Orthopaedics & Traumatology: Surgery & Research (2012) 98S, S171—S177

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ORIGINAL ARTICLE

Anterior cruciate ligament reconstruction in partialtear: Selective anteromedial bundle reconstructionconserving the posterolateral remnant versussingle-bundle anatomic ACL reconstruction:Preliminary 1-year results of a prospectiverandomized study

N. Pujola,∗, P. Colombetb, J.-F. Potel c, T. Cucurulod, N. Graveleaue,C. Hulet f, J.-C. Panissetg, E. Servienh, B. Sonnery-Cottet i, C. Trojani j,P. Djiank, the French Arthroscopy Society (SFA)1

a Versailles Hospital Center, Versailles-Saint-Quentin University, 177, rue de Versailles, 78157 Le Chesnay, Franceb Clinique du Sport, 2, rue Negrevergne, 33700 Mérignac, Francec Clinique Médipôle Garonne, 45, rue Gironis, 31036 Toulouse cedex 1, Franced Clinique Juge, 118, rue Jean-Mermoz, 13008 Marseille, Francee CMC Paris 5, 36, boulevard Saint-Marcel, 75005 Paris 5, Francef CHU de Caen, 14033 Caen cedex, Franceg Clinique des Cèdres, 48, avenue Grugliasco, 38130 Échirolles, Franceh CHU de la Croix-Rousse, 103, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, Francei Centre orthopédique santé, 24, avenue Paul-Santy, 69008 Lyon, Francej CHU de Nice, hôpital de l’Archet, 151, route Saint-Antoine-de-Ginestière, 6200 Nice, Francek Cabinet Goethe, 23, avenue Niel, 75017 Paris, France

Accepted: 25 September 2012

KEYWORDSAnterior cruciate

SummaryIntroduction: Partial tears of the anterior cruciate ligament (ACL) are frequent. Conserving

ligament;Knee;Tear;

ACL remnants is central to the concept of anatomic, biomechanical and biological reconstruc-tion. The interest of such conservation remains theoretical. The present hypothesis was thatselective anteromedial (AM) bundle reconstruction is preferable to the standard single-bundlereconstruction in partial ACL tear.

∗ Corresponding author. Tel.: +33 1 39 63 89 51; fax: +33 1 39 63 95 07.E-mail address: npujol@ch-versailles.fr (N. Pujol).

1 18, rue Marbeuf, 75008 Paris.

1877-0568/$ – see front matter © 2012 Published by Elsevier Masson SAS.doi:10.1016/j.otsr.2012.09.007

S172 N. Pujol et al.

Arthroscopy;Partial

Materials and methods: A multicenter prospective randomized study recruited 54 partial ACLtears operated on either by selective AM bundle reconstruction (Group 1, n = 29) or by standardanatomic single-bundle reconstruction (Group 2, n = 25). All patients were clinically assessed onsubjective and objective IKDC, Lysholm and KOOS scores, with a minimum 12 months’ follow-up. Comparative pre- to postoperative anterior laxity was measured on the Rolimeter® device,with statistical analysis of results.Results: There were no significant preoperative differences between the two groups. Allpatients were followed-up at 6 months and 1 year. Mean subjective IKDC scores for groups 1 and2 respectively were 55.8 and 56.8 preoperatively versus 86.2 and 85.7 at 1 year; Lysholm scoreswere 69.9 and 71.1 versus 90.9 and 91.8. These inter-group differences were non-significant.Differential laxity for groups 1 and 2 respectively was 5.0 mm (range, 2—10) and 5.1 mm (2—12)preoperatively (P = 0.73), versus 1.2 mm and 1.9 mm postoperatively (P = 0.03).Discussion and conclusion: In partial ACL tear, selective AM bundle reconstruction conservingthe posterolateral bundle remnant provides clinical results comparable to the standard single-bundle technique, with better control of anterior laxity. Longer follow-up, however, will beneeded to compare evolution in anterior and rotational laxity and in subjective results overtime.Type of study: Prospective randomized, level I.© 2012 Published by Elsevier Masson SAS.

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postoperatively by the Rolimeter® device, with three suc-cessive measurements per knee, in maximal manual anteriordrawer. Mean and median values were calculated for statis-tical analysis.

Table 1 Sociodemographic data at inclusion.

Group 1n = 29

Group 2n = 25

Total n = 54

SexM 16 (55.18%) 17 (68%) 33 (61.11%)F 13 (44.82%) 8 (32%) 21 (38.88%)

Mean age (years) 31.24 28.56 30Mean weight (kg) 71 70.92 70.96Mean height (cm) 170 173.4 171.96

ntroduction

esions of the anterior cruciate ligament (ACL) are fre-uently partial (5 to 38% depending on the series) [1—6]. Therinciples of modern anatomic ACL reconstruction presentlyonsist in recreating the native ligament insertions, conserv-ng whatever remnants may be present [7—9]. Techniquesonserving the native ACL footprint have been developed,nd partial reconstruction is recommended when a bundleeems to have been spared; taken together, these tech-iques are known as ‘‘ACL augmentation’’ [4,10—17].

Such reconstruction is technically difficult: determin-ng residual tissue quality is delicate, arthroscopic vision isestricted and there is a risk of mislocating tunnels. Ques-ions remain as to the interest of conserving residual fibers.

The present study compared ACL reconstruction in partialear with versus without residual posterolateral (PL) bun-le fiber conservation. The principal hypothesis was thatbjective control of anterior laxity is better with residualL bundle fiber conservation. The secondary hypothesis washat subjective results (functional scores and pivot shift) areikewise better.

aterials and methods

multicenter prospective randomized single-blind designeceived French National Ethics Committee approvalno 2011-A00109-25). All patients provided informed writtenonsent. Fifty-four consecutive patients underwent surgery,fter initial inclusion of all patients with clinically suspectedartial ACL tear.

Pre-inclusion criteria were: Lachman sign with delayedrm end-point, a negative pivot shift test, and MRI aspect

ompatible with partial tear. In case of diagnostic suspicionnd decision to operate, arthroscopy was performed aheadf transplant harvesting, to adapt the graft to peroperativendings.

Diagnosis was confirmed on arthroscopy by a well-nserted PL bundle. Randomization was performed byelephone by an independent agent using a permutationable (n = 6).

All patients not fulfilling the diagnostic criteria (PL bun-le conservation on arthroscopy) were excluded.

In Group 1 (29 patients), isolated AM bundle recon-truction was performed, conserving the PL remnant. Inroup 2 (25 patients), standard anatomic single-bundle

econstruction was performed, without PL bundle fiberonservation.

Tables 1 and 2 show demographic and clinical data forhe two groups at inclusion, which were comparable.

There were 33 male patients and 21 female. Mean ageas 30 years (range, 18—46 yrs).

Type of sportPivot 14 (48.27%) 7 (28%) 21 (38.88%)Pivot-contact 13 (44.82%) 17 (68%) 30 (55.55%)

Anterior cruciate ligament reconstruction in partial tear S173

Table 2 Clinical data at inclusion.

Group 1 n = 29 Group 2 n = 25 Total n = 54

Injured kneeR 15 (51.72%) 13 (52%) 28 (52%)L 14 (48.27%) 12 (48%) 26 (48%)

Context of accidentSport 26 (89.65%) 23 (92%) 49 (90.74%)

Trauma-to-surgery time (days) 159.6 137.9 149.5

Type of traumaValgus external rotation 11 (37.93%) 11 (44%) 22 (40.74%)Varus internal rotation 7 (24.13%) 8 (32%) 15 (27.77%)Non-specified 6 (20.68%) 5 (20%) 11 (20.37%)

Constitutional laxityYes 5 (17.24%) 2 (8%) 7 (12.96%)No 23 (79.31%) 23 (92%) 46 (85.18%)

MorphotypeNeutral 18 (62.06%) 15 (60%) 33 (61.11%)Varus 7 (24.13%) 8 (32%) 15 (27.77%)Valgus 3 (10.34%) 2 (8%) 5 (9.25%)

Flexion (injured knee) 130.7 130 132.3

Flexion (contralateral knee) l 141.3 139 140.2

InstabilityYes 25 (86.2%) 21 (84%) 46 (85.18%)No 4 (13.8%) 4 (16%) 8 (14.81%)

PainYes 17 (48.62%) 17 (68%) 34 (63%)No 12 (41.37%) 8 (32%) 20 (37%)

BlockingYes 6 (20.68%) 5 (20%) 11 (20.37)No 23 (79.31%) 20 (80%) 43 (79.62%)

EffusionNone 9 (31%) 10 (40%) 19 (35.18%)Moderate 5 (17.24%) 3 (12%) 8 (14.81%)Trace 12 (22.22%) 10 (40%) 22 (40.74%)

Preoperative differential anterior laxity (mm) 5.03 5.12 5.07

Pivot shiftAbsent 3 (10.34%) 3 (12%) 6 (11.11%)+ 20 (68.96%) 13 (52%) 33 (61.11%)++ 6 (20.68%) 8 (32%) 14 (25.92%)+++ 0 1 (4%) 1 (1.85%)

Preoperative subjective IKDC 55.82 56.8 56.28

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Preoperative total Lysholm 6

Preoperative total KOOS 6

Lysholm, subjective and objective IKDC and KOOS scoreswere taken, preoperatively and at 6 months and 1 year.

Statistical analysis

Comparison of means: Normal distribution was confirmedgraphically for all study parameters, and the parametricStudent t test was therefore used.

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71.08 70.46

62.61 64.28

Comparison of percentages: the non-parametric Fisherest was used.

The �-value was set at 5%.Mean preoperative differential anterior laxity was 5 mm

range, 2—10 mm) in Group 1 and 5.1 mm (2—12 mm) inroup 2 (P = 0.73).

Pivot shift test was negative in 10.3% of cases in Group 1nd in 12% for Group 2.

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Table 3 Comparison of peroperative data.

Group 1 n = 29 Group 2 n = 25 P

Pivot shift under GAAbsent 3 (10.54%) 4 (16%) 0.59+ 17 (58.62%) 11 (44%)++ 9 (31.03%) 8 (32%)+++ 0 1 (4%)

LACHMAN under GASoft end 8 (27.59%) 8 (32%) 0.65Delayed firm end 21 (72.41%) 16 (64%)

Patellar cartilage lesion (grade)0 26 (89.65%) 23 (92%) 0.51 1 (3.44%) 1 (4%)2 2 (6.89%) 0

Trochlear cartilage lesion (grade)0 27 (93.1%) 25 (100%) 0.491 2 (6.89%) 0

Medial femorotibial cartilage grade0 26 (89.65%) 23 (92%) 0.51 2 (6.89%) 02 1 (3.44%) 2 (8%)

Lateral femorotibial cartilage grade0 28 (96.55%) 24 (96%) 11 1 (3.44%) 1 (4%)

Medial meniscus lesionYes 3 (10.34%) 3 (12%) 1

Lateral meniscus lesionYes 5 (17.25%) 2 (8%) 0.49

Transplant typeHamstrings 26 (89.65%) 20 (80%) 0.44Bone-patellar tendon-bone 3 (10.34%) 5 (20%)

Femoral tunnelOutside-in 9 (31%) 5 (20%) 0.75AM portal 15 (51.72%) 15 (60%)Transtibial 5 (17.24%) 5 (20%)

Femoral fixationInterference screw 17 (58.62%) 12 (48%) 0.58Cortical button 12 (41.38%) 13 (52%)

Tibial fixationInterference screw 11 (38%) 8 (32%) 0.77Double fixation 18 (62%) 17 (68%)

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AM: anteromedial ; GA: general anesthesia.

Mean IKDC, Lysholm and KOOS scores were respectively0.3 (37—78), 89.1 (44—98) and 85.9 (30—87) in Group 1 and9.3 (40—77), 89.3 (10—90) and 84.7 (3—89) in Group 2, witho significant differences.

Mean trauma-to-surgery interval was 4.5 months (range,—16 months) in Group 1 and 5 months (1—24) in Group 2

non-significant; P = 0.5).

Each participating surgeons used his technique of choicetype of graft, tunnels) (Table 3). Reconstruction used ham-tring tendon in 89.6% of cases in Group 1 and 80% in

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roup 2; bone-tendon-bone transplant was used in the otherases.

Arthroscopy found no significant (> grade II) cartilageesions in either group. There were three medial menis-al lesions in both groups; all were repaired. There wereve lateral meniscal lesion in Group 1 (four repaired,

ne abstention), and two in Group 2 (one repaired, onebstention). There were no significant inter-group dif-erences in meniscal lesion distribution or managementP = 0.7).

Anterior cruciate ligament reconstruction in partial tear

Table 4 Comparison of main clinical parameters at 1 year’sFU.

Group 1n = 29

Group 2n = 25

P

Final IKDCA 17 (58.62%) 15 (60%) 0.81B 9 (31.03%) 6 (24%)C 3 (10.34%) 3 (12%)

Pivot shiftAbsent 24 (82.76%) 18 (72%) 0.4+

Differentialanterior laxity

1.24 1.87 0.03

Subjective IKDC 86.17 85.73 0.89

Total Lysholm 90.89 91.86 0.71

Total KOOS 88.09 86.93 0.72

KOOS symptoms 82.14 76.78 0.27

KOOS pain 89.30 88.11 0.76

KOOS daily activity 94.25 95.17 0.74

KOOS sport 79.52 76.11 0.62

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KOOS QoL 76.43 76.05 0.95

FU: follow-up.

The femoral tunnel was outside-in in nine cases inGroup 1 and five in Group 2, anteromedial in 15 cases inboth groups, and transtibial in five cases in both groups(P = 0.75).

Results

There were no peroperative complications. One patient inGroup 1 required arthroscopic arthrolysis for cyclops syn-drome at 3 months.

All patients were followed-up at 6 months and at 1 year.Table 4 shows the main clinical results.At 1 year, 26 patients (89.6%) in Group 1 and 21 (84%) in

Group 2 had IKDC scores A or B (P = 0.81). Pivot shift test wasnegative in 24 patients (82.8%) in Group 1 and 18 (72%) inGroup 2 (P = 0.4).

Mean knee flexion was 138.3◦ (range, 120—150◦) inGroup 1 and 139.6◦ (120—150◦) in Group 2 (P = 0.8). Onepatient in Group 2 showed 10◦ residual flexion deformityat 1 year.

Mean differential anterior laxity on Rolimeter® at 1 yearwas 1.24 mm (range, −3 —3 mm) in Group 1 and 1.87 mm(−1 —4 mm) in Group 2 (P = 0.03). There were no signifi-cant differences in subjective IKDC, KOOS or Lysholm scores(Table 4).

Discussion

The main finding of the present study is that anterior laxityis better controlled over the short-term when the PL bundlefibers are conserved.

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Residual ACL fiber conservation has several theoreticaldvantages: biomechanical [18,19], vascular [20,21], androprioceptive [22,23].

There are just a few retrospective studies on the sub-ect. Sonnery-Cottet et al. [14] reported 36 isolated AMundle reconstructions with more than 2 years’ follow-up;ean postoperative differential anterior laxity was 0.8 mm

n the Rolimeter®. Serrano-Fernandez [13], reported a meanostoperative laximetry of 0.2 mm on the KT1000 in 24 par-ial reconstructions, and Ahn et al. [24] found 1.8 mm atnd of follow-up in 53 patients; these results agree with theresent.

Comparative studies confirm the above. Adachi et al.10], in a retrospective case-control study, compared selec-ive AM bundle reconstruction conserving the PL bundle and

double-bundle technique, in complete ACL tear; in thewo groups of 40 patients, postoperative anterior laxity con-rol and proprioception were significantly better in partialCL lesions. The proprioceptive advantage was confirmed bychi et al. [11], with significant improvement after selective

econstruction compared with preoperative status; propri-ception was actually better in selective reconstruction ofartial tear than in double-bundle reconstruction of com-lete tear.

Chouteau et al. [25] analyzed proprioception in 13 selec-ive ACL reconstructions at a mean 3.4 years’ follow-up, andound no significant difference between the operated andealthy knee.

Regarding vascular advantage, Ahn et al. [24] reportedhat the MRI signal in the conserved PL bundle after ACLeconstruction was normal and continuous in more thanalf the cases, in agreement with the present results. Budat al. [26], in an MRI assessment of 28 selective partialear reconstructions, found normal and continuous graftyposignal in 25 out of 28 cases; the remnant was identi-able in 22 cases; abnormal signal correlated with poorerlinical results. Ohsawa et al. [12] performed control arthro-copies 1 year after selective AM or PL bundle partial ACLear reconstruction: in four of the five isolated AM bun-le reconstructions, the graft was tensed and synovializedith synovialized ligament remnant; in the other case, the

econstructed bundle was lax and non-synovialized, with PLemnant lesion.

The current trend is to maximize any possible liga-ent remnant conservation in the intercondylar groove.akamae et al. [27] used navigation to analyze vari-us types of ACL lesion (PL or AM bundle lesion, onhe posterior cruciate ligament or onto the intercondylarotch) and found that partial ACL tears had differ-nt (and better) mechanical properties than cicatricialesions.

In partial ACL tear, graft size should be adapted to surgi-al findings. In the present series, graft sizes were smaller inroup 1 than Group 2 (mean tunnel diameter, 7.9 mm versus.7 mm, respectively).

The present study had certain limitations. The numberf inclusions led to power less than 80%. Follow-up was

year; results are, however, preliminary. Although anterior

axity control was better in selective reconstruction, sub-ective results were comparable to those obtained with thetandard technique. Rolimeter® measurement of anterioraxity may be less reliable than with Telos® or KT1000®;

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owever, three successive measurements were taken, tomprove accuracy. Analyses of means, medians and variancell showed significant differences between the two groups;he difference, however, was of around 1 mm and it is dif-cult to predict the long-term impact of such a difference.

proprioception measurement would also have been use-ul.

onclusion

n partial ACL tear, selective AM bundle reconstruction con-erving the PL bundle remnant provided results comparableo standard single-bundle reconstruction, with better short-erm control of anterior laxity. Longer-term analysis will beeeded to compare progression of anterior and rotationalaxity and evolution in subjective results.

isclosure of interest

he authors declare that they have no conflicts of interestoncerning this article.

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Anterior cruciate ligament reconstruction in partial tear

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