blade (Fig 5). The desired length of tibial bone plug is now measured and demarcated. The limb is again placed in full extension and the army-navy retractor is replaced, forcing the patella distally into the field. Use a sagittal saw angled at 45° to obtain a wedge-shaped plug. Placing the nondominant index finger around the tendon aids in stabilizing the patella while using the oscillating saw. The plug is then removed by using an osteotome. The army-navy retractor is now removed and smooth retractors are placed distally. The tibial bone plug is removed in similar fashion. Metzenbaum scissors are now used to free the graft of its soft tissue attachment (Fig 6). Proceed in the usual fashion with the arthroscopic part of the procedure while a surgical assistant prepares the graft. Use separate arthroscopic portal sites to avoid tension on the incision during placement of the tibial guide. Subcuticular wound closure is performed at the end of the procedure (Fig 7). DISCUSSION We have described a technique of harvesting a central third patellar tendon autograft using a smaller, single vertical incision. Typically, these incisions are 3 to 4 cm. Female patients with lax skin provide for the best candidates. This technique provides a cosmetic scar without compromising harvesting of the graft.
REFERENCES 1. Harner CD, Marks PH, Fu FH, Irrgang JJ, Silby MB, Mengato R. Anterior cruciate ligament reconstruction: Endoscopic versus two incision technique. Arthroscopy 1994;10:502-512. 2. Buss D, Warren R, Wickiewicz T, Galinat BJ, Panariello R. Arthroscopically assisted reconstruction of the anterior cruciate ligament with use of autogenous patellar-ligament grafts. J Bone Joint Surg Am 1993;75:1346-1355. 3. Paulos L, Cherf J, Rosenberg T, Beck CL. Anterior cruciate ligament reconstruction with autografts. Clin Sports Med 1991;10:469-485. 4. Shelbourne K, Rettig A, Hardin G, William RI. Miniarthrotomy versus arthroscopically assisted anterior cruciate ligament reconstructions with autogenous patellar tendon graft. Arthroscopy 1993;9:72-75. 5. Sgaglione N, Schwartz R. Arthroscopically assisted reconstruction of the anterior cruciate ligament: Initial clinical experience and minimal 2-year follow-up comparing endoscopic transtibial and two-incision techniques. Arthroscopy 1997;13:156165. 6. Barrett G, Richardson K. Comparison of rear-entry (twoincision) and endoscopic techniques for reconstruction of the anterior cruciate ligament. J South Orthop Assoc 1996;5:87-95. 7. O’Neill D. Arthroscopically assisted reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am 1996;78:803813. 8. Al-Zarahini S, Franceschi J. Anterior cruciate ligament reconstruction by mini-arthrotomy. Int Orthop (SICOT) 1997;21:161163. 9. Arciero RA, Scoville CR, Snyder RJ, Uhorchak JM, Taylor DC, Huggard DJ. Single versus two-incision arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 1996;12: 462-469. 10. Struab T, Hunter R. Acute anterior cruciate ligament repair. Clin Orthop Rel Res 1988;227:238-250. 11. O’Donnell J, Scerpella T. Endoscopic anterior cruciate ligament reconstruction: Modified technique and radiographic review. Arthroscopy 1995;11:577-584. 12. Mishra A, Fanton G, Dillingham MF, Carver TJ. Patellar tendon graft harvesting using horizontal incisions for anterior cruciate ligament reconstruction. Arthroscopy 1995;11:749752.