Comparison of traditional and subcutaneous patellar tendon harvest. A prospective study of donor site-related problems after anterior cruciate ligament reconstruction using different graft harvesting techniques

A literature review of autograft and allograft anterior cruciate ligament reconstruction

Knee anterior cruciate ligament reconstructive surgery has significantly evolved and now includes the option of using an allograft. This has resulted in numerous studies evaluating the advantages and disadvantages of allografts. The purpose of this literature review is to evaluate this research and present important findings to allow the selection of the most appropriate graft source when considering allograft versus autograft reconstruction.

Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction: a prospective, randomized study with a 7-Year follow-up

BACKGROUND

The aim of the study was to compare the results after arthroscopic anterior cruciate ligament (ACL) reconstruction using central-third bone-patellar tendon-bone (BTB) autografts and triple/quadruple semitendinosus (ST) autografts.

HYPOTHESIS

In the long-term, ACL reconstruction using BTB autografts will render more donor-site problems than ST autografts.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A randomized series of 71 patients (22 women and 49 men) with a unilateral ACL rupture who underwent reconstructive surgery were included in the study. The BTB graft was used in 34 patients (BTB group) and the ST-tendon graft was used in 37 patients (ST group). The patients were examined a median of 86 months (range, 68 to 114 months) after the reconstruction.

RESULTS

Sixty-eight of 71 patients (96%) were examined at follow-up. The clinical assessments at follow-up revealed no significant differences between the BTB group and the ST group in terms of the Lysholm score, Tegner activity level, International Knee Documentation Committee evaluation system, 1-legged hop test, KT-1000 arthrometer laxity measurements, manual Lachman test, and range of motion. A significant improvement was seen in both groups compared with the preoperative values in terms of most clinical assessments. Donor-site morbidity in the form of knee-walking ability, kneeling ability, and area of disturbed anterior knee sensitivity revealed no significant differences between the groups.

CONCLUSION

Seven years after ACL reconstruction, the subjective and objective outcomes were similar after using the central-third BTB autograft and triple/quadruple ST autograft. Furthermore, no difference in terms of donor-site morbidity was found between the 2 groups.

A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial

BACKGROUND

There are no controlled, prospective studies comparing the 10-year outcomes of anterior cruciate ligament (ACL) reconstruction using patellar tendon (PT) and 4-strand hamstring tendon (HT) autografts.

HYPOTHESIS

Comparable results are possible with HT and PT autografts.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

One hundred eighty ACL-deficient knees that met inclusion criteria underwent ACL reconstruction (90 HT autograft, 90 PT autograft) by one surgeon and were treated with an accelerated rehabilitation program. All knees were observed in a prospective fashion with subjective, objective, and radiographic evaluation at 2, 5, 7, and 10-year intervals.

RESULTS

At 10 years, there were no differences in graft rupture rates (7/90 PT vs. 12/90 HT, P = .24). There were 20 contralateral ACL ruptures in the PT group, compared with 9 in the HT group (P = .02). In all patients, graft rupture was associated with instrumented laxity >2 mm at 2 years (P = .001). Normal or near-normal function of the knee was reported in 97% of patients in both groups. In the PT group, harvest-site symptoms (P = .001) and kneeling pain (P = .01) were more common than in the HT group. More patients reported pain with strenuous activities in PT knees than in HT knees (P = .05). Radiographic osteoarthritis was more common in PT knees than the HT-reconstructed knees (P = .04). The difference, however, was composed of patients with mild osteoarthritis. Other predictors of radiographic osteoarthritis were <90% single-legged hop test at 1 year and the need for further knee surgery. An "ideal" outcome, defined as an overall International Knee Documentation Committee grade of A or B and a radiographic grade of A at 10 years after ACL reconstruction, was associated with <3 mm of instrumented laxity at 2 years, the absence of additional surgery in the knee, and HT grafts.

CONCLUSIONS

It is possible to obtain excellent results with both HT and PT autografts. We recommend HT reconstructions to our patients because of decreased harvest-site symptoms and radiographic osteoarthritis.

The course of the patellar tendon after reharvesting its central third for ACL revision surgery: a long-term clinical and radiographic study

The choice of the optimal graft for anterior cruciate ligament (ACL) revision surgery is still controversial. Reharvesting the patellar tendon has been suggested as one graft alternative. Our hypothesis was that in the long-term, ACL revision surgery using reharvested patellar tendon autografts would render a good clinical outcome and a normal patellar tendon at the donor site as seen on magnetic resonance imaging (MRI). Fourteen consecutive patients (five women, nine men), who underwent ACL revision surgery using reharvested ipsilateral patellar tendon grafts, were included in the study. They underwent bilateral MRI evaluations of the patellar tendon and were tested for clinical outcome 26 (20-35) and 115 months (102-127) after the revision procedure. On the second occasion, they also underwent standard weight-bearing X-ray examinations. The serial MRI evaluations revealed that the thickness of the patellar tendon at the donor site was significantly increased compared with the non-harvested, normal contralateral side and that the donor-site gap was still visible after 10 years. No significant differences were seen between the 2- and 10-year MRI evaluations. Standard weight-bearing X-ray examinations revealed signs of mild degenerative changes in all patients. Clinical results in terms of the Lysholm score, IKDC evaluation system, one-leg-hop test, KT-1000 laxity test and the knee-walking test revealed no significant differences between the 2- and 10-year assessments. In overall terms, the clinical results were considered to be poor on both occasions. The patellar tendon at the donor site had not normalised 10 years after the reharvesting procedure, as seen on MRI. Furthermore, the clinical results were poor after ACL revision surgery using reharvested patellar tendon autograft.

Prospective and randomized evaluation of ACL reconstruction with three techniques: a clinical and radiographic evaluation at 5 years follow-up

A variety of graft sources have been used for ACL reconstruction to improve functions and kinematics in ACL deficient knees. The two most commonly used autogenous grafts are the central third of the patellar tendon and the hamstring tendon constructs. The choice of different grafts and different construct influence the final clinical outcome of ACL reconstruction. The 3 groups, of 25 patients each, were generated by choosing the technique (PT tendon, 4 strand hamstring, and single hamstring plus extraarticular plasty) to utilize and followed for 5 years, with an alternate systematic sampling. Our comparison has shown significant kneeling pain in the patellar tendon with respect to the groups with hamstrings techniques. Single hamstring plus extraarticular plasty achieved subjective score significantly higher with respect to the other two groups as well as for the time to resume sport. The study confirms that patellar tendon and hamstring can be equivalent options for ACL reconstruction. This study demonstrated that a superior outcome as far as subjective clinical findings were concerned, was obtained in group III. Patients in the latter group were also able to return to sports sooner than those in the bone-patellar tendon graft group and the four-strand hamstring group.

Injuries to the infrapatellar branch(es) of the saphenous nerve in anterior cruciate ligament reconstruction with four-strand hamstring tendon autograft: vertical versus horizontal incision for harvest

The goal of this study is to evaluate the incidence rate of iatrogenic injuries to the infrapatellar branch(es) of saphenous nerve during ACL reconstruction with four-strand hamstring tendon autograft. Retrospective review of 226 patients that underwent 230 arthroscopically assisted primary ACL reconstructions with four-strand hamstring tendon autograft, between March 2002 and December 2004. The patients were separated into two groups. In group 1 (116 knees) the tendon was harvested and tibia prepared through a 3-cm vertical surgical incision (between March 2002 and September 2003) and in group 2 (114 knees) through a 3-cm horizontal surgical incision (between October 2003 and December 2004). In group 1, we found 39.7% of the patients with disturbed sensitivity in the area of the infrapatellar branch(es) of the saphenous nerve distribution. In patients of group 2 the incidence of nerve injury was 14.9% (P<0.001). The horizontal surgical incision in harvesting hamstrings tendon autograft for ACL reconstruction was found to have less associated chance of iatrogenic injury to the infrapatellar branch(es) of the saphenous nerve. No technical ties were found in both incisions for graft harvest.

ACL reconstruction using bone-patellar tendon-bone press-fit fixation: 10-year clinical results

Multiple techniques for anterior cruciate ligament (ACL) reconstruction are currently available, most of which use hardware or resorbable material for fixation of the graft inside or outside the bony tunnels. In this study, the long-term results of 95 patients at a mean follow-up of 10.7 years were assessed. The ACL was reconstructed using a patellar tendon autograft with a press-fit fixation. Between 1987 and 1991, 159 patients were operated by the senior author (PH), 95 could be seen for follow-up. Evaluation included detailed history, physical examination, functional knee ligament testing, KT-1000 arthrometer testing, the IKDC standard evaluation form, Lysholm, Flandry, and Tegner scoring systems. Radiographs were obtained preoperatively and at follow-up to assess the grade of osteoarthritis. Subjectively, none of the patients that were seen for follow-up complained of instability. Numbness of the skin was reported by 54% of the patients and pain during knee walking was described as mild in 25% and severe in 2%. The mean Flandry score was 243 (max: 280). The mean Lysholm score was 93.2 at follow-up and the Tegner activity level was 6.8 preinjury and 6.0 postoperatively. The average KT-1000 side-to-side difference was 1.8 mm on a manual maximum pull. The IKDC knee scoring revealed 84% of the patients with normal (A) or nearly normal (B) knee joints, 15% were (C), 1% was (D). Radiographically, joint space narrowing was found in 19%, 15%, and 25% for the patello-femoral, medial, and lateral compartments, respectively. Meniscus surgery was a determining factor. This study presents long-term clinical data on a press-fit fixation for ACL reconstruction. Results were excellent and good in more then 80% of the followed patients. The advantages of the press-fit fixation are direct bone-to-bone healing of the graft, decreased donor site morbidity, cost-effectiveness and ease for revision surgery.

Computed tomography-guided and arthroscopically controlled en bloc retrograde resection of a juxta-articular osteoid osteoma of the tibial plateau

Osteoid osteoma represents approximately 10% to 11% of all the benign bone tumors. The localization at the articular and juxta-articular level of the knee is an atypical picture that causes both diagnostic and therapeutic problems. We present the case of an osteoid osteoma of the lateral tibial plateau just beneath the joint level. The lesion was removed by a rear-entry computed tomography (CT)-guided drill under arthroscopic control and the bony defect filled with bone graft harvested from the proximal tibial metaphysis. Postoperative CT scans at 3 months, and 1 and 2 years were performed. The result of the kneeling test to evaluate donor-site morbidity 1 year after the surgery was negative. There were no immediate or delayed complications. Currently (2 years postoperatively), the patient has no pain and has gone back to his normal active daily lifestyle and routines. The follow-up CT scan 2 years after surgery showed complete excision of the lesion and perfect positioning of the bone graft. This new approach/technique enabled us to avoid damaging the proximal structures, to examine the lesion, and to fill the bony defect. Moreover, as shown by CT scan at follow-up, iatrogenic lesions to the cartilage of the tibial plateau were not reported.

Injury to the infrapatellar branch of the saphenous nerve in anterior cruciate ligament reconstruction: comparison of horizontal versus vertical harvest site incisions

PURPOSE

Damage to the infrapatellar branch of the saphenous nerve (IPBSN) has been described for knee arthrotomy and arthroscopy. The true incidence of damage to this structure during anterior cruciate ligament (ACL) reconstruction has not been reported. Furthermore, the traditional vertical incision for central patellar tendon harvesting runs perpendicular to the course of this nerve. Therefore, a horizontal incision to avoid this potential complication was developed.

TYPE OF STUDY

Case series.

METHODS

A retrospective comparative study of ACL reconstructions was performed in 76 patients with central third patellar tendon as graft with a minimum of 2 years follow-up. Forty-two patients had a horizontal incision and 34 patients had a vertical incision. A questionnaire was used to evaluate function, satisfaction, and evidence of IPBSN damage.

RESULTS

There was no difference between the 2 groups with regard to scar length, pain at rest, and pain with activity. Patients with a horizontal incision were more satisfied with the cosmetic appearance of their scar (P < .004). Twenty patients (59%) with a vertical incision had evidence of damage to the IPBSN as opposed to 18 patients (43%) with a horizontal incision.

CONCLUSIONS

Although technically slightly more difficult, a horizontal incision may be a useful option for ACL graft harvesting to provide a more satisfactory scar with less risk of IPBSN damage. Regardless of the incision used, damage to the IPBSN is a potential complication and patients should be counseled of this preoperatively.

LEVEL OF EVIDENCE

Level IV.

Donor site morbidity and return to the preinjury activity level after anterior cruciate ligament reconstruction using ipsilateral and contralateral patellar tendon autograft: a retrospective, nonrandomized study

AIM

To compare the donor site morbidity after anterior cruciate ligament reconstruction using ipsilateral and contralateral bone-patellar tendon autograft.

STUDY DESIGN

Cohort study; Level of evidence, 2 PATIENTS AND METHOD: Between 1997 and 1999, 100 patients underwent anterior cruciate ligament reconstruction with autologous bone-patellar tendon graft. The reconstructions were performed using ipsilateral bone-patellar tendon graft in 52 patients (group Ip) and contralateral bone-patellar tendon graft in 48 patients (group Co). Group Co consisted of 2 subgroups: group CoD consisted of the donor knees (n=48) and group Co-ACL consisted of the anterior cruciate ligament-reconstructed knees (n=48). Mean follow-up was 39.2 months. Donor site morbidity was evaluated with a questionnaire, computerized historical data, KT-2000 arthrometer measurements, the Cincinnati score, and the Tegner score.

RESULTS

KT-2000 arthrometer evaluation showed a mean side-to-side difference of 0.6 mm in both groups. There were no significant differences between the 2 groups concerning the Cincinnati and Tegner scores. With regard to local tenderness, a significantly higher rate was found in group Ip (59.6%) and group Co-D (58.3%) compared with group Co-ACL (6.3%). In groups Ip and Co-D, high statistically significant differences were also found according to kneeling pain (69.2% and 70.8%, respectively) and knee-walking pain (76.9% and 70.8%, respectively) compared with group Co-ACL (6.3% and 10.4%, respectively). With regard to numbness, there was no statistical significance between the rates of all 3 groups: group Ip=75%, group Co-D=85.4%, and group Co-ACL=64.6%. There was one rupture of the patellar tendon and one patient with chronic patellar tendinitis, both in the donor knee of group Co-D.

CONCLUSION

The contralateral bone-patellar tendon graft appears to present no advantage over the ipsilateral graft, as all symptoms concerning donor site morbidity are shifted from the injured into the healthy knee, and return to activity is not more rapid.

A prospective randomized comparison of bone-patellar tendon-bone and hamstring grafts for anterior cruciate ligament reconstruction

PURPOSE

The aim of this study was to compare the results after arthroscopic anterior cruciate ligament (ACL) reconstruction using central-third, bone-patellar tendon-bone (BPTB group), 3-strand semitendinosus (ST group), or 4-strand semitendinosus/gracilis (ST/G group) autografts.

TYPE OF STUDY

Prospective randomized trial.

METHODS

A randomized series of 134 patients, all with unilateral ACL rupture was included in the study. In all 3 groups, interference screw fixation of the graft was used at both ends and 125 of 134 (93%) of the patients returned for the follow-up examination after 26 months (range, 20 to 43 months). The preoperative assessments in all 3 groups were similar in terms of gender, Tegner activity level, Lysholm score, KT-1000 measurements, 1-leg hop test, and the knee-walking test.

RESULTS

At follow-up, the knee-walking test was significantly worse in the BPTB group than in the ST group (P = .0004) and ST/G group (P < .0001). Furthermore, the knee-walking test was significantly worse at follow-up than preoperatively in the BPTB group (P < .0001). The corresponding findings were not made in the other 2 groups. A significant reduction in knee laxity and an increase in activity level compared with the preoperative assessments were found in all 3 groups, without any significant differences between the groups.

CONCLUSIONS

Two years after ACL reconstruction, the use of ST and ST/G autografts rendered significantly less discomfort during the knee-walking test than the use of BPTB autografts. However, in terms of functional outcome and knee laxity, the groups displayed no significant differences.

LEVEL OF EVIDENCE

Level I.

Muscle performance after anterior cruciate ligament reconstruction

We measured muscle strength in 36 patients after anterior cruciate ligament (ACL) reconstruction with autogenous bone-patellar tendon-bone graft. Quadriceps and hamstring isokinetic strength was assessed during concentric contraction at 60 and 180 degrees /s and was measured at 1, 6, 12 and 24 months postoperatively. At 24 months quadriceps muscle strength had recovered to approximately 90% of the level of the uninvolved side, both at 60 and 180 degrees /s. In contrast, hamstring muscle strength had already recovered to approximately 90% at 6 months. Age, gender, activity level, and anterior tibial laxity did not affect the muscle performance. However, the recovery of muscle strength was delayed in patients with anterior knee pain.

Does the patellar tendon normalize after harvesting its central third?: a prospective long-term MRI study

BACKGROUND

The central third of the patellar tendon is the most frequently used autograft for ACL reconstruction.

HYPOTHESIS

The patellar tendon at the donor site would look normal as seen on MRI 6 years after harvesting its central third.

METHODS

Nineteen consecutive patients were included in the study. MRI examinations of the donor site were performed at 6 (5 to 10) weeks, 6 (6 to 8) months, 27 (24 to 29) months, and 71 (68 to 73) months postoperatively. The contralateral normal side was examined only on the first occasion.

RESULTS

The size of the donor-site gap decreased significantly (P = 0.0001) between 6 weeks and 6 years. In most patients, a thinning of the central part of the patellar tendon was still found at 6 years. The thickness of the peripheral patellar tendon was increased, compared with the contralateral healthy side, until 2 years (P = 0.003). On all occasions, the width was increased compared with the contralateral side (P < 0.015).

CONCLUSION

Prospective MRI examinations revealed that the patellar tendon at the donor site had not normalized 6 years after harvesting its central third. The reharvesting of the patellar tendon can therefore not be recommended.

Ultrasonographic and power Doppler evaluation of the patellar tendon ten years after harvesting its central third for reconstruction of the anterior cruciate ligament: comparison of patients without or with anterior knee pain

BACKGROUND

The long-term morphologic changes in the patellar tendon after harvesting its central third for the reconstruction of the anterior cruciate ligament have not been reported.

HYPOTHESIS

Sonographic morphologic changes in the harvested patellar tendon are common 10 years after the harvesting procedure.

STUDY DESIGN

Retrospective cohort study.

METHODS

Thirty-one patients who had undergone an anterior cruciate ligament reconstruction using central-third bone-patellar tendon-bone autograft with a closure of the patellar tendon defect were included in this study. An ultrasonographic and Power Doppler examination was performed at a mean follow-up of 10 years.

RESULTS

Ultrasonography of the harvested patellar tendon showed intratendinous calcification in 9 patients, hypoechoic lesion in 20 patients, hyperechoic lesion in 1 patient, and peritendinous changes in 1 patient. Only 3 (9.7%) of the 31 patients had no changes in the harvested patellar tendon. No abnormality was visible in the contralateral (normal) patellar tendons of the 31 patients. The harvested patellar tendon was significantly thicker than the contralateral patellar tendon (P < 0.05).

CONCLUSIONS

Sonographic morphologic changes of the patellar tendon were common 10 years after the harvesting procedure, although no evidence of inflammatory process, as could be seen in Power Doppler flow, was found inside of any patellar tendon.

A randomized comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction

BACKGROUND

Patellar and hamstring tendon autografts are the most frequently used graft types for anterior cruciate ligament reconstruction, but few direct comparisons of outcomes have been published.

HYPOTHESIS

There is no difference in outcome between the two types of reconstruction.

STUDY DESIGN

Prospective randomized clinical trial.

METHODS

After isolated anterior cruciate ligament rupture, 65 patients were randomized to receive either a patellar tendon or a four-strand hamstring tendon graft reconstruction, and results were reviewed at 4, 8, 12, 24, and 36 months.

RESULTS

Pain on kneeling was more common and extension deficits were greater in the patellar tendon group. There were greater quadriceps peak torque deficits in the patellar tendon group at 4 and 8 months but not thereafter. In the hamstring tendon group, active flexion deficits were greater from 8 to 24 months, and KT-1000 arthrometer side-to-side differences in anterior knee laxity at 134 N were greater. Cincinnati knee scores, International Knee Documentation Committee ratings, and rates of return to preinjury activity levels were not significantly different between the two groups.

CONCLUSIONS

Both grafts resulted in satisfactory functional outcomes but with increased morbidity in the patellar tendon group and increased knee laxity and radiographic femoral tunnel widening in the hamstring tendon group.

Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction? A prospective randomized study with a two-year follow-up

BACKGROUND

There are well-known problems with the use of bone-patellar tendon-bone autografts for anterior cruciate ligament reconstruction, especially in terms of donor site morbidity. Hamstring tendon grafts have been increasingly used as an alternative, but there are very few controlled studies comparing the methods.

HYPOTHESIS

Use of semitendinosus tendon grafts will cause less donor site morbidity and result in better knee-walking ability.

STUDY DESIGN

Prospective randomized clinical trial.

METHODS

Seventy-one patients who had a unilateral anterior cruciate ligament rupture underwent arthroscopic reconstruction with interference screw fixation and use of either bone-patellar tendon-bone or semitendinosus tendon graft. Outcome assessment was performed by physiotherapists not involved in the patients' care.

RESULTS

At the 2-year follow-up, no differences were found in terms of the Lysholm score, Tegner activity level, KT-1000 arthrometer side-to-side laxity measurement, single-legged hop test, or International Knee Documentation Committee classification results. The knee-walking test was rated difficult or impossible to perform by 53% of the bone-patellar tendon-bone group and by only 23% of the semitendinosus graft patients, a significant difference.

CONCLUSIONS

The semitendinosus tendon graft is at least an equivalent option to the bone-patellar tendon-bone graft for anterior cruciate ligament reconstruction, and we recommend its use.

Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts

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 recommendations 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.

Techniques for reducing anterior knee symptoms after anterior cruciate ligament reconstruction using a bone-patellar tendon-bone autograft

Seventy-five patients underwent unilateral anterior cruciate ligament reconstruction with an ipsilateral bone-patellar tendon-bone autograft at our institution. The graft was harvested using a two-transverse-incision technique, and patellar and tibial bony defects were repaired with cored bone grafts collected by reaming the femoral socket and the tibial socket or tunnel. We evaluated the incidence of anterior knee pain, donor site tenderness, and sensory disturbance after use of these procedures. We also analyzed the correlation between anterior knee pain and age, sex, bone plug length, range of motion, postoperative stability, patellar tendon shortening, infrapatellar nerve injury, and the size of the patellar defect. Thirteen patients reported anterior knee pain. Donor site tenderness was detected in 10 patients and was located on the inferior pole of the patella, the tibial tubercle, or both. Sensory disturbance was found over the infrapatellar nerve area in 13 patients. Statistical analysis showed that anterior instability (side-to-side difference of >3 mm) and residual patellar bony defect (depth >2 mm) were risk factors for anterior knee pain. The results of our study suggest that cored cancellous bone grafting for complete restoration of the donor site bony defects and the two-transverse-incision technique to preserve the infrapatellar branch of the saphenous nerve contribute to prevention of anterior knee symptoms.