1. Results of ACL reconstruction for chronic knee instability, using one third of the patellar tendon augmented by extra- articular plasty " Mac InJones" operation 100 cases - follow-up > 10 years JL. LERAT, F. CHOTEL, F. CLADIÈRE Lyon - France ISAKOS JUIN 2001 MONTREUX

2. Materiel and methods Prospective study 1OO knees from 134 consecutive operations (1 surgeon, 1 technique) Chronic cases Accident to surgery interval : 4 ± 4.8 ys Mean age : 27.8 ± 9 years Males : 58 % Sport’s trauma : 83 % Previous surgery in 32 cases : 15 ACL reconstructions, Meniscal resections : 18 med, 5 lat Follow-up : 11.7 ± 2 ys (10 to 16)

3. "Mac InJones » procedure Patellar tendon (10 mm) Quadricipital tendon : 12 cm Trapezoïdal shaped patellar bone Special femoral visor Diameter : 9 mm bone is recuperated (Derived from both MacIntosh and Jones procedures) Free graft

4. l l Introduction from outside to inside through the condyle l l Stability of the trapezoïdal patellar block into the tunnel by pushing with a hammer l l Fixation in the tibia with a metallic wire and a screw l l Progressive tension until suppression of the drawer l l Bony fragments into the tibial tunnel l l Sometimes 1 additional interference screw "Mac InJones » procedure 1rst step : ACL reconstruction

5. 2d step : Lateral extra-articular plasty Quadricipital tendon is stretched from the condyle to the Gerdy’s tubercule with solid sutures "Mac InJones » procedure

6. With this procedure and the tension adjusted by torsion of a metallic wire on a screw JL Lerat (1979) It had become clear than the graft was sufficiently solidly fixed at both its ends to authorize immediate mobilisation in full flexion and extension and agressive rehabilitation program JL Lerat (1979) 1rst case 1979 Quadricipital tendon is stretched from the condyle to the Gerdy’s tubercule with solid sutures

7. Fragments of bone fill the patellar trench Mean skin incision : 13 cm ± 3

8. MaterielMateriel 100 knees evaluated 88 examinated and radiographied + 12 questionnaires 17 patients lost for follow-up + 3 patients died

9. Anatomical value - KT-1000 arthrometer - KT-1000 arthrometer - Anterior radiological drawer - Anterior radiological drawerFunction - IKDC (International Knee Documentation Commitee) - A.R.P.E.GE score MethodsMethods

10. Methods KT-1000 Arthrometer (preop - post-op) KT 1 : 69 n KT 2 : 89 n KT 3 : maxi-manual Stress radiography (preop - post-op) 20° of flexion Load : 9 kg Translation of medial and lateral compartments

11. Per-operative findings Medial meniscus lesions : 30 % + 25 previous meniscectomies = 55 % Lateral meniscus lesions : 19 % Cartilages lesions : 19 % –Medial : 12 –Lateral : 4 –Both : 3

12. Complications 7 ematomas 2 DVT 1 temporary peroneal nerve palsy 2 SND 3 skin infections 1 infection

13. ResultsResults Flexion : 143° ± 11 Flexion contracture : 4.5° ± 7 Amyotrophy : 1 cm ± 0.8 (28 having none) Recurrence of laxity : 9 cases Pivot-shift test ++ : 3 % + : 22 %

14. Symptoms according to activity level

15. Functional results A.R.P.E.GE : 60 % excellent + good IKDC score : 61 % excellent + good

16. Competition : 58 Recreative : 35 Sport before trauma Sport before trauma

17. Sport activity Satisfaction expressed by the patients : 88 % 78 % of the patients return to sport activities Sport with pivot : 30 % (competition : 17 %) 14 patients stop sport for other reasons

18. Evolution of sport activity level

19. Arthrometric evolution KT-1000 ArthrometerKT 1 : 69 n KT 2 : 89 n KT 3 : maxi-manual

20. « Knee instability after injury to the anterior cruciate ligament Quantification of the Lachman test » JL Lerat, B Moyen, F Cladière, JL Besse, H Abidi J. Bone Joint Surgery VOL. 82-B, N°1, January 2000, 42-47. Radiological anterior drawer

21. Anterior radiological drawer ATMC: Anterior Translation of Medial Compartment ATMC: Anterior Translation of Medial Compartment ATLC : Anterior Translation of Lateral Compartment ATLC : Anterior Translation of Lateral Compartment Flexion : 20°Flexion : 20° Load : 9 kgLoad : 9 kg Free rotationFree rotation Comfortable for the patientComfortable for the patient Simple apparatusSimple apparatus

22. Pathological ATMC and ATLC Anterior radiological drawer

23. Differential laxity Pathological ATMC and ATLC Normal contralateral knee Pathological ATMC and ATLC Normal contralateral knee

24. Precice and objective measurement of preop and post-op laxity Pathological ATMC and ATLC Post op 10 years Pathological ATMC and ATLC Post op 10 years

25. ACL deficient knees : differential ant. translation ATLC 7.3 ± 4 mm ATMC 7.8 ± 4.2 mm

26. Evolution of radiological laxity Gain for ATMC : 62 % Gain for ATLC : 77 % Differential side to side laxity

27. AB/AC x 100 AT/AC x 100 IT/IE x 100 AB/AC x 100 AT/AC x 100 IT/IE x 100 68.6 % ± 9.7 32.7 % ± 8 44 % ± 5.2 68.6 % ± 9.7 32.7 % ± 8 44 % ± 5.2

28. Femoral tunnel : Aglietti index cases index in % AB / AC x 100 68.6 %± 9.7 AB / AC x 100 68.6 %± 9.7

29. cases index in % Tibial tunnel Profile A-P Profile A-P 32 % ± 8 44 % ± 5.2

30. Correlation position of the tunnels/good result Femoral tunnel Anterior (< 52%) : IKDC : 0 A, 4 B, 9 C Posterior (> 80%) : IKDC : 0 A, 6 B, 2 D Tibial tunnel A-P No good result if 50 % Tibial tunnel (profile) Anterior (< 25 %) : IKDC : 4 A, 8 B, 2 C Posterior (> 40 %) : IKDC : 8 C ou D Difficulty to see the position of the ligament into the tunnels on the X-rays

31. Secondary operations Flexion under G.A (6 %) 16 arthroscopies (8 meniscectomies : 5 med, 3 lat) 3 arthrotomies (osteophytes) Removal of 4 screws 1 tibial osteotomy 2 iterative ACL reconstructions

32. Degeneratives lesions 8 secondary meniscectomies during 10 years (10 times minor than during the 4 preop years) Correlation : Arthrosis / meniscal lesions Correlation : Arthrosis / Laxity (Differential laxity : 5.7 vs 8.3 mm)

34. Les séquelles survenant au niveau du système extenseur, après le prélèvement d'un transplant pour intervention de type "Mac InJones " « The sequelae resulting from extensor muscle graft for ACL reconstruction with "Mac InJones" procedure » JL. Lerat, JL Besse, B. Moyen, E. Brunet-Guedj Revue de Chirurgie Orthopédique, 1995, 81, 404-410

35. Patellar height modifications Preop Post-op Difference BlackburneO.72 ± 0.170.69 ± 0.16- O.028 Caton0.87 ± 0.160.86 ± 0.15- 0.01 Insall1.11 ± 0.191.07 ± 0.20- O.037 Comparison of 3 different index No significative modifications for patella

36. Patellar tendon Anterior knee pain Flexion Flexion contracture Calcifications (29 %) –sup pole of the patella : 12 –Patellar tendon : 4 –inf pole : 6 –None of these calcifications requiered repeat surgery Quadriceps value

37. INFLUENCED BY Varus Residual laxity Pivot shift Medial meniscus lesions (57 %) Long time before operation (> 4 y) ARTHROSISARTHROSIS

38. Evolution of arthrosis pre-op post-op pre-op post-op %

39. Study of the failed cases : During the same time : Study of the failed cases : Ruptures or elongations of ACL (7 %) 5 ruptures during sport activity 2 with poor femoral tunnel positionning During the same time : 8 ruptures occured at the opposite ACL (4 years after surgery to the other knee)

40. Literature with long follow-up Johnson & Eriksson (1984) 8 years Aglietti (1992) Demsey & Tregonning (1993) 9 years Dejour & Ait si selmi (1995) (comparisons are not easy : criteria #, follow-up #) There are few well documented series after 10 years

41. Role of the extra-articular reconstruction Not easy to analyse independently of the ACL Nothing to be gained from the adding of lateral plasty –Roth (1987) –Strum (1989) –O Brien (1991) Reduction of the pivot shift –Jensen Slocum Larson (1983) –Noyes Barber-Westin (1991) –Lerat (1997) « Influence of a lateral extra-articular plasty on the results of ACL reconstruction with the patellar tendon. Follow-up 4 years » JL. Lerat, A. Mandrino, JL. Besse, B. Moyen, E. Brunet-Guedj. Revue de Chirurgie Orthopédique, 1997, 83, 591-601

42. ConclusionsConclusions Good results if we compare to the literature Confirmation of the good quality of patellar tendon as an ACL substitute.

43. ConclusionsConclusions Quadruple interest of this prospective study : Original reconstruction of ACL + Lateral extra-articular reconstruction with a single transplant using the quadriceps tendon and thus preserving the ilio-tibial band and the control of varus stability Confirmation of the efficiency of a lateral reconstruction in chronic cases Interest of Radiological measurement of the drawer (1979) Interest of a early agressive rehabilitation program (1979)

44. Thank you

45. pre-op laxity