Bollen's jig and anterior cruciate ligament reconstruction

We report the design of a surgical instrument that facilitates the harvest of the autologous patellar tendon in anterior cruciate ligament (ACL) reconstruction. The advantage of this jig is that it is a simple, self-centring device resulting in a reproducible and consistent autograft. Its use also minimises the potential risks of donor site morbidity such as patellar fracture and tendon rupture. We briefly describe our technique and discuss its advantages.

Keywords: anterior cruciate ligament, autologous tendon, reconstruction.

INTRODUCTION

Recurrent subjective instability that fails to respond to physiotherapy or modification of activity is the main indication for anterior cruciate ligament (ACL) reconstruction. (1)

The two most commonly used autografts for intra-articular reconstruction of the ACL are the central one-third of the patellar and the combined semitendinous and gracilis tendons. (2) The former was first described by Jones (1963) and is the current 'gold standard' for ACL reconstruction. (3,4)

In order to harvest the central one-third patellar bone-tendon-bone autograft, the senior author (SRB) has developed a simple, reproducible device (Figures 1 and 2) designed to provide a convenient, reliable and consistent means of retrieving or harvesting a patellar tendon autograft.

Figure 1 Anterior view of Bollen's jig

Figure 2 Lateral views of Bollen's jig

TECHNIQUE

To facilitate the harvest of a patellar tendon autograft, the senior author (SRB) uses two longitudinal skin incisions of 2 cm for taking the graft. The upper incision is placed at the distal aspect of the patella and the lower just medial to the tibial tubercle (Figure 3).

Figure 3 Siting of the incisions and placement of Bollen's jig

The jig is then inserted in the upper incision and because of its shape centres on the lower pole of the patella (Figure 4).

Figure 4 Placement of Bollen's jig on the lower pole of the patella

Depending on the requirement, by angling the 11-scalpel blade either medially or laterally through the slots, one can consistently obtain a central third patella graft of 9 to 10 mm. The anterior aspect of the patella is incised on either side of the arm, which acts as a guide for cutting the patella block. A trapezoidal-shaped bone block measuring 20 to 25 x 9 mm can be removed from the patella using a small oscillating saw (Figure 5).

Figure 5 Trapezoidal-shaped bone block removed from the patella

The patellar tendon is then split along its length with a finger. The patella block is passed subcutaneously and out of the lower incision and the tibial block is then cut. The autograft is then ready to be used for ACL reconstruction where it is secured by interference screw fixation of the bone blocks.

DISCUSSION

During the procedure of ACL reconstruction using autologous central one-third of the patellar tendon, it is necessary to harvest the patellar tendon autograft. The popularity of the graft is said to be related to the high initial strength, the potential for bone-to-bone healing, and the predictable success in restoring the stability of the knee. However, the donor site morbidity is also well recognized. This includes persistent pain at the donor site, chronic patellofemoral pain, quadriceps weakness, patellar fracture and tendon rupture. The latter two complications can be minimised using the jig here described. To date, we have not seen any patellar fracture and tendon rupture in our series.

In our experience it is a simple, convenient and self-centring device resulting in a reproducible and consistent autograft. Its success has been determined, as it has been used by the senior author (SRB) in more than 300 consecutive cases of central one-third patellar tendon autograft in ACL reconstructions over the last 8 years. We recommend its routine use in ACL reconstruction.

REFERENCES

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