- An innovative surgical technique that minimises the surgical procedure
- Ligament repair in 30 minutes
- Faster recovery with excellent results
Anterior cruciate ligament surgery is undergoing a major revolution, with the development of an innovative surgical technique known as DT4 All Inside, which halves the operating time, minimises the post-operative period and delivers excellent results.
"At Clinique Paris Lilas, we have been helping to develop this new technique for a number of years now, which is a real advantage for patients, particularly professional and amateur sportsmen and women," explains Dr Elias Dagher, an orthopaedic surgeon specialising in knee surgery at Clinique Paris Lilas.
Repair now in 30 minutes
Cruciate ligament surgery accounts for almost 40,000 operations per year in France. The patients concerned are often young and active. The post-operative effects of this operation are considerable, due to the surgical procedure itself and the ensuing recovery period.
"This innovative approach means that arthroscopic ligamentoplasty can now be carried out in just 30 minutes, compared with an hour previously, while reducing the post-operative period. We have made a number of improvements to reduce bleeding, scarring and pain. The results are excellent and comparable to other techniques, as confirmed by recent international studies says Dr Dagher, one of the pioneers of this surgical technique in France.
This new technique minimises tissue damage, both to the bone and to the site where the graft is taken, thereby limiting bleeding, inflammation and post-operative pain. Today, this surgery is carried out on an outpatient basis, compared with a 2 to 3-day stay in hospital in the past.
"Recovery is quicker and the return to active and professional life relatively short, ranging from one week to one month. Whereas a large proportion of patients used to stay in a rehabilitation centre, post-operative rehabilitation is now carried out by physiotherapists in town for leisure sportspeople. Just a few sessions are enough to restore knee function, although it may take three to six months to build up the muscles and resume sport. For professional sportsmen and women, we continue to offer rehabilitation in a specialised centre, which enables us to get them back on the pitch as early as six months post-operatively," stresses Dr Dagher.
A new rationale and broader indications
The whole logic surrounding this operation is changing, particularly the time between the accident and the surgery, the age limit and the sports profile of the patients operated on. With standard techniques, it was necessary to wait a minimum of six to eight weeks between the accident and surgery, because of the inflammatory phenomena, with the risk of ending up with very difficult post-operative rehabilitation. "Now that the damage caused by surgery has been completely minimised, the operation can be offered very quickly, after just a few days, as we do, for example, for our professional sportsmen and women, who appreciate the time saved when they return to sport. We are also realising that early surgery could improve the final healing result," explains Dr Elias Dagher.
Moreover, standard techniques were mainly offered to young, athletic patients. Many patients were left with knee instability. In addition to the inconvenience of daily life and having to give up certain sporting activities, they ran the risk of accelerated deterioration of their joints. The new, less restrictive technique can be offered more easily to occasional sportsmen and women over the age of 40.
"Since we developed this technique in 2010, we have reviewed and assessed all our patients with follow-up MRI scans and muscle and ligament stability tests. The functional results are astonishing in terms of recovery, stability and return to sport. It's a major step forward for our athletes, but also for all future patients," concludes the surgeon.
Today, almost 10% of ACL surgery patients in France benefit from this innovation.
How does the DT4 All Inside work?
Conventional ACL reconstruction techniques of the KJ or DIDT type have until now required the creation of two complete bone tunnels in the femur and tibia. A graft is taken from the knee, the middle third of the patellar tendon with a bony part of the patella and tibia for the KJ, and the tendons of the semitendinosus and the medial rectus for the DIDT. The graft is then passed into the knee and fixed in the bone tunnels by two large screws(diagram 1).
1: Conventional technique with 2 complete tunnels and screw fixation
2: DT4 all inside technique with 2 small bone pockets, short graft and button fixation
The "DT4 All Inside" technique uses new surgical instrumentation that allows the bone to be drilled retrograde, thus preparing small bone pockets instead of full tunnels. This reduces the size of the harvest required, making it possible to use the semitendinosus tendon alone to prepare the graft. The graft is then passed through the knee and fixed by two small buttons on the outside of the joint. This is all done arthroscopically, using a small camera that requires only four small scars measuring 5 to 10 mm around the knee(diagram 2). The development of this technique has been facilitated by the development of new surgical instrumentation that reduces the aggressiveness of the procedure and simplifies the various stages.
Results presented at the French Society of Sports Traumatology Congress (SFTS 2014)
Single-centre, single-operator prospective study of 61 patients operated on for ligamentoplasty using DT4 All Inside between 1 July 2012 and 1 June 2013. All patients were reviewed at 2 years follow-up with calculation of Lysholm functional scores, subjective IKDC and Tegner activity scale. Objective measurement of differential laxity using GNRB at 134N and MRI analysing the characteristics of the tunnels and the graft were performed. We observed a significant improvement in functional scores. The mean Lysholm score was 87.5. The mean subjective IKDC score was 85.4. The mean Tegner score was 5.5. Differential GNRB laxity at 134N at 2 years follow-up was 1.7 mm. 90% of patients had differential laxity of ˂ 3 mm at 134N. MRI of the graft and tunnels was entirely satisfactory. Regeneration of the semitendinosus tendon was visualised in 89% of cases. Only one iterative rupture occurred. By reducing bone tunnels and the morbidity associated with tendon harvesting, anatomical ligamentoplasty with a four-strand semitendinosus (DT4) all the way in provides medium-term functional, laximetric and MRI results comparable to the best results obtained with traditional techniques.
About Clinique Paris Lilas
Founded in 1970, Clinique Paris Lilas offers orthopaedic surgery and sports traumatology services on a short-stay inpatient or outpatient basis. It is also home to the Centre de l'Est Parisien d'Imagerie Médicale (CEPIM), with state-of-the-art equipment (two MRIs and a scanner). The excellence of its renowned surgical and medical teams has made it one of the most highly regarded orthopaedic surgery establishments in the Paris Ile-de-France region, and has regularly earned it a place of honour in the national rankings of leading news magazines. The establishment has 75 beds, including 15 outpatient places. It has 103 employees and 37 independent doctors, and sees 43,000 patients a year, including 6,300 in full or day hospitalisation.
