The rupture of the Anterior Cruciate Ligament (ACL) causes significant functional impairment (knee instability and giving way) and long-term meniscal and cartilage damage (osteoarthritis).

A. The advent of the reconstruction of the "double beam" (Double-Bundle Reconstruction)

ACL reconstruction is a widely practiced procedure that has made ??reliable over time with better knowledge of anatomy and biomechanics of this ligament. [1] Initially, surgeons realized an isolated ACL reconstruction with patellar tendon transplant free (fig 1) with a poor functional outcome rate of 11 to 30% in the long term [2,3] but, above all, the persistence of a blank projection of internal rotation in over 15% of cases [4,5], raising the question of the effectiveness of ACL reconstruction in the prevention of knee osteoarthritis. These techniques only rebuilding the anteromedial bundle which alone can replicate the function of the ACL on the knee while the mobility sector.

Fig1: ACL reconstruction technique

patellar tendon to rupture lca

Technical kJ kenneth jones

To improve the control of the rotational stability was proposed in the late 90s by several authors [6-12] to rebuild in addition anteromedial bundle, the posterolateral bundle ACL. This is the technique of the dual beam. Experimental work [13-16] have shown that ACL reconstructions to a beam have significantly lower performance than the reconstructions say two anatomical beams, both in terms of rotational stability, Antero-posterior. Clinical studies have confirmed this superiority study to a decline of 5 to 10 years found a significantly lower rate of knee OA [17] and a comparative review of randomized trials showed a significantly lower rotational laxity in case of reconstruction double [18] beam.

B. The technique of "double beam"

In France, ACL reconstruction to two beams began in 2001. It was described by Professor Franceschi in 2002 [19] and Professor Christel in 2008 [20]. It typically uses two hamstring passed through four tunnels (two femoral and tibial two) fixed on the femoral side by EndoButtons and on the tibial side by interference screws (4 fasteners).
This technique has been described by several authors: Muneta [9] in 1999, Brucker [21] and Chhabra [22] in 2006. Yasuda in 2004 [23] described the positioning of the tunnels through a cadaver study and presented the results over 2 years follow a series of 57 patients who underwent the procedure. For this author, only the drilling of four tunnels allows anatomic ACL reconstruction. Brucker to [21], the drilling four tunnels provides a larger contact surface between the bone and tendon promoting intra-tunellaire healing. On the other hand, according to Brucker, the passage of two beams in a same tunnel may cause an incorrect position of one of the two grafts.
A survey published by Zantop [24] in 2007 showed that the majority of the panel surgeons used one hand four tunnels and secondly the hamstring rather than the patellar transplant.

C. The attachment means of the graft

Fixing the transplant aims to maintain sufficient voltage during the period of incorporation of the transplant in its intra-tunellaires portions.
Several fastening means are initially used (such as sutures or clips) with a rate of significant complications (rupture, fracture, tissue necrosis ...).
The interference screws were developed to avoid the occurrence of these complications. They are either resorbable or metallic. Resorbable screws are made ??of various materials (PGA, PLA, PLLA, PDLLA, PDS).

Their advantages and disadvantages are:

? The metal screws allow a strong and well tolerated [25,26] but may require further surgery to remove them. They also interfere with the interpretation of the [27] MRI scans but the use of titanium facilitates the interpretation of MRI scanners and postoperative.

? The two major risks of resorbable screws are loss of mechanical stability with the absorption of the material [26,28,29] and the foreign body reaction type of inflammatory synovitis. [30] Resorption of the screw requires a more or less long term.

Loubignac [28] and his team in 1998, decided to return to a screw fastening metal interference following the recognition of a significant osteolysis of resorbable screws. In a recent study [31], among 41 patients randomized to receive either a metal screw (25 patients) or a resorbable screws (16 patients) and followed over 7 years on average, MRI showed that the path of the saw was always visible in 11 of 16 patients absorbable screw group and there were no cases of bone ingrowth on the tibial side. The authors conclude that the supposed advantage of the absorbable screw is not sufficient evidence to recommend their use.

D. The technique "TLS"

The Tape Locking Screw System (TLS®) was developed in 2003 [32,33] and has the CE mark (in 2005 for TLS titanium screws and 2007 for anchor strips). It is also inscribed on the List of Products and Services Redeemable (3197753 Code: bone, tendon or ligament anchor system, nonabsorbable). In 2008, the US Food and Drug Administration has cleared for marketing the "Attaching tendon graft to the femur and tibia in the reconstruction of the Anterior Cruciate Ligament and the posterior cruciate ligament."

This system is based on three technical principles: the preparation of the graft, the shape of the bone tunnels and the original attachment:

• preparation of the graft: a tendon loop closed 4 sprigs short (50mm) from 8 to 10 mm diameter is made ??from a hamstring tendon. TLS® the strip of polyethylene terephthalate braided 7mm increased at each end of the ligament loop. A preload of 500 N is applied for 2 minutes. The static and dynamic tensile tests performed on humans semitendinosus tendons prepared in closed loop (mechanics laboratory CRITT-Charleville, June 2002) showed resistance values ??near normal ABI (1916 ± 349 N) [33- 35];

• bone tunnels small caliber (4.5 mm), they are carried inwards to the tibia and femur. Bone cubicles are dug retrograde. Retrograde tunneling helps limit bone trauma as Morgan had shown [36]. The cadaver study of Mac Adams [37] compared to the anterograde digging digging retrograde. In any case, the anterograde digging caused microfractures subchondral while digging backward not caused any;

• fixing: it is obtained the femur and tibia by screwing inwards of graft suspension strips using a special screw interference (TLS® screws) titanium. According Ishibashi [38], the interference screw would decrease the mobility of the transplant in the tunnels and thus limit their expansion and favor the healing of the graft.
This technique also allows the reconstruction of a single beam grafting only the semitendinosus [35] that the reconstruction of dual beam with the semitendinosus and gracilis. [39]
Postoperatively, the patient has the full support immediately, flexion and extension are free. [40] Rehabilitation can begin right from the day after surgery.

E. Functional results

1. OUTCOME

The main outcome measures used were:
o The functional scores: usually the objective and subjective IKDC,
o The residual laxity and looseness gain to assess the effectiveness of the ligament on correcting the initial laxity evaluated mm from the opposite side (differential laxity). It is measured by the KT-1000 or Télos®.
o The return to the initial level of sport.

2. Global functional results

In studies with a minimum follow-up of 10 years, the objective IKDC (A B) varies 60.4% [41] and 96% [42], regardless of the surgical technique or graft.
Concerning the laxity, the Ait Si Selmi study [43] showed that 27.4% of patients had a differential laxity less than 3 mm and 62.9% less than 5 mm. For Salmon [42], these rates were 60% ??and 97% respectively.
The return to the initial level of sport varies between 51% [44] and 95% [45] depending on the series. Overall, return to the sport of the rate at the same level is an average of 65%. [46] Among the remaining 35%, 24% take up the sport at a lower level and 11% do not return to sports. [46]

F. Complications

1. Postoperative pain

The onset of pain or a previous discomfort is common after ligament reconstruction. First attributed exclusively to the removal of the patellar transplant effort came after hamstring plasty posed the question of multifactorial origin of these pains.
Several studies have evaluated the prevalence of anterior knee pain. In 2008, Lewis [47] found through a literature review a prevalence of 23% at 2 years follow-up in case of single beam reconstruction. Niki [48] in 2011 found in a series of 171 patients operated on using the technique in double beam and having more than 2 years follow a prevalence of 42% at 3 months and 11.1% at 2 years. An extension deficit was predictive of anterior knee pain at 3 months (OR = 2.76, p = 0.004).
Sometimes the pain is mechanical due to a conflict with the fixing material, usually the tibial level. According to Kurzweil [49], this complication was found in fewer than 3% of cases with interference screw, removal of material occurring on average 16 months after the intervention.

2. The tunnel enlargement

The tunnel enlargement is frequently found in postoperative [50,51]. The origin is multifactorial, both biological (elevated cytokine levels, [50]) that biomechanics (mobility graft in the tunnel).
A significant expansion of the femoral and tibial tunnels was found with resorbable screws [52,53] and the metal screws. [26] This expansion concerns both single beam technique as the dual beam. [54]

3. recovery rate

In their multicenter retrospective study on 948 patients, Laxdal [52] observed, with an average follow up of 32 months, 6.3% recovery for stiffness, 5% recovery for tibial material ablation, and 6% recovery for different injury (foreign body, osteophytes ...).

4. Other complications

• The deep infection rate varies from 0.14 to 1.70% [55,56].
• secondary real traumatic rupture rates is 3.4% for the patellar transplant and 4.1% for the hamstring transplant. [57]
• Thromboembolic complications in the first 3 months ligamentoplasties were reported. Their occurrence was correlated with a reconstruction of the anterior cruciate in the acute stage. [58]
• A recent study [59] also showed through a literature review, a decrease in bone density of the lower limb who have suffered the trauma regardless of the rehabilitation protocol followed.
• In the study Laffargue [60], the number of reflex sympathetic dystrophy syndrome, although weaker than arthroscopic open, was 19%

G. The results of the TLS system

A retrospective study [34] of 134 patients operated on between 2003 and 2006, revised down 6 to 36 months, showed an average differential laxity of 1.5 mm to 20 patients, 1.7 mm in 56 cases, and 3, 7 mm in 58 cases. Three infections (2.2%), two thrombophlebitis (0.7%), two important hematomas (1.4%), a RSD (0.7%) and six failures (4.4%) were observed.
A prospective study of 82 patients operated on in 2007 [35] according plasty single beam with a mean follow-up of 2 years, showed a highly significant improvement in subjective IKDC (from 68 to 92 points, p = 0.0001) at last follow 74% of patients were classified as A or B depending on the objective IKDC, laxity measured Télos® from an average of 5.9 mm preoperatively to 1.9 mm (p <0.0001), 74% patients regained their preoperative level of activity and 86% of patients were satisfied. Residual pain was present in 14% of patients. Two patients (2.4%) had a major dystrophy with residual stiffness. One patient (1.2%) had a arthrography fibrosis with extension and flexion deficit.
A study [39] also prospectively in 47 patients operated in 2008 with a reconstruction of the dual beam and a mean follow up of 9.6 months showed that 90% of patients were classified as A or B according to the IKDC objective and at last follow differential laxity was on average 2.9 mm. One patient (2%) developed a RSDS and one patient (2%) infection. One patient had a second break to 7 months following a fall down the stairs.

H. Recommendations of the High Authority for Health (HAS)

These recommendations were released in June 2008 "Therapeutic management of meniscal lesions and isolated lesions of the anterior cruciate ligament of the knee in adults."

The main points are:

1. Any lesion of the anterior cruciate ligament does not require surgical reconstruction

2. ligament, currently in France, is a reconstruction by autograft ACL since sutures are ineffective

3. Three main clinical situations:

i. A patient with functional instability, young, having a sport pin (contact or not) or professional risk justifies surgical reconstruction

ii. A patient with no functional instability regardless of age, having no sporting request pivot, and having no meniscal tear does not justify surgical treatment but functional treatment, monitoring and clear information about the risk of onset of instability, which would lead to talk of intervention

iii. A young patient, given early, even if he has not had time to develop a functional instability, having pivot activity, with significant laxity can be a surgical reconstruction of principle (a fortiori if there is a repairable meniscal lesion)

4. The ligament is preferably performed by arthroscopy given the comprehensive review of the joint it has authorized in the same operation, the more rapid postoperative, reduced morbidity, speed recovery

5. Among the various attachment techniques, the fixation by a screw femoral interference screw and a tibial interference is the reference technique. The screw can be metallic or bioabsorbable (PLA) since it has not been demonstrated difference between bioabsorbable screws and metal screws on clinical outcomes.

I. Conclusion

The purpose of a ligament reconstruction for a ruptured Anterior Cruciate Ligament is prevent or remove functional instability, to limit the risk of secondary meniscal lesion and osteoarthritis.
ACL reconstruction techniques have proved effective on the function and stability of the knee. Plasty dual beam with four drill tunnels allows an anatomical reconstruction and improved anterior-posterior stabilization.
However, the prevalence of anterior knee pain varies between 11% and 23% at 2 years follow-up, the secondary failure rate is 4% and the recovery rate for tibial interference screw ablation of 3%. The return to the initial level of sport varies between 51% and 95% depending on the series, 65% on average.
HAS recommends surgical arthroscopic ACL reconstruction in young top athlete.

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