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

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KNEENavigated intra-articular ACL reconstruction with additionalextra-articular tenodesis using the same hamstring graftPhilippe D. ColombetReceived: 29 March 2010 / Accepted: 9 July 2010 / Published online: 1 September 2010 Springer-Verlag 2010AbstractPurpose In some complex cases, standard anterior cru-ciate ligament reconstruction is not enough and could leadto a new failure. Lateral extra-articular reconstructionshould be added. We describe a new mini-invasive tech-nique using the same hamstring graft for intra-articularreconstruction and lateral tenodesis, optimized with navi-gation.Method This arthroscopic technique is precisely descri-bed, different graft setting are possible, four strands graftinside the joint and two strands for the tenodesis or twostrands graft for all the whole graft. As the lateral tenodesisis not anatomic, tunnel placement could be tricky. The useof navigation system is a real advantage for this techniquewith optimal tunnels placement.Results No results are given.Conclusion This technique is comparable to othersreported previously, showing a clinical advantage and noincreasing of osteoarthritis. The use of the same graftavoids collateral damages, and navigation improves thegraft placement.Keywords ACL Revision ACL reconstruction Hamstring ACL graft Navigated ACL reconstruction Extra-articular tenodesisIntroductionAnterior cruciate ligament reconstruction (ACLR) is nowa-days a safe and effective surgery. However, the func-tional results are not always perfect, the currenttechniques secure good to excellent results in 7080% ofcases [2, 13, 16], and the most common reason for failureis a recurrent instability [12]. In cases without any tech-nical error, early and late failures have been reported withmany 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-articularreconstruction remains an option [10], and we agree withDraganich et al. [8] who believed that the extra-articularreconstruction can protect the graft from excessive,undesired stresses during the early postoperative periodand thus it would be useful in revision anterior cruciateligament surgery. In majority of cases, the iliotibial bandis used to perform these lateral tenodesis in an open pro-cedure [11, 18]. However, these lateral structures, espe-cially iliotibial band and Kaplans fibers, are significantsecondary restraints in resisting the anterior translationand rotational laxity. Many authors [4, 9, 19] havereported disadvantage to harvest the iliotibial band forlateral tenodesis. Hamstring tendon graft has been used forboth the lateral tenodesis and ACL reconstruction; Big-nozzi et al. [3] use an open surgery and passes the graftover the top that is not isometric graft placement. In orderto preserve the lateral structures and to place the graft inbetter isometric position, we perfected a navigated surgi-cal procedure using hamstring tendon graft in continuityto the intra-articular reconstruction to perform a percuta-neous extra-articular tenodesis.P. D. Colombet (&)Sports Medicine Center, 9 rue Jean Moulin,33700 Merignac, Francee-mail: philippe.colombet5@wanadoo.fr123Knee Surg Sports Traumatol Arthrosc (2011) 19:384389DOI 10.1007/s00167-010-1223-0Technical notePatient setup and operative approachThe patient is placed in supine position on the operatingroom table. A pneumatic tourniquet is placed in highestposition on the thigh. We secure a lateral thigh post thatallows full extension and flexion of the knee and ensurethat the foot is supported (Fig. 1). We identify and markthe anterior tibial tubercle (ATT), the tibio-femoral jointlines, the Gerdys tubercle, the hamstring tendon position,and borders of the patellar tendon. The operative approachconsists in arthroscopic antero-lateral portal on lateral partof the patellar tendon, antero-medial portal for arthroscopicinstrumentation. A 3-cm incision is placed 2.5 cm mediallyto the ATT, 4 cm from the medial joint line to harvest theGracilis and Semitendinosus (SemiT) tendons (Fig. 2). Onthe lateral site of the knee, two short skin incisions (1 cm)are performed, one on the Gerdys tubercle and one prox-imally to the lateral condyle tubercle (Fig. 3).Graft preparationThe two tendons are dissected and harvested witha Linvatec tendon harvester in order to get the whole tendons.The muscle fibers are cleaned out from the tendons, and allthe expansions are removed from the tendon in order to geta homogenous and regular graft. The tendons are calibratedand then two kinds of settings are possible depending onthe graft length available: the setting 4 ? 2or 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 perfectlengths for each part of the graft are 9 cm length for thefour strands part and 12 cm for the two strands part. If it isnot possible to get these correct graft dimensions, the2 ? 2 setting must be preferred.Setting 4 ? 2: The joint part of the graft is composedof four strands, two from the Gracilis and two from theSemiT and they are passed through a 5-mm Mersilene loop.The extra-articular part has got only two strands. All thefour strands part is sutured with Polysorb, the two strandsextremity is suture through a Ti-cron two loop (Fig. 4).Setting 2 ? 2: The intra-articular part of the graftconsists of two strands, one from the Gracilis one from theSemiT and the same for the extra-articular part of the graft.The two tendons should be detached from the tibia in casethe graft length is not enough to return to the tibia. A betteroption is to let the tendons attached on the tibia to improvetheir fixation. In both cases, the extremities of the graft aresutured with PolysorbTM 1 suture to increase the interfer-ence screw fixation (Fig. 4).Fig. 1 Patient setup. Complete free knee motion is requiredFig. 2 Skin incision to harvest hamstring tendonsFig. 3 Skin incision for the percutaneous lateral tenodesisKnee Surg Sports Traumatol Arthrosc (2011) 19:384389 385123Tunnel preparationTwo tunnels are drilled in the tibia and one in the femur. TheACL Logics bone-morphing navigation system (Praxim-Medivision, La Tronche, France) is used to optimize tunnelspositions [5]. First of all, a meticulous preparation of thenotch under arthroscopic control is performed. After a shortstep of calibration, the knee is placed at 90 of flexion, a bonemorphing of ACL foot print on the femur and on the tibia isperformed, as well as the extra-articular part of the lateralcondyle. Then, we select two points on the tibia: one on theGerdys tubercle for the outside joint part of the recon-struction and one in the center of the antero-medial bundle ofthe ACL tibial foot print. The system provides two differentisometric maps [6] (Fig. 5). One is located on the lateral partof the intercondylar notch and one outside the lateral con-dyle. Optimal points are selected on these two mapsconstituting two targets. Computer guide drill is used toperform the femoral tunnel in outsidein manner from theoutside target to the inside target (Fig. 5b). The two tibialtunnels 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 theintra-articular femoral tunnel aperture is taken off with acurette to avoid a killer turn. The second tibial tunnel isdrilled in the tibia from the Gerdys tubercle to the tibialwound used to harvest the tendons. This last tunnel isdrilled under the anterior tibial tubercle and returns to thestarting point making a kind of frame (Fig. 6).Graft passage and fixationTwo different procedures are used depending on the kindof graft setting. First of all the knee is flexed at 90.Fig. 4 Graft setting 4 ? 2:Distal part of Gracilis andSemitendinosus are passed overa Mersilene loop and composethe four strands part. The otherextremity is sutured through aTi-cron two loop and composesthe two strand part of the graft.Ideal lengths are 9 cm length forthe four strands part and 12 cmfor the two strands part. Graftsetting 2 ? 2: The twotendons are simply suturedthrough two Ti-cron two loopsat each extremityFig. 5 Navigation screens:a lateral view with isometricmap of extra-articular tenodesis.b Intra-articular navigationwindows with isometric mapon the lateral part of theintercondylar notch. A virtualgraft (dark blue) is provided bythe computer as well as differentparameters and graphic of graftlength difference duringflexion/extension386 Knee Surg Sports Traumatol Arthrosc (2011) 19:384389123In the 2 ? 2 manner, the graft is passed from the tibiato the femur, through the first tibial tunnel, then through thefemoral tunnel inside-out. This part of the graft is securedwith an absorbable interference screw in the tibia 8 9 25(8 mm diameter 25 mm length) and an 8 9 20 in thefemoral tunnel with an outside-in way.In the 4 ? 2 setting, the 4 strands part of the graft istracked from the femur to the first tibial tunnel, with theMersilene tape outside-in in the femoral tunnel and inside-out in the medial tibial tunnel. It is secured in the samemanner with absorbable screws, usually sized 9 mm indiameter because this part of the graft is larger than in the2 ? 2 setting.At this step, the intra-articular part of the reconstructionis finished. The next step is the same in both graft setting.A two strand graft is getting out from the femoral tunnel inboth cases. This part of the graft is passed very carefullyunder the iliotibial band. We recommend using a probe tolift the iliotibial band and place a clamp under to pass thegraft and control with a retractor that the graft is under theband.The lateral aperture of the second tibial tunnel is slightlyenlarged with a cone-shaped reamer. This will be veryhelpful to introduce the last screw. Then, the graft is passedin the last tunnel tracked with the Ti-cron loop. Werecommend placing the screw guide wire in the tunnelbefore passing the graft, because it is difficult to place itcorrectly when the graft is inside the tunnel. An 8 9 20absorbable screw is placed with the tibia in neutralposition.DiscussionThe most important step of this technique is the decisionfor the 2 ? 2 or 4 ? 2 graft setting, the decision istricky. It is needed to know the limits of such a technique.The first limitation of this technique is small and shorthamstring tendons. The concept is based on the additionof a percutaneous extra-articular tenodesis to a standardantero-medial single-bundle hamstring ACL reconstruc-tion. An inappropriate graft diameter could lead to failureby graft rupture; the graft could not be able to supportconstrains during strenuous activity. Not enough graftinside tunnels could provide graft fixation failure.A minimum of 15-mm graft inside the tunnel is neededfor a good fixation. In case, the graft length within thetunnel is close to 15 mm, a double fixation has to be used.In addition to the interference screw, the Mersilene tapeshould be secured on a staple or on a post outside thetunnel. For the tibial fixation of the tenodesis part, theTi-cron loop should be knot over a staple or on soft tissuearound the aperture. We also need a good bone stockaround the tunnels, in patients with tunnels enlargement atwo stage surgery is recommended. For high-level cuttingsports patients going to revision ACL reconstruction, it ismandatory to use a 4 ? 2 graft setting with a minimumof 7-mm-diameter graft for the intra-articular reconstruc-tion. If we are not able to prepare a correct diameter graftsize, we must not apply this technique. We reserve the2 ? 2 setting for revision surgery in patients with anoncutting sport activity.The use of navigation is another limit; most of surgeonsdo not use navigation system for surgery. However, thetunnels can be performed without navigation. The firsttibial tunnel is drilled outside-in as usual using a standarddirector aimerTM (Smith and Nephew) in order to reach theantero-medial bundle (AMB) tibial foot print of the nativeACL. Then, the femoral tunnel is drilled outside in using afemoral aimer. The inside joint target is the center of theAMB insertion on the femur, and outside the jointthe landmark is situated 1 cm proximal and posterior to thefemoral lateral tubercle. This situation was validated withnavigation and confirmed by previous studies [14, 15].However, the use of navigation provides perfect 3D con-ditions to optimize tunnel position, as extra-articulartenodesis is not anatomic; an appropriated tool is needed tofind the best isometric points.Fig. 6 Different graft passages in the femur tunnel and in the twotibial tunnels, the graft return to its initial point making a completeframeKnee Surg Sports Traumatol Arthrosc (2011) 19:384389 387123The placement of the femoral screw has to be carefullydone. The head of the screw must be inside the tunnel, if itis not, the patient will complain of pain and dysfunctionduring flexion extension.Indication of lateral tenodesis is controversial; it has beenestablished long time ago by Amis et al. [1] that in isolatedACL deficient knee, there is nonsignificant biomechanicaladvantage from adding an extra-articular reconstruction.However, Zaffagnini et al. [20] reported in a RCT study5-years follow-up a significant advantage in subjectiveevaluation, a faster return to sport, less kneeling pain and ahigher capacity of return to normal muscle trophysm.If we look at the literature, other techniques have beenreported. In 2006, Ferretti et al. [10] published a similartechnique with four strands hamstring graft in revision ofACL reconstruction. The additional lateral tenodesis wasperformed with the iliotibial band let attached on theGerdys tubercle and passed under the lateral collateralligament, then returned to the initial point and sutured. Heconcluded that this technique is a reasonable alternative forrevision anterior cruciate ligament reconstruction. How-ever, patients should be informed that, despite theachievement of a stable knee following reconstruction,degenerative joint disease frequently occurs. Marcacciet al. [17] reported in 2009 an 11-year follow-up studyusing a similar technique than ours with hamstring passedover the top and fixed on the Gerdys tubercle with astaple. This technique was used for primary ACL recon-struction. He showed satisfactory results, and no significantcartilage degradation of the knee compared to ACLreconstruction without extra-articular augmentation. In histechnique, there are some weak points: the nonisometricplacement of the graft on the femur; the tibial fixation ofthe tenodesis with a staple without any bone tunnel; alwaysonly two strands to reconstruct the ACL and some damagescould appear on the Kaplans fibers.ConclusionExtra-articular tenodesis can be used in addition to intra-articular ACL reconstruction using the same graft andperformed with mini-invasive technique. This technique isindicated in revision of ACL reconstruction without tech-nical error. The tenodesis placement could be optimizedwith navigation system.References1. Amis AA, Scammell BE (1993) Biomechanics of intra-articularand extra-articular reconstruction of the anterior cruciate liga-ment. J Bone Joint Surg Br 5:8128172. Bach BR Jr, Tradonsky S, Bojchuk J, Levy ME, Bush-Joseph CA,Khan NH (1998) Arthroscopically assisted anterior cruciate lig-ament reconstruction using patellar tendon autograft five- to nine-year follow-up evaluation. Am J Sports Med 1:20293. Bignozzi S, Zaffagnini S, Lopomo N, Martelli S, Iacono F,Marcacci M (2009) Does a lateral plasty control coupled trans-lation during antero-posterior stress in single-bundle ACLreconstruction? An in vivo study. Knee Surg Sports TraumatolArthrosc 1:65704. Carson WG Jr (1988) The role of lateral extra-articular proce-dures for anterolateral rotatory instability. Clin Sports Med4:7517725. Colombet P, Robinson JR (2008) Computer navigation ACLreconstruction. In: Fu FH, Cohen SB (eds) Computer navigationACL reconstruction. SLACK incorporated, Thorofare, pp 3613746. Colombet PD, Robinson JR (2008) Computer-assisted, anatomic,double-bundle anterior cruciate ligament reconstruction. Arthros-copy 10:115211607. Denti M, Lo Vetere D, Bait C, Schonhuber H, Melegati G, VolpiP (2008) Revision anterior cruciate ligament reconstruction:causes of failure, surgical technique, and clinical results. Am JSports Med 10:189619028. Draganich LF, Reider B, Ling M, Samuelson M (1990) An invitro study of an intraarticular and extraarticular reconstruction inthe anterior cruciate ligament deficient knee. Am J Sports Med3:2622669. Engebretsen L, Lew WD, Lewis JL, Hunter RE (1990) The effectof an iliotibial tenodesis on intraarticular graft forces and kneejoint motion. Am J Sports Med 2:16917610. 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Knee Surg Sports TraumatolArthrosc 11:10601069Knee Surg Sports Traumatol Arthrosc (2011) 19:384389 389123Navigated intra-articular ACL reconstruction with additional extra-articular tenodesis using the same hamstring graftAbstractPurposeMethodResultsConclusionIntroductionTechnical notePatient setup and operative approachGraft preparationTunnel preparationGraft passage and fixationDiscussionConclusionReferences /ColorImageDict > /JPEG2000ColorACSImageDict > /JPEG2000ColorImageDict > /AntiAliasGrayImages false /CropGrayImages true /GrayImageMinResolution 149 /GrayImageMinResolutionPolicy /Warning /DownsampleGrayImages true /GrayImageDownsampleType /Bicubic /GrayImageResolution 150 /GrayImageDepth -1 /GrayImageMinDownsampleDepth 2 /GrayImageDownsampleThreshold 1.50000 /EncodeGrayImages true /GrayImageFilter /DCTEncode /AutoFilterGrayImages true /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict > /GrayImageDict > /JPEG2000GrayACSImageDict > /JPEG2000GrayImageDict > /AntiAliasMonoImages false /CropMonoImages true /MonoImageMinResolution 599 /MonoImageMinResolutionPolicy /Warning /DownsampleMonoImages true /MonoImageDownsampleType /Bicubic /MonoImageResolution 600 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.50000 /EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode /MonoImageDict > /AllowPSXObjects false /CheckCompliance [ /None ] /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox true /PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXOutputIntentProfile (None) /PDFXOutputConditionIdentifier () /PDFXOutputCondition () /PDFXRegistryName () /PDFXTrapped /False /CreateJDFFile false /Description > /Namespace [ (Adobe) (Common) (1.0) ] /OtherNamespaces [ > /FormElements false /GenerateStructure false /IncludeBookmarks false /IncludeHyperlinks false /IncludeInteractive false /IncludeLayers false /IncludeProfiles false /MultimediaHandling /UseObjectSettings /Namespace [ (Adobe) (CreativeSuite) (2.0) ] /PDFXOutputIntentProfileSelector /DocumentCMYK /PreserveEditing true /UntaggedCMYKHandling /LeaveUntagged /UntaggedRGBHandling /UseDocumentProfile /UseDocumentBleed false >> ]>> setdistillerparams> setpagedevice

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