Anterior cruciate ligament reconstruction. Current trends

Anterior cruciate ligament reconstruction is a common procedure. However, results remain often incomplete with an IKDC A score around 25%. How can those results be enhanced ? By improving our technique? (grafts choice, lateral tenodesis, double bundle reconstruction, ...). By improving the initial assessment of the laxity ? Bone tendon bone or Hamstrings ? Results are globally similar. BTB reconstruction leads to a better control of the laxity but hamstrings reconstruction allows faster recovery and less residual pain. In fact, success doesn't depend on the choice of the graft but on the right positioning and the strong fixation of the graft, on the control of the whole laxity, and the spare of the menisci. Associated Lateral tenodesis is controversial. Its goal is to reduce the antero lateral subluxation of the tibia. It has significant morbidity. It should be used in cases of global laxity. Double bundle reconstruction is of great interest. Its goal is to reproduce the normal anatomy of the ACL, and thus to improve control the laxity, not only in the anterior posterior plane, but also in the rotatory plane. It is performed using hamstrings tendons. Bio-mechanical studies are promising, but preliminary clinical reports did not demonstrate significant improvement in comparison with single bundle reconstruction. In conclusion, our results are still incomplete, but the main principles are now accepted : - young active patients should be operated on in order to stabilize the knee and avoid secondary meniscal lesions - the whole laxity has to be controlled; it means that standard intra articular AL reconstruction is not a universal answer. Associated procedures can be required. - the graft must be well positioned, and strongly fixed in the bony tunnels. Computer assisted surgery might facilitate the positioning in the near future. Respect of these principles should reduce the frequency of failures and iterative reconstructions.