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

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Results of ACL reconstruction for chronic knee
instability, using one third of the patellar
tendon augmented by extra-articular plasty" Mac
InJones" operation100 cases - follow-up gt 10
years

• JL. LERAT, F. CHOTEL, F. CLADIÈRE
• Lyon - France

ISAKOS JUIN 2001 MONTREUX
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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
• Sports 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)

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"Mac InJones  procedure
(Derived from both MacIntosh and Jones procedures)
Free graft

• Special femoral visor
• Diameter 9 mm
• bone is recuperated

• Patellar tendon (10 mm)
• Quadricipital tendon 12 cm
• Trapezoïdal shaped patellar bone

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"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

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2d step Lateral extra-articular plasty
"Mac InJones  procedure

• Quadricipital tendon is stretched from the
  condyle to the Gerdys tubercule with solid
  sutures

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"Mac InJones  procedure
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 mobilisationin full flexion
and extensionand agressive rehabilitation
program JL Lerat (1979)
1rst case 1979

• Quadricipital tendon is stretched from the
  condyle to the Gerdys tubercule with solid
  sutures

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Fragments of bone fill the patellar trench
Mean skin incision 13 cm 3
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Materiel

• 100 knees evaluated
• 88 examinated and radiographied
• 12 questionnaires
• 17 patients lost for follow-up
• 3 patients died

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Methods

• Anatomical value
• - KT-1000 arthrometer
• - Anterior radiological drawer

• Function
• - IKDC (International Knee Documentation
  Commitee)
• - A.R.P.E.GE score

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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

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Per-operative findings

• Medial meniscus lesions 30
• 25 previous meniscectomies 55
• Lateral meniscus lesions 19
• Cartilages lesions 19
• Medial 12
• Lateral 4
• Both 3

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Complications

• 7 ematomas
• 2 DVT
• 1 temporary peroneal nerve palsy
• 2 SND
• 3 skin infections
• 1 infection

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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

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Symptoms according to activity level
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Functional results
IKDC score 61 excellent good
A.R.P.E.GE 60 excellent good
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Sport before trauma
Competition 58 Recreative 35
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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

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Evolution of sport activity level
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Arthrometric evolution
KT-1000 Arthrometer KT 1 69 n KT 2 89
n KT 3 maxi-manual
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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, N1,
January 2000, 42-47.
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Anterior radiological drawer

• Flexion 20
• Load 9 kg
• Free rotation
• Comfortable for the patient
• Simple apparatus

• ATMC Anterior Translation of Medial Compartment
• ATLC Anterior Translation of Lateral
  Compartment

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Anterior radiological drawer
Pathological ATMC and ATLC
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Differential laxity
Pathological ATMC and ATLC
Normal contralateral knee
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Precice and objective measurement of preop and
post-op laxity
Pathological ATMC and ATLC
Post op 10 years
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ACL deficient knees differential ant.
translation
ATMC 7.8 4.2 mm
ATLC 7.3 4 mm
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Evolution of radiological laxity
Differential side to side laxity
Gain for ATMC 62 Gain for ATLC 77
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AB/AC x 100 AT/AC x 100
IT/IE x 100 68.6 9.7
32.7 8 44 5.2
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Femoral tunnel Aglietti index
cases
index in
AB / AC x 100 68.6 9.7
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Tibial tunnel
Profile A-P
cases
index in
32 8 44 5.2
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Correlation position of the tunnels/good result

• Femoral tunnel
• Anterior (lt 52) IKDC 0 A , 4 B, 9 C
• Posterior (gt 80) IKDC 0 A, 6 B, 2 D
• Tibial tunnel A-P
• No good result if lt 30 ou gt 50
• Tibial tunnel (profile)
• Anterior (lt 25 ) IKDC 4 A, 8 B, 2 C
• Posterior (gt 40 ) IKDC 8 C ou D

Difficulty to see the position of the ligament
into the tunnels on the X-rays
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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

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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)

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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
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Patellar height modifications
Comparison of 3 different index

• Preop Post-op Difference
• Blackburne O.72 0.17 0.69 0.16 - O.028
• Caton 0.87 0.16 0.86 0.15 - 0.01
• Insall 1.11 0.19 1.07 0.20 - O.037

No significative modifications for patella
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• 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

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ARTHROSIS

• INFLUENCED BY
• Varus
• Residual laxity
• Pivot shift
• Medial meniscus lesions (57 )
• Long time before operation (gt 4 y)

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Evolution of arthrosis
pre-op post-op

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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)
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Literature with long follow-up
(comparisons are not easy criteria , follow-up
) There are few well documented series after 10
years

• Johnson Eriksson (1984) 8 years
• Aglietti (1992)
• Demsey Tregonning (1993) 9 years
• Dejour Ait si selmi (1995)

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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

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Conclusions

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

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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)

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Thank you
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pre-op laxity
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