Bicruciate Injuries: Simultaneous Autologous Reconstructions
Bicruciate Injuries: Simultaneous Autologous Reconstructions
Abstract & Commentary
Synopsis: A retrospective, nonrandomized study of simultaneous ACL and PCL reconstructions in 15 patients with ipsilateral patellar tendon (PCL/two tunnel technique) and doubled hamstrings (ACL/bone mulch screw or endobutton fixation) grafts noted improvement in Lysholm and IKDC evaluations.
Source: Mariani PP, et al. Arthroscopy. 2001;7:700-707.
This study documents the functional outcome associated with arthroscopically assisted simultaneous ACL and PCL reconstructions for bicruciate knee injuries. Mariani and colleagues noted successful use of autograft using ipsilateral patellar tendon for the PCL reconstruction, and ipsilateral doubled hamstrings for the ACL reconstruction. Preoperative mean Lysholm scores were 65.5 with postoperative scores ranging from 88-100 with a mean of 95.1. Knee flexion at follow-up ranged from 105-135° with an average of 118°. Stability testing used posterior stress views (average 7.3mm at medial plateau), KT-2000 (9 patients with < 2 mm side- to-side difference on manual max), and anterior stress views (average, 3.3 mm). Fixation of the PCL BTB autograft used interference screw fixation; in contrast, ACL hamstring reconstructions were fixed with a bone mulch screw (12 patients) or endobutton (3 patients). Mariani et al recognized their use of autografts over allografts, but noted no negative influence on outcome. Mariani et al recommend allograft when a reconstruction of the posterolateral corner is needed or when there is injury to the extensor mechanism.
Comment by Robert C. Schenck, Jr., MD
Controversy exists over clinical decision making in the management of knee dislocations, especially when discussing timing and one’s background. Patients with multi-trauma and/or closed head injury are probably best managed initially with immobilization, and in most cases with an external fixator. Immobilization for 6-8 weeks followed by a manipulation and arthroscopic evaluation can produce remarkably stable and functional knees in a patient with an inability to participate in a postoperative rehabilitation program. Sports knee dislocations are best classified by what is torn,1 and depending upon the involvement of the posterolateral corner, early range of motion followed by simultaneous bicruciate reconstructions produce straightforward and predictable results.2 Both Wascher, Fanelli, and their colleagues, in separate reports, have shown successful use of allograft bicruciate reconstructions performed in one sitting.3,4 Mariani et al are commended for their good results in this study, but with the severity of associated injuries and the significance of postoperative morbidity, I would still tend to use allografts for a bicruciate reconstruction, and definitely for the PCL. All these investigators used 2 tunnel PCL techniques, and with the advent of PCL inlay other considerations can be made. Unfortunately, PCL inlay and simultaneous ACL reconstruction is difficult to place the ACL tibial tunnel and avoid the tibial inlay screws.
Mariani et al have demonstrated excellent postoperative results. Despite this report, the clinician should be wary of bicruciate injuries and reconstructions, and we routinely counsel our patients that they can have significant postoperative complications and may require a postoperative manipulation to avoid permanent stiffness. One last piece of advice is to carefully evaluate the dislocated knee with an examination under anesthesia (EUA) at time of reconstruction in case one of the avulsed cruciates heals adequately with initial braced range of motion.
References
1. Walker DN, et al. Am J Knee Surg. 1994;7(3):117-124.
2. Wascher D, et al. Ortho Special Ed. 2001;7(2):28-31.
3. Wascher DC, et al. Am J Sports Med. 1999;27(2): 189-196.
4. Fanelli GC, et al. Arthroscopy. 1996;24(12):5-14.
Dr. Schenck, Jr., Deputy Chairman, Department of Orthopaedics, University of Texas Health Science Center, San Antonio, TX, is Associate Editor of Sports Medicine Reports.
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