Aim: The present paper describes the rationale behind the surgical technique and the clinical results of the iso-anatomical, single bundle bone patellar-tendon bone anterior cruciate ligament (ACL) reconstruction. Method: Using a second incision on the distal lateral femur an outside-in femoral tunnel is drilled. Guided by a special aiming device it is possible to place the femoral tunnel in the centre of the ACL footprint in every single case. Conclusion: Since every crucial step of the procedure is under visual control, the technique is safe and reliable, which is mirrored by good clinical result

Arnold, Markus

Duthon, Victoria

Hirschmann, Michael

Neyret, Philippe

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ORIGINAL PAPERDouble incision iso-anatomical ACL reconstruction:the freedom to place the femoral tunnel within the anatomicalattachment site without exceptionMarkus P. Arnold & Victoria Duthon & Philippe Neyret &Michael T. HirschmannReceived: 29 September 2012 /Accepted: 3 October 2012 /Published online: 24 October 2012# Springer-Verlag Berlin Heidelberg 2012AbstractAim The present paper describes the rationale behindthe surgical technique and the clinical results of theiso-anatomical, single bundle bone patellar-tendon boneanterior cruciate ligament (ACL) reconstruction.Method Using a second incision on the distal lateralfemur an outside-in femoral tunnel is drilled. Guidedby a special aiming device it is possible to place thefemoral tunnel in the centre of the ACL footprint inevery single case.Conclusion Since every crucial step of the procedure isunder visual control, the technique is safe and reliable,which is mirrored by good clinical results.IntroductionThe knee with a torn anterior cruciate ligament (ACL)is an archetypical example of an apparently simplerepairable structure. But the more we know, the morewe realise the complexity of the ACL. It is abundantlyclear that it is a difficult job to bring an injured kneeback into its former envelope of function and achievejoint homeostasis [1].In fact, this might be one of the reasons why the ACL andthe questions around its optimal treatment are one of thetopics in knee surgery that have led to such an overwhelm-ing number of publications.As the arthroscopic ACL reconstruction techniquesgained popularity in the mid 1980s the technical focuswas more on simplicity than on anatomical restorationof the ACL insertion sites. To achieve this technicalsimplicity, significant compromises in terms of restora-tion of the femoral attachment site had to be made. Theso-called single incision ACL reconstruction techniquebecame the most popular. Drilling the femoral tunnelthrough the primarily established tibial tunnel leads toseveral anatomical compromises. For example, since thefreedom to manoeuvre the guiding pin into the anatom-ical centre of the femoral ACL-attachment site is mark-edly reduced, it is impossible to place the femoraltunnel anatomically low into the centre of the nativeACL attachment site [2] (Fig. 1).Because of these well-known shortcomings of the singleincision technique, orthopaedic surgeons strived to findother more anatomical ways to reconstruct the ACL. Todate, it is consensus that a lower femoral tunnel placementleads to biomechanical as well as clinical advantages [3–6].There are two ways to achieve an anatomically placedfemoral tunnel:1. Drilling of the femoral tunnel through the medial ar-throscopy portal (inside-out)2. Drilling of the femoral tunnel through a small additionallateral incision (outside-in)At first glance the medial portal technique is appeal-ing. However, avoiding a second incision comes alongwith two major risks. First, a significant iatrogenicM. P. Arnold (*) :M. T. HirschmannDepartment of Orthopaedic Surgery and Traumatology,Kantonsspital Baselland/Bruderholz,4101 Bruderholz, Switzerlande-mail: markus.arnold@ksbh.chV. Duthon : P. NeyretDepartment of Orthopaedic Surgery, Centre Albert Trillat, HCL,Groupement Hospitalier Nord,69004 Lyon, FranceInternational Orthopaedics (SICOT) (2013) 37:247–251DOI 10.1007/s00264-012-1681-8damage to the cartilage of the medial femoral condylemay occur. Second, drilling of the femoral tunnel has tobe performed in deep knee flexion, which makes visualcontrol of this crucial step impossible. Based on thesefacts we not only believe that there is a legitimate placefor the almost forgotten, but also a well-proven double-incision ACL-reconstruction technique [7].The aim of this paper is to present the principles ofthe double-incision ACL reconstruction technique, itsclinical results and discuss the pros and cons of thisspecific type of ACL reconstruction.The operation techniqueThe operation technique has previously been publishedin detail [8]. Hence, the principles are only brieflydescribed as follows.Patient positioningThe patient is placed in supine position with the lowerleg hanging and the distal femur orientated horizontally.A tourniquet and a leg holder is used, which is placedapproximately 10 cm proximal to the patella.Harvesting and preparation of the graftAn anterolateral skin incision from the patella down to thetibial tuberosity is performed. Then a 10-mm wide centralstrip of the patellar tendon is prepared including a smallbone block from the patella and a longer, wedge shapedbone block from the tibial tuberosity (Fig. 2). Both are thenarmed with strong resorbable sutures. Finally the harvestsite is closed.Arthroscopic partFemoral tunnel preparationThe intercondylar notch and the tibial and femoral ACLattachment sites are debrided respecting the bony landmarksunder arthroscopic view. It is of crucial importance to visu-alize the most posterior attachment area of the ACL at thedeep posterior femoral condyle, back at the bone-cartilagetransition. In most cases visualization is enhanced when thearthroscope is placed into the medial portal.Guided by a special outside-in aiming device, a shortsecond skin incision is established. The aiming device isplaced in the center of the native ACL attachment resultingin an extra-articular starting point on the distal lateral femoralFig. 1 Schematic drawing ofthe lateral femoral notch wall. aNormal ACL insertion placeddeep in the notch with a longhigh-low extension along thefemoral condyle cartilage bor-der. b High tunnel positionresulting from transtibial dril-ling. c Low iso-anatomical sin-gle bundle femoral tunnelposition in the centre of thefemoral ACL insertion. d Dou-ble bundle tunnel positions.[Previously published inSpringer publications (KSSTA),reprint permission granted]248 International Orthopaedics (SICOT) (2013) 37:247–251metaphysis. The guide wire is then drilled from outside intothe joint from proximal to distal. The guide pin position isverified via the medial portal and then overdrilled using a10 mm cannulated drill bit. The resulting 10 mm tunnel isexpanded using a manual mill bit (distal 9 mm, proximal13 mm) again from outside-in (Fig. 3). This step is againchecked by placing the arthroscope in the medial portal.Tibial tunnel preparationIn a more familiar way, the tibial tunnel is establishedplacing a tibial aiming device between the tibial spines farenough backwards. Graft notch impingement is not really anissue due to the anatomic femoral tunnel placement. Thetibial tunnel is then drilled outside-in.Antegrade graft introduction and graft fixationShuttle sutures are introduced through the femoral tun-nel and pulled out through the tibial tunnel. The graft isthen inserted into the femoral tunnel. Here it is possibleto determine the rotational position of the bone block inthe femoral tunnel. The goal is the tendon’s backside toface anteriorly. Hence, the tendon fibers, which emergeeccentrically from the bone block, are placed as poste-rior as possible mimicking the round shape of the bonecartilage interface (Fig. 4).Under constant pull distally the bone block is then tappedinto the femoral tunnel until a press-fit anchorage isachieved, ideally flush at the femoral aperture. A goodindicator for optimal press-fit fixation is the same high-pitched sound we are used to from tapping a non-cemented hip-stem into the proximal femur (Fig. 5). Pre-conditioning, check for isometry and tibial graft fixationwith an interference screw complete the procedure.Clinical resultsReports of this technique, one with an associated lateralextra-articular tenodesis, have been published by the Lyonknee group [9–11]. Two other papers by the same groupsummarized the clinical results of patients after intra-articular double incision ACL reconstruction.Bouattour et al. [12] reported a retrospective series of 83patients (n086 knees) who underwent arthroscopic recon-struction of the ACL using a central one-third patellar ten-don autograft. The mean follow-up was six yearspostoperatively. The patients were satisfied or very satisfiedin 88.5 % of the cases. Forty-two patients (61 %) returned toFig. 3 Creation of the cone-shaped femoral tunnel. The 10-mm femoraltunnel is expanded using themanual mill bit allowing for a press-fit fixationof the wedge-shaped bone block in the cone shaped tunnel. [Previouslypublished in Springer publications (EJOS), reprint permission granted]Fig. 4 The manual mill bit entering the femoral tunnel, creating theoutside-in cone-shaped tunnel. It is under constant control with thearthroscope in the medial portal viewing inside-out. [Previously pub-lished in Springer publications (EJOS), reprint permission granted]abFig. 2 Schematic drawing of the prepared BPTB-graft. Note the small,tapered bone block A originating from the patella and the wedgeshaped bigger bone block B originating from the tibial tuberositywhich will be tapped outside-in into the cone shaped femoral tunnel,blocking itself. [Previously published in Springer publications (EJOS),reprint permission granted]International Orthopaedics (SICOT) (2013) 37:247–251 249their sports activities and 9/12 high-level athletes returned tosports at an identical level as preoperatively. Final Interna-tional Knee Documentation Committee (IKDC) score isshown in Table 1. They highlighted that good objectiveoutcome was correlated with a more anatomical femoralposition and preservation of the meniscus.Ait Si Selmi et al. [13] also reported a case series of 60patients who underwent a double-incision BTB ACL recon-struction. The mean follow-up was 16 months. The patientswere satisfied or very satisfied in 93.5 % of the cases.Subjective IKDC score was 88.4±15. Gain of subjectivescore was +13 and 82 % of patients were rated A or B atthe final IKDC scoring (Table 1).In conclusion, with regards to these studies the double-incision technique was a safe way to anatomically recon-struct the ACL leading to convincingly good clinical results.DiscussionThis paper intended to describe the technical principles ofthe double incision iso-anatomic ACL reconstruction tech-nique. In the following the pros and cons of the proposedprocedure are discussed.The only minor disadvantage of the proposed techniqueis the need for a short second skin incision on the lateralfemur. This is however outweighed by a number of technicaladvantages, which are inherent to this technique.First, the biomechanically more critical femoral tunnel isprimarily drilled. There is no pressure loss through leakingof the saline during this step.Second, the proposed ACL reconstruction techniquefacilitates placing the femoral tunnel in the centre of thenative ACL attachment, which is lower than usuallyachieved in transtibial ACL techniques [2]. Furthermore,the created femoral tunnel aperture has a rather circularshape with a defined diameter rather than an ovaloid shapewhen the drill enters the notch in a tangential direction.Third, when compared to techniques where the medialportal is used for drilling of the femoral tunnel, there is norisk of damage to the medial femoral condyle. It is an easyand reproducible ACL reconstruction technique. Every stepof the surgery is arthroscopically controlled and hence it canbe routinely used in a teaching hospital setting.Fourth, as no fixation device is used on the femoral side(press-fit technique) it is less costly than other describedtechniques. And fifth, revision surgery is considered to beless difficult. The surgeon is not limited due to the initialtunnel or fixation device in placing the femoral tunnel.Clinical resultsAlthough there is a tremendous amount of scientific datacomparing single with double-incision ACL reconstructionsin anatomical and cadaveric studies, only few clinical stud-ies compared the outcome in patients undergoing ACLreconstruction using these two techniques.In 1999 Howell [14] compared the clinical outcomeof the single- and double-incision ACL reconstructiontechniques. At two years follow-up in both groups theobjective was achieved, it was therefore concluded thatthere was no clear superiority of either technique. Butthe subjective IKDC score was significantly lower inthe single- than in the two-incision group (P00.008). Itcould be speculated that the more reliable elimination ofthe pivot shift phenomenon using an iso-anatomicdouble-incision ACL-reconstruction might be the mainreason for this clinically relevant difference.ConclusionThe double incision, iso-anatomical ACL reconstructionis a relatively simple, safe, reliable and reproducibletechnique. Anatomical femoral tunnel placement is fa-cilitated without exception.Overlooking the results of the three major ACL-reconstruction techniques, one may conclude that thesingle incision single bundle technique results are bio-mechanically reasonable, the iso-anatomical single bun-dle reconstructions are almost perfect, leaving onlyFig. 5 The ACL graft in place. Note the high-low extension of thegraft (between the two white arrows) mimicking the placement of thenormal ACL. [Previously published in Springer publications (EJOS),reprint permission granted]Table 1 Final International Knee Documentation Committee (IKDC)score of two clinical studies on double-incision ACL reconstructionStudy Final IKDC scoreA B C DBouattour et al. 25 % 50 % 21 % 4 %Ait Si Selmi et al. 27 % 55 % 16 % 2 %250 International Orthopaedics (SICOT) (2013) 37:247–251marginal room for improvement for the double bundleACL reconstructions.Conflict of interest statement No funds were received in support ofthis study. No benefits in any form have been or will be received from acommercial party related directly or indirectly to the subject of thismanuscript.References1. Dye SF (1996) The knee as a biologic transmission with anenvelope of function: a theory. Clin Orthop 325:10–182. ArnoldMP, Kooloos J, van Kampen A (2001) Single-incision techniquemisses the anatomical femoral anterior cruciate ligament insertion: acadaver study. Knee Surg Sports Traumatol Arthrosc 9(4):194–1993. Arnold MP, Verdonschot N, van Kampen A (2005) ACL graft canreplicate the normal ligament’s tension curve. Knete Surg SportsTraumatol Arthrosc 13(8):625–6314. Kanaya A, Ochi M, Deie M, Adachi N, Nishimori M, Nakamae A(2009) Intraoperative evaluation of anteroposterior and rotationalstabilities in anterior cruciate ligament reconstruction: lower fem-oral tunnel placed single-bundle versus double-bundle reconstruc-tion. Knee Surg Sports Traumatol Arthrosc 17(8):907–9135. Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL (2003)Knee stability and graft function following anterior cruciate liga-ment reconstruction: comparison between 11 o’clock and 10o’clock femoral tunnel placement. Arthroscopy 19(3):297–3046. Scopp JM, Jasper LE, Belkoff SM, Moorman CT 3rd (2004) Theeffect of oblique femoral tunnel placement on rotational constraintof the knete reconstructed using patellar tendon autografts.Arthroscopy 20(3):294–2997. Neyret P, Demey G, Servien E, Lustig S (2012) Traité de chirurgiedu genou. Elsevier Masson, Paris, pp 42–648. Arnold MP, Biedert RM, Van Loon C, Hirschmann MT (2011)Isoanatomical bone-patellar tendon-bone single-bundle ACL re-construction: the wedge that gives the edge! Eur J Orthop SurgTraumatol Epub 22.3. 20119. Dejour H, Dejour D, Ait Si Selmi T (1999) Chronic anterior laxityof the knee treated with free patellar graft and extra-articular lateralplasty: 10-year follow-up of 148 cases. Rev Chir OrthopReparatrice Appar Mot 85(8):777–78910. Dejour H, Walch G, Neyret P, Adeleine P (1988) Results ofsurgically treated chronic anterior laxities. Apropos of 251 casesreviewed with a minimum follow-up of 3 years. Rev Chir Orthop74(7):622–63611. Pernin J, Verdonk P, Si Selmi TA, Massin P, Neyret P (2010) Log-term follow-up of 24.5 years after intra-articular anterior cruciateligament reconstruction with lateral extra-articular augmentation.Am J Sports Med 38(6):1094–110212. Bouattour K, Chatain F, Ait Si Selmi T, Neyret P (2002)Arthroscopic reconstruction of the anterior cruciate ligament.Rev Chir Orthop Reparatrice Appar Mot 88(2):130–13813. Ait Si Selmi T, Fabié F, Massouh T, Pourcher G, Adeleine P,Neyret P (2002) Greffe du LCA au tendon rotulien sous arthro-scopie avec ou sans plastie antéro-externe Etude prospectiverandomisée à propos de 120 cas. Paper presented at the 10èmesJournées Lyonnaises de Chirurgie du Genou, Lyon14. Howell SM, Deutsch ML (1999) Comparison of endoscopic andtwo-incision techniques for reconstructing a torn anterior cruciateligament using hamstring tendons. Arthroscopy 15(6):594–606International Orthopaedics (SICOT) (2013) 37:247–251 251

Double incision iso-anatomical ACL reconstruction: the freedom to place the femoral tunnel within the anatomical attachment site without exception

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Double incision iso-anatomical ACL reconstruction: the freedom to place the femoral tunnel within the anatomical attachment site without exception

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