Patellar strain and patellofemoral contact after bone-patellar tendon-bone harvest for anterior cruciate ligament reconstruction.

OBJECTIVE: To characterize the morbific consequences of harvesting a patellar tendon graft for use in reconstructing the anterior cruciate ligament (ACL) of the knee, specifically, (1) to measure changes in patellar strain and patellofemoral contact due to graft harvest, (2) to evaluate the ability of bone-grafting the patellar defect to mitigate these effects, and (3) to characterize failure of the extensor mechanism after harvest of a patellar tendon graft.
DESIGN: Twenty-two cadaver knee joints were tested before and after harvest of a patellar tendon graft and after filling the patellar defect with polymethylmethacrylate to simulate a healed bone graft, Knees were positioned in 30 degrees, 60 degrees, and 90 degrees flexion and loaded while measuring axial strain in the anterior patella and patellofemoral contact. Knees were then loaded to failure.
RESULTS: Harvest of the graft produced increases in axial strain at all flexion angles. Filling the defect restored axial strain to normal values. Patellofemoral contact in the presence of a defect, either filled or empty, was not different from contact for intact patellae. Most knees failed by transpatellar fracture; mean extension moment at failure was 112.8Nm. The best predictors of failure were age and gender.
CONCLUSION: Patients undergoing ACL reconstruction with a patellar tendon graft are at increased risk of anterior knee pain and disruption of the extensor mechanism. Bone-grafting the patellar defect created by graft harvest can reduce these risks. Our findings underscore the importance of carefully controlled rehabilitation and suggest that if an accelerated program of rehabilitation is anticipated, the patellar defect should be bone-grafted. Older patients, particularly women, are at increased risk of catastrophic failure of the knee extensor mechanism after ACL reconstruction using patellar tendon graft.