Current Concepts

Donor-Site Morbidity and Anterior Knee Problems After

Anterior Cruciate Ligament Reconstruction Using Autografts

Jüri Kartus, M.D., Ph.D., Tomas Movin, M.D., Ph.D., and Jon Karlsson, M.D., Ph.D.

Abstract: The authors review the current knowledge on donor site–related problems after using
different types of autografts for anterior cruciate ligament (ACL) reconstruction and make recom-
mendations on minimizing late donor-site problems. Postoperative donor-site morbidity and anterior
knee pain following ACL surgery may result in substantial impairment for patients. The selection of
graft, surgical technique, and rehabilitation program can affect the severity of pain that patients
experience. The loss or disturbance of anterior sensitivity caused by intraoperative injury to the
infrapatellar nerve(s) in conjunction with patellar tendon harvest is correlated with donor-site
discomfort and an inability to kneel and knee-walk. The patellar tendon at the donor site has
significant clinical, radiographic, and histologic abnormalities 2 years after harvest of its central third.
Donor-site discomfort correlates poorly with radiographic and histologic findings after the use of
patellar tendon autografts. The use of hamstring tendon autografts appears to cause less postoperative
donor-site morbidity and anterior knee problems than the use of patellar tendon autografts. There also
appears to be a regrowth of the hamstring tendons within 2 years of the harvesting procedure. There
is little known about the effect on the donor site of harvesting fascia lata and quadriceps tendon
autografts. Efforts should be made to spare the infrapatellar nerve(s) during ACL reconstruction
using patellar tendon autografts. Reharvesting the patellar tendon cannot be recommended due to
significant clinical, radiographic, and histologic abnormalities 2 years after harvesting its central
third. It is important to regain full range of motion and strength after the use of any type of autograft
to avoid future anterior knee problems. If randomized controlled trials show that the long-term laxity
measurements following ACL reconstruction using hamstring tendon autografts are equal to those of
patellar tendon autografts, we recommend the use of hamstring tendon autografts because there are
fewer donor-site problems. Key Words: ACL reconstruction—Autografts—Donor site—Clinical
study—Radiography—Histology.

A t the present time, arthroscopic anterior cruciate

ligament (ACL) reconstruction is one of the most
common surgical procedures in sports medicine. Ev-
the United States.1 After the introduction of the ar-
throscopic technique and the opportunity to perform
reproducible anatomic replacements of the ruptured
ery year, at least 50,000 procedures are performed in ACL, the results in terms of restored laxity and a
return to sports activities have generally been good.2-4
However, persistent donor-site morbidity, such as ten-
From the Departments of Orthopaedics, Sahlgrenska University
derness, anterior knee pain, disturbance in anterior
Hospital, Göteborg (J.K., J.K.); and Huddinge Hospital, Karolin- knee sensitivity, and the inability to kneel and knee-
ska Institute, Stockholm (T.M.), Sweden. walk, is still a problem and is present in approximately
Address correspondence and reprint requests to Jüri Kartus,
M.D., Ph.D., Department of Orthopaedics, Norra Älvsborg Hos- 40% to 60% of patients who have undergone arthro-
pital, SE-461 85 Trollhättan, Sweden. E-mail: juri.kartus@trollhattan. scopic ACL reconstruction using patellar tendon
mail.telia.com autografts.5-12 Despite efforts to utilize synthetic
© 2001 by the Arthroscopy Association of North America
0749-8063/01/1709-2920$35.00/0 materials13,14 and allografts,15,16 the use of autografts
doi:10.1053/jars.2001.28979 remains the most common option for replacing the

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: pp 971–980 971
972 J. KARTUS ET AL.

torn ACL. Common sources of autograft for recon- pain is controversial. Stapleton1 and Kartus et al.36
struction of the ACL include the iliotibial band,17-19 have stated that the loss of flexion causes significantly
the hamstring tendons,20-25 the patellar tendon2,26-31 more anterior knee pain than the loss of extension.
and the quadriceps tendon.32,33 Aglietti et al.37 reported that a loss of flexion exceed-
Provided that the surgical technique was correctly ing 10° might be correlated with anterior knee pain.
used and no internal derangement of the knee has However, Irrgang and Harner34 found that a loss of
occurred, late problems related to the donor site after flexion rarely matters unless the knee flexion is less
ACL reconstruction using autografts can be divided than 110°. Although these reports are all concerned
into 3 categories: (1) general pain and discomfort in with the use of patellar tendon autografts or allo-
the anterior knee region caused by a decrease in func- grafts,34 we can generalize and state that the return of
tion, including range of motion (ROM) and muscular full ROM including full hyperextension is essential to
strength; (2) specific discomfort in terms of numbness, reduce anterior knee problems after ACL reconstruc-
tenderness, and the inability to kneel or withstand tion using any type of graft.
pressure toward the donor site area; and (3) late reac- In line with this, we recommend that it is essential
tions in the tissue in or close to the donor site. to regain normal strength in the lower extremity to
There are several ways of assessing donor site and avoid future pain in the anterior knee region. Risberg
anterior knee region problems. Clinically useful tools et al.38 have reported that pain and strength are the
include (1) measurements of strength using either most important variables to affect the results of ACL
functional tests such as the 1-leg-hop test or dyna- reconstruction using patellar tendon autografts. Mu-
mometers, e.g., Cybex (Hoover, Austin, TX), mea- neta et al.39 reported that patients’ subjective evalua-
surement of loss of motion, assessment of the kneeling tion of the results of ACL reconstruction using either
or knee-walking ability, measurement of the distur- hamstring or patellar tendon autografts was worse if
bance or loss of sensitivity in the area of the donor site the quadriceps or hamstring strength was decreased
or in the area that is innervated by nerves passing the compared with the contralateral side.
donor site; (2) radiographic assessments using stan-
dard radiographs, computed tomography (CT), mag- DISSECTION STUDIES IN THE
netic resonance imaging (MRI), and ultrasonography; KNEE REGION
and (3) histologic and biochemical assessments of
samples obtained from the area of the donor site. Arthornthurasook and Gaew-Im,40 Horner and Del-
The amount of information about the donor site lon,41 Hunter et al.,42 and Kartus et al.43 have shown in
after the use of patellar tendon autografts is fairly dissection studies (Fig 1) that the infrapatellar nerve is
extensive. Some information is available about the
donor site following the use of hamstring autografts;
however, very little information describing the prob-
lems that can occur after ACL reconstruction using
fascia lata or quadriceps tendon autografts is avail-
able.

POSTOPERATIVE RESTRICTION IN ROM

AND LOSS OF STRENGTH
There appears to be agreement in the literature that
the restoration of full extension compared with the
noninjured side after ACL reconstruction is essential
to avoid postoperative discomfort in the anterior knee
region. Irrgang and Harner,34 Harner et al.,35 Sachs et
al.,11 and Kartus et al.36 have stated that the loss of
FIGURE 1. The infrapatellar nerve splits into 2 branches in the
extension contributes to anterior knee pain. Shel- center of a central anterior 8-cm incision. The towel clamps indi-
bourne and Trumper12 have confirmed that the resto- cate the paratenon. The patellar tendon autograft in this specimen
ration of full hyperextension is of major importance was harvested using the 2-incision technique with the aim of
sparing the infrapatellar nerve(s) and the paratenon. In this speci-
when it comes to avoiding anterior knee pain. men, the 2 incisions have been conjoined in order to examine the
The influence of loss of flexion on anterior knee result of the harvesting procedure. (Reprinted with permission.43)
 DONOR-SITE MORBIDITY AFTER ACL RECONSTRUCTION 973

in danger when incisions are made close to or above

the tibial tubercle and the medial side of the knee
joint. It appears from anatomic descriptions of the
prepatellar area that the infrapatellar nerve can be
damaged when incisions are made in the anterior knee
region.44-46 Correspondingly, medial knee incisions
can jeopardize the saphenous nerve.24

KNEE SURGERY AND SENSORY NERVE

COMPLICATIONS
Johnson et al.,47 Swanson,48 and Tapper et al.49
have described postoperative morbidity, such as
numbness and problems with kneeling, after injury to
the infrapatellar branch(es) of the saphenous nerve
after open medial meniscectomies. Chambers50 re-
ported on 3 patients with pain and numbness after
open medial meniscectomies who had scarring or neu-
roma of one infrapatellar branch of the saphenous
nerve. Ganzoni and Wieland51 found a difference in
postoperative sensory loss, depending on whether or
not the infrapatellar nerve(s) were protected during
medial knee arthrotomy.
Mochida and Kikuchi52 have described the possi-
bility of injury to the infrapatellar nerve(s) during
arthroscopic surgery and Poehling et al.53 have de-
scribed the development of reflex sympathetic dystro-
phy after sensory nerve injury in the knee region. The
importance of the sensory nerves in the knee region
was further stressed in reports by Gordon54 and De-
tenbeck55 on prepatellar neuralgia after direct impact
to the anterior knee region, the report by House and
Ahmed56 on the entrapment of the infrapatellar nerve, FIGURE 2. A simple knee-walking test can be used to determine
the discomfort in the anterior knee region after ACL reconstruc-
and the report by Worth et al.57 on the entrapment of tion.62
the saphenous nerve in the knee region. Slocum et
al.58 have discussed the possibility of damage to the
nerves in the anterior knee region during a pes anse- sion was correlated with the area of disturbed or lost
rinus transplantation, which requires an incision sim- anterior knee sensitivity (Fig 3).
ilar to that used for harvesting hamstring tendon au- Mishra et al.60 have reported that the use of 2
tografts. horizontal incisions while harvesting the central third
There are few reports in the literature on the dis- of the patellar tendon may offer an opportunity to
comfort after injury to the infrapatellar nerve or its protect the infrapatellar nerve(s). However, no results
branches in conjunction with ACL surgery. Berg and in terms of nerve function have been presented. Kartus
Mjöberg59 reported that difficulty in kneeling was et al.,43 on the other hand, presented a method using
correlated with the loss of sensitivity in the anterior two 25-mm vertical incisions to reduce the risk of
knee region after open knee ligament surgery. Be- injury to the infrapatellar nerve(s) when harvesting
cause of this, they recommend a lateral parapatellar patellar tendon autografts (Fig 4). This technique was
skin incision. Kartus et al. have, in 2 studies involving first tested in cadavers43 and was subsequently proven
907 and 60436 patients, respectively, reported that the in 2 clinical studies61,62 to produce less loss of sensi-
inability to kneel and knee-walk (Fig 2) after arthro- tivity and a tendency toward less knee-walking dis-
scopic ACL reconstruction using patellar tendon au- comfort than the use of a vertical 7- to 8-cm incision.
tografts harvested through a 7- to 8-cm vertical inci- In a dissection study, Tifford et al.63 reported similar
974 J. KARTUS ET AL.

semitendinosus autografts is of less clinical impor-

tance.
Therefore, it appears that the same amount of dis-
turbance in sensitivity in the knee region after harvest-
ing hamstring tendon autografts causes fewer kneeling
and knee-walking difficulties than after harvesting pa-
tellar tendon autografts. This can be due to the fact
that, after patellar tendon harvest, the pressure when
kneeling is applied directly on or close to the incision
where the injured nerve is located. After harvesting
fascia lata and quadriceps tendon autografts, the risk
of nerve injuries appears to be low and no such reports
have been found in the literature.

LOCAL DISCOMFORT IN THE DONOR

SITE REGION
In a prospective, randomized study, Brandsson et
al.65 have shown that suturing the patellar tendon
defect and bone grafting the defect in the patella did
not reduce anterior knee problems or donor-site mor-
bidity. Boszotta and Prünner 66 also found that bone
grafting the patellar defect did not reduce kneeling
complaints or patellofemoral problems. Therefore, it
appears that suturing and bone grafting the defects
after patellar tendon harvest is of minor importance
when it comes to reducing donor-site problems.
Kartus et al.62 reported that 65% of patients had
difficulty or were unable to perform the knee-walking
test 2 years after patellar tendon harvest using a cen-
tral vertical 7- to 8-cm incision. The corresponding
value after the use of a 2-incision technique with the
aim of sparing the infrapatellar nerve(s) was 47%.62
FIGURE 3. After the use of a central 7- to 8-cm incision to harvest
a patellar tendon autograft, the discomfort during the knee-walking
test correlated with the area of disturbed sensitivity in the anterior
knee region.36,62 (Reprinted with permission.62)

findings and further recommended that incisions in the

anterior knee region should be made with the knee in
flexion so as to avoid injury to the infrapatellar
nerve(s).
When hamstring tendon autografts are harvested, a
branch of the infrapatellar branch of the saphenous
nerve might also be jeopardized24 and, occasionally,
numbness in the skin area supplied by the saphenous
nerve may also occur. Eriksson64 has shown that the
area of disturbed sensitivity after harvesting either
semitendinosus or patellar tendon autografts is com- FIGURE 4. The use of the 2-incision technique to harvest a patellar
tendon autograft resulted in less discomfort during the knee-walk-
parable. However, he suggested that the more distally ing test than the use of the central one-incision technique. (Re-
located area of disturbed sensitivity after harvesting printed with permission.43)
 DONOR-SITE MORBIDITY AFTER ACL RECONSTRUCTION 975

One important finding was reported by Rubinstein et central third and leaving the defect open are contra-
al.,67 who found that isolated donor-site morbidity was dictory. Using MRI assessments, Berg et al.71 and
negligible after ACL surgery when the contralateral Nixon et al.72 claimed that the defect had healed 8
patellar tendon was used as a graft. months and 2 years, respectively, after the index op-
Preoperatively, as well as 2 years after ACL recon- eration. Adriani et al.78 have used ultrasonography to
struction with hamstring autografts, approximately show that the healing of the patellar tendon defect
20% of patients reported that they had difficulty or with tendinous-like scar tissue can be expected ap-
were unable to perform the knee-walking test (Kartus proximately 1 year after harvesting its central third,
et al., unpublished data). Corry et al.68 reported that and Cerullo et al.79 used CT to show that scarring of
only 6% of patients had pain on kneeling 2 years after the open defect takes place within 6 months postop-
reconstruction with hamstring tendon autografts, com- eratively. Rosenberg et al.80 have reported persistent
pared with 31% after reconstruction using patellar defects using CT and MRI, approximately 2 years
tendon autografts. However, no preoperative data after the index operation. In several studies, Kartus et
were presented. Yasuda et al.69 reported that activity- al. have found persistent defects using MRI7,61,75,77,81
related soreness had resolved by 3 months after har- and in 1 study using ultrasonography77 (Figs 5 and 6).
vesting the contralateral hamstring tendon graft. However, even if the defect was still present 2 years
Eriksson64 has shown in prospective randomized stud- after the harvesting procedure it showed a significant
ies that patients operated on using semitendinosus decrease over time in the prospective studies by Kar-
autografts have fewer anterior knee problems and less tus et al.81 and Bernicker et al.82 using MRI and by
donor-site morbidity than patients operated on using Wiley et al.76 using ultrasonography. Liu et al.73 have
patellar tendon autografts, both in the short and long shown that there can be a persistent donor-site gap
terms. These findings suggest that the use of ham- even 13 years after the harvesting procedure. Kartus et
string autografts causes only minor morbidity in the al.7,61 have shown that the kneeling and knee-walking
anterior knee region.
Bak et al.19 reported that 8% of their patients com-
plained of swelling and pain laterally on the thigh after
harvesting a fascia lata autograft; 20% of their patients
also expressed slight dissatisfaction with the cosmesis
of a lateral thigh herniation. However, sensory loss
and nerve injuries were not discussed.
We do not know of any studies of local discomfort
in the donor site region after the use of quadriceps
tendon autografts. However, it has been mentioned by
Chen et al.32 that 1 in 12 patients reported mild har-
vest-site tenderness after an average of 18 months, and
Fulkerson and Langeland33 reported no early quadri-
ceps tendon morbidity in their series of 28 patients.
Thus, both studies regarded the quadriceps tendon as
a low-morbidity graft.

RADIOGRAPHIC ASSESSMENTS
Using MRI assessments of the patellar tendon at the
donor site, Coupens et al.,70 Berg et al.,71 Nixon et
al.,72 Liu et al.,73 Meisterling et al.,74 and Kartus et
al.7,75 have all reported that the thickness of the pa-
tellar tendon increases, at least up to 2 years postop-
eratively, irrespective of whether or not the defect is
sutured. Wiley et al.76 and Kartus et al.77 have had
corresponding findings using ultrasonography. FIGURE 5. A persistent donor-site gap is displayed on this MRI
scan in the axial dimension obtained 26 months after harvesting a
Reports in the literature on the healing of the donor central third patellar tendon autograft. (Reprinted with permis-
site gap in the patellar tendon after harvesting its sion.7)
976 J. KARTUS ET AL.

after harvesting its central third. In contrast, Nixon et

al.72 obtained biopsy specimens from 2 patients 2
years after the harvesting procedure and found tissue
that was indistinguishable from normal tendon using
polarized light microscopy. In a report of a human
case, Berg et al.71 showed that the defect was filled
with hypertrophic “tendon-like” tissue 8 months after
the harvesting procedure. Battlehner et al.88 obtained
biopsy specimens through an open incision from 8
humans a minimum of 24 months after ACL recon-
struction using patellar tendon autografts and found,
using light and electron microscopy, that the patellar
tendon did not regain the appearance of normal ten-
don. In their study, however, the donor-site gap was
FIGURE 6. A persistent donor site gap is displayed on this ultra- closed during the ACL reconstruction. In a biopsy
sonography image obtained 25 months after harvesting a central
third patellar tendon autograft. (Reprinted with permission.77) study of 19 patients 27 months after harvesting the
central third of the patellar tendon and leaving the
defect open, Kartus et al.77 found tendon-like repair
problems did not correlate with any MRI findings in tissue in the donor site. However, histologic abnor-
the patellar tendon at the donor site. The correspond- malities in terms of increased cellularity, vascularity,
ing finding in terms of patellar tendon pain was made and nonparallel fibers were present in both the central
by Kiss et al.83 using ultrasonography. (Fig 7) and peripheral (Fig 8) parts of the tendon. No
After harvesting hamstring tendon autografts, it ap- correlation between the histologic findings and donor-
pears that there is at least some regrowth in the semi- site discomfort were registered (Kartus et al., unpub-
tendinosus and gracilis tendons. This has been re- lished data).
ported in the literature by Cross et al.,84 Simonian et
al.,85 and Eriksson et al.64,86 using MRI. In their pro-
spective ultrasonography study, Papandrea et al.87 re-
ported that the regrowth of the tendons appeared to be
completed 2 years after the harvesting procedure.
However, the insertion of the tendons was approxi-
mately 3 to 4 cm more proximal than the normal
anatomic position. No radiographic data on the donor
site after harvesting fascia lata and quadriceps tendon
autografts are available.

HISTOLOGIC EXAMINATIONS
Reports on donor-site histology in humans are few
in number.71,72,77,88 Histologic descriptions of the area
of the donor site after ACL reconstruction using cen-
tral patellar tendon autografts in a goat model have
been given by Proctor et al.89 They found ill-defined
fascicles and woven collagen fibrils poorly aligned
with the longitudinal axis of the patellar ligament in
the central part of the tendon 21 months after the
harvesting procedure. Correspondingly, in a study of
lambs, Sanchis-Alfonso et al.90 found that the regen-
erated tissue in the harvest-site defect did not have the FIGURE 7. A high-power view of a biopsy specimen obtained
histologic appearance of normal patellar tendon. In a from the central part of the patellar tendon 24 months after the
harvesting procedure showing increased cellularity, vascularity,
dog model, Burks et al.91 found that the entire patellar and nonparallel fibers (H&E, original magnification ⫻200). (Re-
tendon was involved in scar formation 3 and 6 months printed with permission.77)
 DONOR-SITE MORBIDITY AFTER ACL RECONSTRUCTION 977

Increasing concentrations of GAGs are seen in areas

of tendons that are subjected to compression forces as
described by Vogel et al.,96 in pathologic scar tissue in
the Achilles tendon as described by Movin et al.,97 and
in the patellar tendon in “jumper’s knee” (tendinosis)
disease as described by Khan et al.98 and Green et al.99
Furthermore, Kannus and Jozsa100 have reported that
increasing amounts of GAGs are found in ruptured
tendons compared with healthy control tendons. Kar-
tus et al.77 showed that there were no GAGs in the
biopsy specimens obtained from the patellar tendon 27
months after the harvesting procedure. This suggests
that factors other than retained water contributed to
the increase in the cross-sectional area of the patellar
tendon, and furthermore, that the repair tissue did not
display the similarities with the tendon pathology that
has been found in achillodynia and jumper’s knee.
The presence of collagen type III is associated with
early collagen synthesis in a repair process in tendons,
as described by Liu et al.101 and Matsumuto et al.102 in
rat models. Collagen type III has the capacity to
rapidly form cross-linked intermolecular disulfide
bridges.103,104 This capacity is supposed to be a great
FIGURE 8. Photomicrograph of a biopsy specimen obtained from advantage in the development of repair tissue.103 Col-
the peripheral part of the patellar tendon 24 months after the lagen type III fibers are also known to be thin, with
harvesting procedure showing increased cellularity, vascularity,
and nonparallel fibers (H&E, original magnification ⫻100). (Re- inferior mechanical properties, compared with colla-
printed with permission.77) gen type I. Kartus et al.77 failed to find increased
amounts of collagen type III in the central and periph-
eral parts of the patellar tendon, which indicates that
The finding of histologic abnormalities in the hu- no early collagen synthesis was present 27 months
man patellar tendon up to 27 months after the primary after the harvesting procedure.
harvest strongly suggests that reharvesting the central Eriksson64 has shown that the immunoreactivity for
third of the patellar tendon cannot be recommended. collagen types I and III in regenerated semitendinosus
This opinion is supported by the findings of LaPrade tendon was similar to that of normal tendon 20 months
et al.92 in a dog model of inferior mechanical proper- after the harvesting procedure. We do not know of any
ties in the reharvested central third patellar tendon up biochemical data after harvesting fascia lata or quad-
to 12 months after the primary procedure, and by riceps tendon autografts.
Scherer et al.93 in a sheep model, the corresponding
finding in the remaining two thirds of the patellar
CONCLUSIONS
tendon.
Eriksson64 obtained open biopsy specimens from ● There is a lack of knowledge about the course of the
the regenerated tendon in 5 humans 20 months after donor site after harvesting hamstring, fascia lata,
the harvest of a semitendinosus autograft. Surpris- and quadriceps tendon autografts.
ingly, they resembled normal tendon. No histologic ● Reduced strength and loss of ROM are correlated
data from the donor site after harvesting fascia lata or with anterior knee pain after ACL reconstruction
quadriceps tendon autografts are available. using all kinds of autograft. Therefore, efforts
should be made during the surgical procedure and
BIOCHEMICAL INVESTIGATIONS the rehabilitation process for patients to regain full
ROM and full strength after ACL reconstructions
Sulfated glycosaminoglycans (GAGs) possess a regardless of the type of graft used.
very high water-retaining capacity and they appear in ● Loss or disturbance of anterior knee sensitivity
low concentrations in the normal patellar tendon.94,95 caused by intraoperative injury to the infrapatellar
978 J. KARTUS ET AL.

nerve(s) in conjunction with patellar tendon harvest ral problems after anterior cruciate ligament reconstruction.
are correlated with donor-site discomfort and an Am J Sports Med 1989;17:760-765.
12. Shelbourne KD, Trumper RV. Preventing anterior knee pain
inability to kneel and knee-walk. after anterior cruciate ligament reconstruction. Am J Sports
● No correlations can be found between donor-site Med 1997;25:41-47.
discomfort and radiographic or histologic findings 13. Dandy DJ, Flanagan JP, Steenmeyer V. Arthroscopy and the
management of the ruptured anterior cruciate ligament. Clin
after the use of patellar tendon autografts. Orthop 1982;167:43-49.
● If the surgeon wishes to use patellar tendon au- 14. Engström B, Wredmark T, Westblad P. Patellar tendon or
tografts, efforts to spare the infrapatellar nerve(s) Leeds-Keio graft in the surgical treatment of anterior cruciate
ligament ruptures. Intermediate results. Clin Orthop 1993;
should be made during surgery. 295:190-197.
● Because of both radiographic and histologic abnor- 15. Jackson DW, Grood ES, Goldstein JD, Rosen MA, Kurzweil
malities in the patellar tendon after primary harvest, PR, Cummings JF, Simon TM. A comparison of patellar
tendon autograft and allograft used for anterior cruciate lig-
reharvesting cannot be recommended, at least not ament reconstruction in the goat model. Am J Sports Med
for up to 2 years after the primary harvest. 1993;21:176-185.
● If, in prospective randomized studies, the use of 16. Noyes FR, Barber-Westin SD. Reconstruction of the anterior
cruciate ligament with human allograft. Comparison of early
hamstring tendon autografts for ACL reconstruction and later results. J Bone Joint Surg Am 1996;78:524-537.
is shown to produce long-term laxity measurements 17. Nicholas JA, Minkoff J. Iliotibial band transfer through the
equal to those of patellar tendon autografts, we intercondylar notch for combined anterior instability (ITPT
procedure). Am J Sports Med 1978;6:341-353.
recommend the use of hamstring tendon autografts 18. Ekstrand J. Reconstruction of the anterior cruciate ligament
because there are fewer donor site problems. in athletes, using a fascia lata graft: A review with prelimi-
nary results of a new concept. Int J Sports Med 1989;10:225-
232.
19. Bak K, Jörgensen U, Ekstrand J, Scavenius M. Results of
REFERENCES reconstruction of acute ruptures of the anterior cruciate liga-
ment with an iliotibial band autograft. Knee Surg Sports
1. Stapleton TR. Complications in anterior cruciate ligament Traumatol Arthrosc 1999;7:111-117.
reconstructions with patellar tendon grafts. Sports Med Ar- 20. Aglietti P, Buzzi R, Menchetti PM, Giron F. Arthroscopically
throsc Rev 1997;5:156-162. assisted semitendinosus and gracilis tendon graft in recon-
2. Bach BR Jr, Jones GT, Sweet FA, Hager CA. Arthroscopy- struction for acute anterior cruciate ligament injuries in ath-
assisted anterior cruciate ligament reconstruction using patel- letes. Am J Sports Med 1996;24:726-731.
lar tendon substitution. Two- to four-year follow-up results. 21. Puddu G. Method for reconstruction of the anterior cruciate
Am J Sports Med 1994;22:758-767. ligament using the semitendinosus tendon. Am J Sports Med
3. Bach BR Jr, Jones GT, Hager CA, Sweet FA, Luergans S. 1980;8:402-404.
Arthrometric results of arthroscopically assisted anterior cru- 22. Otero AL, Hutcheson L. A comparison of the doubled semi-
ciate ligament reconstruction using autograft patellar tendon tendinosus/gracilis and central third of the patellar tendon
substitution. Am J Sports Med 1995;23:179-185. autografts in arthroscopic anterior cruciate ligament recon-
4. Buss DD, Warren RF, Wickiewicz TL, Galinat BJ, Panariello struction. Arthroscopy 1993;9:143-148.
R. Arthroscopically assisted reconstruction of the anterior 23. Siegel MG, Barber-Westin SD. Arthroscopic-assisted outpa-
cruciate ligament with use of autogenous patellar-ligament tient anterior cruciate ligament reconstruction using the semi-
grafts. Results after twenty-four to forty-two months. J Bone tendinosus and gracilis tendons. Arthroscopy 1998;14:268-
Joint Surg Am 1993;75:1346-1355. 277.
5. Breitfuss H, Fröhlich R, Povacz P, Resch H, Wicker A. The 24. Brown CH Jr, Steiner ME, Carson EW. The use of hamstring
tendon defect after anterior cruciate ligament reconstruction tendons for anterior cruciate ligament reconstruction. Tech-
using the midthird patellar tendon—A problem for the patel- nique and results. Clin Sports Med 1993;12:723-756.
lofemoral joint? Knee Surg Sports Traumatol Arthrosc 1996; 25. Hamner DL, Brown CH Jr, Steiner ME, Hecker AT, Hayes
3:194-198. WC. Hamstring tendon grafts for reconstruction of the ante-
6. Graf B, Uhr F. Complications of intra-articular anterior cru- rior cruciate ligament: Biomechanical evaluation of the use of
ciate reconstruction. Clin Sports Med 1988;7:835-848. multiple strands and tensioning techniques. J Bone Joint Surg
7. Kartus J, Stener S, Lindahl S, Engström B, Eriksson BI, Am 1999;81:549-557.
Karlsson J. Factors affecting donor-site morbidity after ante- 26. Alm A, Gillquist J. Reconstruction of the anterior cruciate
rior cruciate ligament reconstruction using bone-patellar ten- ligament by using the medial third of the patellar ligament.
don-bone autografts. Knee Surg Sports Traumatol Arthrosc Treatment and results. Acta Chir Scand 1974;140:289-296.
1997;5:222-228. 27. Clancy WG Jr, Nelson DA, Reider B, Narechania RG. An-
8. Kohn D, Sander-Beuermann A. Donor-site morbidity after terior cruciate ligament reconstruction using one-third of the
harvest of a bone-tendon-bone patellar tendon autograft. patellar ligament, augmented by extra-articular tendon trans-
Knee Surg Sports Traumatol Arthrosc 1994;2:219-223. fers. J Bone Joint Surg Am 1982;64:352-359.
9. Mohtadi NG, Webster-Bogaert S, Fowler PJ. Limitation of 28. Eriksson E. Reconstruction of the anterior cruciate ligament.
motion following anterior cruciate ligament reconstruction. A Orthop Clin North Am 1976;7:167-179.
case-control study. Am J Sports Med 1991;19:620-625. 29. Jones KG. Reconstruction of the anterior cruciate ligament.
10. Paulos LE, Rosenberg TD, Drawbert J, Manning J, Abbott P. J Bone Joint Surg Am 1963;45:925-932.
Infrapatellar contracture syndrome. An unrecognized cause 30. Jones KG. Reconstruction of the anterior cruciate ligament
of knee stiffness with patella entrapment and patella infera. using the central one-third of the patellar ligament. J Bone
Am J Sports Med 1987;15:331-341. Joint Surg Am 1970;52:838-839.
11. Sachs RA, Daniel DM, Stone ML, Garfein RF. Patellofemo- 31. Marshall JL, Warren RF, Wickiewicz TL, Reider B. The
 DONOR-SITE MORBIDITY AFTER ACL RECONSTRUCTION 979

anterior cruciate ligament: A technique of repair and recon- 55. Detenbeck LC. Infrapatellar traumatic neuroma resulting
struction. Clin Orthop 1979;143:97-106. from dashboard injury. J Bone Joint Surg Am 1972;54:170-
32. Chen CH, Chen WJ, Shih CH. Arthroscopic anterior cruciate 172.
ligament reconstruction with quadriceps tendon-patellar bone 56. House JH, Ahmed K. Entrapment neuropathy of the infrapa-
autograft. J Trauma 1999;46:678-682. tellar branch of the saphenous nerve. Am J Sports Med
33. Fulkerson JP, Langeland R. An alternative cruciate recon- 1977;5:217-224.
struction graft: The central quadriceps tendon. Arthroscopy 57. Worth RM, Kettelkamp DB, Defalque RJ, Duane KU. Sa-
1995;11:252-254. phenous nerve entrapment. A cause of medial knee pain.
34. Irrgang JJ, Harner CD. Loss of motion following knee liga- Am J Sports Med 1984;12:80-81.
ment reconstruction. Sports Med 1995;19:150-159. 58. Slocum DB, Larson RL. Pes anserinus transplantation. A
35. Harner CD, Irrgang JJ, Paul J, Dearwater S, Fu FH. Loss of surgical procedure for control of rotatory instability of the
motion after anterior cruciate ligament reconstruction. Am J knee. J Bone Joint Surg Am 1968;50:226-242.
Sports Med 1992;20:499-506. 59. Berg P, Mjöberg B. A lateral skin incision reduces peripatel-
36. Kartus J, Magnusson L, Stener S, Brandsson S, Eriksson BI, lar dysaesthesia after knee surgery. J Bone Joint Surg Br
Karlsson J. Complications following arthroscopic anterior 1991;73:374-376.
cruciate ligament reconstruction. A 2-5-year follow-up of 604 60. Mishra AK, Fanton GS, Dillingham MF, Carver TJ. Patellar
patients with special emphasis on anterior knee pain. Knee tendon graft harvesting using horizontal incisions for anterior
Surg Sports Traumatol Arthrosc 1999;7:2-8. cruciate ligament reconstruction. Arthroscopy 1995;11:749-
37. Aglietti P, Buzzi R, D’Andria S, Zaccherotti G. Patellofemo- 752.
ral problems after intraarticular anterior cruciate ligament 61. Kartus J, Lindahl S, Stener S, Eriksson BI, Karlsson J.
reconstruction. Clin Orthop 1993;288:195-204. Magnetic resonance imaging of the patellar tendon after
38. Risberg MA, Holm I, Tjomsland O, Ljunggren E, Ekeland A. harvesting its central third: A comparison between traditional
Prospective study of changes in impairments and disabilities and subcutaneous harvesting techniques. Arthroscopy 1999;
after anterior cruciate ligament reconstruction. J Orthop 15:587-593.
Sports Phys Ther 1999;29:400-412. 62. Kartus J, Ejerhed L, Sernert N, Brandsson S, Karlsson
39. Muneta T, Sekiya I, Ogiuchi T, Yagishita K, Yamamoto H, J. Comparison of traditional and subcutaneous patellar tendon
Shinomiya K. Objective factors affecting overall subjective harvest. A prospective study of donor site-related problems
evaluation of recovery after anterior cruciate ligament recon- after anterior cruciate ligament reconstruction using different
struction. Scand J Med Sci Sports 1998;8:283-289. graft harvesting techniques. Am J Sports Med 2000;28:328-
40. Arthornthurasook A, Gaew-Im K. Study of the infrapatellar 335.
nerve. Am J Sports Med 1988;16:57-59. 63. Tifford CD, Spero L, Luke T, Plancher KD. The relationship
41. Horner G, Dellon AL. Innervation of the human knee joint of the infrapatellar branches of the saphenous nerve to ar-
and implications for surgery. Clin Orthop 1994;301:221-226. throscopy portals and incisions for anterior cruciate ligament
42. Hunter LY, Louis DS, Ricciardi JR, O’Connor GA. The surgery. An anatomic study. Am J Sports Med 2000;28:562-
saphenous nerve: Its course and importance in medial arth- 567.
rotomy. Am J Sports Med 1979;7:227-230. 64. Eriksson K. On the semitendinosus in anterior cruciate liga-
43. Kartus J, Ejerhed L, Eriksson BI, Karlsson J. The localization ment reconstructive surgery. Thesis, Karolinska Institutet,
of the infrapatellar nerves in the anterior knee region with Stockholm, Sweden, 2001.
special emphasis on central third patellar tendon harvest: A 65. Brandsson S, Faxén E, Eriksson BI, Kälebo P, Swärd L,
dissection study on cadaver and amputated specimens. Ar- Lundin O, Karlsson J. Closing patellar tendon defects after
throscopy 1999;15:577-586. anterior cruciate ligament reconstruction: Absence of any
44. Abbott LC, Carpenter WF. Surgical approaches to the knee benefit. Knee Surg Sports Traumatol Arthrosc 1998;6:82-87.
joint. J Bone Joint Surg Am 1945;27:277-310. 66. Boszotta H, Prunner K. Refilling of removal defects: Impact
45. Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the on extensor mechanism complaints after use of a bone-
human knee and its functional importance. Am J Sports Med tendon-bone graft for anterior cruciate ligament reconstruc-
1982;10:329-335. tion. Arthroscopy 2000;16:160-164.
46. von Lantz T, Wachmuth W. Praktische anatomie. Berlin: 67. Rubinstein RA Jr, Shelbourne KD, VanMeter CD, McCarroll
Springer-Verlag, 1972. JC, Rettig AC. Isolated autogenous bone-patellar tendon-
47. Johnson RJ, Kettelkamp DB, Clark W, Leaverton P. Factors bone graft site morbidity. Am J Sports Med 1994;22:324-327.
effecting late results after meniscectomy. J Bone Joint Surg 68. Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA. Ar-
Am 1974;56:719-729. throscopic reconstruction of the anterior cruciate ligament. A
48. Swanson AJ. The incidence of prepatellar neuropathy follow- comparison of patellar tendon autograft and four-strand ham-
ing medial meniscectomy. Clin Orthop 1983;181:151-153. string tendon autograft. Am J Sports Med 1999;27:444-454.
49. Tapper EM, Hoover NW. Late results after meniscectomy. 69. Yasuda K, Tsujino J, Ohkoshi Y, Tanabe Y, Kaneda K. Graft
J Bone Joint Surg Am 1969;51:517-526. site morbidity with autogenous semitendinosus and gracilis
50. Chambers GH. The prepatellar nerve. A cause of suboptimal tendons. Am J Sports Med 1995;23:706-714.
results in knee arthrotomy. Clin Orthop 1972;82:157-159. 70. Coupens SD, Yates CK, Sheldon C, Ward C. Magnetic
51. Ganzoni N, Wieland K. The ramus infrapatellaris of the resonance imaging evaluation of the patellar tendon after use
saphenous nerve and its importance for medial parapatellar of its central one-third for anterior cruciate ligament recon-
arthrotomies of the knee. Reconstr Surg Traumatol 1978;16: struction. Am J Sports Med 1992;20:332-335.
95-100. 71. Berg EE. Intrinsic healing of a patellar tendon donor site
52. Mochida H, Kikuchi S. Injury to infrapatellar branch of defect after anterior cruciate ligament reconstruction. Clin
saphenous nerve in arthroscopic knee surgery. Clin Orthop Orthop 1992;278:160-163.
1995;320:88-94. 72. Nixon RG, SeGall GK, Sax SL, Cain TE, Tullos HS. Recon-
53. Poehling GG, Pollock FE Jr, Koman LA. Reflex sympathetic stitution of the patellar tendon donor site after graft harvest.
dystrophy of the knee after sensory nerve injury. Arthroscopy Clin Orthop 1995;317:162-171.
1988;4:31-35. 73. Liu SH, Hang DW, Gentili A, Finerman GA. MRI and
54. Gordon GC. Traumatic prepatellar neuralgia. J Bone Joint morphology of the insertion of the patellar tendon after graft
Surg Br 1952;34:41-44. harvesting. J Bone Joint Surg Br 1996;78:823-826.
980 J. KARTUS ET AL.

74. Meisterling RC, Wadsworth T, Ardill R, Griffiths H, Lane- Montes GS. Histochemical and ultrastructural study of the
Larsen CL. Morphologic changes in the human patellar ten- extracellular matrix fibers in patellar tendon donor site scars
don after bone-tendon-bone anterior cruciate ligament recon- and normal controls. J Submicrosc Cytol Pathol 1996;28:
struction. Clin Orthop 1993;289:208-212. 175-186.
75. Kartus J, Stener S, Lindahl S, Eriksson BI, Karlsson J. Ipsi- 89. Proctor CS, Jackson DW, Simon TM. Characterization of the
or contralateral patellar tendon graft in anterior cruciate lig- repair tissue after removal of the central one-third of the
ament revision surgery. A comparison of two methods. Am J patellar ligament. An experimental study in a goat model.
Sports Med 1998;26:499-504. J Bone Joint Surg Am 1997;79:997-1006.
76. Wiley JP, Bray RC, Wiseman DA, Elliott PD, Ladly KO, 90. Sanchis-Alfonso V, Subias-Lopez A, Monteagudo-Castro C,
Vale LA. Serial ultrasonographic imaging evaluation of the Rosello-Sastre E. Healing of the patellar tendon donor defect
patellar tendon after harvesting its central one third for ante- created after central-third patellar tendon autograft harvest. A
rior cruciate ligament reconstruction. J Ultrasound Med long-term histological evaluation in the lamb model. Knee
1997;16:251-255. Surg Sports Traumatol Arthrosc 1999;7:340-348.
77. Kartus J, Movin T, Papadogiannakis N, Christensen LR, 91. Burks RT, Haut RC, Lancaster RL. Biomechanical and his-
Lindahl S, Karlsson J. A radiographic and histologic evalu- tological observations of the dog patellar tendon after re-
ation of the patellar tendon after harvesting its central third. moval of its central one-third. Am J Sports Med 1990;18:146-
Am J Sports Med 2000;28:218-226. 153.
78. Adriani E, Mariani PP, Maresca G, Santori N. Healing of the 92. LaPrade RF, Hamilton CD, Montgomery RD, Wentorf F,
patellar tendon after harvesting of its mid-third for anterior Hawkins HD. The reharvested central third of the patellar
cruciate ligament reconstruction and evolution of the un- tendon. A histologic and biomechanical analysis. Am J Sports
closed donor site defect. Knee Surg Sports Traumatol Ar- Med 1997;25:779-785.
throsc 1995;3:138-143. 93. Scherer MA, Fruh HJ, Ascherl R, Siebels W. Biomechanical
79. Cerullo G, Puddu G, Gianni E, Damiani A, Pigozzi F. Ante- studies of change in the patellar tendon after transplant re-
rior cruciate ligament patellar tendon reconstruction: It is moval. Aktuelle Traumatol 1993;23:129-132.
probably better to leave the tendon defect open! Knee Surg 94. Amiel D, Kleiner JB, Roux RD, Harwood FL, Akeson WH.
Sports Traumatol Arthrosc 1995;3:14-17. The phenomenon of “ligamentization”: Anterior cruciate lig-
80. Rosenberg TD, Franklin JL, Baldwin GN, Nelson KA. Ex- ament reconstruction with autogenous patellar tendon. J Or-
tensor mechanism function after patellar tendon graft harvest
thop Res 1986;4:162-172.
for anterior cruciate ligament reconstruction. Am J Sports
95. Amiel D, Frank C, Harwood F, Fronek J, Akeson W. Ten-
Med 1992;20:519-525.
dons and ligaments: A morphological and biochemical com-
81. Kartus J, Lindahl S, Köhler K, Sernert N, Eriksson BI,
Karlsson J. Serial magnetic resonance imaging of the donor parison. J Orthop Res 1984;1:257-265.
site after harvesting the central third of the patellar tendon. A 96. Vogel KG, Ordog A, Pogany G, Olah J. Proteoglycans in the
prospective study of 37 patients after arthroscopic anterior compressed region of human tibialis posterior tendon and in
cruciate ligament reconstruction. Knee Surg Sports Trauma- ligaments. J Orthop Res 1993;11:68-77.
tol Arthrosc 1999;7:20-24. 97. Movin T, Gad A, Reinholt FP, Rolf C. Tendon pathology in
82. Bernicker JP, Haddad JL, Lintner DM, DiLiberti TC, Bocell long-standing achillodynia. Biopsy findings in 40 patients.
JR. Patellar tendon defect during the first year after anterior Acta Orthop Scand 1997;68:170-175.
cruciate ligament reconstruction: Appearance on serial mag- 98. Khan KM, Bonar F, Desmond PM, et al. Patellar tendinosis
netic resonance imaging. Arthroscopy 1998;14:804-809. (jumper’s knee): Findings at histopathologic examination,
83. Kiss ZS, Kellaway DP, Cook JL, Khan KM. Postoperative US, and MR imaging. Victorian Institute of Sport Tendon
patellar tendon healing: An ultrasound study. VIS Tendon Study Group. Radiology 1996;200:821-827.
Study Group. Australas Radiol 1998;42:28-32. 99. Green JS, Morgan B, Lauder I, Finlay DB, Allen M. Corre-
84. Cross MJ, Roger G, Kujawa P, Anderson IF. Regeneration of lation of magnetic resonance imaging and histology in patel-
the semitendinosus and gracilis tendons following their tran- lar tendinitis. Sports Exerc Inj 1997;3:80-84.
section for repair of the anterior cruciate ligament. Am J 100. Kannus P, Jozsa L. Histopathological changes preceding
Sports Med 1992;20:221-223. spontaneous rupture of a tendon. A controlled study of 891
85. Simonian PT, Harrison SD, Cooley VJ, Escabedo EM, patients. J Bone Joint Surg Am 1991;73:1507-1525.
Deneka DA, Larson RV. Assessment of morbidity of semi- 101. Liu SH, Yang RS, al-Shaikh R, Lane JM. Collagen in tendon,
tendinosus and gracilis tendon harvest for ACL reconstruc- ligament, and bone healing. A current review. Clin Orthop
tion. Am J Knee Surg 1997;10:54-59. 1995;318:265-278.
86. Eriksson K, Larsson H, Wredmark T, Hamberg P. Semiten- 102. Matsumoto N, Horibe S, Nakamura N, Senda T, Shino K,
dinosus tendon regeneration after harvesting for ACL recon- Ochi T. Effect of alignment of the transplanted graft extra-
struction. A prospective MRI study. Knee Surg Sports Trau- cellular matrix on cellular repopulation and newly synthe-
matol Arthrosc 1999;7:220-225. sized collagen. Arch Orthop Trauma Surg 1998;117:215-221.
87. Papandrea P, Vulpiani MC, Ferretti A, Conteduca F. Regen- 103. Burgeson RE, Nimni ME. Collagen types. Molecular struc-
eration of the semitendinosus tendon harvested for anterior ture and tissue distribution. Clin Orthop 1992;282:250-272.
cruciate ligament reconstruction. Evaluation using ultra- 104. Cheung DT, DiCesare P, Benya PD, Libaw E, Nimni ME.
sonography. Am J Sports Med 2000;28:556-561. The presence of intermolecular disulfide cross-links in type
88. Battlehner CN, Carneiro Filho M, Ferreira JM Jr, Saldiva PH, III collagen. J Biol Chem 1983;258:7774-7778.