ACL Reconstruction with BPTB (Patellar Tendon) Autograft

Overview

Bone-patellar tendon-bone (BPTB) autograft uses the central third of the patient's own patellar tendon, with a bone plug from the kneecap and shin on either end, to reconstruct a torn ACL. Dr. Raffo, a high-volume ACL surgeon treating patients throughout Bethesda and greater Montgomery County, reaches for BPTB most often in high-level contact and collision athletes and in revision ACL surgery, where its bone-to-bone healing and long registry track record carry the most weight.

How Dr. Raffo Performs This Procedure

The central third of the patellar tendon is harvested through an incision over the front of the knee, along with a bone plug from the patella and the tibial tubercle. The native ACL remnant is debrided arthroscopically, femoral and tibial tunnels are drilled, and the graft's bone plugs are secured in the tunnels, allowing bone-to-bone healing rather than the soft-tissue-to-bone healing required with tendon-only grafts. The knee is inspected for meniscal tears at the same time. In revision cases or knees with high-grade rotational laxity, a lateral extra-articular tenodesis may be added through a separate incision in the same setting.

Who Is This For?

• High-level contact and collision-sport athletes, including football, wrestling, and rugby players, are frequently steered toward BPTB because of its long-standing registry performance in demanding knees.
• Revision ACL reconstruction patients are strong candidates for BPTB, particularly when the primary graft was hamstring and a different tissue plane is desirable.
• Patients whose occupation or sport requires prolonged kneeling — flooring, plumbing, wrestling, volleyball — should discuss the elevated kneeling-difficulty risk before choosing BPTB, since that tradeoff is specific to this graft.
• Patients with pre-existing patellofemoral pain, patella baja, or a narrow patellar tendon are generally not good candidates for BPTB and are better served by quadriceps tendon or hamstring autograft.

Recovery & Rehabilitation

Recovery follows the same criteria-based approach used across ACL grafts, with added early attention to patellofemoral symptoms given the harvest site's proximity to the kneecap. Early motion and weightbearing begin immediately, and open-chain quadriceps exercise is avoided for the first several weeks.

• Weeks 0–2: Early active motion and weightbearing; attention to patellofemoral swelling and full extension.
• Weeks 3–6: Progressive closed-chain quadriceps strengthening.
• Weeks 8–16: Return to running once pain, motion, and strength criteria are met (Rambaud et al., BJSM 2018).
• Months 6–9: Sport-specific agility work, formal strength and hop testing.
• Month 9 and beyond: Return to cutting, pivoting, and contact sport only after passing a strength and hop-test battery (Grindem et al., BJSM 2016).