title: [Combined intra- and extra-articular fresh frozen allograft for anterior cruciate ligament repair].
abstract: OBJECTIVE
  The purpose of this retrospective study was to evaluate the results of a novel technique for anterior cruciate ligament repair using a mixed intra- and extra-articular ligamentoplasty with fresh frozen allograft material.
  
  
  METHODS
  The series included 92 knees; 73 were evaluated with the IKDC criteria by an independent examiner at mean follow-up of 4.5 years (range 2-8 years). Diverse types of allograft materials were used and all contained a bony fragment: patellar hemi-tendon (n=37), Achilles hemi-tendon (n=28), anterior or posterior tibia double-strand tendon (n=8). These tendons were used as available. The allografts were harvested from multiple-organ donors and treated with chlorexidine 0.02% and alcohol 70% before fresh freezing at -80 degrees C. Several subgroups were studied: allograft with a tibial muscle tendon versus a patellar hemi-tendon versus an Achilles hemi-tendon. Five subgroups were formed according to time from injury to surgical repair which varied from 1-3 months to more than 36 months. Three subgroups were identified according to duration of follow-up after surgery.
  
  
  RESULTS
  A good final outcome was achieved in 88% of the knees (A 14%, B 74%) and a poor outcome in 12% (C 11%, D 1%). There was no evidence of limited motion postoperatively. The Lachmann test using the KT1000 demonstrated 1 to 2 mm differential laxity for 59% of the knees and 3 to 5 mm for 36%. There was no difference over time (p=0.26). Time between injury and ligamentoplasty was an important prognostic factor with better results in patients operated on within 1 to 3 months (p<0.003). Despite the small number of cases, the tibial muscle tendons appeared to give very good results (p=0.05). Immediate complications led to nine reoperations including four for a second meniscal lesion, two for cyclope syndrome, one to remove a foreign body, one for instability and one for pain. There was no case of reactional synovitis.
  
  
  CONCLUSIONS
  Allografting enables repair with a good quality graft, a reduction of operative time, and smaller incisions. Morbidity of the harvesting site is avoided. Graft treatment with alcoholic chlorexidine then fresh freezing does not alter the tissue and together with donor selection, guarantees sterility. Systematic adjunction of an extra-articular lateral reinforcement is designed to limit dynamic displacement in case of chronic laxity (the majority of cases in our series) and to a lesser extent to protect the central pivot during its incorporation (a long process for allografts). We have found this technique satisfactory. We have found a trend to increased differential laxity with time, which signifies slight graft stretching, but longer follow-up has not demonstrated any significant difference in the IKDC score (p=0.26). Better results are obtained in patients operated on within 1 to 3 months (p<0.003). There would be two explanations linking the development of overall knee laxity with persistent subjective apprehension and a long period of instability in those patients who underwent surgery long after the accident. Tibial muscle tendons have given better results in our series but more data are needed for proper interpretation.
  
  
  CONCLUSIONS
  This study examined the mixed intra- and extra-articular technique, graft choice, and preoperative time. Operations performed 1 to 3 months after injury provide the best results. Few series have examined the use of tibial muscle tendons. Further study of repairs performed with this tendon would be useful to evaluate the quality of the reconstruction in comparison with currently available allografts. Systematic use of allografts and lateral extra-articular reinforcement has provided good results in our hands.
authors.affiliation: Service de Chirurgie Orthopédique et de Traumatologie, Clinique Sainte Anne-Saint Rémi, 1070 Bruxelles, Belgique.
authors.forename: L-N
authors.initials: LN
authors.lastname: Jekeler
authors.forename: J
authors.initials: J
authors.lastname: Thiéry
mesh_terms: D000293:Adolescent; D000328:Adult; D016118:Anterior Cruciate Ligament / Q000601:surgery*; D002648:Child; D005260:Female; D005615:Freezing; D006801:Humans; D008022:Ligaments / Q000637:transplantation*; D008297:Male; D019637:Orthopedic Procedures / Q000379:methods; D016059:Range of Motion, Articular; D020127:Recovery of Function; D012189:Retrospective Studies