Patellar tendon autograft for anterior cruciate ligament reconstruction

Patellar tendon autograft is the most commonly used graft in collegiate and professional athletes due to ready accessibility, mechanical strength, and rapid osseous tunnel integration. Long-term clinical results have been excellent, which has resulted in patellar tendon being the “Gold Standard” of grafts. In this chapter we discuss surgical technique pearls and pitfalls for anatomic anterior cruciate ligament (ACL) reconstruction using patellar tendon autograft, including incision and portal placement and strategy, graft harvest and tunnel placement, graft passing as well as fixation, with a focus on anatomic transtibial as well as medial portal femoral independent drilling techniques. While both techniques are outlined, the authors prefer a modified transtibial technique when possible as it allows for placement of the tibial and femoral tunnels in the native or near anatomic footprints and has been demonstrated to have a lower revision rate as compared to femoral independent drilling techniques. We recommend that surgeons be familiar with both drilling techniques however, as individual anatomy may vary and multiple options should be available and familiar to the surgeon for optimal reconstruction. Outcomes and return to play following ACL reconstruction with patellar tendon autograft have generally been very good to excellent, with similar outcomes, return to play and decreased revision rates as compared to autograft hamstrings, quadriceps, and allograft.