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3 months showed that the transplant had low
signal intensity and was clearly distinguishable
from the remnant ACL which showed a hyper
signal. At 6 months the signal intensity of the
transplant increased, approaching that of the
residual ACL, perhaps signifying an advanced
maturation.
The interest in this technique is in some
respects, similar to those of partial re
construction, with a vascularization and
proprioception advantage to which must be
added:
• Conservation at the tibial attachment of the
ACL with a flare shaped filling of the anterior
part of the intercondylar notch in extension
contributing to stability.
• A recovering of the neo-ligament by well-
organized tissue which puts to rest any
anarchic and exuberant healing that might
lead to a Cyclops lesion.
This technique does not enhance themechanical
properties of the initial transplant and does not
allow for an accelerated rehabilitation program.
The weak point remains the upper part of the
graft which is not covered by the remnant ACL.
AFTER 2010
After Steven Claes’s publication in 2013,
substantial media buzz has put in light a “new”
anatomical structure, the anterolateral ligament
of the knee (ALL) [59]. Since this date,
orthopedic surgeons have demonstrated a
renewed interest in the anterolateral structures
of the knee. More than 85 articles have been
published on this ALL since 2013. Despite this
extensive research effort, there is no consensus
on ALL; on contrary, the ALL is a highly
controversial subject. For some authors; this
anatomical structure does not exist or/and has
no function in knee stability [60-63]. For others
authors, its macroscopic existence has been
demonstrated in all knees, as well as its
histologic appearance being analogous to a
ligamentous structure [64-67]. Moreover, the
ALL appears to be involved in the rotational
control of the knee [68, 69]. This controversy is
mainly due to the difficulty to isolate the ALL
using different dissection protocol and to
identify this structure by imaging including
MRI.
However, the ALL could be the anatomical
missing link justifying the historical “lateral
extra articular tenodesis (Lemaire procedure)”
for rotatory instability in ACL deficient knee.
Despite promising clinical results, the ALL
reconstruction procedure is still in its early
phase of development and it is too soon to
know if this procedure will be largely diffused
or not.
CONCLUSIONS
ACL surgery has evolved considerably over
the past 50 years. At first, this involved an
awareness of the inadequacy of extra articular
procedures and the need to reconstruct the
ACL. The use of PT is at first difficult and
reconstruction using fascia lata or extensor
mechanisms becomes popular. The use of a
free PT graft disrupts the hierarchy and
becomes the “gold standard”. For reasons
relating to frequent secondary pain problems,
some surgeons gradually move towards the
hamstrings. The transition to a double bundle
technique is an evolution linked to a better
understanding of ACL anatomy. All this
evolution is based on the biomechanics of the
ACL. Beginning in 2000, a biological and
mechanical concept emerges. It is on track for
being evaluated and under an interesting
evolutionary path that will provide food for
thought for young surgeons for many years to
come. We must today also evaluate the addition
of an anatomical antero lateral tenodesis.