KNEE

Navigated intra-articular ACL reconstruction with additionalextra-articular tenodesis using the same hamstring graft

Philippe D. Colombet

Received: 29 March 2010 / Accepted: 9 July 2010 / Published online: 1 September 2010

� Springer-Verlag 2010

Abstract

Purpose In some complex cases, standard anterior cru-

ciate ligament reconstruction is not enough and could lead

to a new failure. Lateral extra-articular reconstruction

should be added. We describe a new mini-invasive tech-

nique using the same hamstring graft for intra-articular

reconstruction and lateral tenodesis, optimized with navi-

gation.

Method This arthroscopic technique is precisely descri-

bed, different graft setting are possible, four strands graft

inside the joint and two strands for the tenodesis or two

strands graft for all the whole graft. As the lateral tenodesis

is not anatomic, tunnel placement could be tricky. The use

of navigation system is a real advantage for this technique

with optimal tunnels placement.

Results No results are given.

Conclusion This technique is comparable to others

reported previously, showing a clinical advantage and no

increasing of osteoarthritis. The use of the same graft

avoids collateral damages, and navigation improves the

graft placement.

Keywords ACL � Revision ACL reconstruction �Hamstring ACL graft � Navigated ACL reconstruction �Extra-articular tenodesis

Introduction

Anterior cruciate ligament reconstruction (ACLR) is nowa-

days a safe and effective surgery. However, the func-

tional results are not always perfect, the current

techniques secure good to excellent results in 70–80% of

cases [2, 13, 16], and the most common reason for failure

is a recurrent instability [12]. In cases without any tech-

nical error, early and late failures have been reported with

many different reasons such as posterolateral instability,

graft damage caused surgically, biologically, or traumat-

ically [7]. In revision surgery, the same isolated intra-

articular reconstruction should lead to the same failure.

Revision surgery with an additional extra-articular

reconstruction remains an option [10], and we agree with

Draganich et al. [8] who believed that the extra-articular

reconstruction can protect the graft from excessive,

undesired stresses during the early postoperative period

and thus it would be useful in revision anterior cruciate

ligament surgery. In majority of cases, the iliotibial band

is used to perform these lateral tenodesis in an open pro-

cedure [11, 18]. However, these lateral structures, espe-

cially iliotibial band and Kaplan’s fibers, are significant

secondary restraints in resisting the anterior translation

and rotational laxity. Many authors [4, 9, 19] have

reported disadvantage to harvest the iliotibial band for

lateral tenodesis. Hamstring tendon graft has been used for

both the lateral tenodesis and ACL reconstruction; Big-

nozzi et al. [3] use an open surgery and passes the graft

over the top that is not isometric graft placement. In order

to preserve the lateral structures and to place the graft in

better isometric position, we perfected a navigated surgi-

cal procedure using hamstring tendon graft in continuity

to the intra-articular reconstruction to perform a percuta-

neous extra-articular tenodesis.

P. D. Colombet (&)

Sports Medicine Center, 9 rue Jean Moulin,

33700 Merignac, France

e-mail: philippe.colombet5@wanadoo.fr

123

Knee Surg Sports Traumatol Arthrosc (2011) 19:384–389

DOI 10.1007/s00167-010-1223-0

Technical note

Patient setup and operative approach

The patient is placed in supine position on the operating

room table. A pneumatic tourniquet is placed in highest

position on the thigh. We secure a lateral thigh post that

allows full extension and flexion of the knee and ensure

that the foot is supported (Fig. 1). We identify and mark

the anterior tibial tubercle (ATT), the tibio-femoral joint

lines, the Gerdy’s tubercle, the hamstring tendon position,

and borders of the patellar tendon. The operative approach

consists in arthroscopic antero-lateral portal on lateral part

of the patellar tendon, antero-medial portal for arthroscopic

instrumentation. A 3-cm incision is placed 2.5 cm medially

to the ATT, 4 cm from the medial joint line to harvest the

Gracilis and Semitendinosus (SemiT) tendons (Fig. 2). On

the lateral site of the knee, two short skin incisions (1 cm)

are performed, one on the Gerdy’s tubercle and one prox-

imally to the lateral condyle tubercle (Fig. 3).

Graft preparation

The two tendons are dissected and harvested with

a Linvatec tendon harvester in order to get the whole tendons.

The muscle fibers are cleaned out from the tendons, and all

the expansions are removed from the tendon in order to get

a homogenous and regular graft. The tendons are calibrated

and then two kinds of settings are possible depending on

the graft length available: the setting ‘‘4 ? 2’’or ‘‘2 ? 2’’.

The ‘‘4 ? 2’’ setting is best setting; for a standard patient

(ranged from 1.75 to 1.85 m and 70 to 90 kg), the perfect

lengths for each part of the graft are 9 cm length for the

four strands part and 12 cm for the two strands part. If it is

not possible to get these correct graft dimensions, the

‘‘2 ? 2’’ setting must be preferred.

Setting ‘‘4 ? 2’’: The joint part of the graft is composed

of four strands, two from the Gracilis and two from the

SemiT and they are passed through a 5-mm Mersilene loop.

The extra-articular part has got only two strands. All the

four strands part is sutured with Polysorb, the two strands

extremity is suture through a Ti-cron two loop (Fig. 4).

Setting ‘‘2 ? 2’’: The intra-articular part of the graft

consists of two strands, one from the Gracilis one from the

SemiT and the same for the extra-articular part of the graft.

The two tendons should be detached from the tibia in case

the graft length is not enough to return to the tibia. A better

option is to let the tendons attached on the tibia to improve

their fixation. In both cases, the extremities of the graft are

sutured with PolysorbTM 1 suture to increase the interfer-

ence screw fixation (Fig. 4).Fig. 1 Patient setup. Complete free knee motion is required

Fig. 2 Skin incision to harvest hamstring tendons

Fig. 3 Skin incision for the percutaneous lateral tenodesis

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Tunnel preparation

Two tunnels are drilled in the tibia and one in the femur. The

ACL Logics� bone-morphing navigation system (Praxim-

Medivision, La Tronche, France) is used to optimize tunnels

positions [5]. First of all, a meticulous preparation of the

notch under arthroscopic control is performed. After a short

step of calibration, the knee is placed at 90� of flexion, a bone

morphing of ACL foot print on the femur and on the tibia is

performed, as well as the extra-articular part of the lateral

condyle. Then, we select two points on the tibia: one on the

Gerdy’s tubercle for the outside joint part of the recon-

struction and one in the center of the antero-medial bundle of

the ACL tibial foot print. The system provides two different

isometric maps [6] (Fig. 5). One is located on the lateral part

of the intercondylar notch and one outside the lateral con-

dyle. Optimal points are selected on these two maps

constituting two targets. Computer guide drill is used to

perform the femoral tunnel in outside—in manner from the

outside target to the inside target (Fig. 5b). The two tibial

tunnels are drilled using the same system. These tibial tun-

nels are drilled from the initial navigation selected points.

After femoral tunnel drilling, the anterior edge of the

intra-articular femoral tunnel aperture is taken off with a

curette to avoid a killer turn. The second tibial tunnel is

drilled in the tibia from the Gerdy’s tubercle to the tibial

wound used to harvest the tendons. This last tunnel is

drilled under the anterior tibial tubercle and returns to the

starting point making a kind of frame (Fig. 6).

Graft passage and fixation

Two different procedures are used depending on the kind

of graft setting. First of all the knee is flexed at 90�.

Fig. 4 Graft setting ‘‘4 ? 2’’:

Distal part of Gracilis and

Semitendinosus are passed over

a Mersilene loop and compose

the four strands part. The other

extremity is sutured through a

Ti-cron two loop and composes

the two strand part of the graft.

Ideal lengths are 9 cm length for

the four strands part and 12 cm

for the two strands part. Graft

setting ‘‘2 ? 2’’: The two

tendons are simply sutured

through two Ti-cron two loops

at each extremity

Fig. 5 Navigation screens:

a lateral view with isometric

map of extra-articular tenodesis.

b Intra-articular navigation

windows with isometric map

on the lateral part of the

intercondylar notch. A virtual

graft (dark blue) is provided by

the computer as well as different

parameters and graphic of graft

length difference during

flexion/extension

386 Knee Surg Sports Traumatol Arthrosc (2011) 19:384–389

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In the ‘‘2 ? 2’’ manner, the graft is passed from the tibia

to the femur, through the first tibial tunnel, then through the

femoral tunnel inside-out. This part of the graft is secured

with an absorbable interference screw in the tibia 8 9 25

(8 mm diameter 25 mm length) and an 8 9 20 in the

femoral tunnel with an outside-in way.

In the ‘‘4 ? 2’’ setting, the 4 strands part of the graft is

tracked from the femur to the first tibial tunnel, with the

Mersilene tape outside-in in the femoral tunnel and inside-

out in the medial tibial tunnel. It is secured in the same

manner with absorbable screws, usually sized 9 mm in

diameter because this part of the graft is larger than in the

‘‘2 ? 2’’ setting.

At this step, the intra-articular part of the reconstruction

is finished. The next step is the same in both graft setting.

A two strand graft is getting out from the femoral tunnel in

both cases. This part of the graft is passed very carefully

under the iliotibial band. We recommend using a probe to

lift the iliotibial band and place a clamp under to pass the

graft and control with a retractor that the graft is under the

band.

The lateral aperture of the second tibial tunnel is slightly

enlarged with a cone-shaped reamer. This will be very

helpful to introduce the last screw. Then, the graft is passed

in the last tunnel tracked with the Ti-cron loop. We

recommend placing the screw guide wire in the tunnel

before passing the graft, because it is difficult to place it

correctly when the graft is inside the tunnel. An 8 9 20

absorbable screw is placed with the tibia in neutral

position.

Discussion

The most important step of this technique is the decision

for the ‘‘2 ? 2’’ or ‘‘4 ? 2’’ graft setting, the decision is

tricky. It is needed to know the limits of such a technique.

The first limitation of this technique is small and short

hamstring tendons. The concept is based on the addition

of a percutaneous extra-articular tenodesis to a standard

antero-medial single-bundle hamstring ACL reconstruc-

tion. An inappropriate graft diameter could lead to failure

by graft rupture; the graft could not be able to support

constrains during strenuous activity. Not enough graft

inside tunnels could provide graft fixation failure.

A minimum of 15-mm graft inside the tunnel is needed

for a good fixation. In case, the graft length within the

tunnel is close to 15 mm, a double fixation has to be used.

In addition to the interference screw, the Mersilene tape

should be secured on a staple or on a post outside the

tunnel. For the tibial fixation of the tenodesis part, the

Ti-cron loop should be knot over a staple or on soft tissue

around the aperture. We also need a good bone stock

around the tunnels, in patients with tunnels enlargement a

two stage surgery is recommended. For high-level cutting

sports patients going to revision ACL reconstruction, it is

mandatory to use a ‘‘4 ? 2’’ graft setting with a minimum

of 7-mm-diameter graft for the intra-articular reconstruc-

tion. If we are not able to prepare a correct diameter graft

size, we must not apply this technique. We reserve the

‘‘2 ? 2’’ setting for revision surgery in patients with a

noncutting sport activity.

The use of navigation is another limit; most of surgeons

do not use navigation system for surgery. However, the

tunnels can be performed without navigation. The first

tibial tunnel is drilled outside-in as usual using a standard

director aimerTM (Smith and Nephew) in order to reach the

antero-medial bundle (AMB) tibial foot print of the native

ACL. Then, the femoral tunnel is drilled outside in using a

femoral aimer. The inside joint target is the center of the

AMB insertion on the femur, and outside the joint

the landmark is situated 1 cm proximal and posterior to the

femoral lateral tubercle. This situation was validated with

navigation and confirmed by previous studies [14, 15].

However, the use of navigation provides perfect 3D con-

ditions to optimize tunnel position, as extra-articular

tenodesis is not anatomic; an appropriated tool is needed to

find the best isometric points.

Fig. 6 Different graft passages in the femur tunnel and in the two

tibial tunnels, the graft return to its initial point making a complete

frame

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The placement of the femoral screw has to be carefully

done. The head of the screw must be inside the tunnel, if it

is not, the patient will complain of pain and dysfunction

during flexion extension.

Indication of lateral tenodesis is controversial; it has been

established long time ago by Amis et al. [1] that in isolated

ACL deficient knee, there is nonsignificant biomechanical

advantage from adding an extra-articular reconstruction.

However, Zaffagnini et al. [20] reported in a RCT study

5-years follow-up a significant advantage in subjective

evaluation, a faster return to sport, less kneeling pain and a

higher capacity of return to normal muscle trophysm.

If we look at the literature, other techniques have been

reported. In 2006, Ferretti et al. [10] published a similar

technique with four strands hamstring graft in revision of

ACL reconstruction. The additional lateral tenodesis was

performed with the iliotibial band let attached on the

Gerdy’s tubercle and passed under the lateral collateral

ligament, then returned to the initial point and sutured. He

concluded that this technique is a reasonable alternative for

revision anterior cruciate ligament reconstruction. How-

ever, patients should be informed that, despite the

achievement of a stable knee following reconstruction,

degenerative joint disease frequently occurs. Marcacci

et al. [17] reported in 2009 an 11-year follow-up study

using a similar technique than ours with hamstring passed

‘‘over the top’’ and fixed on the Gerdy’s tubercle with a

staple. This technique was used for primary ACL recon-

struction. He showed satisfactory results, and no significant

cartilage degradation of the knee compared to ACL

reconstruction without extra-articular augmentation. In his

technique, there are some weak points: the nonisometric

placement of the graft on the femur; the tibial fixation of

the tenodesis with a staple without any bone tunnel; always

only two strands to reconstruct the ACL and some damages

could appear on the Kaplan’s fibers.

Conclusion

Extra-articular tenodesis can be used in addition to intra-

articular ACL reconstruction using the same graft and

performed with mini-invasive technique. This technique is

indicated in revision of ACL reconstruction without tech-

nical error. The tenodesis placement could be optimized

with navigation system.

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