Orthopaedics & Traumatology: Surgery & Research (2013) 99, 99—105

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TECHNICAL NOTE

Anterior cruciate ligament reconstruction with fascialata using a minimally invasive arthroscopicharvesting technique

F. Khiami ∗, A. Wajsfisz, A. Meyer, E. Rolland, Y. Catonné, E. Sariali

Department of Orthopaedics and trauma Surgery, La Pitié-Salpêtrière Hospital, 47-83, boulevard de l’Hôpital, 75013 Paris, France

Accepted: 7 September 2012

KEYWORDSAnterior cruciateligament;Ligamentreconstruction;Fascia lata;Arthroscopy;

Summary Anterior cruciate ligament (ACL) reconstruction using the fascia lata has undergonea number of technical modifications since the work of Hey-Groves, MacIntosh, and Jaeger.Arthroscopy has simplified this technique, notably in the positioning of the tunnels. Minimallyinvasive harvesting through two lateral proximal and distal approaches considerably reducescosmetic problems. The femoral tunnel is made from the outside to the inside using a specifictargeting device, and the transplant harvest site is closed using the Jaeger procedure so as notto weaken lateral knee stabilizing structures. This procedure consists in opening the lateral

Minimally invasivesurgery

intermuscular septum 1 cm from the femur to let it shift laterally and allow the transplantharvesting area to be closed. This technique uses a fascia lata transplant, the harvesting ofwhich has shown few iatrogenous complications but requires rigorous adherence to certainrules.© 2012 Elsevier Masson SAS. All rights reserved.

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Introduction

Anterior cruciate ligament (ACL) reconstruction using thefascia lata was first described by Hey-Groves in 1917 [1].A few notable technical modifications were contributed by

MacIntosh in 1972 [2] and more recently by Jaeger [3,4].This technique presents a number of technical and func-tional advantages. The fascia lata is a transplant material

∗ Corresponding author.E-mail address: frederic.khiami@psl.aphp.fr (F. Khiami).

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1877-0568/$ – see front matter © 2012 Elsevier Masson SAS. All rights rehttp://dx.doi.org/10.1016/j.otsr.2012.09.017

ith high biomechanical resistance, comparable to otherurrently used transplants [5] and the preservation of theistal insertion on the Gerdy tubercle is a natural fixationhat no other fixation system would be able to replace. Inhe original technique, the graft strip slides in the femoralunnel with no fixation and then requires a single fixationo the tibia. The femoral tunnel was initially retrocondy-ar, which facilitated ligament repair revision in case ofemoral cavitary enlargement. According to the promo-

ers, the ‘‘combined’’ extra- and intra-articular effect ofhe reconstruction efficiently controls the pivot shift, asemonstrated by Lemaire [6,7] in a purely extra-articularechnique. More recently, the development of arthroscopic

served.

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echniques has promoted the rapid expansion of patellarigament and hamstring reconstruction and relegated theascia lata to the rank of outdated and outmoded tech-iques whose residual scars were imposing and unsightly8], but whose functional results were nonetheless highlyatisfactory [9]. The authors have used the ACL reconstruc-ion technique with fascia lata since 1993. Anteromedialrthrotomy has been replaced by an arthroscopic phaseince 2004 and harvesting of the reconstruction mate-ial, which requires a 15- to 20-cm cutaneous incisionas been replaced by two minimally invasive approachesince 2009. We present the arthroscopic ligament recon-truction technique using minimally invasive fascia lataarvesting.

urgical technique

rthroscopic phase

he arthroscopic phase is comparable to more conventionalechniques. Cleaning the foot of the ACL preserves a rem-ant provided it is not in conflict with the roof of theateral femoral condyle notch. Femur preparation is clas-ic. The intra-articular exit point of the femoral tunnel

s placed on the posterior part of the medial side of theateral condyle (the most posterior quadrant according tohe Bernard method [10,11]). The tibial tunnel procedurediameter, 8 mm) is strictly identical to other single-bundle

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Figure 2 Proximal and distal s

igure 1 Identifying the cutaneous incisions. The total sub-utaneous harvesting of the fascia lata should measure between8 and 20 cm.

econstruction techniques. Its intra-articular exit point islaced between the two tibial eminences, slightly in frontf the lateral tibial eminence, which corresponds to Tsuda’s10] 25 to 50% tibial quadrant.

ubcutaneous detachment.

Ligament reconstruction with fascia lata using minimally invasive harvesting 101

Figure 3 Harvesting the fascia lata begins opposite the lat-eral femoral epicondyle and measures 2 cm in width, opening

Figure 4 The transplant is tubulized and tensioned using ap

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outward and upwardto obtain a 4-cm width at the proximal end.

Harvesting the graft strip

The distal cutaneous incision begins opposite the lateralfemoral epicondyle and continues along the posterior partof the lateral side of the thigh for 5 to 6 cm (Fig. 1). Thesubcutaneous tissue is released from the fascia lata in theincision area and then pulled upward for 6 to 7 cm and down-ward to the Gerdy tubercle (Fig. 2). A 2- to 3-cm proximalcutaneous incision completes the approach, continuing thefirst incision, and begins precisely at the spot where theharvest material will be resected 16 cm above the Gerdytubercle. The fascia strip should be between 18 and 20 cmlong. It is harvested respecting a 2-cm width in the dis-tal direction (the thickest area) and 4 cm at its proximalportion, which is thinner, making it possible to increase thevolume of the transplant on the part that will be used forthe intra-articular portion (Fig. 3). To guarantee sufficientwidth, the two harvesting incisions are widened toward theproximal part; the incision line must remain parallel to thethigh’s axis, contrary to the anterior incision line, whichjoins the middle of the lateral side of the thigh. An endo-scopic exam can improve the view of the harvest zone.The fascia lata incision depth is an important step in har-vesting. The scalpel should not damage the vastus lateralismuscle proximally (to prevent muscle bleeding), nor the

joint capsule or the lateral collateral ligament (LCL) dis-tally. There is a detachment layer between the fascia andthe joint capsule that determines the safety limit so as to

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ull-through suture.

void capsule penetration. The harvest material is carefullyetached from the joint capsule of the vastus lateralis. Theroximal part is tubulized using reverse stitches to facil-tate gliding within the tunnels and to increase the grafttrip volume. A pull-through suture is positioned (Fig. 4).sing a finger, the vastus lateralis is detached from the lat-ral intermuscular septum, which separates the anterior andosterior compartments of the thigh (Fig. 5). This septums opened longitudinally from the distal end to the proxi-al end using a long chisel, leaving 1 cm of septum inserted

t the femur. The opening is lengthened to the proximalnd of the fascia lata harvesting zone. This technique wasntroduced by Jaeger and allows sliding and lateral trans-ation of the intermuscular septum, which will facilitatelosing the strip harvesting site at the end of the proce-ure (Fig. 6). It is useful to localize the ‘‘Lemaire’s’’ vessels,onsistent landmarks near the extra-articular isometry zoneescribed by Lemaire [7] (Fig. 7). Identification of the lat-ral collateral ligament and the lateral femoral epicondylellow one to define the most isometric extra-articular area,ituated approximately 1 cm above and behind the lateralpicondyle [12]. An arthroscopic aimer from the outside tohe inside allows precise positioning of a guidewire (Fig. 8).he tunnel is generally drilled 9 mm from outside in. We rec-mmend oversizing the femoral tunnel by 1 mm comparedo the distal diameter of the strip so that it does not jam,articularly since no femoral press-fit effect is sought. Theull-through stitches are inserted into the femoral tunnelrom outside to inside and then retrieved under arthroscopyn the notch and then at the tibial tunnel (Fig. 9). Inser-ion of the strip under the LCL has been removed fromhe procedure, an improvement of the technique that noonger requires LCL dissection. Gentle turning allows one

o stretch the strip. This tension is checked with a fin-er at the entrance of the femoral tunnel as the limb isxtended. This step confirms that the strip is not blocked

102

Figure 5 Opening the intermuscular septum according to theJaeger technique. The vastus lateralis is retracted away fromthe strip harvest zone exposing the septum. This is opened lon-gc

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itudinally and a lateral translation of the septum allows one tolose the harvest area.

ithin the tunnels. The strip is attached at 30◦ flexionsing a tibial double fixation with an interference screwnd a staple, with the foot in neutral rotation. There is no

emoral fixation. The tourniquet is released before closing,hich allows hemostasis. Closing begins with suturing thearvest area. The intermuscular septum is transferred lat-rally and closed by an overcast stitch (Fig. 10). The skin is

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igure 6 Surgical view of opening the intermuscular septum. Thpened.

F. Khiami et al.

losed using an intradermal overcast stitch. Two non-suctionrains are positioned, one in the joint, the second in theuscle detachment space. Postoperative recovery requires

o particular care compared to more conventional tech-iques, although the authors recommend moderate and veryrogressive rehabilitation in the first month after the pro-edure. Weight bearing is aided by two crutches, extensions complete and flexion limited to 70—80◦ during the firstonth. This restriction of the mobility sectors seems war-

anted so as to limit joint stiffening by early work but inimited sectors to facilitate healing of the muscle and sub-utaneous layers.

he series

hese technical improvements are based on a retrospectiveeries of ACL reconstructions on 37 patients operated onith the classical technique before 2009, then a prospec-

ive series that included our technical modifications since009. Although the functional results at the last follow-upre satisfactory [9,13] and comparable to the more currentlysed techniques reported in the literature, the analysis ofhe postoperative recovery of patients operated before 2009hows a few difficult cases. Among the complications foundefore 2009, we experienced four postoperative hematomashat did not require surgical drainage but that slowed func-ional recuperation. One patient judged her lateral scarufficiently unsightly to request a consultation in cosmeticurgery. Even if the pivot test results were excellent (84%KDC A), we found a mean postoperative anteroposterior lax-ty of 3.8 ± 1.7 mm with an IKDC laxity score classed as A innly 27% of the cases and B in 62%. Before 2009 a single tib-al fixation was used, probably insufficient with only a singletaple. Since 2009, the analysis of these complications andhis residual laxity has allowed us to evolve toward a lessnvasive approach, a more reproducible technique given these of more classical ancillary instrumentation and toward

double tibial fixation with an interference screw and ataple. The analysis of our first 37 cases with the minimallynvasive technique has shown a reduction in hemorrhagicomplications and an improvement in postoperative laxity.

single hematoma has occurred and is evolving favorably

ith local treatment, and the mean postoperative differ-ntial laxity has improved to 1.2 ± 1.1 mm. The IKDC laxitycore was classed as A in 54% and B in 40% of the cases.he pivot test according to the IKDC score was classed

e vastus lateralis is retracted and the septum is progressively

Ligament reconstruction with fascia lata using minimally invasive harvesting 103

Figure 7 Entry point of the femoral tunnel. Locating Lemaire’s vessels aids in identifying the ideal zone, located 1 cm above andbehind the lateral epicondyle (star).

Figure 8 Femoral tunnel preparation using an aimer from outside to inside.

Figure 9 Passage of the strip beginning with the femoral tunnel, then the tibial tunnel. This is done arthroscopically.

104

Figure 10 Closing of the harvest zone with an overcast stitch.T

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his is made possible by opening the intermuscular septum.

in 89% of the cases. We have found no cases of sep-is.

iscussion

he fascia lata reconstruction techniques date fromhe beginning of the last century [1,2] but have beennfrequently used. Anteromedial arthrotomy and the sizef the harvest incision initially used sometimes resultedn unsightly scars [8], compared to more recent arthro-copic techniques and increasingly minimally invasivearvesting techniques [14]. From a technical point ofiew, the dissection phase of the lateral collateral mus-le layer and passage of the posterior capsule couldeem challenging and difficult to reproduce, as may theonstruction of a retrocondylar groove, which used noositioning ancillary instrumentation. Several improvementsave simplified the technique to make it more repro-ucible.

The introduction of arthroscopy has made it possi-le to remove arthrometry and provides an arthroscopicxploration phase comparable to the more classical recon-truction techniques on all points. Creation of the femoralunnel is facilitated since the use of a femoral aimer fromutside to inside, which has done away with the construc-ion of a retrocondylar groove [3,4] and has obviated theeed for detaching the lateral gastrocnemius and openinghe posterior joint capsule.

The main technical pitfalls reside in harvesting the trans-lant. This strip should be harvested in the posterior partf the iliotibial tractus, which is thicker and more solid,nd reduces the size of the harvested strip near the Gerdyubercle (2 cm). The resistance of this type of transplants approximately 3266 N [5], which makes it a transplantaterial whose resistance is comparable to more widely

sed transplants. The risk of harvesting a transplant thats too short is limited if an 18- to 20-cm-long strip is har-ested from the Gerdy tubercle. The incision depth should

e controlled so as not to injure the vastus lateralis or theoint capsule and the LCL. The minimally invasive approachhrough two incisions provides the same exposure as a single

F. Khiami et al.

onger incision, provided that long retractors or endoscopiciewing is available.

Opening the lateral intermuscular septum to facili-ate closing [3,4] the harvest site involves detaching theastus lateralis muscle, requiring detachment of supra-nd subfascial layers, as well as the risk of injuringhe third perforating artery or its anastomoses with theopliteal artery that run under the septum in the loweruarter of the thigh [15]. The authors recommend remo-ing the tourniquet before closing the surgical site withetailed verification that there is no active bleeding.n our experience, given these muscle and subcutaneousetachment planes, we believe that the risk of hem-rrhage can occur up to the 3rd postoperative week.lthough the minimally invasive approach has consider-bly reduced the incidence of bleeding complications, theccurrence of postoperative hematoma has encourageds to continue draining the harvest site and we rec-mmend slow rehabilitation during the 1st postoperativeonth.

isclosure of interest

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

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