What is the preferred graft choice between Bone-Patellar Tendon-Bone (BPTB) and quadriceps tendon autograft for Anterior Cruciate Ligament (ACL) reconstruction?

Bone-Patellar Tendon-Bone vs Quadriceps Tendon for ACL Reconstruction

When choosing between Bone-Patellar Tendon-Bone (BPTB) and quadriceps tendon autograft for ACL reconstruction, surgeons may favor BPTB to reduce the risk of graft failure or infection, while quadriceps tendon offers reduced donor site morbidity with comparable stability outcomes. 1

Comparative Advantages and Disadvantages

BPTB Autograft

• Offers reduced risk of graft failure and infection compared to other autograft options 1
• Associated with higher rates of anterior knee pain (26.7% vs 4.56% with quadriceps tendon) 2
• Higher incidence of anterior numbness (53.3% vs 1.5% with quadriceps tendon) 2
• May result in greater extension loss (mean loss 2.77° vs 0.55° with quadriceps tendon) 2

Quadriceps Tendon Autograft

• Significantly lower donor site morbidity compared to both BPTB (RR 0.17,95% CI 0.09-0.33) and hamstring tendon autografts (RR 0.60,95% CI 0.39-0.93) 3
• Comparable graft survival rates to BPTB and hamstring tendon autografts 3
• Similar functional outcomes (IKDC subjective scores) and stability outcomes to BPTB 3
• Some studies show better stability outcomes compared to hamstring tendon autografts (mean side-to-side difference 1.1±0.9mm vs 3.1±1.3mm with hamstring) 4

Clinical Decision-Making Algorithm

1. Patient Age and Activity Level Assessment

   • For young, active patients requiring reconstruction, carefully weigh the relative risks and benefits of each graft type 5
   • For high-demand athletes where maximum stability is critical, BPTB may be preferred due to lower graft failure rates 1

2. Risk Factor Evaluation

   • If patient has pre-existing anterior knee pain or kneeling requirements, consider quadriceps tendon to reduce risk of anterior knee pain 1
   • If patient has higher risk of infection, BPTB may be preferred 1

3. Anatomical Considerations

   • Quadriceps tendon provides a larger and potentially stronger graft than patellar tendon 6
   • Quadriceps tendon can be harvested with or without bone plug with similar outcomes 3, 2

Important Clinical Pearls

• Early reconstruction (within 3 months of injury) is recommended regardless of graft choice to reduce risk of additional cartilage and meniscal injury 1
• Both single-bundle and double-bundle techniques show similar outcomes regardless of graft choice 1
• Consider augmentation with anterior lateral ligament (ALL) reconstruction or lateral extra-articular tenodesis (LET) when using hamstring autograft in select patients to reduce graft failure 1

Common Pitfalls to Avoid

• Failing to consider patient-specific factors like occupation (kneeling requirements) when selecting graft type 5
• Overlooking the potential for reduced quadriceps inhibition after quadriceps tendon harvest compared to BPTB, which may allow quicker return to sports activities 6
• Not accounting for the increased donor site morbidity with BPTB when counseling patients about recovery expectations 3, 2

Rehabilitation Considerations

• When BPTB grafts are used, rehabilitation protocols should include specific protection strategies for the donor site 5
• Functional evaluation (e.g., hop test) should be considered as one factor to determine return to sport after ACL reconstruction 1