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Lia Pes Anserinus

Lia Pes Anserinus

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Published by: Mikaela655 on Jun 29, 2013
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A. Michallon University Hospital - Grenoble, France
A number of techniques have been found to work well inthe reconstruction of a torn anterior cruciate ligament(ACL). We agree with JY Dupont that the chief outcomecriterion in the long term is an anatomical one, with"complete restoration of the knee joint." However, inaddition to the modified Marshall-MacIntosh and similartechniques for ACL reconstruction, which are known toprovide long-term stability, several arthroscopictechniques have been developed, which have thebenefit of being minimally invasive and of causing lessiatrogenic damage. This, obviously, is a majorconsideration in ACL surgery. With the development of these techniques, the choice of graft harvesting site hasalso become an important factor. It should be borne inmind that, in many athletes, the patellofemoral painfollowing graft harvesting from the extensor mechanismwill rule out a return to sports at the previous level.Using the pes anserinus as a donor site appears to be asafer alternative. While the long-term stability outcomeof semitendinosus-gracilis (STG) grafts is not yet fullyknown, there is a current trend to use these pestendons. With the advent of better arthroscopic aimingand graft fixation systems, an increasing proportion of the ACL reconstruction "market" is being catered for bySTG grafts. However, there are pes tendon grafts andpes tendon grafts, as may be seen from the history of the use of these tendons in ACL reconstruction surgery(P Colombet). The 1999 Symposium of the FrenchSociety for Arthroscopy also stressed the fact that themany ways in which pes tendon grafts may beperformed make it difficult to assess the value of theconcept in a multicentre study. In the interest of evaluation, ACL reconstruction with pes anserinustendons should be performed following certain rules.
This is a crucial aspect of surgical technique, since faultypositioning may result in major technical difficulties.Care should be taken to ensure that the tourniquet isplaced as proximally as possible on the thigh, so as toleave the knee fully mobile. It must be possible to takethe knee from full extension into nearly-full flexion. Athigh-holder placed outside the tourniquet, or a foot-rest, will allow the knee to be positioned in anintermediate position of 70° of flexion. A lateral brace isplaced at the level of the greater trochanter, to allowvalgus stress to be applied during the arthroscopicinspection/treatment of the menisci (Fig. 1).
Fig. 1 Knee positioning. 1 - foot on foot rest; 2 - thigh holder; 3 - tourniquet onproximal thigh; 4 - lateral brace
Once the diagnosis of ACL deficiency has been made (bysuch means as clinical examination, arthrometermeasurements, MRI), the procedure is started by theharvesting of the graft, followed by the arthroscopicinspection of the menisci and treatment of any meniscaland/or cartilaginous lesions encountered. Theanterolateral portal for the scope is at the lateral borderof the patellar tendon, just distal and lateral to the apexof the patella. This provides a good view of the notch,and in particular of the medial aspect of the lateralcondyle; preferably, a scope with a 30° lens should beused.
The anteromedial portal for the instruments should bemore distal and more anterior, so as to provide the idealangle for drilling the femoral tunnel and for inserting theinterference screw, if arthroscopic aiming is being used.With unduly posterior placement of this portal, themedial condyle would obstruct the view; withexcessively anterior placement, the ligamentummucosum would get in the way (Fig. 2a and b).
Fig. 2a and b Arthroscopic portals. L = lateral site; M = medial site. Arthroscopicaiming over the medial meniscus.
This stage of the procedure is a common feature,regardless of the fixation technique to be used. A skinincision is made between 6 and 7 cm distal to thetibiofemoral joint line, and 2 cm medial to the tibialtubercle. The incision is ca. 25 mm long, and requiresmeticulous haemostasis. Great care is taken not todamage the sensory branch of the saphenous nerve(Fig. 3).

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