LIVRE JDG 2016

C. BATAILLER, S. LUSTIG, D. WASCHER, E. SERVIEN, P. NEYRET

anterior and posterior insertions of the ACL on

the femur. The proximal parts of the strip were

passed through these holes. The strip of ITB

could also be fixed with a screw and washer at

the distal insertion of the lateral intermuscular

septum on the linea aspera just anterior to the

posterior femoral cortex. The ITB was then

fixed superficial to the FCL at 30° of flexion

with external rotation.

Müller procedure

[17]

This anterolateral tenodesis was performed by

isolating a 1.25cm strip from the posterior

portion of the iliotibial tract. The distal and

proximal attachments of this strip were

preserved. The isometric point of attachment

for this strip was recognized at the junction of

the femoral shaft and lateral femoral condyle.

The strip was fixed to this isometric point by a

Steinmann pin, and the isometricity was tested.

The strip was then fixed to this site by a

cancellous screw with a toothed washer.

These isolated procedures have been abandoned

progressively faced with unacceptably high

rates of anterior laxity recurrence. They have

increased the lateral compartment stresses and

the degenerative changes, particularly with

medial meniscal injury associated [18].

Combined intra and extra-articular

reconstructions

Combined intra-articular and extra-articular

reconstructions appeared necessary to restore

sagittal and rotational stability in knees

combining ACL and ALL deficiencies. These

procedures do not want to reproduce the

anatomic course of ALL. They realize a

genuine lateral extra-articular augmentation of

the intra-articular reconstruction, which limit

the excessive internal rotation and the anterior

translation of the lateral tibial plate.

They allow protecting the intra-articular graft,

particularly during the healing phase. An

anterolateral reconstruction decreases loads on

an intra-articular graft by 43% [19]. Indeed this

reconstruction allows a better rotational control

by its lateral long lever arm. Ellison described

the ACL as, “the hub of the wheel”, and noted,

“it is easier to control rotation of a wheel at its

rim than at its hub” [20].

Their main indications are: an important pivot

shift; an anterior tibial translation superior to

10mm (particularly on the lateral compartment);

patients with generalized hyper-laxity; revision

ACL surgery, particularly with medial

meniscal injury.

The combined reconstructions can be

performed with two grafts in continuation, or

with previous anterolateral tenodesis associated

to ACL reconstruction. Various techniques are

used, with different type of graft and different

graft positioning. The graft femoral insertion

and graft course affect length change pattern

during knee flexion, and thus the reconstruction

quality. Kittl and Amis observed that a graft

attached proximal to the LFE and which passes

deep to the FCL will provide desirable graft

behavior, without excessive tightening or

slackening during knee motion [21].

KJT technique

[22, 23]

Neyret has described since 1996 an intra-

articular reconstruction by a bone-patellar

tendon-bone graft, in continuation with

hamstring graft to reproduce ALL (fig. 6). The

gracilis is harvested and threaded through a

drill hole in tibial bone block. The femoral

tunnel is created posterior and proximal to the

FCL insertion. The patella tendon graft is

passed from proximal to distal, locking the

gracilis tendon in the femoral tunnel with the

press-fit of the bony block. The free limbs are

then passed deep to the FCL and through either

end of a bony tunnel through Gerdy’s tubercle

and sutured to one another. An interference

screw is used to secure the graft in the tibial

tunnel. After tensioning and cycling, the intra

then extra-articular graft are fixed at 30° of

flexion and neutral external rotation of the knee.