Summary Introduction

1 1

ACL Reconstruction: Indications

2 3

Summary

4

Epidemiology ...................................................................................................................................................... 2

5

Surgery for which patients? ................................................................................................................................ 3

6

Introduction ........................................................................................................................................................ 1

Selection criteria ..................................................................................................................................... 3

I)

7

a)

Medical case history ........................................................................................................................... 3

8

b)

Clinical examination ........................................................................................................................... 4

9

c)

Laxity measurement ........................................................................................................................... 5

10

d)

Medical imaging ................................................................................................................................. 6

11

e)

Evaluating the risk of secondary instability ....................................................................................... 8

12

Conservative treatment ....................................................................................................................... 8

II)

13

Immobilization:........................................................................................................................................... 9

14

Initial phase of rehabilitation: .................................................................................................................... 9

15

Second rehabilitation phase: ....................................................................................................................10

16

III)

Surgical treatment.............................................................................................................................13

17

a)

Why operate ? ...................................................................................................................................13

18

b)

Techniques........................................................................................................................................15

19

c)

Les gestes associés .................................................................................... Erreur ! Signet non défini.

20

Les Indications .................................................................................................................................................22

21

Conclusion ........................................................................................................................................................24

22

Références ........................................................................................................................................................25

23

24

Introduction

25 26 27 28 29 30 31

The number of anterior cruciate ligament (ACL) tears has significantly increased in the last ten years. This increase is due to the rise in physical and sport activities in the population. In addition, the competitive level has risen thanks to improved material, equipment, and physical preparation. Statistically, 80% of ACL tears occur while practicing a sport, especially sports involving pivoting or pivoting + contact. There are, however, several risk factors that may favor the occurrence of an ACL tear. They include: genetic factors; anatomical factors (size of intercondylar notch, inclination of tibial slope (90), valgus deformity); hormonal factors (women are 2 to 5 times more vulnerable

2 32 33 34 35

than men, due to a possible link with menstrual cycles); environmental factors whether intrinsic (diabetes, weight) or extrinsic (nutrition, surface quality, shoes, humidity, etc.); and finally, biomechanical factors (muscle imbalance with too great a superiority of quadriceps over hamstrings also referred to as the ACL “protective” muscles, proprioception quality, training, etc.).

36 37 38 39 40

Improved clinical diagnosis and medical imaging techniques have helped identify many cases of ACL tears, especially isolated tears, which would have otherwise remained unnoticed. These tears would only have been recognized at a stage of ligamentous laxity complicated by the development of meniscus lesions. ACL tears lead to serious consequences for athletes and workers because knee instability can prevent them from practicing their sports or continuing their activities.

41 42 43 44 45

The natural evolution of anterior knee laxity is well known given the numerous epidemiological and statistical works on the topic. Antero-lateral rotatory instability (ALRI) following an ACL tear leads to chronic knee instability which in turn can cause the development of progressive osteoarthritis. Given the risk of these chronic conditions from developing, surgery can be indicated as a preventive measure.

46 47 48 49

Common anatomical lesions are directly responsible for knee instability. They affect the ACL but also lateral peripheral structures such as Kaplan’s iliotibial tract (deep fascia lata fibers) as well as the anterolateral ligament (14), second major ligament responsible for stabilizing medial rotation of the knee.

50 51 52 53 54 55 56

Autografting has been the gold standard for the past 15 years, but the greatest evolution of recent years is that of an early and safer diagnosis. Furthermore, surgical techniques have become minimally invasive, with a trend for more “anatomic” ACL reconstructions. Adapting the surgical technique to the situation such as the type of lesion, the patient’s morphotype, the sport practiced and competitive level, opens the way to a customized approach to surgery which is still in its infancy. We shall attempt here to produce a comprehensive update of current knowledge on the topic of ACL reconstruction, and suggest a guide for therapeutic treatments.

57

Epidemiology

58 59 60 61 62 63 64 65 66 67

According to the French Arthroscopic Society, the number of ACL reconstructions performed each year in France has doubled in the last ten years (approximately 15 000 in 1996, 41 000 in 2010 and 45 000 in 2012). Comparatively, the number of PCL reconstructions has remained relatively constant over the same period of time, with 1241 performed in 2012. The target population remains for the most part young, athletic patients since more than 90% of ACL ruptures are sports-related, and particularly common in pivot sports that involve contact such as soccer, rugby, American football and basketball, but also pivot sports that do not involve contact, particularly alpine/downhill skiing which is associated with a very high incidence of ACL injuries. The ACL ligament not only resists anterior tibial translation, but also provides rotatory stability. Once torn, knee kinematics is altered which leads to clinical laxity, functional instability and a risk of progressive articular degradation of

3 68 69 70 71

the meniscus and cartilage. ACL reconstruction therefore aims at restoring knee stability to avoid the occurrence of early degenerative lesions, and must be completed by a specific physical therapy program to help the knee regain its range of motion and dynamic muscular stability for patients to resume physical activities at work and sports. (see Box No.1)

72

Surgery for which patients?

73

I) Selection criteria

74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96

A good interrogation is the key, it is of utmost importance and must be very detailed, much like a police investigation! The circumstances surrounding the initial trauma are essential to track down any associated lesion and alert the physician. Was the injury caused by a sport or traffic accident? A proper diagnosis depends on being wary of possible associated lesions which could easily go unnoticed, especially of the lateral knee (lateral and posterolateral lesions) very often misunderstood which inevitably lead to reconstruction failure. Look for a lateral tibial plateau fracture with depression, sometimes difficult to detect, which is equivalent to a Hill Sachs lesion but in the knee. Was injury caused by single trauma with no contact? In this case, it is crucial to know whether pivoting was involved, as the absence of torsion implies very little risk for ACL tear. Dislocation must also be carefully investigated (dislocation/relocation are pathognomonic signs of ACL tears) it is a diagnostic on a phone call. Immediate loss of function is almost always a sign of complete ACL tear! Otherwise, a partial or old tear may be the problem. If the onset of effusion is delayed by a few hours and associated with dislocation, a complete ACL rupture can be expected. If no sign of effusion is present, look for an older - even very old - injury as you may be dealing with a secondary knee instability injury, a main cause of medial meniscus tears, or look for ACL deficiency (a narrow intercondylar notch, excessive laxity, inherited collagen deficiency) which may influence the surgical technique. In accidents involving contact, the precise mechanism must be understood, ask for a detailed account! For a violent knee valgus involving torsion, « track down » a lateral and/or posterolateral injury. Whether a pop was felt or heard (even by people in the vicinity) is of great importance when dealing with a patient for whom a physical examination is complicated. Take time to put the patient at ease to obtain reliable Lachman and pivot shift tests, because the probability of an ACL injury is high.

97 98 99 100 101 102 103

If a long period of time has elapsed between the accident and consultation, it is crucial to ask about the “motive” for consulting. For what reason has the patient decided to consult ? Was it pain ? Instability ? Knee locking ? Effusion? Or simply discomfort? That is the aim from which we must not be deflected, even if complementary physical exams or a previous medical advice oriented the diagnosis, often mistakenly so. That is the underlying theme we must follow to guide the therapeutic treatment. The patient’s age, which sport is practiced, and at what competitive level, are all important elements in the decision tree approach for selecting the most appropriate treatment. Finally, do not

a) Medical case history

4 104 105

forget to take into consideration the patient’s height and weight, and to examine the joints above and below the knee. b) Clinical examination

106 107 108 109 110

The clinical examination begins with the patient standing, which allows the physician to better assess the patient’s general morphotype and detect any signs of amyotrophy. Analyzing the patient’s walk can also help identify associated lesions, especially in cases of chronic laxity, flexum, limping, and lateral decoaptation.

111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128

Immediately following a knee sprain (see Video No. 1), the majority of patients come for a consultation wearing a brace to protect the knee in the initial inflammatory phase, often the site of a significant hermarthrosis, with limited range of motion. Under such conditions, clinical examination is often difficult, firstly because the patient is in pain, but also because of an analgesic flexum very often present in an acute phase. To facilitate the physical examination, we suggest you put the patient at ease with slow, gentle movements and by starting with the least painful manipulations. The flexum is often due to a reflex analgesic contraction of the hamstring muscles which becomes more difficult to reduce as time passes: in most cases, 2 very simple exercises can reduce this flexum and facilitate the clinical examination. To begin with, after having placed a small pillow underneath the thigh, have the patient perform flash contractions of the quadriceps. This exercise is often misunderstood and the patient ends up flattening the pillow which generates a co-contraction of the hamstring and quadriceps muscles, which sustains the flexum. The objective of this exercise is to just slightly lift the heel in order to contract only the quadriceps muscle (but avoid crushing the pillow which inevitably causes the hamstring muscles to contract). The second exercise is done with the patient in a prone position, and consists in having the patient perform short consecutive flexions against resistance in order to inhibit the reflex contraction of the hamstring muscles. In just a few minutes these short exercises will help the patient regain full extension and a lower limb both relaxed and less painful, thus facilitating the clinical examination.

129 130

If the patient is seen for an old injury or chronic laxity, the clinical examination is much simpler as it is not hindered by hemarthrosis or pain.

131 132 133 134 135 136 137 138 139 140 141

Knee examination: must be a comparative examination; the patient must be lying on his back, relaxed, and as pain free as possible. Start by examining the non-injured knee, which will serve as a reliable control and reference for joint laxity. Next, inspect the injured knee by first checking for hemarthrosis or bruising which are indicative of a recent sprain. In case of an old sprain or chronic laxity, the presence of a deformity with respect to the contralateral knee should be systematically verified. First, start by checking for intra-articular effusion followed by comparative analysis of the range of motion including asymmetric knee hyperextension. Significant intra-articular effusion evidently limits the patient’s ability to flex the knee. For old sprains, with a dry knee, an ACL tear causes pain when the knee is hyperflexed which the patient associates with limited range of motion. This pain, often felt when squatting, lasts a long time, even after ACL reconstruction. Look for pain when palpating the ATT, lateral and medial patellar retinaculum, patellar tendon, and especially the joint space which is

5 142 143

a sign of a meniscal lesion, or even a bucket handle meniscus tear when associated with a nonreducible flexum.

144 145 146 147 148 149 150 151 152 153 154 155 156

Ligamentous testing: The purpose of the clinical examination is to check whether frontal, anteroposterior and rotatory laxity is asymmetric compared with the non-injured knee. Frontal laxity is detected with varus and valgus manipulations, with the knee both extended and flexed to 30°. These steps are very important and must be repeated if necessary. This examination helps identify associated ligament tears if any, and can be complemented by comparative dynamic radiographs. The Lachman test remains essential; it is rarely painful and can be performed no matter what the circumstances. Snapping knee: The Pivot shift test designed by Mac Intosh is the second key to a good diagnosis (see Video No. 2). It is difficult to perform and requires experience, but it is by itself sufficient to confirm the diagnosis. For the Hughston’s Jerk test, the knee is flexed as you apply a valgus force with internal rotation and bring the knee to full extension; the knee goes from subluxation to reduction, it is the opposite of the pivot shift test. Next, perform the anterior drawer test with the knee flexed to 90°, followed by comparative instrumented measurement of differential laxity. Finally, complete the examination by assessing the posterior cruciate ligament. (see Box No. 2) c) Laxity measurement

157 158 159 160 161 162 163

Laxity measurements represent an important source of information in the detection of lesions of ligaments acting as primary or secondary restraints, and influences strategies and therapeutic options. The measurement methods which remained quite « primitive » until the late 80s experienced a genuine expansion in the 90s thanks to the advent of new technologies. Initially, measuring instruments were very basic, like the Rolimeter (4) and the radiological measures proposed by the teams in Lyon (55,56).

164 165 166 167 168 169

The KT1000 arthrometer and its upgraded version, the KT 2000 which includes an X-Y plotter, added simplicity to a recognized standard. This system offered a precise and accurate measurement with the help of a dynamometer calibrated for different loads, and was reproducible (30,49). This system has become the reference gold standard for the International Knee Documentation Committee (IKDC) which recommends its use for comparing the different series of results from different international authors (35).

170 171 172 173 174 175 176 177

The Telos® system which is based on radiographic imagery appeared around the same time and is also accurate and reproducible (40,74). It comprises a metal frame placed on the radiographic table, which enables the physician to apply a posterior displacement force to the proximal tibial epiphysis with the knee flexed to 15°. On the lateral view of the knee, the femoral condyles must be perfectly superimposed. The position of the tibial plateaus is measured with respect to the femoral condyles. This system remains operator-dependent as the patient must feel reassured in order to avoid having a reflex contraction of the hamstring muscles which would give underestimated or even negative measurements.

178 179 180 181 182

The turn of the century brought a major change with the advent of computer-assisted navigation systems and especially optoelectronic systems (41,52). These systems offered greater accuracy (to one tenth of a mm) and added a third dimension which enabled the physician to measure rotatory instability, the only global essential test because directly related to knee function (17). This measure opens up immense perspective for diagnosing but also monitoring and comparing different surgical

6 183 184

techniques. But these systems have two limitations: they require fixing reflectors to the bones (femur and tibia) and interfere with the physician’s ability to control the forces applied during the test.

185 186 187 188 189 190

In addition to the development of navigation systems, a new arthrometer, the GNRB®, offered far better results than the KT1000 system. It is now complemented by measuring automated rotation coupled to translation. The Porto-Knee Testing device was an improved version of the Telos® as it was based on 3D MR imaging which allowed the physician to separately assess the two femoro-tibial compartments and thus measure coupled rotation (24). By 2010, several teams of physicians focused on rotatory laxity testing which had been criticized as being insufficiently dealt with.

191 192 193 194 195 196 197 198 199

Many different systems were developed: the Rotameter, the Laxitester, and several other prototypes, each more sophisticated than the last (10,60,62,67,76,88). A navigation system with non-invasive tracers is also in the works. Several models of accelerometers are already available, based on technologies widely used in everyday life (58). These accelerometers can record acceleration variations, specifically during subluxation reduction in the Pivot Shift test (PS test). Lopomo et al. (58) reported an in-vivo study with a quantitative assessment of the PS test. This study measured 66 consecutive patients under anaesthesia with good to average interoperator reproducibility, but it especially showed a good specificity of 70% to 80% for judging whether a patient was in the injured group or not, based only on acceleration analysis (59).

200 201 202 203 204 205 206 207

What can be expected from all these measuring devices? The benefits are twofold. Firstly, they will add accuracy to the 3D approach which has become essential. This will undoubtedly be the key to detecting lesions of the ligaments acting as a secondary restraint and permettront leurs démembrements. This detection, which requires the use of objective tools, will modify the strategy for correcting disorders of knee kinematics. Secondly, these new assessment devices will provide more tangible arguments for following-up and comparing different surgical techniques. It is already possible to detect partial ACL tears and identify knees with high rotatory laxity. Patients for whom standard single-bundle reconstructions may be insufficient will require special care (Box No.)

208 209 210

d) Medical imaging Standard X-rays of the knee are essential. Depending on the clinical semiology, additional exams may be required.

211

STANDARD X-RAYS

212 213 214 215 216 217 218 219 220

Views: face, strictly lateral, schuss and sometimes axial views of the patella when possible. Look for avulsion of the pre-spinal bone surface (ACL) (view of the intercondylar notch if needed), or posterior tibial spine (PCL), a Segond fracture (avulsion of the anterolateral ligament) (Fig. 1) (14), a bony avulsion injury of the collateral ligaments. Remodeled tibial spines and tibiofemoral impingement could be signs of an old central pivot ligament injury. Also look for a femoral or tibial fracture, internal or external tiobiofemoral joint line gapping, which are signs of a medial or lateral collateral ligament tear. Three quarter lateral views are useful in case of an avulsion of the anterior external capsular ligament. A lateral femoral condyle notch on a lateral view of the knee (impaction of condyle on posterior edge of tibial plateau « lateral Notch ») is a major sign of a complete ACL tear.

221

DYNAMIC VIEWS

7 222 223 224 225 226

Dynamic views must be comparative views of anterior tibial translation with the knee flexed to 20° (ACL) and can be taken with the Telos® system. They must be completed, if necessary, by varus stress views (lateral collateral ligament), and valgus stress views (medial collateral ligament). These views can seldom be obtained in emergency situations because of pain. A difference greater than 5 mm is the sign of a torn ligament. Laxity can be underestimated because of pain (68).

227

MRI

228 229 230 231 232 233 234 235 236 237 238 239 240 241 243 244 245 246 247 248 249 250

The MRI is not, as can be often heard, the key to the diagnosis which rests on the clinical examination. However, the orthopedic surgeon must know how to read an MRI. The MRI remains essential to assess associated lesions. Anatomy sequences (T1, proton density) help visualize cruciate ligaments, menisci and other osteochondral structures, as well as the extensor apparatus. Fat-suppressed T2 spinecho sequences (T2, FSE, Fat-Sat) are more interesting because bruised areas appear as a high signal intensity (white). Contusions and injuries are immediately noticeable. Especially bone contusions which are very often laterally located (weight-bearing portion of the lateral condyle and posterior edge of the lateral tibial plateau) the main pathognomonic stigmata of an ACL tear. A contusion located on the external face of the lateral condyle could be mistaken for an instability injury though it could be a sign of a patellar dislocation. The MRI is also very important to analyze meniscal and chondral lesions that must be very carefully looked for as they could affect the therapeutic indication (ex: a major condyle contusion associated with a fracture will prompt the surgeon to delay surgery because of the increased risk of developing chondrolysis) (83). These types of contusions can be classified according to three stages. Type A: simple trabecular contusion (bone bruise) ; - type B: subchondral bone contusion without cartilage damage ; - type C: osteochondral impacted fracture.
 An MRI allows the physician to detect occult fractures that cannot be diagnosed from standard radiographs, especially posterior fractures of the tibial plateau, equivalent to a Hill Sachs lesion but in the knee, which, if left untreated, can lead to isolated ACL reconstruction failure. The MRI is also useful in case of peripheral tears (both medial and lateral) identified during the clinical examination as it provides an anatomical and topographical approach that will affect the surgical strategy. For example, in case of a medial collateral ligament (MCL) tear, the MRI will enable the physician to identify whether the ligament was torn where it attaches on the femur, or the tibia, or was completely torn and must be reconstructed.

251

ARTHRO-CT SCAN

252 253 254 255 256 257 258

This type of examination can be useful in cases of acute lesions or when an MRI is not possible. The arthro-CT scan can detect meniscal lesions (flap tear, bucket handle tear, meniscocapsular separation), and is considered the modality of choice for cartilage assessment (78,84) it is also used to detect the presence of intra-articular foreign bodies. The arthro-CT scan is generally less efficient than the MRI, however, multiplanar reconstructions (MPR), or multi-slice CT scans, provide good ACL analyses (51). Arthro-CT scans are difficult for acute lesions due to the presence of hemarthrosis and capsular gaps. The scanner helps reveal fracture lines. (Box No.4)

242

8 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298

e) Evaluating the risk of secondary instability

The decision to perform an ACL reconstruction can be made for two reasons, taken alone or in combination: the appearance of a functional disability due to instability, or the progressive degradation of the joint following a meniscal or cartilage lesion. However, directly following an initial injury, the knee is not immediately unstable and does not necessarily present lesions of the meniscus or cartilage. The choice of therapeutic orientation rests on converging arguments that help establish the patient’s risk for instability. This level of risk, which is either High, Moderate or Low, is taken into consideration when counseling the patient. An excellent study conducted by Donald Fithian showed that in High risk patients, early laxity phase were associated with more meniscus tears than later instability phases (27). Fithian suggests several risk factors that help classify the patients. These factors were mostly taken from Daniel’s study (20). Two main factors were reported. The first is differential laxity measured with the KT1000 at 3 months post-accident, once the knee is again dry, mobile and pain-free. The second factor is the number of hours per year spent practicing a pivoting or pivoting contact sport. These data are used to classify the patients based on levels of risk according to the Surgical Risk Factor (SURF) classification. (Table 1). Fithian followed 209 patients operated between 1992 and 1996, assessed within 4 weeks following injury and classified according to the SURF system. Patient treatment was randomized. The patients were followed up after an average 6.6 years (between 3 and 10). Patients who were not operated in the initial phase underwent more secondary meniscus surgery and were distributed with respect to the SURF classification thusly: High risk group 25% for those not operated compared with 6.5% for those operated early; Moderate risk group 37% vs. 7.7% respectively, P = .01; and Low risk group 16% vs. 0%. He concluded that early surgery diminished residual laxity, the risk of instability and the risk of secondary meniscus surgery. Moderate and low groups had the same risks. However, early intervention did not reduce the appearance of radiographic signs of pre-osteoarthritis. No relationship could be found between the size of the initial contusion and the development of pre-osteoarthritis. In 2008, W. Hurd suggested to add clinical tests, and more specifically the single leg hop test which involves neuromuscular functions (39). The age of the patient must be taken into consideration, as it is difficult to ask of very young patients to reduce their level of practice, as suggested by Moksnes (64). Finally, associated lesions also weigh in the decision tree algorithm, such as a repairable meniscus tear for which the clinical outcome is directly associated with knee stability and even residual laxity. There is no doubt that, in the future, new 3D systems for measuring laxity, along with objective graduations of the Pivot Shift test, will provide the physician with additional arguments in assessing the risk for secondary instability. (Box No. 5)

II) Conservative treatment The indication for conservative treatment is based on a careful appraisal of several criteria (age, sports, general health, profession, instability) but also the patient’s demand to return to higher function and sport activity. In the literature, conservative treatment is justified when surgical reconstruction of the ACL cannot perfectly restore the anatomy and physiology of the knee. The goal of ACL ligament repair is to eliminate instability, however laxity of the knee does not systematically lead to instability and instability is not always caused by ligamentous laxity (22). Furthermore,

9 299 300 301 302 303

physiotherapeutic rehabilitation can be effective in treating instability as demonstrated by several authors (29,39,43,46,63,65,92). This option can be temporary or permanent and must be reassessed with the appearance of symptoms associated with ACL rupture (pain, instability). In all cases, a logical rehabilitation protocol must be followed to counter any instability in order to allow the patient to progressively return to his/her activities without putting the joint at risk.

304 305 306

The strategy for this conservative treatment can be divided into three steps: Immobilization; Restoration of knee function to an acceptable level; and Proprioceptive training program to ensure dynamic stability provided by periarticular muscles and tendons.

307

Immobilization:

308 309 310 311

Immobilization is a key element. Its goal is to allow the secondary ligamentous restraints to heal. Indeed, these structures are not exempt from being injured or stretched even in cases of isolated ACL tears. There does seem to be a consensus regarding the need for a 3 week immobilization with a rigid or hinged knee brace.

312 313 314 315 316

Initial phase of rehabilitation:

317

1st principle: Avoid early hyperextension and maximum flexion, and mobilize the knee along its axis.

318 319 320 321 322 323 324 325 326 327

2nd principle: Avoid early and isolated quadriceps strengthening exercises, whether static, dynamic, or open kinetic chain exercises (OKC) between 0° and 60°. The quadriceps muscle provides an antagonistic action to the ACL. Contraction of the quadriceps creates anterior sliding force of the tibia under the femur, to which the ligament will oppose a resistance. The greater the force generated by the contraction of the quadriceps, the greater the intensity of the anterior sliding force exerted on the tibia, and the higher the stress on the ACL. Dynamic, concentric OKC exercises of the quadriceps generate minimal tension on the ACL with the knee flexed between 60° and 90°. Tension increases between 0° and 60°, and/or when a resistive load is added to the weight of the leg alone. Stress on the ACL increases as the knee is near full extension, as the intensity of the resistive load is increased, and/or as the point to which the resistive load is added is removed from the center of the knee.

328 329 330 331 332 333

3rd principle: Avoid early triceps concentric strengthening exercises with the knee flexed. No matter what the degree of flexion, the soleus muscle provides an agonistic action to the ACL, as its contraction creates a posterior translation force on the tibia. The two-headed calf muscle provides an antagonistic action on the ACL. The contraction of this muscle creates a posterior sliding force on the femur at the proximal insertion of the muscle whose mass pushes the tibia forward which generates an anterior sliding force on the tibia.

The goal is for the patient to regain normal range of motion and dynamic knee stability. Therefore, there is not a single, universally applicable therapeutic protocol. It is best to base the rehabilitation program on the different principles derived from biomechanical data, which are quite similar to those of post-reconstruction programs (82). 5 fundamental principles have been defined:

10 334 335 336 337 338 339 340 341

4th principle: Implement an early strengthening program for the hamstring muscles, in all modes, and begin as early as possible quadriceps-hamstring co-contraction exercises with the knee flexed between 30° and 90°. Hamstring muscles provide an agonistic action to the ACL. Their contraction creates a posterior sliding force of the tibia underneath the femur, with no stress on the ligament no matter what the degree of flexion. The simultaneous contraction of the quadriceps and hamstring muscles cancels out the stress on the ACL when the knee is flexed to at least 30°. That is because the posterior sliding force on the tibia generated by contraction of the hamstrings counteracts the anterior sliding force generated by the contraction of the quadriceps.

342 343 344 345 346

5th principle: Implement an early closed kinetic chain (CKC) exercise program, in the absence of peripheral ligament injury which requires a no loading period. CKC exercises in the 0°/60° range are less stressful than OKC exercises, not only for the ACL but also for the patellofemoral joint. CKC exercises allow for early global strengthening with less risk of deleterious effects on the remaining ACL fibers and less patellofemoral pain.

347 348 349 350 351 352 353 354

Second rehabilitation phase:

355 356 357

The rehabilitation program will generally be divided into progressive steps, each one meeting specific rehabilitation goals determined with respect to the amount of elapsed time since the trauma. A standard protocol is presented below.

358

The schematic outline includes 4 successive steps:

359

D1 - D45: Predominantly analytical rehabilitation

360

D45 - D90: Predominantly functional rehabilitation

361

D90 - D120: Return to monitored physical activities

362

Beyond D120: Complete return to activities

363 364 365

The patient can proceed to the following step provided the therapeutic goals of the previous step were met and the minimum deadline was followed so as not to prematurely introduce activities which are too stressful for the joint.

366 367

It is very important to bear in mind that: restoring knee extension is a priority over restoring knee flexion, and that CKC exercises remains the basis for quadriceps muscle strengthening.

The goal of the proprioceptive training program is to educate the periarticular muscles to create an automatic reflex contraction as soon as a proprioceptive input is received of an incipient patellar subluxation. This phase can occur only if periarticular muscles are in good shape and if Golgi and Paccini proprioreceptors are still present in the remaining ligamentous fibers. This training program mainly consists in exercises on a Freeman balance board and trampoline. However, several other variants are available, each one cleverer than the last, boasted by physiotherapists of rehabilitation centers and fitness facilities alike.

11 368

Predominantly analytical rehabilitation: D1 - D45

369 370

Priority: Restoring quadriceps function with CKC followed by OKC exercises is the prime objective of this phase

371

Goals and methods

372 373 374 375 376

• Recover 0° passive extension and active locking of the knee through a protocol of static contractions of vastus muscles (flash contractions and sustained contractions). On D21, if this goal is met, the patient can start co-contractions of the quadriceps and hamstring muscles with the knee flexed between 30° and 70°, while in a sitting position, and the foot on a sliding surface such as a skateboard.

377 378

• Progressively increase the mobility range to reach 0°/130° on D45 if no peripheral ligament injury is associated with the ACL injury, and gradually increase the range of motion.

379 380 381

• Strengthen and increase the flexibility of hamstring muscles (do not start these exercises before D21, and do so progressively and carefully). Strengthening exercises can be either concentric, static, excentric, in CKC and with increasing resistive loads.

382 383 384

• Strengthen and increase the flexibility of the triceps. Strengthening exercises must be done with the knee in 0° extension to reduce as much as possible the femoral posterior translation generated by the contraction of the two-headed calf muscle.

385 386

• Regain a normal gait without flexum or limping. Once this goal is met, the patient can begin propioceptive exercises with bipodal support based on imbalance provoked by the physiotherapist.

387

Predominantly functional rehabilitation: D45 - D90

388

Priority

389

Strengthening and overall muscle control through CKC exercises

390

Goals and methods

391 392

• Continue exercises to restore flexion range of motion, with the aim of obtaining subtotal knee mobility.

393 394

• Continue the strengthening and flexibility exercises for the posterior chain muscle group (triceps, hamstrings, gluteus).

395 396 397

• Begin quadriceps strengthening with CKC exercises by gradually increasing loads (indoor or outdoor cycling, elliptical trainer with and then without the help of the arms which adds a proprioceptive value to this activity, rower, stepper, oblique leg press, etc.)

398

•

Develop good proprioceptive control.

12 399

Return to monitored physical activities: D90 - D120:

400

Priorities

401 402

During this period, priority is given to quadriceps strengthening with the aim of returning to daily activities.

403

Goals and methods

404

•

405 406 407

• Continue exercises targeted at strengthening the hamstrings, including extreme flexion range of motion, and by keeping in mind the predominantly eccentric role the hamstring muscles play in controlling knee rotation.

408 409

• Beginning on D120, start isokinetic training of the quadriceps with concentric exercises at high angular velocities, and eccentric exercises at low angular velocities.

410 411 412 413 414

• Continue an overall muscle strengthening workout program by progressively resuming sport activities while maintaining the knee along its axis. In parallel, continue working out on the elliptical trainer, the rower and the stepper by gradually increasing the resistance, do half squats, work on the leg press by adding weight progressively, and swim. Always begin and/or end these exercises by stretching the different chain muscle groups depending on the desired effect (warm up or recovery).

415

Complete return to activities: Beyond D120

416 417 418

During this period, the goal is for the patient to resume all pre-injury activities. The point is to verify that the knee is both stable and indolent. If a conservative treatment was followed, it is logical to wait 3 to 6 months in order to objectively assess whether the treatment was a success or failure.

419 420 421 422 423 424 425 426 427 428 429 430 431

Discussion: The much commented article written by Frobell et al.(29) in 2010 and published in the New England Journal of Medecine summarizes quite well the two opposing strategies regarding the management of a torn ACL. This randomized prospective study compared the outcome of early ACL reconstruction associated with structured rehabilitation and optional delayed ACL reconstruction. No significant differences were found regarding knee function between the two groups at 2 and 5 years postoperatively, and the authors underlined the fact that 61% of the patients assigned to optional delayed ACL reconstruction had avoided ACL reconstruction at 2 years. However, several authors criticized the evaluation criteria for being insufficiently pertinent and only applicable to sedentary patients since they only included KOOS, SF-36 and Tegner Activity Scale scores. Hurd et al (39) in a prospective study which covered a period of 10 years, showed that in a population of motivated and athletic patients, 72% were successful with a non-operative return to pre-injury sporting activities without secondary meniscal or chondral damage. These results are similar to those found in the longterm studies carried out by Meuffles (63) and Streich (92).

Restore full and symmetrical mobility

13 432 433 434 435 436 437

Overall, the literature seems to support that ACL reconstruction does not prevent knee osteoarthritis from developing, as it could be caused by meniscal and/or chondral damage associated with the injury, or even by modifications in cartilage turnover (93). Good results are thus obtained after surgical and non-surgical treatments alike. Improved knee stability is the prime objective of ACL reconstruction, and this result can be obtained through neuromuscular rehabilitation in selected patients.

438 439 440 441 442 443

As a conclusion, not all ACL tears require surgical reconstruction. The therapeutic indication for treating an ACL tear depends on the degree of risk for developing secondary knee instability. If this risk is high, everything must be done, including surgically stabilizing the knee, to avoid functional impairment and especially the inevitable emergence of lesions, first on the meniscus and then the cartilage. It is therefore crucial to identify, for each patient, predictive factors of knee instability following an ACL injury (Box No. 6)

444 445

III) Surgical treatment

446 447 448 449 450 451 452 453

Surgical indications for ACL reconstruction have changed a great deal in recent years. This is due to an improved diagnostic approach (earlier and more accurate) but also reflects a better understanding of the degenerative effects caused by secondary instability, whether invalidating or not! Finally, surgical techniques have also considerably changed, and include minimally invasive techniques made possible by arthroscopic procedures, as well as a large choice of techniques which enable the surgeon to better customize the surgery based on the patient’s specific lesions. We shall now look at the different parameters that will influence the surgical decision.

454 455 456 457 458

The patient’s age has long been considered a decisive factor, and until about 15 years ago 40 years of age was the limit beyond which surgery was no longer indicated, though that is no longer the case. Obviously, a young patient will have a better healing potential, but there is no longer a clear age limit, especially in cases of significant functional impairment with well preserved joint cartilage, as evaluated on Schuss radiographs.

459 460 461 462 463 464

The type of sport practiced is a crucial factor, and in cases of pivoting contact sports, surgery is often justified. But a detailed analysis of the activity is necessary. The level of participation (both recreational and professional), the intensity level (high or low energy) and the degree to which the flexor and extensor muscles are being used, all of these factors influence which surgical technique best applies. The demands are different regarding exercises along the transverse axis (non-pivot), they must therefore be studied on a case by case basis.

465 466

For patients who are exposed to a physical risk on the workplace, surgery may also be warranted, as these patients could be exposed to a substantial risk of physical incapacitation or death. A carpenter

a) Why operate ?

14 467 468

who needs to keep his balance on a roof, or a fireman who needs for his knee to be very stable, are but two examples that could influence the surgeon’s decision.

469 470 471

The patient’s morphotype also weighs heavily in the decision, especially for hyper lax knees (a veritable puzzle for the surgeon), and very large patients whose knees are subjected to mechanical stresses which are substantially greater than average. These patients must be carefully considered.

472 473 474

Associated lesions, whether affecting the meniscus, cartilage or secondary restraints, weigh more and more in the decision to complement ACL reconstruction with concurrent treatments. These associated lesions must be treated to ensure overall surgical success.

475 476 477

When is the best time to operate? This question remains open to controversy and debate. Apart from multiligamentous knee injuries and bucket handle meniscus tears in children, there is no medical urgency to operate. The date for surgery shall be determined based on fundamental principles.

478 479 480 481 482 483

Much care must be taken before deciding on an ACL reconstruction on a dry, mobile, pain-free knee. Otherwise, the surgical outcome could be complicated by an increased risk for stiffness. Indeed, in response to ACL injury, large quantities of proinflammatory cytokines are released from the joint tissue. An added trauma caused by surgery would cause these mediators to induce a fibrous scarring reaction which in turn causes knee stiffness. It is important to wait for this « inflammatory storm » to pass (7) before considering surgery.

484 485

The degree of bruising could also influence the surgeon’s choice. Several authors reported an increased risk of secondary chondrolysis aggravated by early surgery (83).

486 487 488 489 490 491 492 493 494

Should surgery need to be performed rapidly, 2 simple rules must be followed to avoid postoperative stiffness: make sure the patient has recovered full active and passive extension and that the quadriceps, especially the vastus medialis, locks the knee efficiently into place. Flexion is of little importance since it is associated with intraarticular effusion. Remove any femoral bone bruise visible on the MRI, which is a negative factor for postoperative recuperation of joint range of motion. Even though a tibial bone bruise has no real consequence, the same is not true for femoral bone bruises, more than likely because the femoral tunnel is drilled in this area which could worsen the inflammatory response. In such a case, we recommend waiting at least 6 weeks before considering ACL reconstruction surgery(83).

495 496 497 498 499 500 501

Many patients involved in competitive sports will feel pressured by upcoming sporting events to rapidly undergo surgery. Communication skills are required of the surgeon to make the patient and his/her medical staff understand and accept the treatment. The ability of associated lesions to heal must be taken into consideration. Strictly isolated ACL tears are very unlikely. Indeed, secondary restraints are usually at least a little stretched, and they must heal properly to ensure good mechanical behavior of the graft, and for the stresses to be evenly shared. Patience is thus necessary to wait for the inflammatory phase to pass, except in cases of partial tears for which it could be opportune to

15 502 503

« surf » the healing wave and benefit from the presence of factors that stimulate repair produced by the initial tear.

504 505 506 507 508 509

Remember that hurrying can only cause trouble, there is usually plenty of time to act. Occupational disability is often the most critical factor. But waiting for a more favorable moment from a professional perspective does not mean surgery must be definitely abandoned. An appropriate rehabilitation program and patient follow-up is crucial. In case of post-traumatic residual laxity, the risk for a secondary medial meniscus tear is very high and must be clearly explained to the patient. (Box No.7)

510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540

Treatment of ACL injury has been a subject of controversy for many years. Suture repair of the torn ligament has often been tempted in the past but mostly led to failure. ACL reconstruction involving the replacement of the damaged tissue is the only technique which has given satisfactory clinical results. The term « reconstruction » is preferable to « ligamentoplasty » which is not specific enough and can lead to confusion! The purpose of ACL reconstruction is to add a collagen based scaffold so it may be colonized by synovial tissue, blood vessels and finally fibroblasts capable of generating collagen chains. This process, also called ligamentization, leads to a structured living organization which guarantees the long-term success of the surgery. Non-collagen based structures are being studied and could offer an interesting alternative for providing sufficient amounts of grafts with respect to length and diameter. For now, the collagen is taken from the patient; these autografts are the types of grafts that are most widely used. When the graft comes from a human donor other than the patient, it is called an allograft. Allografts are supplied by tissue banks, and are widely used in the United States. They help avoid harvest-site morbidities, but present the following drawbacks: the risk of donor-transmitted infections (e.g. viral or bacterial), and a high rate of rejection by the receiving organism. A few studies have reported the use of grafts from animals, or xenografts, but these remain isolated. For organizational reasons and due to a high cost factor, allografts are rarely used in France and mainly for repeat surgery or multiple ligament injuries. And yet, our main source of graft material is our own collagen which is available in limited quantities. There are four main types of grafts available, by decreasing order of use they are: the hamstring tendons, the patellar tendon, the quadriceps tendon, and the fascia lata. Let’s start by looking at the pros and cons of each type of graft. The mechanical properties required of a graft are based on the normal ACL reference values as described by S. Woo with respect to age and which correspond to a mean ultimate tensile strength of 2,160 (± 157) N for specimens aged 22 to 35 years, and 1,503 (± 83) N for those from 40 to 50. Stiffnees is respectively 242 (± 28) and 220 (± 24) N/mm (96,97). The semitendinosus (ST) and gracilis (G) tendons have an ultimate tensile strength of 2,640 (± 320) N and stiffness of 534 (± 76) N/mm for the double ST and respectively 2,830 (± 538) N and 455 (± 39) N/mm when prepared as a four strand ST+G. The mechanical properties of these tendons are thus satisfactory, and they offer a wide variety of variations as far as diameter and length are concerned depending on the type of construct that is chosen. Even though tendon harvesting is followed by a certain amount of regeneration, a deficit in flexion has been reported (French Society of Arthroscopy 2007 annual

b) Techniques

16 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581

congress) (19). These tendons do not comprise any bony portion. This makes for a random fixation which be chosen with care. The patellar tendon has an ultimate tensile strength of 2,977 (± 516) N for a standard thickness of 10 mm and a stiffness of 455 (± 57) N/mm. It is harvested with two bone blocks, one patellar and one tibial, which offer high quality fixation and healing in the bone tunnels. However, it is only slightly flexible and can generate local morbidity such as a tendinopathy or rupture of the extensor apparatus. The quadriceps tendon, with a width of 27 mm and a thickness of 7 mm, has a strength of 1,075 (± 449) N (32), it comprises a patellar bone block and a free tendinous extremity. Harvesting this type of tendon requires experience and sound knowledge of the anatomy (57). This type of tendon is an excellent alternative when the others have failed or in the case of multiligamentous reconstruction. The different reconstruction techniques are based on three anatomical and/or biomechanical and/or functional objectives. In situ ACL reconstruction depends on the anatomy of the native ligament and its biomechanical properties. Our knowledge of the shape and attachment of the ACL, which could seem simple and universal, has greatly evolved over time. The ACL was initially described as a band of dense connective tissue, that stretches from the femur to the tibia, surrounded by synovial tissue (11). The bony insertions studied by Odensten remain good references (73) (Fig. 2). But the exact structure of the ACL and its orientation is still a matter of contention. The mechanical behavior of the ACL during knee flexion-extension causes the fibers to tighten and twist which has led several authors to distinguish separate functional groups referred to as fiber bundles. Most authors recognize two fiber bundles, one anteromedial (AM) and on posterolateral (PL), but others speak of a third intermediate fiber bundle. Some have also described a fourth fiber bundle, which complicates the approach to reconstruction. More recently, a study based on meticulous dissections, complemented by modern MRIs, speaks in favor of a flat structure, or « ribbon concept », attached to tibial and femoral bone crests (Smigielski R.) (Fig. 3-4). This concept could make a major difference in how we consider the ACL and provide a radical change to reconstruction techniques which, up to now, aimed at replacing one or several fiber bundles by more or less cylindrically shaped grafts. But the principles of reconstruction are not only based on anatomical considerations, they also rely on knee kinematics and especially on the concept of isometric graft placement. Isometry refers to the preservation of the observed length between a femoral point of ACL insertion and its corresponding point on the tibia during knee flexion-extension (2,28). This variation in length represents, in cases of single-bundle reconstruction, a risk of graft loosening on flexion or extension and consequently a risk of residual laxity. Consequently, several authors suggested anchoring the grafts in a position in which this difference is at its smallest, which can lead to nonanatomic positions. When a surgeon chooses to strictly adhere to an anatomic position, it is preferable to replace the two main AM and PL fiber bundles so as to always obtain a taut bundle. Finally, one last important point is the notion of intercondylar notch/graft conflict. The intercondylar notch is a rather narrow space which was formed around the cruciate ligament structures during knee development. When the notch is very narrow, or in the presence of osteophytes, or when the graft is either not well positioned or too large, a notch/graft conflict can appear which gradually damages the graft and leads to failure. We covered anatomical and biomechanical aspects, let us now look at the functional issues. Above all, the knee must be functional, which means stable, with no dislocation/relocation which causes impairment. In the 70s, M. Lemaire suggested a non-anatomic

17 582 583 584 585 586 587

technique to treat knee ligament instability (53). He performed an anterio-lateral extraarticular tenodesis of the knee using a short strip of fascia lata with the aim of limiting internal rotation of the tibia underneath the femur. This surgery is still proposed in association with in situ ACL reconstruction with an autologous graft in most cases (18). The working principle remains controversial, this extra-articular lateral technique can restrict internal rotation but also helps share the stresses from anterior tibial translation with the ACL graft (15).

588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607

Techniques using the hamstring tendons: The most widely used is the technique which uses a four strand semitendinosus and gracilis (STG) tendon graft (Fig. 5). This technique was developed by L. Pinczewski in the early 90s and used two round-headed interference screws (RCI)(79). Several variations of this standard technique have been developed, using a four-strand semitendinosus alone (4ST) (85) but also a more complex STG construct described as a 4+2 setting or “DiDt cadre” (18) (Fig. 6). The diameter of the graft is also a parameter which can be worked on. Thin tendons call for 6-strand STG grafts, whereas for a very thick semitendinosus, a 3-strand ST graft will do. A 3+1 ST graft can be prepared with 2 or 3 strands of the gracilis and one strand from the ST, the extremity of the ST tendon can be used, for example, to reconstruct the medial collateral ligament (Fig. 7). Both tendons can be prepared separately in two-strand or three-strand constructs for a two bundle anatomic reconstruction in which the semitendinosus and gracilis tendons are respectively used to reconstruct the AM and PL fiber bundles (Fig. 8) (8). As suggested, these tendons offer a wide range of possibilities which allow for optimal adaptation of the graft on a case by case basis, a determining factor for an à la carte surgical approach. The choice of tendon fixation is dominated by suspensory systems for which the graft is attached to the lateral femoral cortex. The best known is the Endobutton family of devices (see chapter 91: graft fixation). This type of fixation must be adapted to the type of construct to be used. Using interference screws means having to suture the tendons to provide a better grip. To be acceptable, these fixations must guarantee a minimum load to failure of 700 N, that is the necessary threshold in case an aggressive rehabilitation program is implemented (61). Walking and jogging only demand 150 N and 450 N respectively.

608 609 610 611 612 613 614 615 616 617 618 619 620

The patellar tendon is harvested in its central portion with a bone block on either side. Harvesting this tendon requires an anterior longitudinal incision liable to damage nerve branches and generate local sensory disturbances. A horizontal double incision technique (Video No. 3) has been described which greatly relieves this problem. The peritendon is carefully closed to enable proper healing, which has led some authors to suggest iterative patellar tendon harvesting which is no longer recommended because of the poor mechanical properties it offers. The length of this graft is directly dependent on the patient’s anatomy which must therefore be taken into consideration. The bone blocks must be placed inside and not outside the tunnels. Inside the joint, they could lead to a potential notch-graft conflict, and outside the tunnel they could be a source of discomfort for the patient and require technical solutions to keep the effect of the bone/bone fixation, which is the main advantage of this type of graft. An angle for the aiming device set to “N + 7°” (where N = length of the patellar tendon alone, without the bone blocks) results in acceptable tunnels 89% of the time, according to Miller. Interference screws remain the preferred choice of fixation for the patellar tendon. However, it may

18 621 622 623 624 625

be necessary to place the bone block more anteriorly on the femur to preserve a posterior bone wall to guarantee the quality of fixation. To avoid this pitfall, the external hardware-free technique can be used, by passing the graft from the femur toward the tibia after having sculpted a conical bone block that will be press-fitted inside the femoral tunnel. Another method to remain « all inside » is to use a fixed but adjustable endobutton to control the position of the bone block inside the tunnel (Fig. 9).

626 627 628 629 630

The free quadriceps tendon graft is harvested from the mid to anterior portion of the tendon. A 10 mm wide and 6 mm thick band is harvested over a length of 9 cm (69) A minimally invasive technique for harvesting this type of graft was described by Fink (26)(Video 4). This graft is an excellent choice in cases of revision surgery for which multiple tendons were already harvested. All of these techniques have described in much detail in EMC (38) (Box No. 8)

631

c) Associated surgical procedures i.

Extra-articular ligament plasty

632 633 634 635 636 637 638

In some instances, an ACL tear is accompanied by a peripheral lesion. The mechanism can stem from the initial injury, as the energy which causes the ACL to tear travels to peripheral structures, especially the anterolateral ligament (Fig. 10) (14) causing a pathognomonic Segond fracture. But the peripheral lesion can also be caused by secondary mechanisms, when an initially isolated anterior laxity is followed by a gradual loosening of a peripheral ligament in reaction to a change in the kinematics of the loaded knee.

639 640 641 642

The lateral and posterolateral compartments are most often affected and require an accurate assessment of laxity. The clinical examination must test all the anatomical components of the knee. Should surgery be indicated, the confirmation of combined anterior laxity will necessitate a specific treatment.

643 644 645 646 647 648 649 650 651 652 653 654 655

Anterolateral rotary instability (ALRI) ligament reconstruction: Lemaire was the first to develop this technique in 1967. The main goal of this procedure is to correct ALRI. This ligament reconstruction does not correct anterior tibial translation. Harvesting the fascia lata and damaging the Kaplan fibers weakens the le hauban externe. For these reasons, this type of surgery can lead to the development of osteoarthritis in the long term. It is rarely used by itself but often supplements an ACL reconstruction to provide some protection of the ligamentization process of the graft and decrease residual ALRI. As far as biomechanical properties are concerned, studies have focused on the isometry of ligament reconstruction. Krackow (48) followed by Kurosawa (50) demonstrated that the best ligament position is, on one end, posterolateral to the femur (above and behind the insertion of the LCL) and on the tibial end, a point anterior to Gerdy’s tubercle according to Krackow, and a point posterior according to Kurosawa. Despite these findings, the ligament is not perfectly isometrically positioned (maximum strain of 12%). Krackow insisted on the need to avoid positioning and tensioning the graft with the tibia externally rotated.

656 657

There are several techniques to choose from : Lemaire’s technique (54), for example, uses a strip of fascia lata, detached proximally but which remains attached to Gerdy’s tubercle (Fig. 11). The sides

19 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681

of the fascia lata must imperatively be closed. It is thus necessary to divide the lateral retinaculum and mobilize the Kaplan fibers. A 1 cm wide and 10 cm long fascia lata strip is harvested while keeping it anchored to Gerdy’s tubercle. The graft is passed underneath the lateral collateral ligament (LCL), and through the femoral tunnel on either side of the LCL insertion, and is then sutured to itself. P. Christel (12) suggested a simplification by fixing the proximal end in the femoral tunnel with an interference screw. The graft is passed and tensioned with a pin which goes through both condyles (Fig. 12). JC Imbert uses one quarter of the lateral portion of the patellar tendon, harvested along with a tibial bone block, and a strip of the quadricipital tendon. The tibial block is implanted in the femoral tunnel placed above and behind the lateral epicondyle. It is fixed with an interference screw or staple. On the tibia, the graft passes in a bony tunnel drilled through Gerdy’s tubercle. This graft does not pass underneath the LCL. It is tensioned with the tibia in neutral rotation and fixed outside the tibial tunnel by one or two staples. More recently, minimally invasive techniques using hamstring tendons have been developed. Imbert P. uses the gracilis and between the joint capsule and the fascia lata. This graft is introduced in the bone tunnels and is fixed to the femur and then to the tibia with interference screws (Fig. 13). P. Neyret supplements an ACL reconstruction for which the patellar tendon is fixed to the lateral condyle from the outside-in with the use of the gracilis tendon which is passed through the femoral bone block to provide lateral reinforcement. These two strands cross underneath the LCL and are fixed inside a vertical tunnel around Gerdy’s tubercle. They are not isometrically positioned, but are used separately depending on the degree of knee flexion (Fig. 14). Colombet P (16) suggests a different way to prepare the gracilis and semitendinosus tendons, referred to as « DiDt Cadre »: (Fig. 15) to optimize the use of the collagen fibers to carry out an extra-articular percutaneous complement to the intra-articular reconstruction. This technique adds a framing effect which improves the rotatory stability of the external compartment. It is both an intra- and extraarticular, minimally invasive technique, which is easy to perform.

682 683 684

Indications: Even though individual techniques vary, the indications depend on each surgeon’s preference as no consensus has yet been reached on the matter. These extra-articular ligament reconstructions are usually advised in the following situations:

685 686

For a revision surgery after failure of an intra-articular reconstruction that did not involve an obvious technical error.

687 688

When the clinical examination reveals an explosive pivot-shift especially in patients with hypermobile joints.

689 690

For some patients who practice a high-energy pivoting contact sport and/or when differential laxity is very high (>10 mm). (Box No.9)

691 692 693 694 695

ii)

Tibial osteotomy

In the presence of osteoarthritis associated with knee laxity, two types of corrections can basically be contemplated (37): either a valgus tibial osteotomy (HTO) or a tibial deflection osteotomy. Valgus HTOs most often involve medial opening because of the medial tibial approach shared by most reconstruction techniques. The correction obtained is accurate, and stabilization is ensured with plate

20 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722

and screw osteosynthesis, with or without a washer. This technique presents no difficulty, but sometimes requires filling the space with wedge-shaped absorbable bone substitutes (in hydroxyapatite or tricalcium phosphate) (23). Precalibrated bone wedges can also be used, they come either from femoral heads provided by bone banks (Video 5) or from the iliac crest. Different authors prefer using a closing wedge (external subtraction) HTO for tibial valgisation, which require a lateral counterincision, and offer the advantage of early weight bearing and rapid consolidation. In men whose bones are more liable to break, closing wedge HTO can be used for up to 5° of valgisation, beyond that, medial opening is recommended. In women, closing wedge can be used for up to 7°. The second type of osteotomy is tibial deflection osteotomy, which can be associated with a valgus HTO. It is used to correct an excessive posterior tibial slope which, when it is greater than 10°, can lead to anterior dislocation of the tibia elicited by weight bearing on knee which in turn generates excessive stress on the graft causing it to gradually loosen which leads to anatomical and functional failure (36). It seems as though high tibial slope is more problematic in women (95). This osteotomy is trickier and often ignored. The need to control the posterior tibial slope must be kept in mind when performing a valgus osteotomy which can easily generate an increase in PTS. Here again, either a lateral closing or medial opening-wedge technique can be used. An osteosynthesis device must be used for stabilization. In 2004, N. Bonin reported a study on 29 patients who underwent a combined ACL reconstruction with valgus osteotomy with an average 12-year follow-up. It was concluded that the combined operation has a low morbidity, allows many patients to return to sports does not result in a rapid progression of osteoarthritis (9). But these patients must already show signs of medial compartment arthritis for this combined surgery to be indicated. Indeed, Kim showed that there was no use in prescribing an osteotomy to treat a varus knee in the absence of osteoarthritis (45). However, this association can be recommended in the presence of multi-ligament tears especially when the lateral and posterolateral ligaments were involved, as demonstrated by F. Noyes in a study on 41 young patients with an average 4.5-year follow-up (71). The osteotomy can influence the type of reconstruction surgery. In a study on biomechanics, Kilger showed that the HTO generated high stresses on the posterolateral bundle causing it to rupture (44). (Box No.10)

723 724 725 726 727

iii) Meniscus lesions Meniscal lesions must be taken into account in the treatment of an ACL tear. Even though it has not been clearly demonstrated that ACL reconstruction protects the injured knee from developing osteoarthritis joint degradation, it is now established that a meniscectomy inevitably leads to OA degradation, even more so as the knee is unstable.

728 729 730 731 732 733

The frequency of meniscal lesions observed after an ACL tear varies between 30 to 70% depending on the studies (13,31,75,94). A recent meta-analysis by Noyes published in the Journal of Arthroscopy in 2012 (70) found meniscal lesions in 60 % of cases out of approximately 20 000 ACL tears, with a slightly higher number of medial meniscus tears. Lesions affecting both menisci are not rare since they are found in10 to 20% of ACL injuries. Papastergiou et al demonstrated that the risk for meniscal lesions increases as the time from injury to ACL reconstruction also increases (75). This

21 734 735

risk significantly increases beyond one year and mainly affects the medial meniscus, whereas the frequency of lateral meniscal tears remains stable (75).

736 737 738 739 740

Another meta-analysis by Pujol et al (80) showed that non-operative management which consists in stabilizing the knee and leaving meniscal tears in situ for spontaneous healing to occur yields poor results especially for the medial meniscus. The rate of residual pain and/or secondary meniscectomy varied between10 and 66 % depending on the studies, with a lower rate for the lateral meniscus, and the failure rate varied between 4 and 22%.

741 742 743 744 745

In a multi-center study published in 2002, Kartus et al (42) evaluated functional results at 3-year follow-up of 137 meniscectomies performed concurrently with an ACL reconstruction. When these results were compared with a control group of 275 ACL reconstructions carried out during the same period that did not involve initial meniscal lesions, the authors found in the “meniscectomy” group more persistent pain, residual effusion and differential laxity..

746 747 748 749 750

In 2007, Koukoulias et al (47) published a study on a series of patients operated for an isolated suture repair of the medial meniscus posterior segment following an ACL tear. For various reasons, these patients chose not to undergo concomitant ACL reconstruction. Even though the number of subjects in this study was low, the results are clear, with 30% secondary meniscectomies and a compelling 90% of patients which reported recurring pain and effusion which forced them to reduce their activity.

751 752 753 754 755 756 757 758 759 760 761

All of the elements reported in the literature encourage us to perform suture meniscal repair along with concomitant ACL reconstruction (French Society of Arthroscopy 2007 annual congress) (7). In a meta-analysis on suture meniscal repair published in 2011, Paxton et al (77) showed that suture meniscal repair associated with ACL reconstruction gave good results when performed concurrently. Out of slightly more than 1000 patients, the failure rate for suture meniscal repair was of approximately 10 % at 4-year post-surgery with a higher revision rate for the medial meniscus (12,4 % compared with 8 % for the lateral meniscus). However, the rate of healing for suture meniscal repair depends on the type of lesion. Though good results are obtained for peripheral tears (3), the healing rate of a longitudinal tear depends on its location (1). The healing rate for bucket handle tears also seems to be lower especially in the presence of locking (3,25,72) except when the lateral meniscus is affected (86). The healing rate for radial tears is also lower (21,87).

762 763 764 765 766 767 768 769 770

Overall, the rate of failure for suture meniscal repair is high as it varies between 3 and 16 % depending on the case series, with a higher rate for medial meniscus tears. Given the anatomy of the medial femorotibial compartment and the obstruction of the medial condyle, the quality of the suture repair of the medial meniscal posterior segment, no matter what implant is used, is related to suture meniscal repair failure. Several authors recommend an arthroscopic exploration of the posteromedial compartment as part of knee assessment, by positioning the arthroscope in the intercondylar notch to better visualize the posterior segment of the medial meniscus. If a lesion is found, a posteromedial portal will be used for a visually aided suture repair as described by Craig Morgan several years ago (66).

22 771 772 773 774

There is no specific rehabilitation protocol suggested in the literature following meniscal repair. Some authors recommend limiting or delaying weight bearing with the knee flexed to 90° maximum during the first month. Others report that accelerated rehabilitation program with complete weight bearing and no limitation in mobility does not seem to alter the rate of healing (5). (Box No. 11)

775

Indications

776 777 778 779 780 781 782 783 784 785 786 787 788 789 790 791 792 793 794 795 796 797 798 799 800 801 802 803 804 805 806 807 808 809

We saw that the ACL can be either completely or partially torn, and that depending on the type of trauma the ACL tear can be accompanied by other types of ligamentous injuries and meniscal or articular cartilage lesions. Furthermore, when both the femoral and tibial lateral bruises caused by the initial trauma are superimposed, it becomes clear that an isolated ACL tear is impossible. This degree of knee dislocation inevitably causes at the very least the secondary ligament restraints to loosen. These multiple lesions are responsible for complex knee laxity that cannot be accurately assessed with basic clinical laxity tests. New generation equipment designed to measure residual laxity allows the physician to differentiate these different types of lesions. Other parameters such as morphotype (height, weight, joint hypermobility, etc.) and type of sporting activity (pivoting, pivoting-contact, high energy pivoting-contact, leisure, professional level, etc.) subdivide even more the population of patients resulting in a highly diverse lesional context. It is thus difficult to imagine that these different cases can be managed with a single, standardized, universal therapeutic approach. These observations have led physicians to adapt the treatments and modify the techniques to offer an à la carte type of surgery. This concept was made possible by the modularity provided by the hamstring tendons for different graft settings and by an improved assessment of knee laxity. The first step was to adapt the diameter of the graft to the patient’s size. Using the ST alone or in combination with the gracilis has enabled the surgeon to control the desired diameter by varying the number of tendons and the number of strands. Therefore, starting with a basic 4-strand STG graft construct (STG4), other types of constructs have been developed: ST2, ST3, ST4, G2, G3, STG6, STG4+2, STG3+1, STG2+2 (Tab. 2). These different constructs are used for both single-bundle and double-bundle ACL reconstruction, but also medial collateral reconstruction, and ACL reconstruction with concurrent extra-articular lateral reconstruction. Using suspensory type fixations has reinforced the tendon fixation and facilitated the preparation of ST4 type short graft constructs. The concept of à la carte surgery appears even more pertinent, as the menu has been refined to offer even more options to satisfy any situation. To begin with, the « day’s special » corresponds to the basic standard procedure of a single-bundle reconstruction using the patellar tendon or hamstring tendons with a 4-strand STG construct, or 6strand construct if the tendons are thin. It applies to patients whose knees are unstable during sporting or daily activities, with a low rotatory component which results in a Rotation to Translation rate (R/T) lower than 0.5. This basic menu can be supplemented by an extra-articular lateral tendon reconstruction with the fascia lata in an open-sky approach, or the hamstring with a percutaneous technique. This supplement can be indicated for patients with hypermobile kne joints, for which good anatomical results are difficult to obtain, but can also be indicated for patients who practice a highenergy pivoting contact sport. More sophisticated menus are also available. A « connoisseur » menu, for example, could refer to a double-bundle anatomical reconstruction, in which a 2-3 or even 4 strand

23 810 811 812 813 814 815 816 817 818 819 820 821 822 823 824 825 826 827 828 829 830 831 832 833 834 835 836 837 838 839 840 841 842 843 844 845 846 847 848 849 850

ST graft is used to reconstruct the AM bundle, and a 2 or 3 strand gracilis is used to reconstruct the PL bundle. The aim of this technique is to better control rotatory laxity as demonstrated in vitro and in vivo at T0 (preoperatively). It is indicated for predominant rotatory laxity i.e. with an R/T index greater than 0.5, which is clinically manifested by an explosive pivot-shift graded “D” according to the IKDC classification. This particular feature makes this technique suitable for patients with hypermobile knee joints or for those who practice high-energy pivoting contact sports. This option can also be applied in cases where a single-bundle reconstruction will not achieve complete restoration of the native tibial ACL footprint, as suggested by R. Siebold (89). The double-bundle technique will then provide the restoration of a greater area of the native ACL insertion site (Fig. 16). Next comes the « gourmet » menu which aims at treating laxity, including any coexisting laxity. It can concern medial lesions of the medial collateral ligament (MCL) and posteromedial structures. In such a case, an STG+1 construct is well adapted since it allows the surgeon to reconstruct the ACL and the MCL with the same graft. The position of the tibial tunnel is then slightly modified to make its external extremity meet the tibial insertion of the MCL’s superficial bundle. The MCL’s residual tissue is incised vertically up to the medial condylar tubercle. A curvilinear tunnel is drilled underneath this tuberosity and the graft goes down towards the tibia (Fig. 17). The graft is stabilized by suturing it along its full length and the medial capsular ligament plane is closed La greffe est sécurisée par faufilage sur toute sa longueur et le plan médial capsulo-ligamentaire est refermé pardessus avec solidarisation au passage du mur du ménisque médial. Do not forget to reinforce the posteromedial angle. Better results are obtained for recent grade III injuries. Laterally, tendon and ligament structures may need to be reconstructed especially when ACL lesions are accompanied by lateral or posterolateral lesions. These types of lesions are not exceptional and too often remain undiagnosed. The interrogation must be carefully conducted because these types of lesions are often caused by varus knee injury mechanisms. The clinical examination of an ACL tear must always include a lateral laxity assessment with the knee in slight flexion and complete flexion. An STG 4+2 construct is ideally indicated in this case to reconstruct the ACL and lateral collateral ligament (LCL) and/or the popliteus tendon. For this, using the contralateral tendons could prove to be helpful. Finally, there is a « light » menu in case of a partial rupture when faced with the following clinical profile : a patient victim of an accident during which there is no doubt that the ACL was injured. This patient may have been diagnosed on site by a doctor familiar with ACL injury assessment tests, and had a very positive Lachman test, or an MRI may have revealed a continuous but unstructured ACL with a hyperintense signal, associated with typical mirror image contusions on both the femoral and tibial lateral compartments. When a long period of time has elapsed between the accident and the clinical examination, the Lachman test gives either a delayed hard stop or even a negative result. In this case, we are dealing with a partial tear, which, in a patient who practices a pivoting contact or high-energy pivoting contact sport, is very likely to result in a secondary instability accident, often associated with a peripheral ligamentous lesion and/or a medial meniscal tear. The study reported by C Baudot (6) illustrates this risk very well. In this situation, an additional reconstruction of the injured tendon bundle can be directly proposed to the patient. This technique depends on the diagnosis which is not always easy to confirm, the injured bundle must be identified by exploratory arthroscopy (French Society of Arthroscopy 2010 annual congress) (81,91). The reconstruction technique is

24 851 852 853 854 855 856 857

complex and must be carried out by an experienced surgeon. Proper positioning of the femoral tunnel is trickier than for a standard technique, which itself requires of the surgeon to be experienced, due to lack of visibility caused by the remaining tissue. This additional reconstruction technique should be left to experienced surgeons. These notions can be found in the best practice guidelines and guidelines on the management of meniscal lesions and isolated lesions of the anterior cruciate ligament (ACL) of the knee in adults issued by the French National Authority for Health (HAS) (33,34).

858 859 860 861 862 863

From this data, a decision tree can be formulated for patients with closed physes (Table 3), based on the information collected from the clinical interrogation with a focus on the circumstances surrounding the accident, and a detailed clinical examination complemented by MRI findings. Exploratory arthroscopy may be necessary before making the final decision, especially when a partial tear is suspected in a patient who practices a high-energy pivoting contact sport, or in a patient with an associated significant meniscus tear. (Box No. 12)

864 865 866 867 868 869 870 871

Conclusion

872 873 874 875

The future remains wide open with great adventures to come. Artificial ligaments are already on the market, and fully developed new laxity assessment tools for use in the office will soon be available. But the next big step will concern the use of these new assessment tools to explore secondary ligament restraints, far too often overlooked, even in cases of ACL tears considered as isolated.

Indications for ACL reconstruction have changed considerably over the years. The concept of a single universal type of surgery is slowly being replaced by a customized, à la carte surgery. This evolution has been driven by earlier diagnoses as well as surgical techniques that have become more accurate and less invasive. Each new beginning was initiated by a return to the fundamental principles of anatomy, a domain which remains rich in discoveries and full of surprises, and by increasingly sophisticated measuring systems that have enabled us to better understand knee kinematics.

25 876 877 878 879 880 881 882 883 884 885 886 887 888 889 890 891 892 893 894 895 896 897 898 899 900 901 902 903 904 905 906 907 908 909 910 911 912 913 914 915 916 917 918 919 920 921 922

References 1.

2.

Ahn JH, Lee YS, Yoo JC, Chang MJ, Koh KH, Kim MH. Clinical and second-look arthroscopic evaluation of repaired medial meniscus in anterior cruciate ligament-reconstructed knees. Am J Sports Med 2010; 38: 472-7. Amis A, Zavras TD. Isometricity and graft placement during anterior cruciate ligament reconstruction

The knee 1995; 2: 5-17. 3. Asahina S, Muneta T, Yamamoto H. Arthroscopic meniscal repair in conjunction with anterior cruciate ligament reconstruction: factors affecting the healing rate. Arthroscopy 1996; 12: 541-5. 4. Balasch H, Schiller M, Friebel H, Hoffmann F. Evaluation of anterior knee joint instability with the Rolimeter. A test in comparison with manual assessment and measuring with the KT-1000 arthrometer. Knee Surg Sports Traumatol Arthrosc 1999; 7: 204-8. 5. Barber FA, Click SD. Meniscus repair rehabilitation with concurrent anterior cruciate reconstruction. Arthroscopy 1997; 13: 433-7. 6. Baudot C, Colombet P, Thoribé B, Paris G, Robinson J. Cicatrisation du ligament croisé antéro-externe Devenir fonctionnel à plus d’un an. J. Traumatologie du Sport 2005; 22: 141-147. 7. Beaufils P, Cassard X. [Meniscal repair--SFA 2003]. Rev Chir Orthop Reparatrice Appar Mot 2007; 93: 5S12-3. 8. Bellier G, Christel P, Colombet P, Djian P, Franceschi JP, Sbihi A. Double-stranded hamstring graft for anterior cruciate ligament reconstruction. Arthroscopy 2004; 20: 890-4. 9. Bonin N, Ait Si Selmi T, Donell ST, Dejour H, Neyret P. Anterior cruciate reconstruction combined with valgus upper tibial osteotomy: 12 years follow-up. Knee 2004; 11: 431-7. 10. Branch TP, Browne JE, Campbell JD, Siebold R, Freedberg HI, Arendt EA, et al. Rotational laxity greater in patients with contralateral anterior cruciate ligament injury than healthy volunteers. Knee Surg Sports Traumatol Arthrosc 2010; 18: 1379-84. 11. Christel P, Anatomie du ligament croisé antérieur et isométrie, in Arthroscopie, Editors: A. Frank, H. Dorfman. 1999, Elsevier: Paris. p. 124-131. 12. Christel P, Djian P. [Anterio-lateral extra-articular tenodesis of the knee using a short strip of fascia lata]. Rev Chir Orthop Reparatrice Appar Mot 2002; 88: 508-13. 13. Church S, Keating JF. Reconstruction of the anterior cruciate ligament: timing of surgery and the incidence of meniscal tears and degenerative change. J Bone Joint Surg Br 2005; 87: 1639-42. 14. Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J. Anatomy of the anterolateral ligament of the knee. J Anat 2013; 223: 321-8. 15. Colombet P. Knee laxity control in revision anterior cruciate ligament reconstruction versus anterior cruciate ligament reconstruction and lateral tenodesis: clinical assessment using computer-assisted navigation. Am J Sports Med 2011; 39: 1248-54. 16. Colombet P. Plastie latérale extra-articulaire additionnelle du genou: Une technique mini invasive originale. Maitrise Orthpédique 2013; Aout/Septembre 6-9. 17. Colombet P, Robinson J, Christel P, Franceschi JP, Djian P. Using navigation to measure rotation kinematics during ACL reconstruction. Clin Orthop Relat Res 2007; 454: 59-65. 18. Colombet PD. Navigated intra-articular ACL reconstruction with additional extra-articular tenodesis using the same hamstring graft. Knee Surg Sports Traumatol Arthrosc 2011; 19: 384-9. 19. Condouret J, Cohn J, Ferret JM, Lemonsu A, Vasconcelos W, Dejour D, et al. [Isokinetic assessment with two years follow-up of anterior cruciate ligament reconstruction with patellar tendon or hamstring tendons]. Rev Chir Orthop Reparatrice Appar Mot 2008; 94: 375-82. 20. Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR. Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med 1994; 22: 632-44.

26 923 924 925 926 927 928 929 930 931 932 933 934 935 936 937 938 939 940 941 942 943 944 945 946 947 948 949 950 951 952 953 954 955 956 957 958 959 960 961 962 963 964 965 966 967 968 969 970

21. 22. 23.

24.

25.

26. 27.

28. 29. 30. 31.

32.

33.

34.

35. 36.

37. 38.

DeHaan A, Rubinstein RA, Jr., Baldwin JL. Evaluation of success of a meniscus repair device for vertical unstable medial meniscus tears in ACL-reconstructed knees. Orthopedics 2009; 32 Delince P, Ghafil D. Anterior cruciate ligament tears: conservative or surgical treatment? A critical review of the literature. Knee Surg Sports Traumatol Arthrosc 2012; 20: 48-61. Demange MK, Camanho GL, Pecora JR, Gobbi RG, Tirico LE, da Mota e Albuquerque RF. Simultaneous anterior cruciate ligament reconstruction and computer-assisted open-wedge high tibial osteotomy: a report of eight cases. Knee 2011; 18: 387-91. Espregueira-Mendes J, Pereira H, Sevivas N, Passos C, Vasconcelos JC, Monteiro A, et al. Assessment of rotatory laxity in anterior cruciate ligament-deficient knees using magnetic resonance imaging with Porto-knee testing device. Knee Surg Sports Traumatol Arthrosc 2012; 20: 671-8. Feng H, Hong L, Geng XS, Zhang H, Wang XS, Jiang XY. Second-look arthroscopic evaluation of buckethandle meniscus tear repairs with anterior cruciate ligament reconstruction: 67 consecutive cases. Arthroscopy 2008; 24: 1358-66. Fink C, Veselko M, Herbort M, Hoser C. Minimally invasive reconstruction of the medial patellofemoral ligament using quadriceps tendon. Arthrosc Tech 2014; 3: e325-9. Fithian DC, Paxton EW, Stone ML, Luetzow WF, Csintalan RP, Phelan D, et al. Prospective trial of a treatment algorithm for the management of the anterior cruciate ligament-injured knee. Am J Sports Med 2005; 33: 335-46. Friederich NF, Anatomie fonctionnelle du pivot central du genou, in Pathologie ligamentaire du genou, Editors: P. Landreau, P. Christel, P. Djian. 2004, Springer-Verlag: Paris. p. 1-44. Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med 2010; 363: 331-42. Graham GP, Johnson S, Dent CM, Fairclough JA. Comparison of clinical tests and the KT1000 in the diagnosis of anterior cruciate ligament rupture. Br J Sports Med 1991; 25: 96-7. Granan LP, Bahr R, Lie SA, Engebretsen L. Timing of anterior cruciate ligament reconstructive surgery and risk of cartilage lesions and meniscal tears: a cohort study based on the Norwegian National Knee Ligament Registry. Am J Sports Med 2009; 37: 955-61. Harris NL, Smith DA, Lamoreaux L, Purnell M. Central quadriceps tendon for anterior cruciate ligament reconstruction. Part I: Morphometric and biomechanical evaluation. Am J Sports Med 1997; 25: 23-8. Haute-Autorité-de-Santé. Prise en charge thérapeutique des lésions méniscales et des lésions isolées du ligament croisé antérieur du genou chez l’adulte. 2008 [cited; Available from: http://www.hassante.fr/portail/jcms/c_681019/fr/lesions-meniscales-et-du-ligament-croise-anterieurargumentaire. Haute-Autorité-de-Santé. Prise en charge thérapeutique des lésions méniscales et des lésions isolées du ligament croisé antérieur du genou chez l’adulte Synthése des recommandations professionelles. 2008 [cited; Available from: http://www.has-sante.fr/portail/upload/docs/application/pdf/200807/lesions_meniscales_et_du_ligament_croise_anterieur_-_synthese.pdf. Hefti F, Muller W, Jakob RP, Staubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1993; 1: 226-34. Hohmann E, Bryant A, Reaburn P, Tetsworth K. Does posterior tibial slope influence knee functionality in the anterior cruciate ligament-deficient and anterior cruciate ligament-reconstructed knee? Arthroscopy 2010; 26: 1496-502. Hulet C, Arthrose et laxités du genou, in Conférence d'EnseignementSOFCOT, Editor E.S. Française. 2005: Paris. Hulet C, Lebel B, Colombet P, Pineau V, Locker B, Traitement chirurgical des lésions du ligament croisé antérieur, in EMC Techniques chirurgicales -Orthopédie-Traumatologie, Editor E.M. SAS. 2011: Paris. p. 44-780.

27 971 972 973 974 975 976 977 978 979 980 981 982 983 984 985 986 987 988 989 990 991 992 993 994 995 996 997 998 999 1000 1001 1002 1003 1004 1005 1006 1007 1008 1009 1010 1011 1012 1013 1014 1015 1016

39.

40.

41. 42.

43.

44.

45.

46.

47.

48. 49. 50.

51.

52. 53. 54. 55.

Hurd WJ, Axe MJ, Snyder-Mackler L. A 10-year prospective trial of a patient management algorithm and screening examination for highly active individuals with anterior cruciate ligament injury: Part 2, determinants of dynamic knee stability. Am J Sports Med 2008; 36: 48-56. Jardin C, Chantelot C, Migaud H, Gougeon F, Debroucker MJ, Duquennoy A. [Reliability of the KT1000 arthrometer in measuring anterior laxity of the knee: comparative analysis with Telos of 48 reconstructions of the anterior cruciate ligament and intra- and interobserver reproducibility]. Rev Chir Orthop Reparatrice Appar Mot 1999; 85: 698-707. Julliard R, Lavallee S, Dessenne V. Computer assisted reconstruction of the anterior cruciate ligament. Clin Orthop 1998: 57-64. Kartus JT, Russell VJ, Salmon LJ, Magnusson LC, Brandsson S, Pehrsson NG, et al. Concomitant partial meniscectomy worsens outcome after arthroscopic anterior cruciate ligament reconstruction. Acta Orthop Scand 2002; 73: 179-85. Kessler MA, Behrend H, Henz S, Stutz G, Rukavina A, Kuster MS. Function, osteoarthritis and activity after ACL-rupture: 11 years follow-up results of conservative versus reconstructive treatment. Knee Surg Sports Traumatol Arthrosc 2008; 16: 442-8. Kilger RH, Stehle J, Fisk JA, Thomas M, Miura K, Woo SL. Anatomical double-bundle anterior cruciate ligament reconstruction after valgus high tibial osteotomy: a biomechanical study. Am J Sports Med 2006; 34: 961-7. Kim SJ, Moon HK, Chun YM, Chang WH, Kim SG. Is correctional osteotomy crucial in primary varus knees undergoing anterior cruciate ligament reconstruction? Clin Orthop Relat Res 2011; 469: 14216. Kostogiannis I, Ageberg E, Neuman P, Dahlberg L, Friden T, Roos H. Activity level and subjective knee function 15 years after anterior cruciate ligament injury: a prospective, longitudinal study of nonreconstructed patients. Am J Sports Med 2007; 35: 1135-43. Koukoulias N, Papastergiou S, Kazakos K, Poulios G, Parisis K. Mid-term clinical results of medial meniscus repair with the meniscus arrow in the unstable knee. Knee Surg Sports Traumatol Arthrosc 2007; 15: 138-43. Krackow KA, Brooks RL. Optimization of knee ligament position for lateral extraarticular reconstruction. Am J Sports Med 1983; 11: 293-302. Kryszohn F, Luber M, Binder E, Schaff P. [Mechanical effects on measuring displacement of the knee joint with the knee arthrometer KT1000 and KT2000]. Biomed Tech (Berl) 1999; 44: 202-5. Kurosawa H, Yasuda K, Yamakoshi K, Kamiya A, Kaneda K. An experimental evaluation of isometric placement for extraarticular reconstructions of the anterior cruciate ligament. Am J Sports Med 1991; 19: 384-8. Kursunoglu S, Pate D, Resnick D, Andre M, Sartoris D. Computed arthrotomography with multiplanar reformations and three-dimensional image analysis in the evaluation of the cruciate ligaments: preliminary investigation. Can Assoc Radiol J 1986; 37: 153-6. Lavallee S, Bainville E, Bricault I. An overview of computer-integrated surgery and therapy. Crit Rev Diagn Imaging 2000; 41: 157-236. Lemaire M. [Chronic knee instability. Technics and results of ligament plasty in sports injuries]. J Chir (Paris) 1975; 110: 281-94. Lemaire M, Combelles F. [Plastic repair with fascia lata for old tears of the anterior cruciate ligament (author's transl)]. Rev Chir Orthop Reparatrice Appar Mot 1980; 66: 523-5. Lerat JL, Moyen B, Dupre Latour L, Mainetti E, Lalain JJ, Brunet E. [Measurement of anterior knee instability using dynamic radiography and the KT 1000 arthrometer]. Rev Chir Orthop Reparatrice Appar Mot 1988; 74 Suppl 2: 194-7.

28 1017 1018 1019 1020 1021 1022 1023 1024 1025 1026 1027 1028 1029 1030 1031 1032 1033 1034 1035 1036 1037 1038 1039 1040 1041 1042 1043 1044 1045 1046 1047 1048 1049 1050 1051 1052 1053 1054 1055 1056 1057 1058 1059 1060 1061 1062 1063 1064

56.

57. 58.

59.

60. 61.

62.

63.

64.

65. 66. 67. 68. 69. 70. 71. 72. 73. 74.

75.

Lerat JL, Moyen B, Jenny JY, Perrier JP. A comparison of pre-operative evaluation of anterior knee laxity by dynamic X-rays and by the arthrometer KT 1000. Knee Surg Sports Traumatol Arthrosc 1993; 1: 54-9. Lippe J, Armstrong A, Fulkerson JP. Anatomic guidelines for harvesting a quadriceps free tendon autograft for anterior cruciate ligament reconstruction. Arthroscopy 2012; 28: 980-4. Lopomo N, Signorelli C, Bonanzinga T, Marcheggiani Muccioli GM, Visani A, Zaffagnini S. Quantitative assessment of pivot-shift using inertial sensors. Knee Surg Sports Traumatol Arthrosc 2012; 20: 7137. Lopomo N, Zaffagnini S, Signorelli C, Bignozzi S, Giordano G, Marcheggiani Muccioli GM, et al. An original clinical methodology for non-invasive assessment of pivot-shift test. Comput Methods Biomech Biomed Engin 2012; 15: 1323-8. Lorbach O, Wilmes P, Theisen D, Brockmeyer M, Maas S, Kohn D, et al. Reliability testing of a new device to measure tibial rotation. Knee Surg Sports Traumatol Arthrosc 2009; 17: 920-6. Markolf KL, Willems MJ, Jackson SR, Finerman GA. In situ calibration of miniature sensors implanted into the anterior cruciate ligament part II: force probe measurements. J Orthop Res 1998; 16: 46471. Mayr HO, Hoell A, Bernstein A, Hube R, Zeiler C, Kalteis T, et al. Validation of a measurement device for instrumented quantification of anterior translation and rotational assessment of the knee. Arthroscopy 2011; 27: 1096-104. Meuffels DE, Favejee MM, Vissers MM, Heijboer MP, Reijman M, Verhaar JA. Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletes. Br J Sports Med 2009; 43: 347-51. Moksnes H, Engebretsen L, Eitzen I, Risberg MA. Functional outcomes following a non-operative treatment algorithm for anterior cruciate ligament injuries in skeletally immature children 12 years and younger. A prospective cohort with 2 years follow-up. Br J Sports Med 2013; 47: 488-94. Moksnes H, Risberg MA. Performance-based functional evaluation of non-operative and operative treatment after anterior cruciate ligament injury. Scand J Med Sci Sports 2009; 19: 345-55. Morgan CD. The "all-inside" meniscus repair. Arthroscopy 1991; 7: 120-5. Musahl V, Bell KM, Tsai AG, Costic RS, Allaire R, Zantop T, et al. Development of a simple device for measurement of rotational knee laxity. Knee Surg Sports Traumatol Arthrosc 2007; 15: 1009-12. Neyret P, Lésions ligamentaires complexes récentes: triades, pentades et luxations, in Cahier d’enseignement de la SOFCOT N°59, Editor E.S. Française. 1996: Paris. p. 37-52. Noyes FR, Barber-Westin SD. Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft. Am J Sports Med 2006; 34: 553-64. Noyes FR, Barber-Westin SD. Treatment of meniscus tears during anterior cruciate ligament reconstruction. Arthroscopy 2012; 28: 123-30. Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med 2000; 28: 282-96. O'Shea JJ, Shelbourne KD. Repair of locked bucket-handle meniscal tears in knees with chronic anterior cruciate ligament deficiency. Am J Sports Med 2003; 31: 216-20. Odensten M, Gillquist J. Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg Am 1985; 67: 257-62. Panisset JC, Ntagiopoulos PG, Saggin PR, Dejour D. A comparison of Telos stress radiography versus Rolimeter in the diagnosis of different patterns of anterior cruciate ligament tears. Orthop Traumatol Surg Res 2012; 98: 751-8. Papastergiou SG, Koukoulias NE, Mikalef P, Ziogas E, Voulgaropoulos H. Meniscal tears in the ACLdeficient knee: correlation between meniscal tears and the timing of ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2007; 15: 1438-44.

29 1065 1066 1067 1068 1069 1070 1071 1072 1073 1074 1075 1076 1077 1078 1079 1080 1081 1082 1083 1084 1085 1086 1087 1088 1089 1090 1091 1092 1093 1094 1095 1096 1097 1098 1099 1100 1101 1102 1103 1104 1105 1106 1107 1108 1109 1110 1111

76. 77. 78.

79.

80. 81.

82. 83.

84. 85. 86.

87. 88.

89. 90.

91.

92.

93.

Park HS, Wilson NA, Zhang LQ. Gender differences in passive knee biomechanical properties in tibial rotation. J Orthop Res 2008; 26: 937-44. Paxton ES, Stock MV, Brophy RH. Meniscal repair versus partial meniscectomy: a systematic review comparing reoperation rates and clinical outcomes. Arthroscopy 2011; 27: 1275-88. Pelousse F, Olette J. [Arthro-scanner of the knee: current indication, examination of the femoro-tibial compartment. Comparative study with classical simple-contrast media arthrography]. J Belge Radiol 1993; 76: 377-81. Pinczewski LA, Thuresson P, Otto D, Nyquist F. Arthroscopic posterior cruciate ligament reconstruction using four-strand hamstring tendon graft and interference screws. Arthroscopy 1997; 13: 661-5. Pujol N, Beaufils P. Healing results of meniscal tears left in situ during anterior cruciate ligament reconstruction: a review of clinical studies. Knee Surg Sports Traumatol Arthrosc 2009; 17: 396-401. Pujol N, Colombet P, Potel JF, Cucurulo T, Graveleau N, Hulet C, et al. Anterior cruciate ligament reconstruction in partial tear: selective anteromedial bundle reconstruction conserving the posterolateral remnant versus single-bundle anatomic ACL reconstruction: preliminary 1-year results of a prospective randomized study. Orthop Traumatol Surg Res 2012; 98: S171-7. Quelard B, Rachet O, Sonnery-Cottet B, Chambat P, Rééducation post-opératoire des greffes du Ligament Croisé Antérieur, in Encyclopédie Médico-chirurgicale Editor E.M. SAS. 2010: Paris. p. 1-16. Quelard B, Sonnery-Cottet B, Zayni R, Ogassawara R, Prost T, Chambat P. Preoperative factors correlating with prolonged range of motion deficit after anterior cruciate ligament reconstruction. Am J Sports Med 2010; 38: 2034-9. Roger B, Imagerie du genou traumatique du sportif. , in Cahier d’enseignement de la SOFCOT N°59. 1996, Expansion Scienti- fique Française: Paris. p. 7-18. Rosenberg TD, Brown GC, deffner KT. Anterior criciate ligament reconstruction with a quadrupled semitendinosus autograft. Sports Med Arthros Rev 1997; 5: 51-58. Shelbourne KD, Dersam MD. Comparison of partial meniscectomy versus meniscus repair for buckethandle lateral meniscus tears in anterior cruciate ligament reconstructed knees. Arthroscopy 2004; 20: 581-5. Shelbourne KD, Rask BP. The sequelae of salvaged nondegenerative peripheral vertical medial meniscus tears with anterior cruciate ligament reconstruction. Arthroscopy 2001; 17: 270-274. Shultz SJ, Shimokochi Y, Nguyen AD, Schmitz RJ, Beynnon BD, Perrin DH. Measurement of varusvalgus and internal-external rotational knee laxities in vivo--Part II: relationship with anteriorposterior and general joint laxity in males and females. J Orthop Res 2007; 25: 989-96. Siebold R. The concept of complete footprint restoration with guidelines for single- and doublebundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2011; 19: 699-706. Sonnery-Cottet B, Archbold P, Cucurulo T, Fayard JM, Bortolletto J, Thaunat M, et al. The influence of the tibial slope and the size of the intercondylar notch on rupture of the anterior cruciate ligament. J Bone Joint Surg Br; 93: 1475-8. Sonnery-Cottet B, Panisset JC, Colombet P, Cucurulo T, Graveleau N, Hulet C, et al. Partial ACL reconstruction with preservation of the posterolateral bundle. Orthop Traumatol Surg Res 2012; 98: S165-70. Streich NA, Zimmermann D, Bode G, Schmitt H. Reconstructive versus non-reconstructive treatment of anterior cruciate ligament insufficiency. A retrospective matched-pair long-term follow-up. Int Orthop 2011; 35: 607-13. Svoboda SJ, Harvey TM, Owens BD, Brechue WF, Tarwater PM, Cameron KL. Changes in serum biomarkers of cartilage turnover after anterior cruciate ligament injury. Am J Sports Med 2013; 41: 2108-16.

30 1112 1113 1114 1115 1116 1117 1118 1119 1120 1121 1122

1123

94.

95. 96.

97.

Tandogan RN, Taser O, Kayaalp A, Taskiran E, Pinar H, Alparslan B, et al. Analysis of meniscal and chondral lesions accompanying anterior cruciate ligament tears: relationship with age, time from injury, and level of sport. Knee Surg Sports Traumatol Arthrosc 2004; 12: 262-70. Todd MS, Lalliss S, Garcia E, DeBerardino TM, Cameron KL. The relationship between posterior tibial slope and anterior cruciate ligament injuries. Am J Sports Med 2010; 38: 63-7. Woo SL, Hollis JM, Adams DJ, Lyon RM, Takai S. Tensile properties of the human femur-anterior cruciate ligament-tibia complex. The effects of specimen age and orientation. Am J Sports Med 1991; 19: 217-25. Woo SL, Karaoglu S, Dede O. [Contribution of biomechanics to anterior cruciate ligament reconstruction]. Acta Orthop Traumatol Turc 2006; 40: 94-100.