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T Aitsiselmi E Kaya Bicer Ph Neyret

T Aitsiselmi E Kaya Bicer Ph Neyret. Ligamentoplastie à double faisceau, «mode» ou réalité ?. Frequently injured during high impact or sports activities 250 000 ACL injuries per year in USA Incidence: 0.3 - 0.34 / 1000 75 000 – 100 000 ACL reconstructions per year only in USA.

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T Aitsiselmi E Kaya Bicer Ph Neyret

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  1. T Aitsiselmi E Kaya Bicer Ph Neyret Ligamentoplastie à double faisceau, «mode» ou réalité ?

  2. Frequently injured during high impact or sports activities 250 000 ACL injuries per year in USA Incidence: 0.3 - 0.34 / 1000 75 000 – 100 000 ACL reconstructions per year only in USA ANTERIOR CRUCIATE LIGAMENT Nielson A B, et al. Epidemiology of acute knee injuriesJ Trauma 1991;31:1644--1648. Brown CH Jr et al. Revision ACL surgery Clin Sports Med 1999;18:109-171.

  3. Intraarticular, extrasynovial dense connective tissue Femur: A fossa on the posteromedial edge of LFC. Tibia: Anterior intercondylar fossa ANATOMY OF ACL

  4. ANATOMY OF ACL How many bundles? 1 BUNDLE • 1985 Odensten M, Gillquist J • 1989 Fuss FK 2 BUNDLES • 1856 Weber brothers • 1938 Palmer I • 1975 Girgis FG • 1983 Arnoczky SP 3 BUNDLES • 1979 Norwood LA, Cross MJ • 1991 Amis AA, Dawkins GP

  5. Today…. • ‘Double bundle concept’ • mostly accepted But it might be an oversimplification of a complex organization!!!

  6. Femoral origin is at the most posterior medial aspect of the LFC. ACL is covered with a fibrous surface membrane. Femoral Insertion Site

  7. Origin of AM and PL AM: proximal aspect of femoral origin PL: inferior aspect of femoral origin Femoral Insertion Site

  8. Femoral Insertion Site In ext,PLB located posterior andinferior to the AMB In flex, PLB located shallowand inferior to the insertion of AMB Zantop et al KSSTA 2006

  9. Femoral Insertion Site • Residents’ ridge (Lateral intercondylar ridge) • Coined by William Clancy Jr. • Thick bony landmark running from prox to distal through the entire ACL footprint • No fibers of ACL attach anterior to this ridge Clancy WG et al

  10. Lateral Bifurcate Ridge Ridge separating AM & PLbundles on the femoral attachment site Visible only in the anterior part Femoral Insertion Site Ferreti et al Ferretti M et al Osseous landmarks of the femoral attachment of the ACL Arthroscopy 2007;23:1218-1225.

  11. ACL inserts to the anteriorintercondylar fossa (anterolateral to medialtibial spine) Lack of attachment to the tibial spines Foot type of region Broadest part of ACL Tibial Insertion Site Tibial spines Arnoczky SP Anatomy of the ACL CORR 1983;172:19-25. Harner C et al. Quantitative analysis of human cruciate ligament insertions Arthroscopy 1999;15: 741-749.

  12. AM and PL bundles are described according to the relative anatomic positions of their attachments on the tibia. Tibial Insertion Site Amis AA, Jakob RP. ACL graft positioning,tensioning and twisting. KSSTA 1998;6:S2-S12

  13. Tibial Insertion Site 8.9 ± 1.2 mm CAM– CPL 17 ± 2 mm CAM– RER 5 ± 1 mm CAM – Med spine 16.1 ± 3.05 mm CAM – Ant border Colombet et alArthroscopy 2006 Petersenet al CORR 2006 Edwards et alKSSTA 2007 Tállay et al KSSTA 2008 Siebold et al Arthroscopy 2008

  14. Tibial Insertion Site 4 ± 1 mm CPL – Med spine 10 ± 1 mm CPL - RER 24.05 ± 3.6 mm CPL – Ant border Colombet et alArthroscopy 2006 Petersenet al CORR 2006 Edwards et alKSSTA 2007 Tállay et al KSSTA 2008 Siebold et al Arthroscopy 2008

  15. Midsubstance of ACL • From its femoral attachment, the ACL runs anteriorly, medially, and distally to the tibia. • Width ofACL:7 – 12 mm • Length of ACL:22 – 41mm (mean, 32 mm) mostly implying length of AM Amis AA, Dawkins GP. Functional anatomy of the ACL: Fiber bundle actions related to ligament replacements and injuries. JBJS Br 1991;73:260–267

  16. The length of AM & PL bundles are different Kummer & Yamamato Arthroskopie 1988 Length of PL bundle: 17.8 mm Midsubstance of ACL AM PL

  17. Due to the bony attachments, during the flexion movement AM bundle makes a lateral turn on PL bundle. Spatial Orientation Girgis et al • During the whole ROM there is always a • functional part which is under tension.

  18. Spatial Orientation

  19. Spatial Orientation In extension: Bundles are almost parallel PL bundle:tight AM bundle:moderately lax During the knee flexion The femoral attachment of the ACL becomes more horizontal AM bundle tightens PL bundle loosens ArnoczkyCORR 1983;172:19-25. Duthon et al KSSTA 2006;14: 204–213

  20. Biomechanics During the ROM, • ACL fibers do not have isometricbehavior • The change in the length of each bundle is different • AM bundle maintains aconstant tension • The tension of the PLbundle is more variable

  21. ACL resists Anterior tibial translation Rotational loads Biomechanics www.stanford.edu www.clinique-des-lilas.com AM and PL bundles have varying contributions to knee stability during the ROM

  22. Magnitude ofthe in situ forcein the intact ACL, AM andPL under 110 Nof applied anterior tibialload Biomechanics Sakane et al Sakane et al In situ forces in ACL and its bundles in response to anterior tibial loads J Orthop Res 1997;15:285-293.

  23. In situ force in theintact ACL, AM andPL in response to combined rotatoryload Biomechanics Gabriel MT et al Gabriel MT et al Distribution of in situ forces in ACL in response to rotatory loads J Orthop Res 2004;22:85-89.

  24. Biomechanics PL bundle has a significant role inthestabilization of the knee againstcombinedrotatory loads. Gabriel MT et al Distribution of in situ forces in ACL in response to rotatory loads. J Orthop Res 2004;22:85-89.

  25. Injured ACL: Biological Aspect • Nonop treatment: Persistent joint instability and knee pain • Different biologic properties of intraarticular and extraarticular ligaments Fu F et al. Current trends in ACLR AJSM 1999;27:821-830.

  26. Injured ACL: Biological Aspect • Injury to a ligament Hematoma formation • ACL Expandable, thin, synovial lining • Torn synovium Bleeding into the joint; no hematoma • Complete ruptures:No local healing response Fu F et al. Current trends in ACLR AJSM 1999;27:821-830. Hefti FLet al. Healing of the transected ACL in the rabbit JBJS1991;73:373–383.

  27. ACL Reconstruction • Single bundle ACLR 80 – 90 % successful patient outcome • But…. 10 – 30 % of patients Persistent instability and knee pain • 15 % persistent pivot shift Buoncristiani AM et al. Anatomic DB ACLR Arthroscopy 2006;22:1000–1006. Crawford C et al. Anatomic DB ACLR KSSTA 2007;15:946-964. Bach BR Jr et al. Arthroscopically-assisted ACLR using patellar tendon autograft. AJSM 1998;26:20-29.

  28. ACL Reconstruction SB ACLRdoes not restore normal transverse plane knee rotatory control during • walking • stair descent • jumping- landing • downhill running Georgoulis AD et al.Three-dimensional tibiofemoral kinematics of the ACL-deficient and reconstructed knee during walking AJSM 2003;31:75–79. Ristanis S et al. The effects of ACLR on tibial rotation during pivoting after descending stairs. KSSTA 2003;11:360–365. Tashman S et al. Abnormal rotational knee motion during running after ACLR AJSM 2004;32:975–983.

  29. ACL Reconstruction Persistent Instability Prevention of osteoarthritis

  30. ACL Reconstruction • SB ACLR:mostly addresses AM bundle • To improve knee stability and mimic the native biomechanical behavior of ACL Reconstruction of both AM and PL bundles ‘Anatomic DB ACLR’

  31. Anatomic DB ACLR • Mae et al 2001 Arthroscopy Single vs two femoral socket ACLR technique: cadaveric study Greater stability and bundle load sharing with DB technique • Yagi M et al 2002 AJSM Biomechanical analysis of an anatomic ACLR: cadaveric study Anatomic DB ACLR more closely restores the normal knee kinematics

  32. Which DB ACLR? • Double incision • Single incision • Transtibial tunnel • drilling • AM portal tunnel • drilling 2 femoral, 2 tibial tunnels 2 femoral, 1 tibial tunnel 1 femoral, 1 tibial tunnel • Extracortical fixation • Aperture fixation

  33. Graft Preparation Double stranded ST and G autografts Endobutton Graft preparation on tension board Krackow stitches Surgical Technique endo.smith-nephew.com Christel P et al Christel P et al 2005Oper Tech Orthop

  34. Surgical Technique Tibial site Femoral site • Marking of native bundle insertion sites • with a thermal device Images: F. FU www.orthosupersite.com

  35. Preparation of the PL Femoral Tunnel First PL tunnel In 110° flex, via accessory AM portal a guide wire is placed at the native PL insertion site 5 – 7 mm posterior and 3 mm superior to the anterior articular cartilage Surgical Technique www.endo.smith-nephew.com Shen W et al 2007 JOS

  36. Preparation of Tibial Tunnels First PL tunnel Tibial drill guide Angle set at 55° Starting point on the tibial cortex: Anterior to the superficial MCL Insertion of tibial guide wire Surgical Technique www.endo.smith-nephew.com

  37. Surgical Technique Arthroscopic and radiographic views of tibial guide wires 8 – 9 mm Aglietti P et al Järvelä et al Positions of the guide wires checked in flex & ext to rule out impingement Christel P et al. 2005Oper Tech Orthop Aglietti P et al. 2005Oper Tech Orthop Järvelä T et al. 2008 AJSM

  38. Preparation of the AM FemoralTunnel Last drilled tunnel AM femoral tunnel:~ 5 to 6 mm posterior to the posterior margin of the PL tunnel Mostly free hand drilling Surgical Technique www.endo.smith-nephew.com www.orthonet.pitt.edu Shen W et al 2007 JOS

  39. Surgical Technique 1 3 approaches: • Transtibial AM tunnel approach • Transtibial PL tunnel approach • Medial portal approach 2 3 Shen W et al Shen W et al Shen W et al Shen W et al 2007 JOS

  40. Surgical Technique Bony bridge between tunnels Järvelä et al The arthroscopic view of the femoral tunnels (through the AM portal) Right knee in extension Järvelä T et al 2008 AJSM

  41. Graft Passage Retrograde graft insertion via the tibial tunnels into the femoral tunnels First G graft (PL) inserted Beath needle is used for graft passage Surgical Technique Christel P et al Christel P et al Christel P et al. 2005Oper Tech Orthop Aglietti P et al. 2005Oper Tech Orthop

  42. Fixation PL: 15° flex AM: 75° flex Bioabsorbable screws Single staple on the tibial cortex Surgical Technique www.endo.smith-nephew.com Crawford et al

  43. Prospective-randomized comparison of single AM, single PL, anatomic ACLR • 20 patients in each group • 1 year follow-up • Evaluation: IKDC, KT-1000, pivot shift with 3D electromagnetic sensors • Evidence Level: II

  44. Results Following DB ACLR Yagi et al 2006 CORR No difference in the rate of negative test results

  45. Yagi et al 2006 CORR Instrumented pivot shift The average acceleration values of the tibial motion during the pivot shift in AM and PL reconstruction groups were larger than in DB ACLR group Results Following DB ACLR

  46. Results Following DB ACLR Yagi et al 2006 CORR • Clinical Results Supporting DB ACLR • ‘DB ACLR can provide better dynamic • rotatory stability during the pivot shift test than • either of the single-bundle AM and PL • reconstructions.’

  47. Results Following DB ACLR Yagi et al 2006 CORR • Limitations: • No IKDC evaluation score or knee arthrometry • differences • No long term follow-up • Validation of the pivot shift measurement system • not confirmed

  48. Prospective-randomized study Totally 108 patients Follow-up: mean 32 months Evaluation: KT-2000, Cybex II dynamometer (to asses joint position sense) 1 tunnel 2tunnels 1 tunnel 1 tunnel

  49. Results Following DB ACLR Adachi et al 2004 JBJS • Clinical Results Objecting DB ACLR • ‘No significant difference between SB and DB ACLR • regarding to either anterior laxity or joint position sense ’ • Limitation: • Single tibial tunnel • No data regarding to rotational stability

  50. Prospective clinical study • Evidence level: II • 25 patients in each group • 2 year follow-up • AP and pivot shift stability • superior in group 3 • compared to group 1

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