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N. TARDY, M. THAUNAT, B. SONNERY-COTTET, C.G. MURPHY, P. CHAMBAT, J.M. FAYARD
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Surgical technique
Our surgical management was based on a
systematic operative strategy. The first surgical
step was an anterior arthroscopic release.
The subquadricipital pouch and both the medial
and lateral gutters were released using
anteromedial and anterolateral portals, with two
superomedial and superolateral portals if
necessary. Next, the anterior interval was ins
pected and released if adhesions were present.
The intercondylar notch was debrided of scar
tissue. The knee was then mobilized in flexion.
The intercondylar notch was then analysed in
extension to treat potential causes of an
extension deficit, such as a localized
arthrofibrosis [9, 10] (“Cyclops” lesion [11]),
an impingement of the ACL graft with the roof
of the notch in extension [12] called the
“cyclopoïde” aspect [13] or a technical error
such as protrusion of an interference screw. A
notchplasty was systematically performed
when an anterior impingement was present. If
the impingement persisted after the notchplasty
because of ACL graft malposition, we were
sometimes obliged to debride the graft.
Knee motion was then assessed. If full
extension could not be achieved, a posterior
open procedure with a posterolateral and a
posteromedial approach was used. With the
knee flexed at 90° to take away the popliteal
neurovascular bundle, a posterolateral 10cm
skin incision was made. Proximally, the
incision started at the posterior part of the
femoral shaft and ran distally to the lateral
epicondyle and was curved towards Gerdy’s
tubercle. The incision continued on the
posterior third of the iliotibial band, allowing
the biceps femoris to be retracted backward
and the vastus lateralis forward. The
capsulotomy was performed between the
lateral collateral ligament and the lateral
gastrocnemius, taking care not to injure the
popliteus tendon. So the posterolateral
recess was progressively open. This supra
meniscal posterior release was continued
subperiostally until the posterior cruciate
ligament was reached.
For the posteromedial approach, a 7-8cm
longitudinal incision was made starting at the
top from the soft point between the medial
epicondyle and the adductor tubercle and
running parallel to the axis of the tibia as
described by Lobenhoffer
et al.
[6] (fig. 1a).
The retinaculum was also incised and the
sartorius muscle displaced posteriorly
protecting the saphenous nerve and vein. The
retroligamentous capsulotomy was performed
behind the medial collateral ligament fibres at
the junction with the posterior oblique
ligament, exposing the medial condyle and the
posterior horn of the medial meniscus. In
arthrofibrotic knees, dense scar tissue was seen
instead of the normal thin synovial layer. This
fibrotic tissue was released subperiostally to
enter the posteromedial recess of the knee.
Using the two retroligamentous approaches,
the posterior cruciate ligament and its synovial
fold were visualized. The posterior cruciate
ligament fold was carefully divided from the
posterior capsule using scissors to create a
posterior space behind the femoral condyles
connecting
both
posterolateral
and
posteromedial recesses. The scissors should
cross this posterior space and be visible from
both sides of the femur in both incisions
(fig. 1b). All adhesions in the posterior recess
were then released. A complete posterior
subperiosteal capsular release was performed,
detaching the capsule and the head of the
gastrocnemius muscles from the posterior
femoral condyles and shaft, a technique
described as the “femoral peel” by Windsor
and Insall in the context of total knee
arthroplasty revision [14] (fig. 1b). The release
was mainly focused on the femoral capsular
attachment to preserve the posterior horn of
medial and lateral menisci. On the tibial side,
the dissection stopped above the meniscal
limit, unlike Millett
et al.
[15], who performed
the tibial dissection behind the posterolateral
part of the tibia with an occasional release of
the semimembranosus tendon.
Passive extension was regularly tested and the
subperiosteal dissection was continued until
full extension could be achieved. At the end of
the procedure, the ACL graft was checked