Presentations

Abstract

Introduction: The patellar tendon autograft is a popular graft choice for anterior cruciate ligament reconstruction (ACLR) in skeletally mature athletic populations. However, it has been historically debated whether to leave the patellar tendon (PT) open or to close it with suture following harvest. There is conflicting evidence as to whether closure of the PT defect can result in excessive scarring, tendon shortening, and incidence of patella baja. The aim of this study was to assess the impact of PT autograft site closure on the size of the residual PT defect and knee functional outcomes.

Methods: This was a retrospective cohort study. Patients of two surgeons who underwent ACLR with PT autograft between 2011 and 2023 at a private practice were identified. One surgeon routinely reapproximated the PT with sutures and the other left the tendon open and only closed the overlying paratenon. Patients from both groups underwent the same postoperative protocol, including physical therapy. Included patients were at least one-year post-op and 13 years or older at the time of surgery. Exclusion criteria were: revision ACLR, workman's compensation case, or chronic pain condition. Enrolled patients underwent ultrasound evaluation of the operative knee by an independent examiner to determine PT width and PT defect width and depth. The Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC), and Single Assessment Numeric Evaluation (SANE) were collected. Percent residual defect of the PT was calculated by dividing the postoperative width of the PT defect by the width of the harvested PT autograft. Summary statistics were calculated, and comparative tests were performed using JMP Pro 18.0.1.

Results: Eighty-one subjects met criteria and completed the ultrasound and surveys. There were 57 patients in the PT left open group and 24 patients in the PT closed group. Their average age was 23.6 years ± 7.6 and 27.0 years ± 6.4, respectively (p = 0.05). The average PT width was 3.1 cm (2.2 - 3.8 cm), which was not significantly different between groups (p = 0.23). A PT defect was present in all patients after a mean follow-up of 2.97 years (1.0 - 9.6 years). Mean PT defect width was significantly larger in the patients who had the PT left open (4.3 mm ± 1.4) compared to the patients who had the PT closed with sutures (2.2 mm ± 1.1, p < 0.001). Mean depth of the PT defect was 3.7 mm ± 0.8 in the patients who had the PT left open and 3.3 mm ± 1.0 in the patients who had the PT closed (p = 0.082). Mean percent residual defect of the PT was significantly greater in the patients who had the PT left open (41.7% ± 13.4) than the patients who had the PT closed (22.0% ± 10.7, p < 0.0001). There were no differences between the PT left open and closed groups regarding KOOS (83 ± 13.4 vs. 80.1 ± 13.5, p = 0.29), IKDC (83.9 ± 14.8 vs. 78.4 ± 14.7, p = 0.052), and SANE (89.5 ± 13.0 vs. 84.3 ± 16.9, p = 0.061) scores.

Conclusion: A PT defect was present in all patients at the time of follow-up. In contrast to previous studies, closure of the PT autograft site with sutures did not result in increased depth of the PT defect but did result in decreased defect width. Outcomes were the same between those who had the PT closed and those that had the PT left open. Intraoperative closure of the PT with suture may not be necessary for patients undergoing ACLR with PT autograft.