Transcript Cupule Spring - lerat orthopedie

Results of ACL reconstruction for chronic knee instability,
using one third of the patellar tendon augmented by extraarticular plasty
" Mac InJones" operation
100 cases - follow-up > 10 years
JL. LERAT, F. CHOTEL, F. CLADIÈRE
Lyon - France
ISAKOS
JUIN 2001
MONTREUX
Materiel and methods
Prospective study
1OO knees from 134 consecutive operations
(1 surgeon, 1 technique)
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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)
"Mac InJones » procedure
(Derived from both MacIntosh and Jones procedures)
Free graft
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Patellar tendon (10 mm)
Quadricipital tendon : 12 cm
Trapezoïdal shaped patellar bone
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Special femoral visor
Diameter : 9 mm
bone is recuperated
"Mac InJones » procedure
1rst step : ACL reconstruction
 Introduction from outside to
inside through the condyle
 Stability of the trapezoïdal
patellar block into the tunnel by
pushing with a hammer
 Fixation in the tibia with a
metallic wire and a screw
 Progressive tension until
suppression of the drawer
 Bony fragments into the tibial
tunnel
 Sometimes 1 additional
interference screw
"Mac InJones » procedure
2d step : Lateral extra-articular plasty
Quadricipital tendon is stretched from the condyle
to the Gerdy’s tubercule with solid sutures
"Mac InJones » procedure
1rst case 1979
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)
Quadricipital tendon is stretched from the condyle
to the Gerdy’s tubercule with solid sutures
Fragments of bone fill
the patellar trench
Mean skin incision : 13 cm ± 3
Materiel
100 knees evaluated
• 88 examinated and radiographied
• + 12 questionnaires
17 patients lost for follow-up
+ 3 patients died
Methods
Function
- IKDC
(International Knee
Documentation Commitee)
- A.R.P.E.GE score
Anatomical value
- KT-1000 arthrometer
- Anterior radiological
drawer
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
Per-operative findings
• Medial meniscus lesions : 30 %
+ 25 previous meniscectomies = 55 %
• Lateral meniscus lesions : 19 %
• Cartilages lesions : 19 %
– Medial : 12
– Lateral : 4
– Both : 3
Complications
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7
2
1
2
3
1
ematomas
DVT
temporary peroneal nerve palsy
SND
skin infections
infection
Results
• 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 %
Symptoms according to activity level
60
50
40
Activity +++
activity ++
activity +
sedentary
30
20
10
0
Pain
e ffus ion
appre he ns ion
Functional results
50
45
40
35
30
25
20
15
10
5
0
ARPEGE score
IKDC
Excellent Good - B Poor - C
-A
Bad - D
IKDC score : 61 % excellent + good
A.R.P.E.GE : 60 % excellent + good
Sport before trauma
No sport
other
Volley
Tennis
Ski
rugby
fight
Mountain
Basket
Football
Running
Basket
sports
0
10
20
30
40
Competition : 58
Recreative :
35
50
Sport activity
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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
60
50
40
Before trauma
30
20
preop
10
follow-up
0
pivotcontact
pivot
Without
pivot
No
sport
Evolution of sport activity level
70
60
50
before trauma
preop
follow-up
40
30
20
10
0
competition
recreative
active
sedentary
Arthrometric evolution
16
14
12
10
KT 1
KT 2
KT3
8
6
4
2
0
preop
G.A preop G.A postop
KT-1000 Arthrometer
6m
10 years
KT 1 : 69 n
KT 2 : 89 n
KT 3 : maxi-manual
Radiological anterior drawer
« 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.
Anterior radiological drawer
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Flexion : 20°
Load : 9 kg
Free rotation
Comfortable for the
patient
Simple apparatus
ATMC:
ATLC :
Anterior Translation of Medial Compartment
Anterior Translation of Lateral Compartment
Anterior radiological drawer
Pathological ATMC and ATLC
Differential laxity
Pathological ATMC and ATLC
Normal contralateral knee
Precice and objective measurement of
preop and post-op laxity
Pathological ATMC and ATLC
Post op 10 years
ACL deficient knees : differential ant. translation
80
70
ATMC
7.8 ± 4.2 mm
60
50
40
30
20
10
0
-5
0
5
10
15
20
Diffe rential ATMC
80
70
ATLC
7.3 ± 4 mm
60
50
40
30
20
10
0
-5
0
5
10
15
20
Differential ATLC
25
Evolution of radiological laxity
Differential side to side laxity
9
8
7
6
5
ATMC
ATLC
4
3
2
1
0
preop
6m
1 year > 10 y
Gain for ATMC : 62 %
Gain for ATLC : 77 %
AB/AC x 100
68.6 % ± 9.7
AT/AC x 100
IT/IE x 100
32.7 % ± 8
44 % ± 5.2
position du tunnel tibial face
30
35
25
30
20
45
40
35
25
30
20
25
20
15
15
15
10
10
10
5
5
0
5
0
28-40
0
<50%
51-55
56-60
61-65
66-70
71-75
76-80
>80
2125
2630
3135
3640
4145
4648
41-45
46-50
51-57
Femoral tunnel : Aglietti index
cases
30
25
20
15
10
5
0
<50%
51-55
56-60
61-65
66-70
71-75
76-80
>80
index in %
AB / AC x 100
68.6 %± 9.7
Tibial tunnel
Profile
A-P
cases
position du tunnel tibial face
35
45
30
40
35
25
30
20
25
20
15
15
10
10
5
5
0
28-40
0
2125
2630
3135
3640
4145
41-45
46-50
4648
index in %
32 % ± 8
44 % ± 5.2
51-57
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 < 30 ou > 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
Secondary operations
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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
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)
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
Patellar height modifications
Comparison of 3 different index
Preop
• Blackburne
• Caton
• Insall
O.72 ± 0.17
0.87 ± 0.16
1.11 ± 0.19
Post-op
0.69 ± 0.16
0.86 ± 0.15
1.07 ± 0.20
Difference
- O.028
- 0.01
- O.037
No significative modifications for patella
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Patellar tendon
Anterior knee pain
Flexion
Flexion contracture
Calcifications (29 %)
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sup pole of the patella : 12
Patellar tendon : 4
inf pole : 6
None of these calcifications requiered repeat surgery
• Quadriceps value
ARTHROSIS
INFLUENCED BY
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Varus
Residual laxity
Pivot shift
Medial meniscus lesions
(57 %)
• Long time before
operation (> 4 y)
Evolution of arthrosis
pre-op
post-op
JOINT
SPACE
F-T
medial
F-T
lateral
Normal
76
15.5
7
1.5
97 93.5 30.5 78 66.3
0.7 6.5 44.5 13.5 20.5
1.5 0 11.5 5.3 9.6
0.7 0 13.5 3.1 3.6
Remodeled
Stage I
Stage II
F-P
F-T
medial
F-T
lateral
F-P
%
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)
Literature with long follow-up
(comparisons are not easy : criteria #, follow-up #)
There are few well documented series after 10 years
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Johnson & Eriksson (1984) 8 years
Aglietti (1992)
Demsey & Tregonning (1993) 9 years
Dejour & Ait si selmi (1995)
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
Conclusions
• Good results if we compare to the literature
• Confirmation of the good quality of patellar tendon as an
ACL substitute.
Conclusions
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)
Thank you
pre-op laxity
Pre-op
varus
LAXITY extension
none
129
slight
6
++
2
severe
0
varus
flexion
116
16
2
1
valgus
extension
121
14
2
0
valgus
flexion
95
28
11
1