Arthroscopic treatment of flexion deformity after ACL reconstruction

After anterior cruciate ligament (ACL) reconstruction, one frequent complication is the restriction of the range of motion and loss of extension. In addition to the presence of adhesions in the suprapatellar pouch, it is possible to detect two different pathological findings in the intercondylar notch: a misplacement of graft causing an intercondylar impingement, or the presence of hypertrophic tissue originating from the graft that blocks the last degrees of extension, causing an "anterior impingement." We reviewed 18 consecutive cases treated by arthroscopic release. All patients had knee range-of-motion restriction after an ACL procedure. The follow-up at 1 and at 6 months shows that good results have been obtained in cases of anterior impingement, whereas in cases of intercondylar impingement a restricted range of motion, especially of flexion, did remain. In all cases, after arthroscopic treatment the postoperative extension was between 5 and 10 degrees, but this deficit regressed after 6 months in 12 patients, whereas a dropout case was necessary in the remaining 6 patients.     

Case Report Ganglion Cysts of the Bilateral Cruciate Ligaments

Ganglion cysts originating from the cruciate ligaments have been reported rarely. A 38-year-old woman developed symptoms of knee pain with 10 degrees loss of knee extension. Preoperative magnetic resonance imaging showed a well-demarcated cystic mass surrounding the posterior cruciate ligament so clearly that further examination was not recommended. Because examination under anesthesia confirmed full extension of the knee, we presumed that pain produced by compression caused the diminished extension, and that mechanical block was not the reason. During arthroscopic examination, a mass was impinged between the anterior cruciate ligament and the intercondylar notch when extension of the knee was attempted. The mass was resected and immediate improvement was noted. The patient had experienced the same episode in the contralateral knee and removal of a ganglion cyst on the cruciate ligament 10 years ago. At the latest follow-up she was completely symptom free in both knees without any sign of recurrence.     

Acute extension block caused by anterior cruciate ligament tear: A case report

Acute knee locking is usually attributed to a displaced meniscus tear. This case involved late diagnosis of mechanical extension block caused by anterior displacement of a torn anterior cruciate ligament (ACL) with impingement in extension. Definitive reconstruction was delayed after debridement of the ACL stump to improve preoperative range of motion. Despite this, the patient still had difficulty regaining extension after surgery. Early treatment of mechanical extension block may facilitate motion recovery after ACL reconstruction.     

Intraarticular fibrous nodule as a cause of loss of extension following anterior cruciate ligament reconstruction.

Loss of motion is a well-known complication following anterior cruciate ligament (ACL) reconstruction. We have found that loss of extension is more disabling than loss of flexion, and is a more common problem following arthroscopic assisted ACL reconstruction. We are reporting on a group of 21 patients who have developed restricted knee extension following ACL reconstruction utilizing either the central one-third of the patellar ligament or the hamstring tendons as an autogenous graft. The patients presented at an average of 4 months postoperatively with a clinical syndrome of loss of extension associated with pain at terminal extension, crepitus, and grinding with attempted extension beyond their limit. The consistent finding at arthroscopy was a fibrous nodule occupying the intercondylar notch, varying in size from 1 x 1 to 2 x 3 cm, and presenting a mechanical block to full extension. It appears that anterior placement of the graft, particularly on the tibia, results in injury to the graft and subsequent nodule formation. Removal of the nodule resulted in improvement of an average preoperative loss of extension of 11 degrees, to 3 degrees at surgery, and 0 degrees at 1 year follow-up. The average side-to-side difference in terminal extension at final examination, using the uninvolved limb for comparison, was 3 degrees. Histology was available for review on 19 of the 21 patients operated on. The consistent microscopic finding within the nodule was the presence of disorganized dense fibroconnective tissue that, with time, underwent modulation to fibrocartilage. It is postulated that this occurs in response to compressive loading of the nodule.     

Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries

This work studied the fibre bundle anatomy of the anterior cruciate ligament. Three functional bundles--anteromedial, intermediate, and posterolateral--were identified in cadaver knees. Their contributions to resisting anterior subluxation in flexion and extension were found by repeated tests after sequential bundle transection. Changes of length in flexion and extension and in tibial rotation were measured. None of the fibres were isometric. The posterolateral bundle was stretched in extension and the anteromedial in flexion, which correlated with increased contributions to knee stability and the likelihood of partial ruptures in these positions. Tibial rotation had no significant effect. The fibre length changes suggested that the 'isometric point' aimed at by some ligament replacements lay anterior and superior to the femoral origin of the intermediate fibre bundle and towards the roof of the intercondylar notch.     

The cyclops lesion: a cause of diminished knee extension after rupture of the anterior cruciate ligament.

Four patients presented with persistent diminution of knee motion after rupture of the anterior cruciate ligament with a novel lesion as the cause. Each had participated in an aggressive rehabilitation program for a minimum of 2 months with emphasis on regaining full range of knee motion. Because chronic impairment of knee extension can be disabling, in those who did not regain full range of motion, arthroscopy of the knee ensued. All had a lesion in the intercondylar notch near the tibial insertion of the anterior cruciate ligament that acted as a mechanical obstruction to full knee extension. Grossly and histologically, these were similar to the cyclops lesion that also has been shown to cause loss of knee extension after anterior cruciate ligament reconstruction. Arthroscopic debridement of the cyclops lesion and manual manipulation of the knee under anesthesia lead to restoration of full knee extension in all knees. In 1 other knee with chronic instability after anterior cruciate ligament rupture, the cyclops lesion was present but was very small and was not associated with diminished knee extension. When loss of full extension persists for 2 months after anterior cruciate ligament disruption despite aggressive rehabilitation, the presence of a cyclops lesion should be considered.     

Correlation of intercondylar notch cross sections to the ACL size: a high resolution MR tomographic in vivo analysis

Introduction To correlate cross sections of the intercondylar notch to cross sections of the anterior cruciate ligament (ACL) and to analyze gender-related differences in notch and ACL morphometry with an attempt to explain the observation that a small intercondylar notch and the female gender predispose to a rupture of the ACL. Material and methods High resolution MR imaging was performed on a 1.5 T magnet using a dedicated extremity-coil in ten left and ten right knee joints of 20 volunteers (10 male, 10 female, mean age 25 years) with no history of knee abnormalities. Continuous axial T2-weighted MR images perpendicular to the longitudinal axis of the ACL were acquired. Cross-sectional areas of the ACL midsubstance at the contact area to the posterior cruciate ligament were measured. For imaging and evaluation of the osseous limits of the intercondylar notch a 3D-dataset of the knee was acquired. Anterior, middle and posterior planes of the intercondylar notch were calculated and analyzed for measurement of the notch area A_N and notch width index NWI. The ratio of the ACL cross-sectional area of the ACL and the cross-sectional area of the notch was defined as the ACL notch index (ANI) and used as a standardized tool for evaluation. For statistical evaluation, linear regression analysis was performed. Mean values between male and female were compared using a t test. In addition, five matched pairs of male and female volunteers of same height were analyzed. Results Mean cross-sectional size of the ACL at the crossing with the PCL was 54.4 ± 20.4 mm². Regression analysis showed a significant correlation (P < 0.05) of the ACL cross-sectional area to the notch areas on all three planes and NWI, respectively. Comparison between the sexes revealed that female participants had significantly smaller cross-sectional areas of the ACL, the notch areas, the NWI and ANI. This difference was found for both the complete study group and the matched pairs of same height. Conclusions The smaller the intercondylar notch the smaller the cross-sectional area of the ACL midsubstance. In addition to the impingement of the ACL at the anterior and posterior roof of the notch, a biomechanically weaker ACL may be the reason for disposition to an ACL rupture in patients with a small intercondylar notch. Women have a thinner ACL midsubstance than men of the same height which may be one of the critical etiologic factors that predispose women to an ACL rupture.     

The Value of Intercondylar Notch Visualization of the Posteromedial and Posterolateral Compartments During Knee Arthroscopy

Summary: The intercondylar notch views allow for visualization of the posteromedial and posterolateral compartments of the knee without the use of accessory portals. The purpose of this study was to prospectively evaluate whether these views are useful either diagnostically or therapeutically in the performance of knee arthroscopy. Two surgeons at one institution performed 150 consecutive knee arthroscopies. After arthroscopic examination of the knee using standard portals, a diagnosis and treatment decisions were made. Thereafter, visualization of the posteromedial and posterolateral compartments through the intercondylar notch was undertaken. Each view was performed initially with a 30° arthroscope and 3 questions were asked: (1) Did the view change the diagnosis or add additional information? (2) Did it change the surgical treatment? (3) Was it useful during performance of the procedure? The 70° arthroscope was then used and the same three questions were addressed. In 20.6% of the cases, the intercondylar notch views made a diagnostic and/or therapeutic difference, and the surgical procedure was changed in 11.3% based solely on this information. The views were 3 times as likely to make a difference in anterior cruciate ligament (ACL) reconstructions when compared with arthroscopy without ACL reconstruction (P < .01). The 70° arthroscope added nominal additional information. There were no significant complications. We advocate visualization of the posteromedial and posterolateral compartments through the intercondylar notch as a valuable part of routine knee arthroscopy.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 8 (November), 1999: pp 813–817     

Effects of notchplasty and femoral tunnel position on excursion patterns of an anterior cruciate ligament graft

Purpose: Errors in femoral tunnel placement in anterior cruciate ligament (ACL) reconstruction can cause excessive length changes in the graft during knee flexion and extension, resulting in graft elongation during the postoperative period. To improve the accuracy of tunnel placement and to avoid graft impingement, a notchplasty is commonly performed. The purpose of this study was to determine the effects of varying the position of the femoral tunnel and of performing a 2-mm notchplasty of the lateral femoral condyle and roof of the intercondylar notch on excursion patterns of a bone–patellar tendon–bone graft. Type of Study: Biomechanical cadaveric study. Methods: A cylindrical cap of bone, containing the tibial insertion of the ACL, was mechanically isolated in 15 fresh-frozen cadaveric specimens using a coring cutter. The bone cap was attached to an electronic isometer that recorded displacement of the bone cap relative to the tibia as the knee was taken through a 90° range of motion. After native ACL testing, the proximal end of a 10-mm bone–patella tendon–bone graft was fixed within femoral tunnels drilled at the 10-, 11-, and 12-o'clock (or 2-, 1-, and 12-o'clock) positions within the notch. The distal end of the graft was attached to the isometer. Testing was then completed at each tunnel position before and after notchplasty. Results: Before notchplasty, mean graft excursions at the 10- or 2-, 11- or 1-, and 12-o'clock tunnels were not significantly different from the excursions of the native ACL or each other. After a 2-mm notchplasty, mean graft excursions at the 3 tunnel locations were not sigificantly different from each other but were greater than mean graft excursions before notchplasty. After notchplasty, all grafts tightened during knee flexion. Conclusions: Although errors in placement along the arc of the intercondylar notch did not significantly affect graft excursion patterns, the apparent graft tightening with knee flexion that was observed for all 3 tunnel positions after notchplasty suggests that graft forces would increase with knee flexion over this range. This would indicate that as little amount of bone as possible should be removed from the posterior portion of the intercondylar notch in ACL reconstruction.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 4 (April), 2003: pp 340–345     

The static stabilizing function of the popliteal tendon in the knee. An experimental study

We investigated the importance of the anterior cruciate ligament (ACL), its two components (the AMP and PLP), and the lateral compartment ligaments with special attention to the popliteal tendon (PT) in relation to valgus-varus, axial rotation, and anterior-posterior instability. Mobility patterns were drawn from 15 osteoligamentous knee preparations after successive transection of the structures. Even when combined lesion involved the lateral collateral ligament (LCL), the PT, and the posterolateral capsule (PLC), anterior tibial displacement was not effected until the ACL was cut. The lateral structures acted as secondary restraints to anterior displacement, and prevented simultaneous anterolateral rotation during application of the anterior force. LCL and PLC transection affected varus stability in full extension, and instability improved on additional section of the PT, even if the ACL remained intact. Maximum instability after combined lateral lesion occurred at 40 degrees of flexion, whether the ACL was transected or not. Further flexion caused a rapid decrease of instability. The PT was shown to effectively restrain varus instability from 0 to 90 degrees of flexion. It was experimentally established with regard to axial rotation that marked posterolateral instability was impossible with an intact PT. Maximum instability was recorded at 30 degrees of flexion after combined lesion to the lateral structures. Even in the extension, considerable posterolateral instability was observed. The restraining effect of the PLC was prominent in extension.     

Anterior cruciate ligament and intercondylar notch in the coronal oblique plane: anatomy complemented by magnetic resonance imaging in cruciate ligament-intact knees.

We assessed the anatomy of the anterior cruciate ligament (ACL) and femoral intercondylar notch on cryosections from one cadaveric knee specimen in the coronal oblique plane oriented parallel to the intercondylar roof. We determined the course of the ACL, the widths of the cruciate ligaments at intersection, and the intercondylar notch configuration on coronal oblique plane magnetic resonance images in 51 adult cruciate ligament-intact knees (25 women, 26 men; age range, 16 to 47 years). The intercondylar notch widths were measured at the notch entrance, at the intersection of the ACL and posterior cruciate ligament (PCL), and at the notch outlet. In the coronal oblique plane, the ACL exhibited a diagonal course from the central and medial part of the anterior intercondylar area of the tibia distally, across the lateral third of the intercondylar notch, to the intercondylar surface of the lateral femoral condyle proximally. At the cruciate ligament intersection, the absolute widths of the ACLs measured on average 6.1+/-1.1 mm in men and 5.2+/-1.0 mm in women representing 31.9% and 31.1% of the ACL/central intercondylar notch width ratios. The absolute widths of the PCLs measured on average 9.6+/-1.3 mm in men and 8.5+/-1.3 mm in women representing 50.4% and 51.4% of PCL/central intercondylar notch width ratios. On average for both groups, men and women, the absolute widths of the PCLs were significantly larger than the absolute widths of the ACLs. However, the relative widths of the cruciate ligaments with respect to corresponding intercondylar notch widths were not significantly different. In the coronal oblique plane, the intercondylar notch widths showed on average a significant decrease from posterior to intersection and from intersection to anterior. At notch outlet, the mean notch width measured 21.4 mm in men and 18.5 mm in women. At intersection, the mean notch width measured 19.1 mm in men and 16.6 mm in women. At notch entrance, the notch width measured 14.6+/-1.8 mm in men and 12.7+/-2.1 mm in women. We recommend magnetic resonance tomography of the knee in the coronal oblique plane oriented parallel to the intercondylar roof as the imaging modality of choice to visualize accurately the anatomic diagonal course of the ACL and its relation to the intercondylar notch and posterior cruciate ligament complex.     

Gender differences in passive knee biomechanical properties in tibial rotation

The anterior cruciate ligament (ACL) is the most commonly injured knee ligament with the highest incidence of injury in female athletes who participate in pivoting sports. Noncontact ACL injuries commonly occur with both internal and external tibial rotation. ACL impingement against the lateral wall of the intercondylar notch during tibial external rotation and abduction has been proposed as an injury mechanism, but few studies have evaluated in vivo gender‐specific differences in laxity and stiffness in external and internal tibial rotations. The purpose of this study was to evaluate these differences. The knees of 10 male and 10 female healthy subjects were rotated between internal and external tibial rotation with the knee at 60° of flexion. Joint laxity, stiffness, and energy loss were compared between male and female subjects. Women had higher laxity (p = 0.01), lower stiffness (p = 0.038), and higher energy loss (p = 0.008) in external tibial rotation than did men. The results suggest that women may be at greater risk of ACL injury resulting from impingement against the lateral wall of the intercondylar notch, which has been shown to be associated with external tibial rotation and abduction. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 26:937–944, 2008     

Extension block secondary to partial anterior cruciate ligament tear on the femoral attachment of the posterolateral bundle

Purpose: The purpose of this investigation was to prove that a partial tear of the anterior cruciate ligament (ACL) at the femoral attachment of the posterolateral bundle can result in mechanical knee locking and trigger the injury mechanism of an isolated ACL injury. Type of Study: Case series. Methods: From February 1993 through June 1999, 19 cases of knee locking with observation of a torn ACL, confirmed under arthroscopy, were investigated. Patients’ ages ranged from 22 to 54 years. The causes of injury were sporting activities in 14 patients (8 skiing, 4 soccer, and 2 badminton); slipping and falling in 2 cases; a pedestrian car accident in 2 cases; and an unknown low-velocity injury in 1 case. Results: On physical examination, each patient indicated that the chief complaint was knee pain; all had a locked knee at 5° to 20° of full extension and 4 cases showed a locked knee at full flexion. Of the 19 cases, Lachman testing was positive in 3. With respect to intra-articular injuries, 3 patients had a tear in the medial meniscus and 1 had a tear in the lateral meniscus. The average time span between arthroscopy examinations was 3 months with a range of 1 to 10 months. Arthroscopic diagnosis and treatment were performed and meniscal tear was ruled out as the cause of locking in all patients. Conclusions: The mechanisms of injury for isolated ACL were knee hyperextension and internal rotation of lower extremity brought on especially by a low-velocity injury. The partial ACL tears were found on the femoral attachment site of the posterolateral bundle. The torn segment of the ACL was interposed between the lateral femoral condyle and the lateral tibial condyle and acted as a mechanical obstruction, giving rise to the locking symptom. In all 19 cases, the torn portion of the ACL was excised under arthroscopy and the locked knees were treated properly.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 3 (March), 2002: pp 227–231     

急诊关节镜下清创复位联合二期韧带重建治疗急性膝关节后外侧旋转脱位

目的总结急诊关节镜下复位清创联合二期韧带重建手术在急性膝关节后外侧旋转脱位治疗中的效果。方法回顾性分析2007年9月至2008年8月第三军医大学西南医院收治的3例急性膝关节后外侧旋转脱位患者的临床资料,3例患者均急诊行关节镜手术清创＋复位治疗,其中1例内侧副韧带（MCL）Ⅲ度损伤患者行MCL修补缝合术;2例MCLⅡ度损伤患者佩戴铰链支具保守治疗。术后3个月,3例患者接受LARS人工韧带前交叉韧带（ACL）重建术。观察患者膝关节活动度和Lysholm评分结果。结果平均随访15个月。3例患者均未出现膝关节前向不稳,前抽屉试验、轴移试验阴性;均未发生关节内异位骨化等病变。术后3个月,3例患者的膝关节活动度分别为0°～130°、0°～120°、0°～130°;重建术后12个月,3例患者的Lysholm评分分别为91、88、94分。结论急诊关节镜下复位、关节腔清理术结合标准化的ACL重建术对于膝关节后外侧旋转脱位的治疗效果较好。     

Case series utilizing drop-out casting for the treatment of knee joint extension motion loss following anterior cruciate ligament reconstruction

STUDY DESIGN: Case series. CASE DESCRIPTION: Four patients who had developed knee extension motion loss following anterior cruciate ligament reconstruction were referred to physical therapy for treatment. They were treated with drop-out casting and completed a Lower Extremity Functional Scale at baseline, at the time of application of the drop-out casting, and at discharge. OUTCOMES: Three males and 1 female with a mean age of 20.5 years (range, 18-22 years) were referred to physical therapy a mean of 31 days (range, 19-49 days) following bone-patella tendon-bone autograft anterior cruciate ligament reconstruction. The mean number of physical therapy sessions attended was 29.5 visits (range, 20-47 visits). The mean improvement in knee extension range of motion (ROM) and knee flexion ROM prior to the application of drop-out casting was 4.3 degrees (range, -1 degree to 10 degrees) and 24.3 degrees (range, 0 degree to 40 degrees), respectively. The mean improvement on the Lower Extremity Functional Scale was 10.3 points prior to drop-out casting. At time of discharge, the total mean improvement in knee extension ROM loss was 11.0 degrees (range, 4 degrees to 15 degrees), knee flexion ROM was 30.8 degrees (range, 22 degrees to 35 degrees), and Lower Extremity Functional Scale was 12 points (range, -5 to 21 points). Two of the patients were able to complete a running program without difficulty, while the other 2 patients had difficulty with higher-level activities. DISCUSSION: Despite the low incidence of knee extension ROM loss following surgery, the inability to achieve full knee extension does occur and can have debilitating consequences. When early emphasis of full passive knee extension has been inadequate, these results suggest that improving knee extension motion without inhibiting knee flexion motion is possible with the use of a drop-out cast. Future research should focus on comparison of drop-out casting to dynamic splinting, as well as the optimal frequency and duration of low-load long-duration stretching using a drop-out cast.     

Anatomy and biomechanics of the posterolateral aspect of the canine knee.

The purpose of this study was to describe the anatomy and characterize the biomechanics of the posterolateral aspect of the canine knee. Ten adult canine knees were each used for anatomy and biomechanical testing. Distances and motion limits were measured using a 6 degree-of-freedom electromagnetic tracking system. Canine knee dissection reproducibly identified structures present in the human posterolateral knee. The course and attachment sites of the fibular collateral ligament, popliteofibular ligament, and popliteus tendon were similar to human anatomy. Sequential sectioning of the fibular collateral ligament, popliteofibular ligament, and popliteus tendon all significantly increased varus translation at full extension, 60 degrees , and 90 degrees of knee flexion. Sectioning of the fibular collateral ligament significantly increased external rotation at flexion angles near full extension, while popliteus tendon sectioning also significantly increased external rotation at 90 degrees of knee flexion. Based on the fact that the anatomy of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and the biomechanical properties of the canine posterolateral knee are similar to the human knee, we believe the canine knee is a suitable model to study the natural history of posterolateral knee injuries. The canine model will also prove valuable in the validation of reconstruction techniques and studying the potential development of medial compartment osteoarthritis following posterolateral knee injuries.     

Evaluation of the anterior cruciate ligament integrity and degenerative arthritic patterns in patients undergoing total knee arthroplasty

We prospectively reviewed 107 consecutive primary total knee arthroplasties performed over a 1-year period. Intraoperatively, the integrity of the anterior cruciate ligament (ACL), the characteristics of the intercondylar notch, and the patterns of cartilage wear were evaluated. The ACL was found to be deficient in 41 knees (39%) at the time of surgery. The ACL-deficient knee had significantly narrower intercondylar notch widths compared with knees with an intact ACL (average, 9.75 vs 16 mm, P < .01). Furthermore, patients with ACL deficiency were found to have a higher percentage of Outerbridge grade IV changes at the lateral femoral condyle, lateral tibial plateau, and patellar surfaces when compared to the ACL-intact group. An intact ACL appeared to be protective against severe patellar degeneration. In conclusion, intercondylar notch narrowing from the arthritic process can lead to attrition and rupture of the ACL. An ACL deficiency appears to be associated increased wear of the lateral femorotibial and patellofemoral joints.     

Intercondylar notch measurements with special reference to anterior cruciate ligament surgery

The femoral intercondylar notch width was measured in 93 patients with chronic anterior cruciate ligament (ACL) insufficiency (Group 1), in 62 patients with an acute tear of the ACL (Group 2), and in 38 fresh anatomic specimen knees (Group 3). In six of the specimen knees, further anatomic studies of the intercondylar notch were performed after tissue removal. The average intercondylar distance was 16.1 mm in Group 1, 18.1 mm in Group 2, and 20.4 mm in Group 3. All differences were highly significant. The intercondylar notch was wider in the posterior part and had no crossing bony ridges but had generally concave walls, which provided a functional shelf for the ACL to insert on the lateral side. Significant osteophyte formation and stenosis of the anterior outlet of the intercondylar notch occur early in the ACL-deficient knee. A narrow anterior outlet of the intercondylar notch without osteophytes was also found in knees with an acute ACL rupture. At reconstruction of the ACL, notchplasty should be performed concomitantly.     

Arthroscopic reconstruction of the anterior cruciate ligament using double anteromedial and posterolateral bundles

We propose a method for repairing the anterior cruciate ligament which takes advantage of the multifascular nature of the ligament to achieve better physiological anteroposterior and rotational stability compared with conventional methods. Arthroscopic reconstruction of the anteromedial and posterolateral bundles of the ligament closely reproduces normal anatomy. We have used this technique in 92 patients with anterior cruciate ligament laxity and present here the mid-term results. The hamstring tendons (gracilis and semitendinosus) are harvested carefully to obtain good quality grafts. Arthroscopic preparation of the notch allows careful cleaning of the axial aspect of the lateral condyle; it is crucial to well visualize the region over the top and delimit the 9 h-12 h zone for the right knee or the 12-15 h zone for the left knee. The femoral end of the anteromedial tunnel lies close to the floor of the intercondylar notch, 5 to 10 mm in front of the posterior border of the lateral condyle, at 13 h for the left knee and 11 h for the right knee. The femoral end of the posterolateral tunnel lies more anteriorly, at 14 h for the left knee and 10 h for the right knee. The tibial end of the posterolateral tunnel faces the anterolateral spike of the tibia. The tibial end of the anteromedial tunnel lies in front of the apex of the two tibial spikes half way between the anteromedial spike and the anterolateral spike, 8 mm in front of the protrusion of the posteriolateral pin. The posterolateral graft is run through the femoral and tibial tunnels first. A cortical fixation is used for the femoral end. The femoral end of the anteromedial graft is then fixed in the same way. The tibial fixation begins with the posterolateral graft with the knee close to full extension. The anteromedial graft is fixed with the knee in 90 degrees flexion. Thirty patients were reviewed at least six months after the procedure. Mean age was 28.2 years. Mean overall IKDC score was 86% (36% A and 50% B). Gain in laxity was significant: 6.53 preoperatively and 2.1 postoperatively. Most of the patients (86.6%) were able to resume their former occupation 2 months after the procedure. The different components of the anterior cruciate ligament and their respective functions have been the object of several studies. The anteromedial bundle maintains joint stability during extension and anteroposterior stability during flexion. The posterolateral bundle contributes to the action of the anteromedial bundle with an additional effect due to its position: rotational stability during flexion. In light of the multifascicular nature of the anterior cruciate ligament and the residual rotational laxity observed after conventional repair, our proposed method provides a more anatomic reconstruction which achieves better correction of anteroposterior and rotational stability. This technique should be validated with comparative trials against currently employed methods.     

The figure-of-four view to evaluate ACL injury

Standard arthroscopic assessment of the anterior cruciate ligament (ACL) injury through an anterior view can be sub-optimal for evaluation of the femoral origin, particularly the posterior component. The figure-of-four view provides increased exposure to the posterolateral aspect of the intercondylar notch, thereby facilitating diagnosis of proximal ACL injury and avulsions of the ACL origin.