GRAAL 2009


18 & 19 Septembre 2009 - Annecy


  1. History of the TLS technique : Xavier Cassard

  2. Semitendinosus-gracilis grafts and the TLS system Biomechanical aspects : Docteur COLLETTE

  3. ACL reconstruction using the TLS method - surgical technique : Hubert Lanternier

  4. Partial ACL lesions : Treatment using the TLS technique : Henri Robert


  6. TLS operating technique for ACL reconstruction in children : Xavier Cassard

  7. TLS surgical technique for posterior cruciate ligament reconstruction

  8. Results of ACL procedures using a single-bundle TLS Technique with at least 1 year’s clinical follow-up : Henri Robert/Thierry de Polignac/Rodolphe Limozin

  9. CLINICAL, ECHOGRAPHIC, ISOKINETIC, and TOMODENSITOMETRIC APPROACH With 1 year’s follow-up on 30 ligamentoplasties using the TLS system : Dr F. CHALENCON / R. BOISSIN

  10. Double-bundle ACL results : Nicolas Lefevre

  11. Clinical evaluation of a continuous series of anterior cruciate reconstructions. Anatomic double-bundle TLS technique: preliminary results : Nicolas Lefevre/Serge Herman

  12. TLS ACL Reconstruction, the Finnish Experience : A. Harilainen, MD, Assoc. Prof.

  13. Double bundle ACL reconstruction using 4 tunnels technique and two different fixation systems : Jacek Kaczmarczyk M.D. Ph.D., Marcin Sergiew Jr.

  14. After 10 years of KENNETH JONES, followed by 10 years of semitendinosus-gracilis, I have now switched to TLS. Why? : JJ Lallement

  15. Day case anterior cruciate ligament reconstruction: A study of 39 patients : S. Dojcinovic

History of the TLS technique

Xavier Cassard - Toulouse

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The TLS, Tape Locking Screw, concept was invented in Brussels by Michel Collette in 2001. For almost 15 years, he had been using a short graft for ACL reconstruction, "anchoring" traction tape using an endo-button equivalent on the femur and tying the threads onto screws in the tibia. In response to criticisms regarding the excessive elasticity of this type of mounting, and in order to find a solid fixation without the need for any additional bone tunnelling, the idea emerged of “pinning” the tape into the tunnel.
An ice spike pinning down two Mercilene® strips provided an impressive level of resistance to traction.
An initial screw prototype, based on the ice spike design, was produced by FHI and tested at the CRITT in June 2002, with exceptional mechanical results. And so TLS was born.

An initial surgical procedure involving the TLS principle was launched in late 2002, with a one-way application and... some technical difficulties in applying this fixation! An operating theatre-based meeting in Brussels in June 2003, organised by FH-Orthopedics, convinced us to get involved in developing the current technique. We opted for a method involving identical, retrograde tunnelling into the tibia and femur, requiring a specific drilling guide and a retrograde drilling tool. The basic principles of the current technique started to take shape. Development of the instrumentation took many months.
Philippe Calas, who had a great deal of experience with short grafts, helped with the validation of this technique through a large number of patients operated on, between late 2003 and 2007. He continues to use this principle today. The TLS group was then reformed, with the arrival of its “first disciples”. Hubert Lanternier, Thierry de Polignac and Henri Robert joined us and helped develop the technique in terms of applications and improvements to the instrumentation, but also distribution. Nicolas Lefèvre recently joined us, becoming involved more specifically in the double-bundle ACL technique.
It is now 8 years since the ice pick idea. Over 5,800 patients have been operated on, from Brussels to Toulouse and as far away as Helsinki, Chicago, Cracow and various other places.
The story of this technique is not yet over. Other developments based on TLS are planned. This first “TLS Day” is an opportunity for us to continue our collaboration, which is continuing to grow as more and more surgeons adopt the technique.

Semitendinosus-gracilis grafts and the TLS system
Biomechanical aspects

Dr Collette - Brussels

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In recent years, there has been an increasing tendency to use semitendinosus-gracilis grafts in surgical reconstruction of the anterior cruciate ligament. The less-invasive nature of this type of graft, compared with patellar grafts has been clearly proven in literature and is very probably the main reason for this increase in use.
SG grafts still have a reputation, however, for inferior mechanical results when compared with patellar grafts.

The main objective of this presentation is to analyse the various factors which could explain this mechanical inferiority.
It is very probably a result of the quality of the graft fixations and the rigidity characteristics of the fixation-graft-fixation complex. Unlike patellar tendon grafts, SG grafts include many deformable interfaces which, when extended, are subject to a permanent and irreversible initial lengthening of the system, leading to a rapid decline in the initial tension created by the surgeon when performing the graft.

The second objective is to show how the TLS system responds to the different mechanical problems likely to occur when using traditional SG grafts. The results of the mechanical tests carried out in laboratory conditions provide a clear illustration of the particular effectiveness of the TLS system compared with other systems currently available. The TLS system provides the surgeon with a means of fixation – identical on the femur and tibia – offering major and beneficial tissue savings, and whose effectiveness is such that traditionally-used post-operative protection measures (walking sticks, crutches etc.) can be abandoned without risk to the final mechanical result.

ACL reconstruction using the TLS method - surgical technique

Hubert Lanternier - St Nazaire

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ACL reconstruction using the TLS method is starting to become recognised as a technique in its own right, alongside other techniques using the hamstring tendons. The surgical technique has been widely covered over the past few days, but there are a few technical points which make it special and which are worth pointing out.
- Harvesting is slightly more technically challenging, as it is important to use only the semitendinosus tendon, which is deeper and hidden by the gracilis tendon. The “failsafe” method should be used.
- Preparation of the short graft requires care and attention, due to the precise nature of details.
- The shallow recesses are known for allowing press-fit application and preserving bone stock. Technical points are envisaged and the “waddle” is described.
- The femoral approach from outside inwards requires care when being performed. Using the “pilot hole” it allows the graft to be positioned on the axial face of the femoral head, in accordance with modern ligament surgery recommendations, thus avoiding the excessively vertical assemblies whose negative effects are now widely known. It is likely to become the norm, in time, regardless of the type of fixation or graft used. It is already compulsory for double bundles. Its justification and technique are specified to reflect this.
- Finally, the graft transfer, screw tightening and other technical details are covered during the presentation.

Partial ACL lesions.
Treatment using the TLS technique

Henri Robert, Centre hospitalier Nord Mayenne, 53100, Mayenne

The clinical or functional definition of partial lesions is relatively simple – it refers to patients with a trauma involving torsion of the knee, with clinical Lachman testing having revealed a firm endpoint and only weak (+) or no shifting, and a differential threshold using KT-1000 or GNRB below 3 mm (Robert). This scenario can correspond to various anatomical situations: global distension, rupture of one bundle and distension of the other, rupture and adhesion to the PCL or notch, or rupture of one bundle with the other intact.

The generally accepted anatomical definition of a partial rupture is one ruptured bundle (AM or PL) with the other intact (Fritschy, DeFranco..). This situation corresponds to 20 % of cases seen, with the AM bundle more commonly torn than the PL bundle.

Clinical identification of Lachman’s asymmetry is difficult, even some time after the accident (Hole). KT-1000 quantification of the differential anterior translation of the tibia is theoretically possible (Fritschy) but difficult (Defranco). Use of a GNRB arthrometer to measure laxity would appear to be an essential choice, given its precision of measurement and repeatability. A laxity differential between 1.5 and 3 mm is an indicator of partial rupture with 80% sensitivity and 87% specificity 87% (Robert). Identification of shifting is a decisive factor in evaluating the seriousness of the lesion, as free movement (++ or +++) indicates not just a partial rupture but a complete rupture (Defranco). An MRI scan revealing the presence of primary indicators (localised intraligamentary hypersignal, loss of rectitude, partial visibility of fibres) and the absence of secondary indicators (osteochondral lesions, femoral notching, anterior tibial translation) enables diagnosis in 55% of cases (Umans). Use of oblique sagittal and coronal scans, along the axis of the ligament, helps to increase the sensitivity of the diagnosis (Steckel). MRA can be useful in detecting possible meniscal lesions (10 to 50% of cases) or chondral lesions.

Following these examinations, if a partial lesion is still strongly suspected, the action to be taken should be determined according to the type of sport practised and at what level, and the patient’s wishes. In patients with low sporting demands, proprioceptive rehabilitation may be sufficient. Close monitoring is strongly recommended, when sporting activities are resumed, in order to detect any occurrences of instability or destabilisation of the knee. In patients with major sporting demands, especially where there are medial meniscal lesions, single-bundle repairs can be proposed.

Under anaesthetic, laxity testing is important to confirm the partial rupture (weak Lachman results) and pinpoint the rupture to the AM bundle (no shifting, weak anterior laxity) or the posterior bundle (no laxity, weak interior shifting). Only arthroscopy can provide confirmation of the partial lesion and assess the quality of the remaining tissue. This assessment remains difficult, as theoretically the anterior bundle tenses during flexion and the PL bundle relaxes during flexion. According to Fritschy:Arthroscopy is not reliable in estimating the quality of fibers judged intact on hook palpation ».

In our experience, GNRB provided precious assistance in analysing the curve differentials of the ligamentary elasticity charts. A gentle slope indicates that the remaining tissue is of good quality. Otherwise the remaining tissue is of poor quality (partial rupture of the other bundle, distension) and cannot be preserved, in which case a complete repair should be performed, either single- or double-bundle.

The TLS single-bundle repair technique is compatible with the double-bundle technique. We implant a 4-strand AM or PL bundle (semitendinosus for the anterior bundle, gracilis for the posterior bundle) onto the anatomic tibial and femoral landmarks. “Out-in” femoral drilling helps to protect the insertions of the remaining bundle and the tibial drilling stops in the footprint of the ACL (AM or PL). Tensioning using the “sardine tin manoeuvre” is carried out in extension for the PL bundle and at 45° flexion for the AM bundle. Personally, we have altered the basic technique: the semitendinosus is left pedunculated to the tibia and prepared in 3 or 4 strands. The graft crosses the entire intraarticular tibial stump and is fixed to the femur in its recess, in accordance with the TLS technique. The graft is tensed along the femoral cavity and fixed with a TLS screw (length 20 mm). The graft is locked into the tibial tunnel using a 7 mm diameter resorbable screw (PLLA-ß-TCP) wi. Immediate postoperative care is identical to the traditional technique: immediate weight-bearing with no brace, active mobilisation, closed-chain rehabilitation.

There are real advantages to single-bundle repairs:

  • Easy anatomical identification,

  • Preservation of the tibial stump supports the mechanoreceptors,

  • Revascularisation occurs via the remaining bundle and stump.

The initial resultsof these selective repairs are very satisfactory. No specific complications occurred.

Adachi et al were the first to describe single-bundle repairs, in 2000. Their series of 40 partial repairs achieved better results in terms of laxity and proprioceptive control than the series of conventional repairs. These results have since been confirmed by a more recent series (Ochi M).

The TLS partial lesion repair technique, preserving the greatest possible amount of healthy tissue, can be referred to as ACL augmentation procedure rather than the single bundle procedure.


Adachi N, Ochi M, Uchio Y, Sumen Y. ACL augmentation under arthroscopy. A minimum of 2 years follow-up in 40 patients. Arch Orthop Trauma Surg 2000; 120: 128-133

DeFranco MJ, Bach BR. A comprehensive review of partial ACL tears. J Bone Joint Surg. 2009; 91:198-208

Fritschy D, Panoussopoulos A,Wallensten R, Peter R. Can we predict the outcome of a partial rupture of the ACL ? Knee Surg Sports Traumato Artho. 1997; 5: 2-5

Hole RL, Lintner DM, Kamaric E, Moseley JB. Increased tibial translation after partial sectioning of the ACL. The postero-lateral bundle. Am J Sports Med. 1996; 24: 556-560

Ochi M, Adachi N, Uchio Y, Deie M, Kumahashi N, Ishikawa M. A Minimum 2-Year Follow-up After Selective Anteromedial or Posterolateral Bundle Anterior Cruciate Ligament Reconstruction.

Arthroscopy. 2009 ; 25 :117-122

Robert H, Nouveau S, Gageot S, Gagnière B. A new knee arthrometer: the GNRB: experience in ACL complete and partial tears. Ortho Trauma Surg Research. 2009; 95: 171-176

Steckel H, Vadala G, Davis D, Musahl V, Fu FH. 3-T MR imaging of partial ACL tears: a cadaver study.

Knee Surg Sports Traumatol Arthrosc. 2007; 15: 1066-71.

Umans H, Wimpfheimer O, Haramati N, Applbaum YH, Bosco J, Diagnostic of partial tears of the ACL of the knee: value of MR imaging. Am J Roentgenol. 1995; 165: 893-897

Diagram showing an AM bundle repair using the TLS technique.



Thierry DE POLIGNAC – Annecy

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Greater knowledge of the anatomy and biomechanics of the anterior cruciate ligament (ACL), as well as residual shifting rates and long-term failures following ACL reconstruction have led to the development of new, more anatomical ACL reconstruction techniques: isolated reconstruction of the damaged bundle in partial ruptures (augmentation plasty) and double-bundle reconstruction. The TLS system would appear particularly suitable for these anatomic reconstructions from a biomechanical and technical point of view.

The TLS system has 3 based principles:

1)short, 4-strand graft from a hamstring tendon pre-tensioned using tapes

2)retrograde bone recesses

3)screwed fixation of tapes, close to the joint, respecting the graft’s integrity

Single-bundle reconstruction uses a short 4-strand (DT4) graft (50 to 55 mm) from a single tendon – the semitendinosus. The graft is pre-tensioned on a specific table at 500N. Creation of bone recesses, press-fit insertion of the graft and fixation methods are identical for both the femur and the tibia. Post-operative weight-bearing is immediate and without splints. Traditional rehabilitation is used, with “pivoting” sports being resumed after 6 months.

In partial ACL ruptures, the isolated reconstruction of the damaged bundle (most commonly the anteromedial bundle) uses a single tendon – the semitendinosus, for a 4-strand (DT4) graft. The TLS system offers several advantages for this type of reconstruction, preserving the bundle intact:

- the femoral stages are carried out at 90° flexion (retrograde) and the femoral insertion of the anteromedial bundle is carried out in this position (not the 120° bent knee position) unobstructed at the front by the intact posterolateral bundle

- the positioning of the graft is not affected by the fibres in the bundle preserved, due to the possibility of strong traction using a specific method known as the “sardine tin” manoeuvre.

Double-bundle reconstruction uses a 4-strand semintendinosus bundle (DT4, 50-55 mm) for the anteriomedial bundle (AM) and a 4-strand gracilis bundle (DI4, 40-45 mm) for the posterolateral bundle (PL).
In both the femur and tibia, 2 independent tunnels are made, in anatomic position. Identification of the centres of each bundle is based on knowledge of anatomic landmarks, analysis of the remnant fibres from the torn ligament and experience in the reconstruction of partial ruptures. An image intensifier or CAS system may also be used.
The femoral stages are performed with the knee at 90°, with the traditional femoral guide, retrograde. The AM bundle guide is first and is more sagittal and vertical than the PL bundle guide. The centre of the AM bundle is situated at “11 o’clock” (right knee), 5 mm before the “over-the-top” position. The centre of the PL bundle is further forward and lower; close to the cartilage. The distance between the two centres is approximately 8 mm. Divergence between the two guides must be at least 15°. Identification of the centre of the PL bundle is facilitated by the ocular, placed through the anteromedial portal.
The tibial stages are carried out using the traditional tibial guide. The AM bundle guide is more sagittal than the PL bundle guide. To ensure the AM bundle is as anterior as possible without conflicting with the notch ceiling, identification of the centre of the bundle is performed with the knee extended. The centre of the PL bundle is more posterior and lateral, 5 mm before the PCL. The distance between the two centres is approximately 8 mm. Divergence between the two guides should be at least 15°.
The PL bundle graft is applied before the PL bundle graft. Each bundle is fixed to the femur using a TLS screw, then the PL and AM bundles are tensioned and fixed to the tibia at 20° flexion, using one TLS screw for each.

Studies are currently underway to confirm the ACL anatomic reconstruction principles using the TLS system.

- partial rupture: isolated reconstruction of the damaged bundle (DT4)

- complete rupture: double-bundle reconstruction (DI4DT4) or single-bundle (DT4).

TLS operating technique for ACL reconstruction in children

Xavier Cassard - Toulouse


The natural history of anterior cruciate ligament (ACL) rupture in children is known for developing more quickly with the early appearance of instability and meniscal lesions.
ACL reconstruction in children is now accepted and age is not a restrictive factor. Techniques should avoid all risk of epiphysiodesis for the femoral and tibial growth plates and should avoid the removal of the patellar tendon’s tibial and patellar bone insertion.
The TLS technique can be adapted to the particularities of a growing knee, whilst maintaining its basic principles.
The technique is carried out under the dual control of arthroscopy and an image intensifier. The patient’s position is not important, but must allow per-operatory radioscopic control in order to monitor the realisation of the femoral and tibial tunnels.
Preparation of the graft is identical, using the semidtendinosus tendon. The length of the graft can be kept constant (between 50 and 60 mm), as the tibial insertion site allows for adaptations to be made.
The femoral tunnel is made intra-epiphysarily under arthroscopic and radioscopic control, for the positioning of the guide. The tibia tunnel must be more “vertical” (guide angle between 60 and 70°) to be central to the physis. The retrograde drilling of the tibial recess is carried out under radioscopic control, to drill into the physiary plate. The insertion and positioning of the graft are identical.
Resorbable 7x23 interference screws have sometimes been used directly in the 4.5 tunnel, with no need for tapping.
One month’s strict post-operatory immobilisation using a resin knee brace, fitted at the end of the operation, was systematically imposed. Sports could be resumed after 10 to 12 months.
Over 20 cases (ages 9 to 14 years) were operated on with no effect on residual growth.
The TLS technique is suitable for a growing skeleton. The small diameter of the tunnels and the harvesting of just one tendon make it particularly advantageous in children. Nevertheless, the mechanical properties of the primary fixation of the graft in the TLS system are not fully used and we believe it is essential to immobilise children strictly for one month, to avoid rapid mobilisation.

TLS surgical technique for posterior cruciate ligament reconstruction

Xavier Cassard - Toulouse

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Posterior cruciate ligament (PCL) reconstruction using the TLS system follows the same principles of graft preparation, tunnels and fixation as for anterior cruciate ligament reconstruction. Specific PCL instrumentation has been developed (guides, rasp, wire guide).

The technique is performed under dual control using arthroscopy and an image intensifier. The patient’s position is not important, but should allow per-operatory radioscopic monitoring during the drilling of the tibial tunnel.

Single-bundle reconstruction is carried out using only the semitendinosus tendon in a short, 4-strand graft. Double-bundle reconstruction requires harvesting of both hamstring tendons. The graft is prepared in a double loop, with a V closure for a single tibial insertion and 2 independent femoral insertion sites. The AL bundle consists of 4 semitendinosus strands and the PM bundle 3 or 4 gracilis strands, depending on the length of tendon available. The technique describes the tensioning sequence for the two bundles and the position of the knee during their fixations.

PCL reconstruction using the TLS technique is reproducible and presents the following advantages:

  • Mechanical properties of the graft

  • Types and quality of primary and secondary fixations

  • Possibility of single- or double-bundle reconstruction

  • Tissue savings (bone tunnels and tendons harvested)

  • Extensor mechanism respected

  • Technical simplification: single-tendon graft for single-bundle reconstruction, no “ killer turn”, optimal tensioning of the graft, fully arthroscopic technique

PCL surgery is still poorly codified, not only in terms of indications, but also in terms of analysis of results with regard to the diversity of the lesions operated on and the techniques used. The natural consequences of PCL rupture are not insignificant (anterior pain, instability, arthritis) and surgical treatment is often envisaged. A simplification of the reconstruction technique, without compromising on quality and post-op care, could lead to the reconstruction of this ligament being envisaged with fewer reservations.

Results of ACL procedures using a single-bundle TLS Technique with at least 1 year’s clinical follow-up

Henri Robert, Mayenne.
Thierry de Polignac, Annecy.
Rodolphe Limozin, Rodez

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We have reviewed the results of 82 patients operated on between 2007 and 2008 by 3 surgeons experienced in ligament surgery and the TLS technique.

All the patients were operated on for a complete ACL rupture using a traditional, single-bundle TLS technique. This was a continuous, prospective series. Patients had a unilateral rupture and underwent a primary repair between 2 and 12 months post-trauma. Patients underwent a subjective evaluation pre- and post-operatively, providing subjective IKDC, Lysholm and Tegner scores. Objective evaluation of the knee was carried out by the operating surgeon pre- and post-operatively.

Breakdown :

Sex ratio: F: 24 M: 58

Average age: 29 years, range from 14 to 51 years.

Sides: Right: 45 Left: 37

Sporting levels: Occasional hobby: 14%

Regular hobby: 30%

Competitive: 56%

Results :

All patients were reviewed with an average follow-up of 19.4 months, ranging from 14 to 24 months.

43 knees presented a meniscal lesion, 20 of which involved the internal meniscus, 17 the external meniscus and 6 both. 19 were not treated. A partial menisectomy was carried out in 23 cases, 7 lesions were sutured via endoscopy.

  1. Subjective IKDC score


Average subjective IKDC increased from 66 to 92 points at 12 months minimum (p< 0.0001). All patients except one (case at 48%) saw an improvement in their pre-op score, with an average improvement of 44%.

Details of 3 cases < 70 points:

  • case at 48%: algodystrophy, patellar tendinitis and neuroma on the anterointernal arthroscopy scar. The patient is not satisfied (score of 2/10) and would not repeat the operation.

  • Case à 60%: algodystrophy and arthrofibrosis: extension deficit > 10°.

  • Case at 64%: pain and arthrofibrosis: extension deficit 3° and flexion deficit 10°.

  1. Lysholm Score


The average Lysholm score increased from 68 to 93 points at 12 months minimum (p< 0.0001))

  1. Pain results


Pre-op, the average pain score was 3.4 on a scale of 0 to 10. At the last post-op control, this value was 1.1. The drop is statistically significant (p<0.0001). 8% of patients evaluate their knee pain as slightly more frequent post-op (increase of 1 or 2 points)

  1. Subjective stability result

To the question “What is the highest level of activity you can reach without your knee giving way?” the answers were:


21% of patients are not yet fully confident in their knee.

  1. Objective IKDC Scor


The 2 cases in category D are patients who developed an algodystrophy.

The 7 cases in category C are 3 patients with laxity (6 to 10 mm), 2 patients with pain in the graft harvesting site or the thigh, 1 patient with knee pain and one patient with a chronic effusion.

  1. Laxity measured with Telos at 200 N


At 200 N, with Telos there are 2 cases of differential laxity over 6 mm. Average Telos was reduced from 6.8 mm pre-op to 2.2 mm post-op. (p< 0.0001)

  1. Laxity measured with GNRB.


At 134 N, there is one case of differential laxity greater than 6 mm but 2 cases if effort is made at 250 N. Average laxity dropped from 6.7 mm to 1.7 mm at 134 N.

At 250 N, the percentage of laxities between 3 and 5 mm or > 6 mm increased. The laxity rate < 6 mm is similar with both methods, if we compare Telos at 200N (92%) and GNRB at 250N (94%).

  1. Le Pivot Shift.


  1. Complications.

There were no thromboembolic complications or infections.

One patient had a tibial screw ablation at 8 months for persistent pain.

There were no re-ruptures of the plasty, but 4 cases of laxity > 6mm (Telos or GNRB measurements, taken with pressure > 200N), not hampering sporting activities.

2 patients had major algodystrophy with residual stiffness.
1 patient had an arthrofibrosis with extension deficit (3°) and flexion deficit (10°).
1 patient developed a Cyclops syndrome which was treated arthroscopically at 6 months post-op.

  1. Evaluation of satisfaction

a. Patients:

Average score at 3 months: 8.3 /10

Average at 6 months: 8.4 /10

Average at 12 months: 9.1 /10

« Would you redo the operation? » (Answers after 12 months) 

86% definitely,

10 % with some hesitancy,

4 % certainly not.

b. Surgeons’ Score

Average at 3 months: 8.2 /10

Average at 6 months: 8.7/10

Average at 12 months: 9/10

Both patients’ and surgeons’ satisfaction scores correspond and correlate closely with any complications occurring: pain, limited mobility, algodystrophy... and are determined in the first few months. Paradoxically, the same cannot be said of patients’ scores regarding objective stability of the knee.

Early identification and treatment of algodystrophy would seem to be decisive in establishing a long-term prognosis for the knee.

  1. Literary Review

This study has been compared with a meta-analysis by Lewis et al. in 2008, covering 11 prospective and randomised studies of hamstring procedures (4 strands) and patellar tendon repairs. The minimum clinical follow-up was 2 years

911 patients were included in this study.


The results concerning the objective IKDC in the TLS study correspond to those from another study (Biau DJ et al): Class A: 33%, class B: 45% in the hamstring group.

The laxity measurements in the TLS study are particularly strenuous (pressures of 200N or 250N), which is not the case in the published literature (KT-1000 at 134 N or with maximum manual traction). Despite this, the results are identical in the TLS study - 6 or 8% laxity > 6mm – compared with 5% in the Lewis study. It is worth wondering what the laxity results would be with a more stringent arthrometric method …


The results of the TLS study, covering 82 cases and 3 surgeons’ experiences, are very satisfactory from both subjective (IKDC and Lysholm Scores) and objective (IKDC, laxity measurement, Pivot-shift) points of view.

Complications mainly involve the occurrence of algodystrophy and arthrofibrosis. Post-operative pain management and follow-up of rehabilitation would appear to be essential in detecting such complications as early as possible.

Further studies are necessary to confirm these preliminary results.


Biau DJ, Tournoux C, Katsahian S, Schranz P, Nizard R. ACL reconstruction, a meta-analysis of functional scores. Clin Orthop Rel Res. 2007

Lewis PB, Parameswaran D, Rue JP, Bach BR. Systematic review of single bundle ACL reconstruction outcomes. Am J Sports Med 2008 ; Vol 36, N° 10 : 2028-2036

Robert H, Nouveau S, Gageot S, Gagnière B. A New Knee Arthrometer: the GNRB: experience in ACL complete and partial tears. Ortho Trauma Surg Research. 2009; 95: 171-176

CLINICAL, ECHOGRAPHIC, ISOKINETIC, and TOMODENSITOMETRIC APPROACH With 1 year’s follow-up on 30 ligamentoplasties using the TLS system.

Dr F. CHALENCON / R. BOISSIN - Clinique Mutualiste de Saint Etienne.

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As part of a medical doctoral thesis, we decided to evaluate the ACL reconstruction technique using a short, single hamstring graft and a fixation with no direct contact with the transplant – the TLS system. The aim of our study was to demonstrate that the functional results are satisfactory and that the harvesting of a single hamstring improves post-operatory progress and reduces iatrogeny. We also monitored post-operatory social and professional progress to appreciate the impact of this method.


30 patients suffering from isolated chronic laxity were included prospectively, excluding patients presenting a meniscal and/or cartilaginous lesion, with 1 year’s post-op follow-up (the thesis paper covers 50 patients, but only the first 30 operated on have sufficient follow-up for this study). They were operated on by the same surgeon for an intraarticular ligamentoplasty under arthroscopy, using the semitendinosus tendon and the TLS system (instrumentation and fixation screw). They were clinically assessed pre-operatively and on each review (45 days, 4 months, 6 months and 1 year) with objective and subjective IKDC, using SF36. Laximetry was measured using the KT 1000 arthrometer pre-operatively, at 6 months and at 1 year. A subjective assessment was carried out immediately post-op, before leaving the hospital, along with a questionnaire regarding social and professional activities at 45 days. Isokinetic assessments evaluated muscular deficit at 4 months, 6 months and 1 year. We carried out an echographic assessment of the impact of transplant harvesting at various stages and a tomodensitometric assessment of the recesses at 1 year to check for enlargement.


30 patients were reviewed at 12 months post-op. All 30 patients included were monitored for 1 year post-operatively, with all the scheduled examinations completed (except in one case), with no patients dropping out.

One patient presented an iterative rupture of the transplant at 7 1/2 months post-op, and was revised with a patellar tendon procedure (KJ). The one-year review did not, therefore, take place.

Subjective IKDC scores increased from 71.31 ±12 [85-4.,6] pre-operatively to 92.45 ±7.38 [99.9-72.4] at 1 year post-op.

Objective IKDC scores were A for 26 patients post-operatively, B for 3 patients, with one IKDC score D (the iterative rupture).

The average differential laxity between the healthy knee and pathological knee was 5.15 mm ±2.63 [10mm-1mm] pre-operatively and 1 mm ±1.21 [4mm-0mm] post-operatively. On the KT-1000, average anterior shifting reduced from 3.52 mm to 0.87 mm and the passive displacement of the quadriceps dropped from 2.68 mm to 1.3 mm.

The SF36 score increased from 71.27 ±10.24 [95-41] pre-operatively to 87.27 ±10.24 [98-51] at one year post-op.

From a functional point of view, the average inpatient stay was 5 nights and quadriceps contraction was recovered at 2.5 days on average. Patients were discharged with a pain level evaluated on average at 1.4 with 42 % of patients judging their progress to be excellent and 52% good. The brace was removed on average at 3 days post-op, crutches no longer required at 25 days and driving a car possible at 26.33 days, following an average of 11.7 physiotherapy sessions. Average time off work was 66 days and the number of physiotherapy sessions was 32.5.

Isokinetic assessment identified a 19.6% deficit in the quadriceps and 6.10% in the hamstring at 6 months, regressing to 9% for the extensors and under 5% for the flexors at 1 year.

From an echographic point of view, impact on the muscle body of the semitendinosus harvested was low. At 45 days post-op, lesions were present on the muscle body. None of the lesions observed were recent and patients did not present any symptoms. There was no impact on the IKDC and SF36 scores.

At 4 months post-op, several lesions remained. No lesions were found at 1 year post-op.

Retraction of the semitendinosus muscle body compared with the healthy side was 5.45 cm ±2.3 [10cm-1cm] on average, at 45 days post-op, with little change between day 45 and 4 months post-op. It stabilised at 7 cm ±3.3 [14cm-1cm] at one year post-op.

The tendon transplant harvest and muscle retraction zone, measured using the popliteal fossa as a reference (distance between the muscle and popliteal fossa), was 11 cm ±2.75 [4cm-16cm] on average, and did not change much between the echographic scans at 45 days and one year after the operation.

Appearance of the transplant harvest zone: there were changes in the appearance of the harvest zone or “muscle sheath” between the various scans. In this harvest zone, a fibrillar structure was observed in 21% of cases at 45 days post-op and in 47% of cases at 4 months. This fibrillar structure was filling the “shaft” in 74% of cases at one year post-op and in the large majority of cases ended under the joint space in contact with the medial gastrocnemius.

From a tomodensitometric point of view, the tibial tunnels had enlarged more, with the majority of enlargements apparently having occurred during the first 6 months post-op and not having worsened after that point.


We will discuss our clinical, functional and radiological results together, with published bibliographical references.


Our study would appear to confirm the advantages of using a single hamstring, with this method of fixation, at 1 year post-op. This work is still an intermediary report on our results, as our final series will include 50 cases and will be published.

Double-bundle ACL results

Nicolas Lefevre - Paris

Anatomic reconstructions of ACL with double bundle graft: Study of the diameter of AM and PL bundles in two surgical techniques.

Auteurs: Nicolas Lefevre, Serge Herman

Anatomic reconstructions of ACL with double bundle graft: Study of the diameter of AM and PL bundles in two surgical techniques.

Reconstruction of the anterior cruciate ligament (ACL) using the double bundle technique is an anatomic ACL repair. Nevertheless, this reconstruction is not always possible, due to the variability of the transplant quality: the length and diameter may be insufficient. In the double-bundle semitendinosus-gracilis repair technique, the diameter of the posterolateral (PL) bundle is sometimes less than 6 mm and the anteromedial (AM) bundle sometimes less than 7 mm. The FH Orthopedics™ TLS® double-bundle technique systematically allows higher-calibre grafts to be obtained.

Equipment and methodology:

We operated on 15 patients with a complete ACL rupture, using the standard TLS® technique for each bundle. The gracilis tendon and semitendinosus tendon were used to perform two short closed-loop 4-strand grafts measuring 45 to 50 mm. A retrograde arthroscopic technique allowed the 4 tunnels to be created with precision. The graft was secured using textile tapes which were passed through the tunnels and locked using 4 titanium screws, with the knee in extension for the PL and at 45° for the AM. We measured the diameter of each bundle.
The results were compared with 15 patients operated on using the semitendinosus-gracilis double-bundle technique with femoral Endobutton® and tibial screws.


Neither group had any per- or post-operatory complications.
The average diameter of the PL bundle was 6.2 mm for the Endobutton group and 7.9 mm for the double TLS group (p< 0.001). The average diameter of the AM bundle was 7.4 mm for the Endobutton group and 9.2 mm for the double TLS group (p< 0.001). The diameter of each bundle using the TLS technique is therefore significantly larger than the check group. There was no conflict in the femoral notch and no post-operative extension deficit.


The TLS technique has already displayed excellent results in single-bundle reconstruction of ACL ruptures. The double-bundle TLS technique allows a quality and high-calibre transplant to be obtained in all cases, regardless of the semitendinosus-gracilis harvest.
The long-term results should confirm the effectiveness of this double-bundle technique.

Clinical evaluation of a continuous series of anterior cruciate reconstructions. Anatomic double-bundle TLS  technique: preliminary results.

Nicolas Lefevre/Serge Herman

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Analyse and provide preliminary results for a continuous prospective series of ACL repairs using FH orthopedics™ TLS double-bundle semitendinosus-gracilis reconstruction.

Equipment and methodology:

WE operated on 47 patients between May and December 2008, 42 males and 5 females. The average age of the series at the time of the operation was 27.8 years (15 to 44 years). Our study only included complete and isolated ACL ruptures with no associated ligamentary lesions. We used the same TLS® double-bundle technique for each patient. The semitendinosus and gracilis tendons were used to perform two short closed loop, 4-strand grafts, 45 to 55 mm in length. A retrograde arthroscopic technique enabled us to drill the 4 tunnels with precision. The graft was secured using fabric tapes, secured using 4 titanium screws, with the knee in extension for the PL and at 45° for the AM. We assessed the clinical results using the Lysholm score, IKDC (International Knee Documentation Committee) score, manual Lachman test and pivot shift test. We took a laxity measurement using the radiological TELOS technique.


There were 25 meniscal or bimeniscal lesions out of 47 cases (53% of knees operated on). 17 were internal meniscus lesions (36%), 3 were external meniscus lesions (6%), and 5 were bimeniscal lesions (10%). We carried out 12 menisectomies (25%), 8 conservative treatments (17%) and 5 meniscal sutures (10%). We encountered 2 complications: a sepsis at 3 weeks post-op, treated by lavage and prolonged antibiotic treatment (staphylococus epidermidis) and one algodystrophy of the knee with stiffness at 3 months requiring mobilisation under GA. There were no cases of Cyclops syndrome and no extension deficit.

With an average follow-up of 9.6 months (6.3 to 13.4 months), only 19 files were useable, notably with pre- and post-op Telos assessments. The Lysholm score increased from 65.6 to 92.8 post-op. The IKDC score at the latest follow-up was 66% group A, 24% group B, 8% group C and 2% group D. The manual Lachman-Trillat test was negative in 77% of cases, positive grade 1 in 21% of cases and grade 2 in 2 % of cases. The pivot shift test was negative in 91% of cases, grade 1 in 7 % of cases and grade 2 in 2% of cases. The result of the Telos assessment at 15 kg revealed an average differential of 2.9 mm (0 to 7 mm). We had one traumatic rupture of the graft at 7 months post-op, following a fall down stairs. The patient was revised with a KJ-Lemaire.


The TLS double-bundle reconstruction technique is a reliable and repeatable technique for any patient and any hamstring transplant. Short-term results are good. Long-term results should confirm the effectiveness of this double-bundle technique.

TLS ACL Reconstruction, the Finnish Experience

A. Harilainen, MD, Assoc. Prof. - ORTON Hospital, Helsinki, Finland

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Background: The use of hamstring grafts in ACL reconstruction has increased with less interest focused in traditional BTB graft technique. The optimal fixation method has not been determined and new devices for graft fixation and reconstruction methods are released to clinical use with variable clinical follow-up data.

Hypothesis: The new fixation method, Tape Locking Screw (TLS) has clinical results comparable with other techniques currently used.

Study Design: Prospective clinical follow-up of ACL reconstruction with hamstring graft and TLS fixation.

Methods: To date (30.6.2009) 40 cases of ACL reconstruction in 20 female and in 20 male patients using semitendinosus tendon with TLS fixation are available. The median age of the patients was 33 years (range, 16 to 64 years). There were 36 primary and 4 revision procedures. In 10 cases there was also a torn ACL in the contralateral knee (reconstructed or untreated). The evaluation methods were clinical examination, knee scores and instrumented laxity measurements (1 year postoperatively).

Results: 9 patients have reached the 1-year follow-up, 11 and 10 patients have been seen 6 and 3 months postoperatively, respectively. There was an infection of the operated knee in one case with good healing after arthroscopic lavage and antibiotic treatment. Before 1 year follow-up a failure of the reconstruction was noted in one case (already second time revised). A major technical failure (posterior blow-out) occurred in one case with unknown end result so far. In three cases (in one case 1 year follow-up and in two cases (6 months follow-up) a grade one + Lachman test was observed with the rest of the cases being stable. KT 2000 laxity measurements (1 year postoperatively) were available in 6 cases (bilaterals excluded) and the mean preoperative side-to-side laxity difference of 4 mm had diminished to 2.4 mm (p=0.0422). Preoperative mean Lysholm knee score (69) had increased to 90 (p=0.0030) and the corresponding mean Tegner activity level had improved from 2.2 to 5.2 (p=0.0011).

Discussion: The follow-up is too short in order to make definitive conclusions of the results of this novel technique. TLS technique differs from all other fixation methods with the fixation being in the tapes at both ends of the graft. The graft is not interfered by the fixation material therefore having a possibility to 360 degrees incorporation in the bone socket.

Conclusions: Short follow-up does not reveal any alarming signs of the reconstruction method but strict monitoring is needed to make definitive conclusions.

Key Words: anterior cruciate ligament reconstruction; hamstring tendon autograft ; prospective ; tape locking screw; clinical outcome

Double bundle ACL reconstruction using 4 tunnels technique and two different fixation systems.

Jacek Kaczmarczyk M.D. Ph.D., Marcin Sergiew Jr.

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Objective: The aim of this retrospective study was to describe early results of primary double bundle ACL reconstruction using 4 tunnels technique and two different fixation systems: SMITH&NEPHEW implants and TLS system.

Methods: From 2007 to 2009 44 patients were involved in the study. Patients with total ACL rupture were included in the study. Patients with multi-ligament injuries were excluded from the study. All patients involved in the study were treated with primary double bundle ACL reconstruction using 4 tunnels technique and two different fixation systems.

Patient were randomly divided into two groups(group1 and group2). Group1 was 23 patients and they were treated using SMITH&NEPHEW implants. Group2 was 21 patients and they were treated using TLS system. 18 patients (11 in Group1 and 7 in Group2) had associated meniscus lesions in both groups which were treated with meniscectomy at the same surgery.

Patients were assessed before the operation and at the final follow up with Lysholm Knee Scale. The duration of follow-up was at least 6 months.

Results: The results in Lysholm Knee Scale were 48–56/100 in group1 and 46-58/100 in group2 before the procedure. The results in Lysholm Knee Scale were 88-96/100 in group1 and 86 – 98/100 in group2 at the final follow-up. There was no statistical difference between group1 and group2 (p=0.29) at the final follow-up.

We belive that SMITH&NEPHEW implants and TLS system are a valuable options for primary double bundle ACL reconstruction using 4 tunnels technique.

Key words: total ACL rupture, double bundle reconstruction

After 10 years of KENNETH JONES, followed by 10 years of semitendinosus-gracilis, I have now switched to TLS. Why?

JJ Lallement - Polyclinique Montier la Celle. 10120 Saint André près Troyes

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The KJ:  :

  • The Kenneth Jones is the ideal, the Gold Standard.


  • Bone-tendon-bone harvesting is invasive and leads to post-operative pain, in some cases severe.

  • It is a difficult operation to rehabilitate from in younger subjects, especially young girls under 16 years of age, or patients over 40, with a certain risk of stiffness and algodystrophy.

  • Sensory problems on the external face of the knee are common.

  • Anterior pain is common, whether linked to a femoral-patellar syndrome or harvesting on the patellar tendon, and often lasts up to 2, 3 or even 5 years.

  • We are all familiar with tunnel enlargements which can sometime reach impressive proportions.


  • I switched to SG as we were informed it offered identical results to KJ. SG is perhaps slightly more lax, but certainly easier to rehabilitate.

  • Harvesting is less invasive and does not touch the extensor mechanism. There is therefore considerably less risk of stiffness or flexum.

  • Rehabilitation is easy and we would not hesitate to offer it to young girls under 16 or older patients – up to 60 or 65 years of age.

  • Sensory problems on the external face are practically non-existent, as long as a small, horizontal approach is made.

  • Anterior pains are rare and do not affect the patellar tendon.


  • Post-op enlargements are found on the tunnel routes.

  • We sometimes have the unpleasant surprise of finding small-calibre tendons, which only allow a small graft of less than 7 mm, even in athletic patients. There is no direct relation between the patient’s build and graft diameter.

  • Tibial fixation is sometimes the weakest link, due to cancellous, low-density bone in the tibia


  • Le TLS is attractive as post-op care is simpler than with SG. 

  • There is practically no pain, probably because the tunnels are drilled by hand, rather than with a motorised drill, thereby avoiding the creation of micro-fissures in the cancellous bone.

  • There is no brace required. Patients are able to walk immediately, with full weight-bearing.

  • Rehabilitation is therefore very easy and this type of graft can be offered to very young or older subjects..

  • The minimum graft diameter is always at least 8 mm

  • There are very few sensory problems or anterior pain as found with the SG method..

  • Bone stock loss is minimal, representing just 10 mm in the femur and 20 mm in the tibia.


  • The enlargement problem is not solved by this technique; however it only affects a very small area of the femur or tibia.

  • Short- and medium-term results are encouraging – just as good as for SG grafts. We must now wait to see the long-term results.

Day case anterior cruciate ligament reconstruction: A study of 39 patients.

S. Dojcinovic Centre Hospitalier du Haut Bugey, 1 Route de Véyziat, 01108 OYONNAX E-mail :

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Mots clés : ligament croisé antérieur, chirurgie ambulatoire, tendon de la patte d’oie.

Key-words : anterior cruciate ligament, day case, hamstring tendon

Daycase ACL reconstruction is commonly performed under general anaesthesia with a patella tendon graft. We report our experience with hamstring reconstruction under regional anaesthesia.

Over a 12-month period, 39 daycase arthroscopic ACL reconstructions were performed by one surgeon and one anaesthetist. All operations were performed under spinal anaesthesia with a femoral nerve block. Patients were discharged with oral analgesia, brace and a cryocuff.

39 patients were prospectively evaluated with a IKDC chart. 95). IKDC score was 40% A, 50% B, 8%C, 2 %D. 100% patients were happy to be discharged on the same day. 1 patient was admitted from the daycase unit for infection. A second presented a rupture of ACL reconstruction.

The mean visual analogue pain score was 1.0 at discharge, 1.8 in the middle of the first night, and 2.1 on the first post-op day. Patients experienced significantly more pain the day after surgery than the evening of surgery (p=0.04).

We conclude that hamstring ACL reconstruction under regional anaesthesia is well tolerated by patients as a daycase procedure.