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subsequent publications described dynamic
tests executed in different ways that, in an
index knee, were also effective in showing
lateral condyle subluxation or reduction from a
subluxed position on the lateral tibial plateau.
These tests were helpful to the clinician and
patient to the extent that they afforded different
ways to clinically reproduce a sensation similar
to the one the patient felt when their knee gave
way. It also aided in a better understanding of
the role the ACL plays.
It became evident in cases of ACL deficiency,
that subluxation occurred with the knee closer
to extension than 90° of flexion. Any surgery
being proposed therefore had, as its goal, a
method for opposing the sliding of the lateral
condyle at a position near extension.
In 1967, Lemaire [7, 9] described an
anterolateral tenodesis using the fascia lata
which limited the gliding. Such an operation
had previously been proposed by Matti [10, 11,
12]. Other surgeons subsequently proposed
similar techniques [13, 14, 15, 16, 17, 18].
It was Marcel Lemaire’s technique of lateral
tenodesis that we adopted in Lyon. At first¸ we
combined it with a posteromedial imbrication
followed by cast immobilization. This resulted
in poor outcomes. It was then performed as an
isolated procedure. If at first, this anterolateral
reconstruction gave quite good results, we soon
noticed a clinical deterioration in outcome.
This evolution was later confirmed by Dodds
[19] who, in 2011, wrote: the technique (extra
articular reconstruction) has not gained favor
due to the residual instability and the subsequent
development of degenerative changes.
With peripheral reconstructions not affording
long term stability to the knee, it became
evident that attention needed to be directed to
reconstructing the ACL. Albert Trillat began
this journey based on the technique described
by Jones [20], using the patellar tendon (PT)
with some modifications (drilling a tibial and
femoral tunnel from outside to inside), with the
technique subsequently modified by using the
medial third of the patellar tendon as described
by Erikson [21], in a manner of where it was
left attached distally. This technique was
similar to that described by Brüchner [22],
known only by German surgeons, who in 1966
also proposed to use the medial third of the
patellar tendon. In our practice these techniques
were all cast immobilized post operatively.
Rehabilitation was difficult, with postoperative
stiffness due to immobilization and incorrect
positioning of the graft.
During this same period, perhaps because of
the difficulties encountered using the PT,
surgeons offered other techniques using fascia
lata (FL) or the extensor mechanism. The
former was described in operations by Insall
[23] and MacIntosh (MacIntosh II) [24].
Insall’s operation consisted of harvesting a
band of FL and freed at its distal attachment
with a bone block. This was passed “over the
top” and secured with a screw to the anterior
tibial plateau. The MacIntosh II operation freed
a strip of FL proximally and passed it “over the
top” to then assume the path of the ACL and
insert into a tibial tunnel. The first description
using the extensor mechanism was also
attributable to MacIntosh (MacIntosh III) [24]
who harvested a continuous strip of PT, pre
patellar fascia throughout its pre patellar
surface and a tubularized strip of quadriceps
tendon. The proximal portion was passed
through a tibial tunnel, “over the top” and then
fixed to the femur. Marshall then suggested
adding a synthetic ligament to the pre patellar
portion (weak point of the previous operation)
to strengthen it.
This technique, known most commonly as the
“Marshall MacIntosh”, was most popular in the
late 70’s, some surgeons enhancing the
technique by tenodesing the proximal end of
the quadriceps tendon to reinforce the antero
lateral corner.
YEARS 1980-2000
A free patellar tendon graft
Regarding the use of patellar tendon, its use
seemed again possible after hearing Franke’s