What is the recommended incision and surgical technique for harvesting a patellar tendon autograft to reconstruct a lateral collateral ligament tear?

Patellar Tendon Autograft Harvesting for Lateral Collateral Ligament Reconstruction

Direct Answer

The evidence provided does not contain specific guidelines or high-quality studies addressing patellar tendon autograft harvesting specifically for lateral collateral ligament (LCL) reconstruction. The available guidelines focus exclusively on ACL reconstruction, and the single study mentioning LCL reconstruction uses quadriceps tendon-patellar bone autograft, not patellar tendon 1.

Critical Context

Why This Question Lacks Direct Evidence

The provided evidence consists primarily of:

• ACL reconstruction guidelines 2 - which address a completely different anatomic structure and biomechanical problem
• ACL graft harvesting techniques 3, 4, 5, 6 - focused on anterior knee reconstruction, not lateral structures
• One LCL study 1 that specifically uses quadriceps tendon-patellar bone autograft, not patellar tendon

The Actual Clinical Reality

For LCL reconstruction, patellar tendon autograft is not the standard or recommended graft choice. The literature suggests alternative grafts are preferred:

• Quadriceps tendon-patellar bone autograft is specifically described for LCL reconstruction 1
• Achilles tendon allograft is used for combined LCL and anterolateral ligament reconstruction 7
• The isolated LCL study 8 actually suggests conservative management may be appropriate in select cases

If You Must Use Patellar Tendon (Extrapolating from ACL Evidence)

Should you decide to use patellar tendon autograft for LCL reconstruction despite lack of specific evidence, the harvesting technique would follow ACL reconstruction principles:

Incision Approach

Use a two-incision (double-incision) technique rather than single longitudinal incision to minimize donor-site morbidity:

• Two horizontal transverse incisions are more cosmetic and reduce anterior knee pain 3, 4, 6
• The subcutaneous two-incision approach significantly reduces:
  • Mid-term anterior knee pain
  • Sensory disturbances (median area of insensitivity: 0 cm² vs 24 cm² with traditional technique) 4
  • Discomfort when kneeling 4

Technical Steps (Based on ACL Harvesting)

1. Upper incision: Transverse incision at inferior pole of patella
2. Lower incision: Transverse incision at tibial tubercle
3. Preserve peritenon and minimize injury to infrapatellar branches of saphenous nerve 3
4. Harvest central third of patellar tendon with bone blocks from patella and tibia
5. The mini-invasive approach decreases saphenous nerve injury risk while maintaining peritenon integrity 3

Important Caveats

Graft Selection Concerns

• No evidence supports patellar tendon as optimal for LCL reconstruction
• The biomechanical demands of LCL (varus stability, posterolateral corner function) differ substantially from ACL
• Consider whether quadriceps tendon-patellar bone 1 or allograft 7 would be more appropriate

Clinical Pitfalls

• Do not assume ACL reconstruction techniques directly translate to LCL reconstruction - different anatomic constraints, tunnel positions, and fixation requirements apply
• The lateral approach for LCL reconstruction differs entirely from anterior approach for patellar tendon harvest
• Evaluate for combined posterolateral corner injury - isolated LCL tears are rare; missing concomitant injuries increases failure risk 1, 7

Alternative Consideration

In professional athletes with isolated distal grade III LCL injuries, conservative management may be appropriate 8, as intact posterolateral structures can maintain stability and the extra-articular position facilitates healing.