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

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    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


    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-


    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


    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 7080% 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 Kaplans 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



    Knee Surg Sports Traumatol Arthrosc (2011) 19:384389

    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 Gerdys 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 Gerdys 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 ? 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 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

    Knee Surg Sports Traumatol Arthrosc (2011) 19:384389 385


  • 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 bonemorphing 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

    Gerdys 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 outsidein 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 Gerdys 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 isometricmap of extra-articular tenodesis.

    b Intra-articular navigationwindows with isometric map

    on the lateral part of the

    intercondylar notch. A virtual

    graft (dark blue) is provided bythe computer as well as different

    parameters and graphic of graft

    length difference during


    386 Knee Surg Sports Traumatol Arthrosc (2011) 19:384389


  • In the 2 ? 2 manner, the