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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.  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  and a comparative review of randomized trials showed a significantly lower rotational laxity in case of reconstruction double  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  and Professor Christel in 2008 . 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  in 1999, Brucker  and Chhabra  in 2006. Yasuda in 2004  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 , 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  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  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.  Resorption of the screw requires a more or less long term.
Loubignac  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 , 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 . The cadaver study of Mac Adams  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 , 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  that the reconstruction of dual beam with the semitendinosus and gracilis. 
Postoperatively, the patient has the full support immediately, flexion and extension are free.  Rehabilitation can begin right from the day after surgery.
E. Functional results
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%  and 96% , regardless of the surgical technique or graft.
Concerning the laxity, the Ait Si Selmi study  showed that 27.4% of patients had a differential laxity less than 3 mm and 62.9% less than 5 mm. For Salmon , these rates were 60% ??and 97% respectively.
The return to the initial level of sport varies between 51%  and 95%  depending on the series. Overall, return to the sport of the rate at the same level is an average of 65%.  Among the remaining 35%, 24% take up the sport at a lower level and 11% do not return to sports. 
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  found through a literature review a prevalence of 23% at 2 years follow-up in case of single beam reconstruction. Niki  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 , 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, ) 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.  This expansion concerns both single beam technique as the dual beam. 
3. recovery rate
In their multicenter retrospective study on 948 patients, Laxdal  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. 
• 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. 
• A recent study  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 , the number of reflex sympathetic dystrophy syndrome, although weaker than arthroscopic open, was 19%
G. The results of the TLS system
A retrospective study  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  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  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.
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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This technique of reconstruction of the anterior cruciate ligament plasty involving extra and intra-articular fascia lata was described by Hey-Groves in 1917, modified in 1972 and MacIntosh Jaeger recently. This reconstruction is a technique increasingly practiced for controlling the tibial rotation and rotational jump experienced by the patient and the surgeon objectified by clinical examination.
This lateral grafting used in this technique is called the fascia lata is a transplant with high resistance comparable to other biomechanical transplants used. The fascia lata retains its tibial insertion, which is a natural attachment system and therefore superior to any other system used. This technique has the advantages of not having to levy tendon and therefore the hope of postoperative muscle recovery and normalization of the fastest isokinetic tests.
The coracoid bone block screwed in front of the glenoid realized today either open or arthroscopically.
The advantages of arthroscopic abutment technique are:
- Take stock of the damage to the joint, bead, cartilage, loss of bone substance, tendon injuries
- The precise positioning of the stop because under direct control by the camera,
- Of smaller sizes scars,
- The treatment of lesions as lesions of the biceps (SLAP lesion) or lesions of the rotator cuff (tendon rupture) that can be treated in the same operation
- Early functional recovery
Latarjet arthroscopic intervention
The procedure is most often performed under general anesthesia with an inter-scalene block made ??preoperatively by the anesthetist. It involves taking a bone block of about 2 cm at the expense of the coracoid and place it in the anterior and inferior part of the glenoid cavity, passing through the subscapularis muscle. The coracoid can be positioned upright and secured by a screw according to Bristow or lying and fixed by two screws according Latarjet. (read more..)
The shoulder dislocations and recurrent anterior instability is a common problem among young athletes making up 90% of shoulder dislocations. Surgical indication can be provided in these cases of glenohumeral dislocations previous recurrent, but also in cases of painful and unstable shoulders. A question now arises, should we offer it immediately after the first dislocation or should we expect one or more recurrences? (Read more ...)
Patient, 58, sporting good level with chronic tendinitis of the Achilles tendon of the left.
chronic Achilles tendon pain lasting for more than a year after a triathlon.
The patient has received medical treatment (necessary before any surgical decision): rehabilitation, Stanish stretching, shock wave, orthopedic soles. (read more...)
While muscle injuries of the posterior region of the thigh are common in athletes, the proximal hamstring rupture is a rare disease. A study published in 2003  analyzed in a consecutive series of 170 patients, 179 trauma hamstrings occurred over a period of 3 years. MRI and / or ultrasound showed that only 12% of the injuries were fractures of the proximal and 9% complete ruptures. It is also little known, the first cases described in the literature from 1988 . Clinically the patients describe a violent pain in the buttock (stab printing) followed by leg weakness. ( To be continued..)