Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons: a review

Abstract

The purposes of this paper are to summarize the concepts relating to the use of a combined intra-articular and extra-articular reconstructive procedure in the arthroscopic treatment of a torn ACL and to review several operative techniques utilizing gracilis and semitendinosus tendons that are currently in use to treat this instability. The highly satisfactory results obtained over the time show that a combination of intra- and extra-articular procedures for ACL reconstruction is a valid surgical option.

Introduction

Numerous surgical procedures have been described to stabilize a knee with a torn anterior cruciate ligament (ACL).

Regarding the graft choice, for many years the central third of the patellar tendon has been the most common type used because of excellent long-term results and strong bony fixation [1]. More recently the use of hamstrings rise up due to some interesting advantages: small incision, large graft when gracilis and semitendinosus are sutured together, very similar biomechanical characteristics to ACL, rapid and safe harvest.

Regarding graft location, ACL reconstruction techniques can be divided in two major groups: intra-articular and extra-articular. The various intra-articular reconstructions repair the primary ACL lesion. The extra-articular ones attempt to prevent the lateral tibial condyle anterior sub-luxation, controlling the most dynamic compartment of the knee. However, extra-articular procedures alone (as techniques by Lemaire [2] or MacIntosh [3]) do not directly repair the primary lesion that causes instability and have demonstrated a high percentage of degenerative changes at long-term [4, 5].

The first authors to combine the intra- and extra-articular routes were Zarins and Rowe [6]. The principle behind their open technique was a simultaneous “over-the-top” transfer of the semitendinosus tendon and a strip of the ileotibial tract. Both transfers were passed along an identical parallel course: through an oblique drill hole in the anteromedial tibia, across the joint, over the top of the lateral femoral condyle, above the lateral intermuscular septum and deep to the fibular collateral ligament. Both were simultaneously pulled tightly and sutured to one another. This was a very invasive technique, requiring two (medial and lateral) big incisions, no longer in use after the development of modern arthroscopic techniques.

The first arthroscopic procedure developed for combined intra- and extra-articular ACL reconstruction with hamstrings and used in clinical practice since 1992 is the one developed by Marcacci, Zaffagnini, et al. [7••, 8, 9]. From this starting point, after the first good preliminary results [8], many authors developed similar techniques [10–13].

The purposes of this paper is to summarize the concepts relating to the use of both an intra-articular and extra-articular reconstructive procedure in the arthroscopic treatment of a torn ACL and to review several operative procedures utilizing autogenous ipsilateral gracilis and semitendinosus tendons that are currently in use to treat this instability.

Surgical techniques

1. Combined intra-articular “over-the-top” and extra-articular lateral plasty using semitendinosus and gracilis tendons: Marcacci et al. [8]

   The graft used is the semitendinosus and gracilis tendons, sutured together as a double-stranded graft. Their tibial insertion is left intact.

   After the tendons have been harvested (through a 3–4 cm oblique incision over the pes anserinus) and prepared, one tibial tunnel is drilled, trying to reproduce the posteromedial part of anterior cruciate ligament (ACL) tibial insertion. This guarantees reproduction of the more functional part of the ACL, avoiding impingement and extension deficit.

   A 3–5 cm longitudinal incision is then made superolaterally, just proximal to the lateral femoral epicondyle. The ileotibial band is divided sharply in its posterior third and retracted anteriorly. Once the lateral intermuscular septum has been clearly identified, it is possible to reach the posterior aspect of the joint capsule by passing over this structure. The correct placement of the “over-the-top” position is found by palpating the posterior tubercle of the lateral femoral condyle with a finger. This manoeuvre also leads to protection of the noble posterior structures during the next step.

   A curved Kelly clamp is passed from the anteromedial portal into the notch, and its tip is placed against the posterior part of the capsule as far proximal as possible. Once the tip of the clamp can be palpated from the lateral surgical access, just posterior to the intermuscular septum, it is pushed through the thin posterior layer of the knee capsule to reach the posterior space previously prepared. A suture loop is placed into the tip of the clamp, which is then pulled anteriorly through the anteromedial portal and put into a wire loop previously inserted in this portal. Pulling the wire loop from the tibial side, the suture enters the tibial tunnel and exits from the tibial incision, ready to pull the harvested graft.

   The stitches on the free end of the semitendinosus and gracilis tendon grafts are tied onto the passing suture that is pulled through the knee joint.

   When the graft is retrieved from the lateral incision, a groove is made with an osteotome on the posterolateral aspect of the lateral condyle of the femur to enhance healing of the graft to the femur while aiding in graft stabilization (Fig. 1a and b). Ten cycles of knee flexion-extension are performed for graft pretensioning. The tendons are then fixed into this groove to the cortical bone of the femur using 2 bone titanium staples (Fig. 1c), with the knee flexed to 90° with external tibial rotation and a posterior drawer applied. The remaining part of the graft is then passed deep to the ileotibial band and over the lateral collateral ligament. This lateral plasty is fixed with a single titanium staple below Gerdy’s tubercle acting as extra-articular tenodesis [8] (Fig. 2).

2. Intra-articular doubled semitendinosus plus single-strand gracilis single-bundle combined with single-strand gracilis extra-articular lateral plasty: Buscayret et al. [10]

   The graft used is the semitendinosus and gracilis tendons, leaving their tibial insertion intact. Three intra-articular strands (a doubled semitendinosus plus the gracilis) are used to perform a single-bundle ACL reconstruction. A lateral tenodesis is used with continuity via the graciclis. This technique requires 3 tunnels: 2 standard tunnels (1 tibial and 1 femoral) for the single-bundle reconstruction and 1 more tibial tunnel for the lateral plasty. Fixation of graft is performed by 2 tripod bone staples, one for femoral and one for tibial side [10].

3. Intra-articular doubled semitendinosus and gracilis tendons single-bundle combined with ileotibial tract extra-articular lateral plasty: Ferretti et al. [12]

   The graft used is the semitendinosus and gracilis tendons, harvested by an open tendon stripper and completely detached from their tibial insertion. They are used together as a doubled graft to perform a double incision single-bundle four-strand ACL reconstruction with 1 tibial and 1 femoral tunnel. The graft is fixed on the femur with the Swing-Bridge (Citieffe, Bologna, Italy) and on the tibia with the Evolgate device (Citieffe, Bologna, Italy). The Swing-Bridge is a femoral fixation device that can be used in double incision ACL surgery. The Evolgate is a tibial fixation device for soft tissues that is composed of three components: a screw, a coil that is inserted inside the bone tunnel to reinforce the walls of the tunnel, and a washer for cortical fixation. An extra-articular procedure (the Coker-Arnold modification of the MacIntosh technique) is also performed. In this procedure, a portion of the iliotibial band is detached proximally, reflected and passed under the lateral collateral ligament, and sutured under tension with periosteal stitches to Gerdy’s tubercle while the tibia is kept in maximum external rotation. The procedure was developed for revision ACL surgery [12].

4. Intra-articular doubled semitendinosus single-bundle combined with single-strand gracilis extra-articular lateral plasty: Imbert [13]

   The graft used is the semitendinosus and gracilis tendons, harvested in order to get the whole tendons and completely detached from their tibial insertion. This technique uses the semitendinosus for a usual intra-articular double-strand single-bundle reconstruction and the gracilis to perform an extra-articular single-strand lateral reinforcement procedure. Interference screws inside bone tunnels are used for femoral and tibial fixation of the graft. Drilling of the tunnels, insertion of the graft, and its fixation with interference screws are performed through two 1.5-cm-long incisions. Between them, the graft application is completed through blount dissection under the fascia lata through the distal incision with a pincer. The technique requires 4 bone tunnels: 2 for the intra-articular reconstruction and 2 for the lateral reinforcement (one tibial and one femoral for each graft) [13].

5. Combined intra-articular single-bundle and extra-articular lateral plasty using semitendinosus and gracilis tendons: Colombet [11]

   The graft used is the semitendinosus and gracilis tendons, harvested in order to get the whole tendons and completely detached from their tibial insertion. They are sutured together as a double-stranded graft and used to perform a single-bundle ACL reconstruction by one tibial and one femoral tunnel. The two-strand graft getting out from the femoral tunnel is passed under the ileotibial band and inside a third tibial tunnel to perform a percutaneous lateral tenodesis. Fixation is achieved by reabsorbable screws, one for each of the three required tunnels. The author perform this technique by using a bone-morphing navigation system to optimize tunnel positions [11].

Fig. 1.

Illustration of the groove in the lateral aspect of the femur posteriorly (a) and laterally (b). This permits a slight anteriorization of the graft for a more isometric position. The graft is fixed with two staples in the groove (c). (reproduced with permission from Marcacci et al. [8])

Fig. 2.

Anterior cruciate ligament reconstruction with hamstring tendons plus extra-articular plasty. a anteroposterior view; b lateral view. (reproduced with permission from Marcacci et al. [7••])

Discussion

The rationale behind this combined intra- and extra-articular ACL reconstructions with gracilis and semitendinosus tendons is to combine into one operation the advantages of both methods.

The principles at the basis of these procedures could be summarized into the following key-points:

1. to increase the tensile strength of the reconstruction using two grafts;

2. to protect the intra-articular reconstruction from excessive loads, expecially in the rehabilitation period;

3. to better control rotation laterally, expecially in some complex cases as revision ACL surgery;

4. to leave the extensor apparatus of the knee undisturbed.

The presence of the extra-articular lateral augmentation protects the graft reducing the load applied to the intra-articular portion of the graft. In vitro analysis performed by Engebretsen et al. [14] have shown that the extra-articular plasty, when used in combination with intra-articular reconstruction, reduces the stress on the graft by approximately 43%. Bignozzi et al. [15•] also showed by navigation in their “in vivo” study that the addition of an extra-articular tenodesis to single-bundle ACL reconstruction may be effective in controlling coupled tibial translation during the Lachman test and in reducing antero-posterior laxity at 90° of flexion.

The site of femoral fixation is the key-step to obtain a good extra-articular plasty. In fact almost all authors, with the exception of Ferretti et al. (that prefer a modified MacIntosh procedure for the extra-articular reinforcement), perform a lateral tenodesis fixing the graft behind the femoral lateral collateral ligament insertion. This point corresponds to the optimal isometric position, as defined by Krackow et al. [16] and Draganich et al. [17, 18].

Pearl and Bergfeld [19] concluded that the role of extra-articular procedures in the final outcome is limited. Although we acknowledge that most of ACL injuries can be solved by an isolated intra-articular reconstruction, we do believe that the importance of extra-articular augmentation should be reconsidered.

The longest follow-up for this type of arthroscopic combined procedure was published in 2009 by Marcacci, Zaffagnini, et al. [8]. They demonstrated very good success rates, with more than 90% of knees normal or nearly normal based on the IKDC rating system, and no severe degenerative changes after a mean 11-year follow-up [7].

Ferretti et al. [12] achieved similar clinical and radiological results at a mean of 5 years after surgery.

New different combined intra- and extra-articular procedures have been presented in this review for hamstrings ACL reconstruction [10, 11, 13], but their reported follow-up is not sufficient to compare them with the two mentioned above.

The last four presented techniques [10–13] significantly differ from the first by Marcacci, Zaffagnini, et al. [8] because all of them avoid the use of the “over-the-top” passage. Although the over-the-top position does not allow an exact anatomic reconstruction, Karlson et al. [20] have shown in a prospective study no significant clinical differences between patients who underwent hamstring ACL reconstruction using the “over-the-top” technique and patients who had femoral graft placement through femoral condylar tunnel. The first technique is highly reproducible and eliminates the risk of surgical error associated with placement of the femoral tunnel (especially for not experienced knee surgeons). Moreover this extra-articular procedure does not damage any lateral structures commonly used in other extra-articular augmentation procedures (like the iliotibial band). Another benefit of this technique is the need of only 3 titanium staples for graft fixation, which results in a reduction of surgical costs. This fast and cheap technique is also a simple solution for revision cases, eliminating the issues of management of femoral tunnel malposition, presence of intra-articular hardware or tunnel enlargement.

As previously showed by Zaffagnini et al. [21•] in a prospective randomized fashion, a simple intra-articular procedure combined with an extra-articular augmentation may achieve better results in maintaining rotational control with less risk of technical error and better clinical results than a single-bundle ACL reconstruction.

Conclusions

The highly satisfactory results obtained over the time with the above reported techniques show that a combination of intra- and extra-articular procedures for ACL reconstruction is a valid surgical option in the ACL deficient knee.