There are a few papers in the literature to indicate the likely functional outcome of conservatively managed sportsmen in whom primary outcome cruciate ligament [ACL] healing occurs.

We reviewed 298 sportsmen presenting with isolated ACL rupture that were conservatively managed with a rehabilitation programme, based on regaining proprioceptive and hamstring control, and aimed at achieving primary ACL healing. All were protected in a hinged brace. In 50 patients, the ACL was determined as having healed clinically; these patients underwent instrumented laximetry testing with KT 1000 arthrometry and were determined: IKDC A [Normal] or IKDC B [nearly normal]. An MRI was also performed which confirmed healing in 39 patients with ACL fibres parallel to Blumenstat's line. In 11 patients the ACL stump had healed to the PCL. The 50 patients were followed up for an average 16 months [range, 14 to 17 months].

56% of patients suffered recurrent instability when they returned to their preinjury level of contact or pivoting sport. For competitive athletes, 76.5% suffered further instability on return to sport despite the four-month rehabilitation and independent arthrometry score or MRI findings. However, for occasional, recreational athletes only 7% suffered recurrent instability.

This study suggests that a rehabilitation programme aimed at primary ACL healing affords satisfactory results for the occasional, recreational athlete but does not achieve the quality of restraint sufficient for contact or pivoting sports in competitive athletes. These patients suffer high levels of recurrent instability and are exposed to the risk of secondary chondral and meniscal injury.

Purpose: To define the positions of the attachments of the anteromedial (AM) and posterolateral (PL) bundles of the ACL facilitating accurate tunnel placement during two-bundle reconstruction.

Methods: The positions of the femoral and tibial attachments of the AM and PL bundles was determined in 7 fresh-frozen, unpaired, cadaveric knees by 6 independent observers, using landmarks visible at arthroscopy. This included, on the tibia, the retro-eminence ridge (lying just anterior to the PCL), a bony landmark that could be reliably identified arthroscopically. Tantallum beads were then inserted so that the bundle attachments could be clearly identified on a plain lateral radiograph of the knee. The position of the centres of the AM and PL attachments were described relative to Amis and Jakob’s line on the tibia and Bernard’s grid on the femur.

Results: The AM femoral attachment lay high and deep in the notch with the most posterior fibres 1.8 mm anterior to the “over–the-top” position. The PL femoral attachment was low and shallow in the notch with the most anterior fibres 2.8 mm from the border of the articular cartilage. The centres of the bundles were 8.2 mm apart. The position of the bundles relative to Bernhard’s grid is shown in figure 1.

On the tibia, the centre of the AM attachment was located 18 mm anterior to the Retro-eminence ridge (RER). The centre of the PL bundle lay 8.4 mm posterior to the centre of the AM bundle. These positions were at 35% and 52% along Amis and Jacob’s line

Conclusions: This study details the morphology of the AM and PL bundle attachments and demonstrates reliable arthroscopic techniques to assist with accurate tunnel placement in reconstruction surgery. In addition, it provides reference data for radiographic evaluation of tunnel placement.

Cadaveric experiments using knee testing machines have suggested that anatomical ACL reconstruction, replacing both antero-medial (AM) and postero-lateral (PL) bundles, restores knee rotation kinematics more effectively than does a single-bundle. The aim of this study was to measure intra-operatively the control of the translation and coupled rotations that occur with standard clinical laxity tests (anterior drawer, Lachman and pivot shift).

The knee kinematics of 10 patients were measured using a surgical navigation system and described in terms of tibial axial rotation and antero-posterior translation. In the ACL deficient knee, the average maximum tibial rotation during the pivot shift test was 29.0° and the mean maximum translation 17.0 mm. Reconstruction of the AM bundle (which behaves in a biomechanically similar way to a single-bundle reconstruction) reduced the rotational component to 16.4° (p< 0.0001) and translation to 6 mm (p = 0.0002). Addition of the PL bundle further reduced rotation to 12.6° (p = 0.0007) but had no significant effect on translation. Addition of the PL bundle also significantly reduced coupled tibial internal rotation during the Lachman and Anterior draw tests.

The pivot shift test simulates the instability suffered by patients with ACL deficiency and this study suggests that its rotational component is better restrained by anatomical, 2 bundle ACL reconstruction.

Purpose: The anterior cruciate ligament (ACL) is composed of two strands, the anteromedial (AM) and the posterolateral (PL). Each strand has a distinct biomechanical role. The classical techniques for reconstruction of the ACL using a one-strand graft cannot replace the AM strand of the ligament. Control of knee laxity after graft reconstruction with a single strand cannot restore physiological laxity.

Material and methods: This study was performed on 16 matched cadaver knees randomised for reconstruction technique. Anterior tibial dislocation was measured with the Rolimeter arthrometer using manual traction on the intact knee, after section of the ACL, and after arthroscopic reconstruction of the ACL using a 2-strand or 4-strand hamstring method at 20°, 60°, and 90° flexion. Changes in the length of each reconstructed strand were measured.

Results: For the 16 intact knees, anterior laxity was measured at 20°, 60° and 90°. After section of the ACL, laxity increased significantly at all angles studied. Statistical parametric and non-parametric tests demonstrated a significant difference between laxity after ACL section and after ACL reconstruction (one-strand) at 20°, 60° and 90° flexion. There was a significant difference between intact ACL and reconstructed ACL at 20° flexion, the residual laxity was greater after one-strand reconstruction. Conversely, at 60° and 90°, there was no difference in anterior displacement of the tibia for intact and reconstructed ACL. There was a statistically significant improvement in laxity between sectioned and reconstructed (two-strand) ACL at 20°, 60° and 90° but no difference in anterior dislocation between the intact ACL and the reconstructed ACL at 2°, 60°, and 90° flexion.

Conclusion: Two-strand reconstruction of the ACL provides laxity comparable with that of the intact ACL at 20°, 60°, and 90° flexion while one-strand reconstruction only re-establishes physiological laxity at 60° and 90°.

Purpose: Outome after arthroscopic management of anterior instability of the shoulder has varied since the early series. The results proposed at the 1993 symposium of the French Society of Arthroscopy suggest we should be using this technique with prudence. We report here our experience with patients operated on between 1993 and 1997 who were selected on the basis of the 1993 conclusions that excluded patients with multiple recurrent instability and fractures of the anterior rim of the glenoid cavity.

Material and methods: Sixty-seven shoulders were operated on between 1993 and 1997. Mean follow-up for 58 of these shoulders (86%) was five years. These 58 patients constituted the study group. There were 31 men and 27 women, mean age 25 years, who had 30 recurrent shoulder dislocations, 12 shoulder subdislocations and 16 painful unstable shoulders. Forty-six percent of the patients participated in competition-level sports with forced shoulder movements in 39.6% of the cases. The surgical technique involved retightening the inferior glenohumeral ligament that was fixed with resorbable sutures. Immobilisation with elbow-to-body contention was strictly applied for three weeks at least followed by progressive rehabilitation exercises until renewed sports activities starting four months postoperatively.

Results: The mean overall Duplay score was 85.5 (sport 21/25; stability 18/25; mobility 24/25; pain 22/25). Outcome was good and very good in 82.7% of the patients, fair in 8.6%, and poor in 5 (recurrence). Subjectively, 55% of the patients were very satisfied, 27.5% were satisfied, 15.5% were disappointed and 1.7% were displeased. There were four complications (one infection cured with antibiotic therapy with a final score of 100 and three serious cases of capsulitis that recovered before one year). Gender, age, type and duration of instability, level of sports activity, and articular laxity appeared to affect outcome.

Discussion: The rate of failure (8.6%) is similar to that with open surgery (4.6% in the SOFCOT symposium 1999) and would be well below the rates observed in the 1993 arthroscopy series although the different patient selection does not allow valid comparison.

Conclusion: Arthroscopic stabilisation of the shoulder is a technically difficult procedure that has progressively shown its effectiveness after an appropriate learning curve and in carefully selected patients. Favourable elements include age over 20 years, competition level sports activity, recent instability, and absence of constitutional hyperlaxity.