Introduction

and purpose: Football is the most popular sport worldwide and anterior cruciate ligament (ACL) reconstruction is one of the most common surgical knee interventions in football players . The ideal graft does not exist, but Bone-Patella-Bone (BTB) autograft considering to be the gold standard not only for its high initial tensile strength, stiffness and excellent incorporation at both ends with direct bone to bone healing, but also due to lower infection and revision rates compared to hamstrings (HA) autograft. Donor site morbidity and anterior knee pain (AKP) remains a significant side effect after BTB ACL reconstruction. As the donor site morbidity and AKP after BTB ACL reconstruction and cannot be considered solved, various techniques has been described in the literature to eliminate those potential drawbacks. In our study, autologous cancellous tibial bone is transplanted to the osseous defect at the patella harvest donor site in order to minimize the donor site morbidity and AKP. Our aim was to investigate in MRI, the healing process of the grafted patella defect with an autologous cancellous tibial bone and evaluate the donor site morbidity and AKP, using Kujala Anterior Knee Pain Scale and kneeling test at 3, 6 and 12 months post-operative.

Methods

A total of 60 ACL reconstructions with BTB autograft in elite and amateur football players were included in this retrospective study. Among them, 52 was males and 8 females with mean age 25±7 years, mean height 175±10cm and mean Body Mass Index (BMI) 23± 3/m2. Informed consent was given by all patients, and the institutional ethics committee of our hospital approved the study protocol. All of the procedures were primary ACL reconstructions and all patients followed up for at least 1 year postoperatively. The patellar osseous defect packed with an autologous cancellous tibial bone graft harvested from the tibial bone block in all patients during a 3-year period, from 2020-2023. Anatomic reconstruction performed via antero-medial portal drilling of the femoral tunnel and all grafts fixed with metallic screws in femoral and tibial tunnels. Patients excluded from the study were those with a past history of ACL reconstruction, other previous knee surgery or patella fracture in the same knee. In MRI, healing of the graft at the patella harvest donor site was evaluated at 3, 6 and 12 months postoperatively. The donor site morbidity and AKP assessed using the Kujala Anterior Knee Pain Scale and kneeling test (minutes in kneeling position, <1min, 1-5min, 5-15min, unrestricted).

Results

Bone healing, with sufficient regeneration and lack of marrow edema, was established in 0% (0/60) of our patients by 3 months, 25% (15/60) by 6 months and 100% (60/60) by 12 months. At 3 months the Mean Kujala score was 43 with kneeling time <1min in 45 patients, at 6 months the mean Kujala score was 73 with kneeling time <5min in 50 patients and at 12 months the mean Kujala score was 93 and the kneeling time >5min in 55 patients.

Conclusion

In MRI, this meticulous operative technique where the patellar osseous defect packed with an autologous cancellous tibial bone graft harvested from the tibial bone block showed a complete bone healing in all football players and a consistent improvement of the Kujala Anterior Knee Pain Scale and kneeling test post-operative, thus allowed football players to play (RTP) in 7.5± 1.5 months.