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The ESSKA Congress at Nice in the spring 1998 was a great success. Maîtrise Orthopédique asked the organizers, Philippe Beaufils and Pierre Chambat, to tell us about the main conclusions of the conference, and how they themselves see knee surgery today.
M.O. : What is ESSKA?
P. Chambat : The acronym stands for the European Society for Sports Traumatology, Knee Surgery and Arthroscopy. This organization was set up 14 years ago, in Berlin. The main idea was to have a European knee and arthroscopy society; sports traumatology was added, some four years ago. Today, the Society has around 900 members..
P. Chambat : ESSKA was the brainchild of Werner Müller, Ejnar Eriksson, and a Dutch surgeon, Theo van Rens. Initially, the Nordic countries predominated, but over the last few years, the pattern has become more balanced. First, there were Congresses held in the south of Europe, in Palma de Majorca and in Nice; and then southern Europeans assumed office in the Society. Incidentally, the ESSKA President at this point in time is an Italian, Giancarlo Puddu. Ever since the foundation of the Society in Berlin, 14 years ago, congresses have been held every other year.
P. Chambat : Having been involved in the first negotiations, I think that Ejnar and Werner Müller felt very frustrated because the societies that were around at the time were letting the Americans rule the roost; this was particularly true of the IKS, which, in those days, was the international knee society. The Europeans were not represented in the North American societies, and wanted to have their own forum in which to express their ideas.
P. Chambat : I think that, 15 years ago, the Americans were undoubtedly the leaders: European surgeons were looking more or less towards the States. Some of them eventually came to be fed up with this scientific monopoly of the Americans, and wanted to create a counterbalance: that was why ESKA was set up. I think that nowadays the position of European surgeons vis-à-vis the United States is totally different from the one 20 years ago. There is now a European counterbalance, which did not exist at that time. In those days, if you wanted to communicate with your colleagues, you had to go to the States.
P. Beaufils : In other words, to meet a German colleague, you’d go to Washington.
P. Chambat : Yes, but these symposia were chiefly for the French. There were many Italians and Swiss; but no Germans or Scandinavians.
P. Beaufils : ESSKA really is the first European orthopaedic society. Once this organization had been created, the movement spread, and European societies were set up to deal with shoulder, paediatric, and spinal surgery; and then EFORT was founded.
P. Chambat : Knee surgery and arthroscopy. Fourteen years ago, the only joint amenable to arthroscopy was the knee. There was virtually no shoulder or ankle arthroscopy being done. So, initially, it all made sense: “the knee” meant the athlete’s knee, the osteoarthritic knee; and arthroscopy was a means of treating the various knee disorders.
P. Beaufils : This decision was taken after much discussion. What one had to bear in mind was the different training and practice patterns in the different countries: in the Nordic countries in particular, surgeons do either trauma surgery or surgery for OA, but not both. In other countries, an orthopaedic surgeon will treat anything that is wrong with a knee, regardless of whether it is OA or a sports injury. There was a bit of a tug-of-war between these two subdisciplines, which meant that until quite recently, OA was somewhat overshadowed by sports traumatology. The S for Sports Traumatology introduced into the original ESKA acronym was to demonstrate this emphasis. Nowadays, we are trying to achieve a more balanced pattern.
P. Chambat : I personally think that ESSKA is a society that works well, and which organizes useful congresses; sometimes, though, it gives the impression of being worried about missing out, about being deprived of its market share. I think that is why the S was put in. It is my opinion that ESSKA should deal only with the knee of the athlete and with degenerative knee conditions, and leave the rest - especially degenerative shoulder conditions and sports injuries of the shoulder - to people with more experience in that field. However, that is not, at present, the way the Society has decided to go.
P. Beaufils : Ultimately, societies that have a commonality of interests in joint disorders will need to come to an understanding, and we are working along these lines, by trying to organize joint congresses.
P. Chambat : Yes, but is it really necessary to have a Shoulder Day at ESSKA?
P. Beaufils : It is, because many participants are interested in both joints; but it is also necessary for this Shoulder Day to be run by competent people, in this case by the European Society for Surgery of the Shoulder and the Elbow. That was exactly what was done at the Nice Congress, and I think that this “all-time first” was a good thing.
P. Beaufils : If you are asking whether there is universal agreement on patient selection principles, the answer can only be No. However, one can say that, in Europe, ESSKA is now welding the various countries together in the fields of sports traumatology, arthroscopy, and knee ligament surgery; bringing about a unified view on the treatment of OA of the knee has proved less straightforward. As Pierre was saying, the Americans are now coming to the ESSKA congresses. This was very well demonstrated, at this last Congress, by the number of papers submitted by American authors. We have had lots of compliments from the Americans, who say that ESSKA need not fear comparison with their Society.
P. Chambat : There has been a profound change, over the last few years, in the attitude of the North Americans towards the Europeans. This has been partly thanks to ESSKA, and to the exchange of young surgeons between the United States and Europe, within the scheme of travelling fellowships. This way, people understand each other better. When I was in training, we had no such facilities. Trillat used to tell us, “You’ve got to travel.” Trouble was, we didn’t know where to go.
P. Beaufils : The main subjects covered the fields of interest of ESSKA, with a strong emphasis on basic science research. There were comparatively few papers on ACL research, but many on meniscus preservation, i.e. repair, meniscal allografts, meniscal replacement with collagen, etc . There were also two major sessions on cartilage repair, one dealing with basic science research aspects, and the other with clinical applications. This is a very topical subject that deserves detailed consideration. As an innovation, we had a symposium (French-style; not American-style, where they simply line up the panellists, who each presents his own series): the participants pooled their information, so what we got was something like European multicentre studies. That was an all-time first in Europe, as far the knee is concerned. We had four such symposia: the treatment of ankle instability (over 400 cases); the treatment of knee dislocation (over 250 cases); osteonecrosis after meniscectomy - this was a “minor” subject, which should, however, be explored in greater depth; and, finally, patellar problems in TKA. Also, there was one day given over to the shoulder; this was organized in collaboration with ESSSE.
P. Chambat : One thousand three hundred! It was a huge conference, considering that this was a subspecialty event.
P. Beaufils : Some 50 techniques have been described; these may be roughly subdivided into anatomical repair and tenodesis techniques. The major conclusion of the symposium was that the long-term (> 10 years) functional outcome of anatomical repair was better, especially in terms of pain relief, than that of tenodesis.
P. Beaufils : All the techniques that try to recreate the lateral collateral ligament from what remains of the capsule and the ligaments, or from the adjacent periosteum.
P. Beaufils : Yes, because ultimately these patients will have subtalar pain. The anatomical techniques, including simple capsular retensioning in front of the fibula, are the ones to be used.
P. Beaufils : What one needs to bear in mind is that there are two major dislocation patterns: direct anterior/posterior dislocation, and dislocation involving major collateral - medial or lateral - soft-tissue damage. Apart from the problem of diagnosing the lesions that have occurred, and from searching for complications (for the detection of which arteriography should be used liberally), these injuries are very difficult to manage in the acute stage. The symposium showed that nonoperative, treatment, conservative treatment, will only very rarely give satisfactory results; and that the best treatment is surgery to repair all the lesions. It is no longer a question of “I’m not going to do the PCL, I’m not going to do the posteromedial corner, that’s too difficult.” I think that by now the concept of repairing each and every lesion is a fundamental one.P. Chambat : I don’t know - I don’t think I would be that dogmatic. Where both cruciates are damaged, I would use a softly-softly approach: I have often put a patient in plaster for six weeks, and then treated the sequelae. At the symposium, there were not many cases that had been treated nonoperatively; and I think the study was biased since we really only had cases from surgeons who operate on all their patients immediately after the accident.
P. Beaufils : One could put it differently by saying that secondary surgery for a dislocation is not, to put it mildly, the solution to all our problems. Both the functional and the anatomical outcome tend to be disappointing.
P. Chambat : I quite agree, but what we need is a prospective study of emergency surgery vs conservative management followed by treatment of the sequelae. The trouble is that we do not have sufficient patient numbers to do such a study, and, as things stand, nobody can truly answer the question. We know roughly what we can get from emergency surgery; and what we can get is not always brilliant, because we tend to be a bit aggressive. I am sure that with primary surgery we cause peripheral necrosis, especially at the posterolateral corner. I always tell my juniors, “The posterolateral corner - you so much as look at it, you damage it.”
P. Chambat : One cannot say “completely dislocated.” Anyway, if there is no position of stability, surgery will not produce an excellent result, either.
P. Chambat : At present, nobody can say that a knee which does not have any stable position (anterior/posterior, posterior, medial, or lateral) could have a good outcome following surgery.
P. Chambat : Of course! I do a lot of casting. I am not very proud of it - it’s not great surgery.
P. Chambat : I’d take a chance and operate.
P. Chambat : A chance is a chance.
P. Beaufils : No - firstly, because it has been shown that this will not completely stabilize the knee; and, secondly, because it’s bad for the patellofemoral joint. We prefer the use of an external fixator, providing that the knee is fixed in “zero position”, i.e. without any anterior or posterior drawer, without any angulation in the coronal plane, and in 30° of flexion.
P. Beaufils : With the cruciates, I prefer to do primary reconstruction. With the collaterals, it’s a question of the injury pattern: one often sees periosteal avulsion of the collaterals, which may be reduced; otherwise, one should repair the tears, with autologous augmentation.
P. Beaufils : Nothing - because he would go straight to Chambat!
P. Chambat : And I’d tell him to go and see Beaufils, especially if he plays for Paris-Saint-Germain!
P. Beaufils : Seriously, though, I would tell him that he will never play soccer again, regardless of how he is treated. Then, I’d operate on him on the tenth day or so, because by then any arterial problems will have been sorted out, and the soft tissues will be starting to calm down. At the same time, the lesions would still be comparatively fresh, and healing conditions would therefore be optimal.
P. Beaufils : I use autologous reconstructions. Once you are doing primary surgery, it’s reconstruction with autografts; sutures are out, certainly for the cruciates.
P. Beaufils : It cannot - the suture would not hold. I would rather do a reconstruction with patellar tendon, for the PCL. For the ACL, I would use one or two hamstring tendons, if the quality is good. If the hamstring tendons cannot be used, I take quadriceps tendon from the same side, or a graft harvested from the other knee.
P. Beaufils : This is highly specialized surgery. It is major surgery, which carries a high risk of infection, of stiffness, of graft malpositioning. One really has to have a sound knowledge of ligament surgery before venturing into it.
P. Beaufils : Yes - if one thinks surgery is indicated, and is insufficiently experienced oneself. The first thing to do, though, is to check that there is no vascular damage.
P. Beaufils : They were very well received, by the general audience and by the panel members of each symposium. Everybody thought that they had had a lot of benefit. This is a good way of fusing different orthopaedic cultures - much better than saying that the Germans have submitted 40 individual papers, and the French 40, and the Spanish 40, and the Italians 40, etc. At these symposia, people were working together. And that is what a European society is all about. And if people have worked together once, they will go on working together.
P. Beaufils : Possibly, as far as scientific validity is concerned. As Pierre was saying, it’s true that only very few patients had received nonoperative treatment for their knee dislocations. However, this “scientific” drawback is compensated for by several major benefits: with knee dislocations, one can pool the different technical approaches used in the management of a single disorder; with post-meniscectomy osteonecrosis, a very, very rare condition, one can get a sufficiently large sample to draw conclusions on a subject that everybody has heard about, yet none can say that they have any actual experience of.
P. Chambat : Yes, this way we were able to put together some 50 cases of proven osteonecrosis following medial meniscectomy. I would like to stress that these were really cases of condylar necrosis that had occurred after meniscectomy, since we have preoperative MRI evidence that the femoral condyles were normal before surgery, that there was no necrosis at the time of the meniscectomy. So, it wasn’t a case of diagnostic error to begin with.
P. Beaufils : MRI is the investigation that allows us to distinguish between a meniscal lesion and condylar necrosis, where it exists. Even if there is nothing wrong with the bone before surgery, the patient may develop necrosis following meniscectomy, since the procedure itself can cause necrosis to occur. But at least one can be certain that there was no necrosis beforehand. So, to answer your question - yes, one needs to do MRI before a meniscectomy in a patient over 55. What started this whole thing about post-meniscectomy osteonecrosis was the laser. With the advent of laser meniscectomy came the first papers reporting osteonecrosis. Initially, the laser was blamed. It is probable that the use of the laser has led to an increased rate of osteonecrosis; but a review of the earliest patient notes showed that there have been cases of genuine condylar osteonecrosis following conventional meniscectomy, and these weren’t cases where pre-existing necrosis had been missed!
P. Beaufils : It is not a thermal effect, because the holmium-YAG laser used in arthroscopic surgery has a very limited thermal effect away from the point of application of the tip. It’s more likely to be due to a shock-wave effect, since these are pulsed delivery systems - it’s what’s known as a photoacoustic effect. Still, this has not been conclusively proved, and there is disagreement on the extent to which the laser is implicated. However, Philippe Hardy and myself have presented, at ESSKA, the results of laser meniscectomies, which are less good than those of conventional meniscectomy. We did not see necrosis, but the 1-year X-rays showed substantial chondrolysis.
P. Beaufils : It always happens. Those who say that necrosis after meniscectomy is just a pre-existing necrosis that was missed before meniscectomy are wrong. Sometimes, there is a genuine necrosis that was not there prior to meniscectomy, and which appears afterwards. These patients are never all right after surgery; they still have pain and effusion. Radionuclide and MR scans will provide early evidence; X-rays won’t show any changes until 6-8 months later. It has been - very tentatively - suggested that the removal of the meniscal shock absorber leads to a sudden increase in stress levels in the femoral condyle, and that this is what causes necrosis.
P. Beaufils : It is histologically proven necrosis.
P. Beaufils : I can’t answer that question.
P. Beaufils : Yes, in an American-style symposium: this was not a collective effort; instead, experts such as Peter Walker, John Insall, MAR Freeman, Paolo Aglietti, and Werner Müller each reported their own experience, and gave their personal opinion on the subject.
P. Beaufils : Yes - but without any conclusions being reached. Some were for, others against. At present, no one can say which is the better policy. Getty, from London, feels that the decision should be governed by the preoperative level of the patella: if the patella is low before surgery, resurfacing will produce the better result. To him, this is an important prognostic criterion.
P. Chambat : I always resurface. I knew Insall’s first prostheses, which were not anatomical and which did not have a patellar button. After two or three years, there would be deep scores in the patella. Surgical practice is often like a pendulum - it first swings one way, and then the other. The same goes for cementing: first all devices are cemented - and then none are. It’s a case of “if it works, don’t fix it.” There should be a small group to look into the question. I think that in surgery it is dangerous for everybody to go running off in all directions. What we need is a team, with a sound approach, who says, “We think such and such should be done; we will, therefore, do a prospective evaluation.” And afterwards, everybody should adopt whatever that team recommends, in the light of its studies.
P. Chambat : You know, they present the most dazzling results of all sorts of things. But we must be honest, and stop waffling: knee replacements don’t always work very well. I always tell my patients who come for a TKA, “This is not a hip replacement; your knee will never feel like a completely normal knee.” But even after this warning, some come back and say, “Doctor, it hurts, there.” And I say, “That’s nothing to worry about. It always hurts there. But it will get better, by and by.” Then 6 months later, they are back: “Doctor, it hurts, there.” “But the X-ray is fine. I promise you, it will be all right.” Eighteen months later: “It still hurts, there.” One doesn’t know what to tell them at this stage, so one says, “I can’t do anything about it; it’s not serious.” I have tried everything - I have revised patients, I have done arthroscopy. Earlier on, I would move heaven and earth when they said, “It hurts, there.” I wanted to see why they had that pain, but often I could not find anything. No - I don’t think TKA is what it’s cracked up to be by the big American stars. One works like mad sometimes, and one is still left with 3-5% of cases of residual pain of totally unknown origin.
P. Chambat : Certainly no routine lateral release! When the trials have been inserted and the implant doesn’t quite fit, to say, “That’s not right, the patella doesn’t work - let’s do a lateral release,” is wrong. Implant stability comes from the correct placement of the individual parts of the prosthesis.
P. Beaufils : To obviate problems of patellar instability in TKA, the femoral component has to be correctly positioned, in slight external rotation; and medial rotation of the tibial component must be avoided at all cost. The most important thing is that the patellar cut should not be considered as something minor that gets done quickly, at the end of the procedure. The insertion of the patellar button is something very demanding, and has to be done in a strictly controlled manner, taking into account the rotation of the femoral and tibial components, the level of the patella, the overall bulk in the sagittal plane, the thickness of the implant, and the positioning of the button in the patella, in the coronal plane. If all these requirements are met, there should be very, very little call for a lateral release.
P. Chambat : One mustn’t get the rotation wrong - that would be an acknowledgement of failure. I do not think that there is any justification for a lateral retinacular release when inserting a TKA. The only indication would be a genu valgum with patellar subluxation, or patellar dislocation in an OA knee. However, I use a lateral incision in these knees, and this approach will resolve the problem in the majority of cases.
P. Chambat : There are arguments for and against. The concepts involved vary widely. Some of the devices have rotation without posterior stabilization. To me, that makes a nonsense of TKA, because there is no femoral roll-back in flexion. Then there are the ones that have rotation and anteroposterior translation - with them, one has to preserve the PCL, or else they are pointless. Now, we are seeing the advent of “rotation-translation” devices that are posterior stabilized - something I really fail to understand.
P. Chambat : Because with a posterior stabilized system, when the femoral condyle bears on the tibia, the condyle cannot roll back because the mobile bearing escapes forwards.
P. Chambat : These implants are intended for knees that still have reasonably sound collaterals. At the moment, things are going every which way. Mobile bearings are what the market wants, they are the in thing.
P. Beaufils : You name it, they said it. First, there was a session on basic science research, showing the abnormalities that occur in cartilage with age, the inability of cartilage to regenerate spontaneously. Then there was a session showing what is basically possible in terms of cartilage reconstruction. There are several things surgeons can do: periosteal grafts; cell (chondrocyte) culture; and autogenous osteochondral “core” grafts. The important thing clinically - and I think that is the most important message from the Congress - is that these cartilage reconstructions are, at present, limited to the treatment of focal defects surrounded by healthy cartilage. What this means is that, in practice, cartilage fractures or osteochondritis dissecans would be amenable, while cartilage degeneration could not possibly be managed in this way. Patients have learned through the media that this treatment is now available, and we are beginning to be asked to do cartilage grafts for degenerative conditions.
P. Chambat : No, that would not be a suitable case for this treatment. If this is a sequel of a meniscectomy, it is, by definition, wear and tear of cartilage, it is degenerative.
P. Beaufils : In Europe, this cell culture technique is mainly being used by Peterson’s group, in Sweden. Their studies have shown the technique to work in the femoral condyles, but not in the patella. In France, a multicentre study under the aegis of the Société Française d’Arthroscopie (SFA) is due to start in the near future.
P. Chambat : I know that in Lyon the Hospice group of hospitals had agreed to a study, but it had to be a properly controlled trial. Of course, it is enormously difficult in France to run a controlled study that meets all the requirements imposed by recent legislation. Also, at 70,000 French francs, the treatment is still prohibitively expensive.
P. Chambat : . According to the literature, “core” autografts - mosaic plasties - are reliable. They work, providing that the patients have been carefully selected. We shall get a better grip on selection as we go along. I think that, for the time being, this procedure should be practised only by a few very highly specialized surgeons. Doing just one or two of them a year is useless. If you know a surgeon that you like and who has got the necessary experience, do refer your patients to him. That is how we must work nowadays. I myself have no experience whatsoever of this procedure, so the few patients I have that could benefit from this treatment get sent to someone more experienced.
P. Beaufils : No - but in order to draw conclusions, we shall have to have just a few teams working with it in France. If there are a few cases being done here, and another few cases there, we shall not be able to analyze the results.
P. Chambat : Mosaic plasties do not require great technical prowess, but for the time being, the patients concerned should be done by a small number of teams, who should then be able to tell us quite rapidly whether the technique is useful or not. After that, the procedure could be practised more widely. Who in France has got experience right now? Christel has done some ten or fifteen cases. I think we shall really have come of age in orthopaedics when we can say to a patient, “I know someone who does this operation. You should go and see him.”
P. Beaufils : I myself would not do an osteochondral graft under these circumstances, because the outcome would be too uncertain.
P. Chambat : The thing to bear in mind is that although we used to consider osteochondritis dissecans as a benign condition, it may be disastrous, leading to early OA. That point cannot be emphasized enough. So, one either has to treat very early, preserving the fragment; or else the condition could be serious.
P. Beaufils : At the moment, everyone is still looking at things in mechanistic terms: there is some cartilage missing; we put in cartilage to fill the defect, so that the joint can cope again with compressive stresses. However, it is obvious that, in future, things will be looked at more in biological terms. We have seen this trend towards a biological approach with ligament, cartilage, and meniscus repairs, using growth factors and healing factors.
P. Chambat : The whole thing is going to be a problem of our modern society. It all has to do with ageing. In Nice, there was a conference on gene therapy - and it is quite obvious that, in ten or fifteen years’ time, we as orthopaedic surgeons will not be mechanists so much as biologists.
P. Beaufils : Philippe Neyret spoke for the SFA, and the one thing that came out of his paper loud and clear was that the long-term results of meniscectomy, even arthroscopic meniscectomy, are not excellent. Partial meniscectomy - a term about which one may argue - does not protect against cartilage wear, especially where the lateral meniscus is concerned. This gave rise to an idea that has been advocated for a long time, but which has not yet become generally established, of meniscus-sparing surgery, i.e. of preserving the meniscus whenever possible, or even repairing it. Saving the meniscus means using sutures, doing a meniscal repair whenever possible. It is known that in the unstable knee meniscal suture combined with ACL repair gives good results. It has also been shown that one could leave the meniscal tear unsutured, providing that the ligament is repaired. In the stable knee, on the other hand, in the ACL-intact knee, the success rate is very much lower. I think that in a young subject with a properly reparable lesion in the vascularized portion of the meniscus, every attempt should be made to preserve the meniscus; these patients should be offered suturing even if recovery will take much longer than after a meniscectomy, and even though the anatomical failure rate, the failure to achieve true healing of the meniscus, is around 30-50%.
P. Beaufils : A meniscal suture in an ACL-intact knee has a guaranteed clinical failure rate of 10%; the incomplete-healing rate has been between 30 and 50% in different studies (many anatomical failures are, in fact, asymptomatic). The problem of what to do arises when the patient is a young person of, say, 20 years of age. Rather than doing a routine meniscectomy, would it not be better to tell him that one is going to take a risk and suture the meniscus, and that he has a 60% chance of being all right,?
P. Chambat : I think that some people have an “ailing meniscus” when they are 35-50; and there is a very, very small number who have that condition when they are 20. What I mean is deficient fixation of the meniscus, which is a bit floppy.
P. Beaufils : In stable knees, one suture for every 30 meniscectomies. I do 250 meniscectomies, which means six or eight sutures a year, no more. However, these cases need attention, especially where the lateral meniscus is involved.
P. Chambat : Of course. The largest series of meniscal sutures were in the 80s, because surgeons were doing them in very advanced cases of chronic instability. With the ACL, the one thing that has changed completely is that people now have themselves operated on earlier. Injuries are diagnosed earlier. As soon as they feel their knees giving way, people will see a surgeon. They can then be readily persuaded that they need surgery. They are very aware, and as soon as their knees start giving way, they get worried, and go for surgery sooner than they would have done in the past. I think that that is the main difference between now and then. Also, if there is a limited posterior lesion with a stable meniscus, one may do the ACL, but decide not to suture the meniscus afterwards.
P. Chambat : The more specialized one is, the less one tends to see advanced instability; or else one sees other surgeons’ failed cases. I always say that it is easier to be hyperspecialized in the knee, because the hyperspecialist sees patients who worry about what is wrong with them. The surgeon in a general department of orthopaedics, which is not specialized in the knee, tends to see fewer patients who engage in sports, and fewer who are worried by their knees. These people will wait a long time before seeking medical advice, and by the time they present, the instability will be worse.
P. Beaufils : At present, meniscal allografts and collagen meniscus implants are entirely experimental. It is very difficult to assess the results of allografts, for example, because usually there is also an osteotomy or ligament reconstruction involved, and nobody knows for sure which does what in this context. The in-vivo biomechanical potential of the grafted meniscus has not yet been assessed. The most that one can say is that biopsies taken at a later stage have shown the allograft to be repopulated by host cells, and viable.
P. Beaufils : By doing biopsies, one can show whether the graft has been repopulated. Freeze-dried grafts are doomed to failure. Cryopreserved grafts were investigated by René Verdonk, who showed that what happens once the graft is inside the knee varies widely. The menisci were viable, i.e. there were cells inside them. Sometimes these were donor cells that had survived; sometimes the allograft had been completely repopulated by host cells; and sometimes the cell population was a mixture of the two. However, that tells one nothing about the biomechanical competence of the allograft.
P. Chambat : The technical problem is of somewhat secondary importance. Some surgeons use bone plugs; some just suture the graft in. I think Verdonk just uses sutures. The main problem is one of sizing, to prevent graft size mismatch between the donor and the host.
P. Beaufils : Because of this, some surgeons, such as D. Kolm, use patellar tendon autografts. Just as an autograft “ligamentizes”, it can also “meniscalize”, and then one doesn’t have a problem with an improperly sized graft. Obviously, this is still a very experimental technique. We are now also hearing of collagen meniscus implants (CMI), which provide a scaffold for the host collagen to grow into.
P. Chambat : These mixed reconstructions should be used only in cases of advanced instability. As I was saying earlier, we tend to see fewer and fewer of those knees. In cases of anterior instability with a major difference compared with the uninvolved knee, we can add an anterolateral reconstruction, although this is not a universally approved concept. In posterolateral instability, I would hesitate to do an additional posterolateral procedure, because, and I repeat, the posterolateral corner - you so much as look at it, you damage it. With posterolateral lesions, a corrective osteotomy should be performed in preference to posterolateral surgery, whose outcome is not very well known. On the posteromedial side, capsular retensioning has been shown to have its limitations. At Lyon, Henri Dejour has done capsular retensioning; the results were not great. I think the only indication on the medial side is, perhaps, the reconstruction of the medial collateral ligament if there is valgus instability. I think any peripheral reconstruction should be done using free grafts; there should be no retensioning after disinsertion. For the medial collateral ligament, for example, I use patellar tendon or quadriceps tendon with an attached bone block. The bone block is placed in a blind tunnel at the proximal end of the medial collateral ligament, and the tendinous portion augments the deficient collateral.
P. Beaufils : To return to the question of ACL reconstruction-lateral tenodesis - this may be necessary in some knees, but nothing is known as yet about which knees can be managed with just an intra-articular reconstruction, and which require an additional extra-articular procedure. To date, nobody can tell exactly what the degree of instability has to be; however, prospective studies are under way.
P. Chambat : If, on the KT-1000, I find a 1 cm difference, or if there is a recurvatum of more than 30°, I create a lateral check rein. However, I admit that these are completely arbitrary cut-offs.
P. Beaufils : Apart from the fact that the media got hold of this subject, there have been two reasons for the development of these techniques - one right and one wrong. The right one is that, after procedures using the central one third of patellar tendon, there have been some cases of patellar tendinitis and anterior knee pain. The wrong one is that there is quadriceps weakness after the harvesting of a graft from the extensor mechanism: it is well known that quadriceps strength will be back to 93% of baseline by the end of the first year, and 95% by the end of the second year after surgery. However, these reconstructions should be explored further.
P. Beaufils : Animal studies have shown fixation at 3 weeks. In humans, however, very, very few histological studies have been done. Such as have been performed show healing of the tendon in the tunnel, with the appearance of Sharpey fibres, which are the fibres that fix the collagen of tendons to the bone.
P. Chambat : Technically, this is certainly a very attractive procedure; however, we do not know what the result will be at 10 years. In athletes, I have had more retears with this technique than when using patellar tendon. I think it is a very good technique, but it has not superseded the use of patellar tendon, although it may do so, eventually, if the long-term results warrant it. So, for the time being, the patellar tendon has its place in knee surgery. There is also the problem of graft stretch with cyclic loading. When a graft is cyclically loaded, there would appear to be more stretching in the case of a bone-tendon construct - in other words, semitendinosus - than in the case of a bone-tendon-bone construct - in other words, patellar tendon.
P. Chambat : Ten years ago, I would not have operated on someone over 40. Recently, I had a 52-year-old patient undergoing surgery. If patients are disabled by their condition, they need surgery. And in that case, one has to do a semitendinosus graft. If the instability has been there for the last 15 years, and a meniscus tears, the problem is quite different. In that case, one should treat the meniscus in the first instance, and see if that is enough.
P. Chambat : Because that is more major surgery, and there is a risk of pain afterwards.
P. Chambat : I think that is that surgery has had its day. A Lemaire is more invasive than an arthroscopic reconstruction using STG. There is a bigger incision, and a greater risk of haematoma formation.
P. Beaufils : There are two reasons. We tend to see instabilities that have developed more recently; the degree of instability is less, and the meniscus is intact. Also, we have minimum-access surgery. So, the results are better overall, even though the knee is rarely perfect to the extent that the patient forgets he or she ever had a knee problem.
P. Chambat : Because we are better at it! You don’t know what ACL surgery was like in the 60s. In those days, it was a venture. I saw Albert Trillat do medial transfers of the tibial tubercle, Emslie-Slocum procedures, in patients with a torn ACL. And would you believe it - sometimes it worked! Then, between 1973 and 1975, the practice in Lyon was to reconstruct the ACL using patellar tendon, but leaving the tendon attached on the tibia, as in the original Kenneth Jones technique. What a shambles! If the patient could so much as flex his knee after surgery, we were delighted. We followed the patients up ourselves: it was grim. After that, in 1978, we started doing free patellar tendon grafts. I was then a senior registrar in Dejour’s department, and found that it was easier to do a Guépar knee replacement than an ACL. One worried about the operation three days before and three days afterwards. We had so many problems in the 80s that patients had to spend 3 months in rehab. Nowadays, they grumble if they can’t go home on Day 2.
P. Chambat : If there is just a torn ACL, without any blood outside the capsule, we can operate very quickly, because the risk is minimal. However, once there is a haematoma, with blood leaked outside the capsule into the collateral soft tissues, I think that one should wait, so as not to run into a prolonged and difficult course after surgery.
P. Chambat : If there is swelling, subcutaneous haematoma, or peripheral point tenderness, one should suspect capsular lesions, and postpone surgical intervention.
P. Chambat : Yes - it’s all a question of how much credibility and how much prestige one has in sports circles.
P. Chambat : I would not operate on her, but I would devise and monitor her conservative treatment from A to Z. She would undergo 4 months’ functional treatment of exactly the same kind as that prescribed to patients who have undergone surgery.
P. Chambat : If the functional treatment has been carried out properly, it is most unlikely that she will be back 8 months later. If you say to your patients, “I’m not going to operate on you. You’ll have to see how you manage,” they’ll start using their knees straight away, and then they will finish up with instability. One has to look after them, and follow them up long-term. They mustn’t be allowed to go back to sports too soon; the knee must be kept in flexion, the quadriceps must not be exercised. If a patient does open-chain quad exercises two weeks into a conservative treatment programme, it’s no wonder the ACL suffers - it’s like letting him play soccer!
P. Chambat : Both. I am currently reviewing my patients, and I am amazed at how many no longer have any instability: one in four is now completely stable. In 1994, I had 105 torn ACLs in one skiing season. I operated on 65 of them, and treated 40 nonoperatively. Of the 40 who were managed conservatively, only two needed surgery in the end. I have seen a World Cup-level skier with a conservatively managed ACL tear, who is now completely stable. I think there are many athletes with ACL tears who easily could go back to sports after nonoperative treatment, though perhaps they might have to see which sport they could practise. The problem is that we do not have the courage not to operate on them, because we worry that conservative treatment may fail, whereas we are 95% sure of our surgical technique. I would say that there is too much ACL surgery being done.
P. Beaufils : In London, in the year 2000, from 15-20 September, under the presidency of David Dandy. I am sure it will be at least as great a success as the one we have had in Nice.
(Transl: KRMB)
