Template Versus Freehand Bone-Patellar Tendon-Bone Harvest for Anterior Cruciate Ligament Reconstruction: Its Effect on Patellofemoral Morbidity

J South Orthop Assoc. 2001;10(2) 

In This Article

Abstract and Introduction

To test the hypothesis that a template system for harvesting bone-patellar tendon-bone (BTB) would cause fewer postoperative patellofemoral problems than freehand graft harvests, two groups of 20 patients who had arthroscopically assisted anterior cruciate ligament (ACL) reconstructions were compared at 1 and 3 years. Three years after surgery, no significant differences were found in the quality of the ligament reconstruction. One intraoperative patellar fracture occurred in the freehand group (group 1). All other complications were similar between groups. Squatting profiles were slightly better in the template group (group 2). Averaged and outlier scores from three published patellofemoral scoring systems showed no significant differences between the two groups. It was concluded that current methods for measuring patellofemoral function detected little morbidity and no significant outcome differences between ACL reconstructions done with BTB grafts harvested by freehand versus templated techniques.

The functional results of anterior cruciate ligament (ACL) reconstruction have been excellent with either patellar tendon or hamstring tendons as the graft source for the ligament substitute.[1,2,3,4,5,6,7,8,9] The bone-patellar tendon-bone (BTB) graft is strong and dependable, but it has been maligned for being associated with greater donor site (patellofemoral) morbidity.[3,5,8,9,10,11]

As ACL reconstruction has evolved, central third patellar tendon grafts were initially harvested freehand with an end cutting oscillating saw without depth stops. The size and depth of the bony segments of the graft were determined by judgment or reference to a hand-held ruler. Invariably, some degree of blunt articular cartilage trauma occurred from mallets and osteotomes used to pry the patellar bone plug from its dense cortical bed.[12] In 1991, a template system was developed that made graft harvest faster and more uniform in size.[13]

It was hypothesized that patellar tendon graft procurement with a cutting template would cause less iatrogenic blunt cartilage injury[12] and would be associated with fewer patellofemoral sequelae. To determine whether the method of graft harvest clinically affected patellofemoral morbidity, I evaluated a prospectively identified group of ACL reconstructions done by identical surgical procedures except for the manner in which the ACL graft was harvested.