Mémorie
Influence d’une ligamentoplastie extra-articulaire latérale sur les résultats de la reconstruction du ligament croisé antérieur avec le ligament patellaire avec 7 ans de recul: Intra-articular reconstruction of the anterior cruciate ligament with and without extra-articular supplementation by quadricipital tendon plasty: seven-year follow-up

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Résumé

Il peut s’avérer intéressant de recourir à une plastie extra-articulaire antérolatérale venant renforcer la nécessaire reconstruction du ligament croisé antérieur (LCA), quand la laxité antérieure est globale, soit à cause des lésions périphériques initiales soit secondairement par distension de l’enveloppe périphérique avec une composante antérolatérale, mais la controverse existe.

Les auteurs ont comparé, avec un recul de 7 ans, 2 séries randomisées de reconstructions du LCA, l’une intra-articulaire (autogreffe libre au ligament patellaire, groupe 1, 34 patients), l’autre intra et extra-articulaire (Mac-InJones, groupe 2, 29 patients), avec comme critère d’inclusion, une laxité différentielle médiale d’importance moyenne, comprise entre 7 et 12 mm sur des radiographies dynamiques passives à 20̊ de flexion.

Le score fonctionnel subjectif IKDC, pour 72 % du groupe 1, était de 83,6 ± 3,5 et ±pour 68 % du groupe 2, il était de 83,5 ± 3,5. Pour le score IKDC global, dans le groupe 1 : 0 % classés A, 52,4 % B, 28,6 % C, 19 % D et pour le groupe 2 : 5,5 % classés A, 50 % B, 33,3 % C, 11,1 % D. Le ressaut dans le groupe 1 était absent dans 61,9 % des cas, de stade 1 : 28,6 %, de stade 2 : 9,5 %. Dans le groupe 2, le ressaut était absent dans 78,9 % des cas, de stade 1 : 15,8 %, de stade 2 : 5,3 %. Le KT-1000 ne montrait pas de différence de gain sur la laxité : 31 % pour le groupe 1 et 27 % pour le groupe 2. Il n’y avait pas de différence non plus pour les mesures radiologiques avec un gain de 43,9 % sur la laxité différentielle initiale du compartiment médial et 45,3 % sur celle du compartiment latéral dans le groupe 1, contre un gain médial de 51,9 % et latéral de 41,8 % dans le groupe 2. Le positionnement des tunnels n’était pas différent dans les 2 groupes selon la méthode d’Aglietti.

Les critères d’inclusion seraient aujourd’hui différents et seraient basés sur l’importance de la laxité du compartiment latéral.

Abstract

Purpose of the study

Reconstruction of the anterior cruciate ligament (ACL) is a common procedure, but use of lateral reinforcement is still a subject of debate. The purpose of this study was to compare two randomized series of ACL reconstructions, one using an intra-articular method (patellar tendon autograft) and the other an intra- and extra-articular method (Mac-InJones).

Material and methods

From January 1995 to March 1998, 63 knees underwent surgery for ACL reconstruction. Inclusion criteria was significant medial differential laxity measured between 7 and 12 mm on passive dynamic x-rays as 20̊ flexion. Group 1 (patellar tendon intra-articular reconstruction) included 34 patients (27.1±7.5 years) and group 2 (intra-articular reconstruction plus extra-articular quadircipital tendon plasty) included 29 patients (28.5±12 years). The IKDC score was determined for 72% of the knees in group 1 and 68% in group 2 at seven years follow-up on average (102 and 93 months respectively). Anterior laxity was measured radiographically and with KT-1000. The position of the tunnels was controlled using the Aglietti method.

Results

The subjective functional score was 83.6±3.5 in group 1 and 83.5±3.5 in group 2. The overall IKDC knee score classes for group 1 were 0% A, 52.4% B, 28.6% C, and 19% D and for group 2 were 5.5% group A, 50% group B, 33.3% group C, and 11.1% group D. In group 1, the pivot test was negative in 61.9% and noted stage 1 in 28.6% and stage 2 in 9.5%. In group 2, the pivot test was negative in 78.9% and noted stage 1 in 15.8% and stage 2 in 5.3%. The KT-1000 showed no difference in gain in laxity: 31% for group 1 and 27% for group 2. Similarly, radiographically there was no difference with a 43.9% gain in differential laxity for the medial compartment and 45.3% for the lateral compartment in group 1. In group 2 the corresponding values were 51.9% and 41.8%. The position of the tunnels was the same in the two groups.

Discussion

In a preliminary study with two years follow-up, the results in these two series were not significantly different. It was concluded that there was not clear advantage to adding the extra-articular lateral plasty. At the present 7-year follow-up, pivoting appears to be better controlled in the lateral plasty group (p=0.23), but with no significant difference for laxity for both knee compartments. The inclusion criteria would be different today and would be based on the laxity of the lateral compartment.

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