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  • Orthopaedics & Traumatology: Surgery & Research (2013) 99, 99105

    Available online at

    www.sciencedirect.com

    TECHNICAL NOTE

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

    F. Khiami , A. Wajsfisz, A. Meyer, E. Rolland, Y. Catonn, E. Sariali

    Department of Orthopaedics and trauma Surgery, La Piti-Salptrire Hospital, 47-83, boulevard de lHpital, 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.

    dx.doi.org/10.1016/j.otsr.2012.09.017http://www.sciencedirect.com/science/journal/18770568mailto:frederic.khiami@psl.aphp.frdx.doi.org/10.1016/j.otsr.2012.09.017
  • 1 F. Khiami et al.

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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

    rpo[

    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 Tsudas10] 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 thethighs 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

    tge

    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 Lemaires 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 tensi