192 / 244
THE EVOLUTION OF ACL RECONSTRUCTION OVER THE LAST 50 YEARS
191
that leads to a retraction of the remnants. It is
also very difficult to say that the supposed
healthy bundle doesn’t have a lesion, at a
minimum, intra ligamentously or at its
insertion. The percentage of these lesions
confirmed in the operating room after a
thorough arthroscopic examination varies
according to the literature and represents 10-
15% of the anatomical lesions of the ACL [49,
50, 51]. The techniques used to reconstruct the
affected bundle is variable but we remain
confident that the “outside-in” techniques can
preserve as much of the supposed healthy
bundle as possible.
The results of patients operated on according to
this view are, in the literature, very satisfactory
with a significant improvement in anterior
translation of the tibia relative to the
preoperative measurement and a differential
laxity measured at 1 mm [52, 53]. One must
note in these patients, a very small percentage
of positive dynamic tests (5%) [52, 53] and a
significant improvement in knee’s pro
prioceptive qualities compared to a knee
undergoing a conventional intervention.
Surgically speaking, the interest to preserve the
intact bundle is beneficial for several reasons
all described in the literature [54]:
• Improvement in the postoperative mechanical
quality, with a mechanically solid bundle
protecting the graft and its fixation and
allowing a more aggressive rehabilitation.
• Preservation of the vascularity at the level of
the synovial envelope required for healing of
the graft [55].
• Preservation of existing mechanoreceptors in
the intact bundle. This improves the
proprioceptive qualities of the knee, therefore
its ability to resume physical activity [56].
Technically it is an intervention requiring a lot
of attention, with a delicate balance between
too much resection which may damage the
supposed healthy bundle and not enough which
can lead to impingement at the notch.
RECONSTRUCTION WITH
PRESERVATION OF
LIGAMENT TISSUE
The benefits associated with conservation of an
assumed intact bundle in partial ruptures, has
led surgeons to consider the possibility of
preserving as much as possible ligamentous
tissue, even when ruptures are complete.
The possibility of such a surgical option can be
first eluded to on MRI if there is a high
avulsion, but it is the arthroscopic exploration
that will decide that (high avulsion without
retraction). This is possible only if the
intervention is performed relatively acutely.
The femoral tunnel is drilled from outside-in
with a prudent release of the posterior portion
of the axial wall of the lateral femoral condyle.
The drilling of the tibial tunnel is even more
delicate [57]. The tibial guide is positioned for
emergence of the guide pin in the center of the
tibial insertion and the tunnel is drilled with
drill bits of increasing diameter. The perforation
must stop as soon as the intra-articular bone is
crossed and the drill bits must remain strictly
within the base of the ACL. This way, the entire
residual tissue is preserved. A “shaver” is
passed through the tibial tunnel and into the
foot of the ACL and used to progressively
skewer and emerge in the upper part of the
residual ligament, permitting a piercing of the
remnant ACL and creating a passage for the
future transplant. The transplant (semi
tendinosus) harvest may remain attached
distally. It can be passed intra-particularly in
double or triple, from distal to proximal. At the
completion of the procedure the transplant
itself is not visible, covered in its entirety by
the preserved ACL tissue [58].
During our experience in 2009, this technique
represented 10% of operated patients. Our
short-term review showed no significant
differences compared with conventional
techniques for range of motion, Lachman test,
the “Pivot Shift” and the differential. We
performed subsequent MRI studies which at