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Received : 26-10-2020

Accepted : 30-12-2020

Available online : 06-04-2021



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Shivanna and Dinesh K M: Simultaneous arthroscopic reconstruction of anterior cruciate ligament and posterior cruciate ligament: An outcome analysis


Introduction

Knee joint is subjected to many injury patterns involving osseous structures and ligaments. Combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injury is rare. There are few studies in the literature related to this topic. It is important to manage these injuries with great accuracy as it may involve damage to neurovascular structures associated with knee dislocation.1, 2, 3, 4 Though there are studies advocating non operative management of these injuries5, 6, there are also evidence suggesting operative management with better outcomes.7, 8 The objective of our study is to examine the outcomes in the management of combined ACL and PCL injuries.

Materials and Methods

Ours is a prospective study evaluating the outcomes of combined ACL and PCL injuries in 20 patients at our centre who were managed arthroscopically between 2014 to 2018 by a single surgeon. Preoperative and post-operative lyscholm scores and IKDC scores were assessed to evaluate the patient’s outcomes. Patients were evaluated clinically during their follow up visits and for those who could not come for follow up, data was collected over phone. Statistical analysis was done and p value calculated to assess the statistical significance between the comparative data.

Results

In our study we evaluated the functional outcome of the simultaneous arthroscopic ACL and PCL reconstruction in patients who had both ACL and PCL injuries. Out of 20 patients who were operated, 14 patients were in the age group of 21-40 years (Table 1) and 18 out of 20 were male population (Table 2).

Table 1

Distribution of sample by age

Age group

Frequency

Percentage %

<20

3

15

21-30

8

40

31-40

6

30

41-50

0

00

51-60

3

15

>60

0

00

Total

20

100

Table 2

Distribution of sample by gender

Gender

Frequency

Percentage

Male

18

90

Female

2

10

Total

20

100

Road traffic accidents (RTA) accounted for 75 % of the incidences and was the most common mechanism of injury. Domestic fall accounted for 2 cases and sports related injury contributed to 3 cases out of 20 cases. (Table 3)

Table 3

Mechanism of Injury

Mechanism

Frequency

Percentage

RTA

15

75

Domestic fall

2

10

Sports

3

15

Total

20

100

Out of 20 patients operated for ACL plus PCL injury, 14(70%) of them had had excellent to good results and rest 6 had fair result with none of the patient reporting poor result (Table 4). Comparative analysis was done between pre surgery and post-surgery lyscholm score and we found that there was a statistically significant difference between them with p value <0.0001(Table 6). The mean post-operative lyscholm score for our patients was 89.1 and the mean IKDC score was 84.7.

Table 4

Distribution of sample based on functional outcome

Functional outcome

Frequency

Percentage

Excellent (95-100)

6

30

GOOD (84-95)

8

40

FAIR (65-83)

6

30

POOR <64

0

0

Total

20

100

Table 5

Comparision of pre-op and post-op IKDC scores

Mean

SD

Variance

Pre-op IKDC

30.6

5.361

28.74

Post-op IKDC

84.7

4.506

20.30

Table 6

Comparision of pre-op and post-op Lyscholm scores

Mean

SD

Variance

Difference

Std error

95% CI

“t” statistic

P Value

Pre-op Lysholm

35.7

5.506

30.32

53.4

1.938

49.4 to 57.3

27.5

<0.0001

Post-op Lysholm

89.1

6.695

44.83

Figure 1

Tibial tunnel for ACL

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Figure 2

Femoral tunnel for ACL

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/d754b88f-f94e-4b19-b48b-de1c6a49195a/image/6646b249-45ab-44aa-bb6a-606fad7db940-uimage.png

Figure 3

ACL graft passing

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/d754b88f-f94e-4b19-b48b-de1c6a49195a/image/bf878ce0-a959-4a8f-a9bc-21a3bd8f53f3-uimage.png

Figure 4

Bioscrew for ACL

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/d754b88f-f94e-4b19-b48b-de1c6a49195a/image/2665e545-dd87-4ed3-a316-8706e76a713b-uimage.png

Figure 5

Portals for PCL reconstruction

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/d754b88f-f94e-4b19-b48b-de1c6a49195a/image/676518d9-4768-4d52-bf23-32450f88cef5-uimage.png

Figure 6

PCL tunnel preparation

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/d754b88f-f94e-4b19-b48b-de1c6a49195a/image/74015772-6c8d-4240-86d0-edcc71d37b36-uimage.png

Figure 7

Post operative knee flexion

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/d754b88f-f94e-4b19-b48b-de1c6a49195a/image/6f2063f7-9c75-415b-b25c-9cba9366d582-uimage.png

Figure 8

Post operative knee extension

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/d754b88f-f94e-4b19-b48b-de1c6a49195a/image/c2dafbb4-1108-452c-9fd3-9243a6a7357e-uimage.png

Discussion

Combined ACL and PCL injuries are one of the rare knee injuries when neglected can lead to early degenerative changes in the knee. With advancement in the arthroscopic techniques, simultaneous reconstruction of ACL plus PCL has become possible these days. In our current study, we have arthroscopically managed 20 cases of ACL plus PCL injury through arthroscopic reconstruction using hamstring and sometimes BPTB grafts. It has been proven that surgical management is superior to conservative treatment as mentioned in few of the previous studies by Robertson A et al., Liow RY et al., Taylor AR et al., Wong CH et al.4, 8, 9, 10 In our management technique, we have always used autograft because of nonavailability of allografts and also to reduce the risk of disease transmission. Moreover autografts also has advantages of earlier incorporation.11 The average age of our patients was 31.6 years with majority of them in the age group of 21- 40 years which indicates that this injury pattern is common among active adult population. This is similar to findings in other similar studies dealing with combined ACL and PCL injury.3, 12 Our study also noted that RTA was the most common mechanism of injury and this too is similar to findings in other similar studies by Mariani et al., and Lo YP et al.3, 12 Coming to the functional outcomes, the average Lyscholm score post-surgery in our patients was 89.1 and the average IKDC scores was 84.7. There is a statistically significant difference in the functional outcome based on this scores with p value <0.0001 compared to its pre operative scores. This is in consensus with study conducted by Lo YP et al. and Mariani et al. From our study we also noticed that both early and late surgery for this combination of injury showed equally good results in relation to stability depending upon the extent of damage to the cartilage.

Conclusion

Simultaneous ACL and PCL reconstruction using arthroscopic technique is an effective and safe procedure irrespective of the time since injury and also this is more helpful to achieve early rehabilitation and to cut short the number of days of hospital stay and repeat surgery that the patient has to undergo if reconstructed in a staged manner. This also brings down the hospital expenses of the patient.

Source of Funding

None.

Conflict of Interest

The authors declare that there is no conflict of interest

References

1 

R Panigrahi AK Mahapatra A Priyadarshi DS Das N Palo MR Biswal Outcome of Simultaneous Arthroscopic Anterior Cruciate Ligament and Posterior Cruciate Ligament Reconstruction With Hamstring Tendon Autograft: A Multicenter Prospective StudyAsian J Sports Med20167110.5812/asjsm.29287

2 

CJ Peskun DB Whelan Outcomes of operative and non operative treatment of multiligament knee injuries: an evidence-based reviewSports Med Arthrosc Rev201119216773

3 

YP Lo KY Hsu LH Chen CJ Wang WL Yeh YS Chan Simultaneous arthroscopic reconstruction of the anterior and posterior cruciate ligament using hamstring and quadriceps tendon autograftsJ Trauma20096637808

4 

A Robertson RW Nutton JF Keating Dislocation of the kneeJ Bone Jt Surg Br20068870611

5 

CD Harner RL Waltrip CH Bennett Surgical management of knee dislocationsJ Bone Joint Surg20048626273

6 

AR Taylor GP Arden HA Rainey Traumatic dislocation of the knee: a report of forty-three cases with special reference to conservative treatmentJ Bone Joint Surg [Br]19725496102

7 

J Werier JF Keating RN Meek Complete dislocation of the knee — the long-term results of ligamentous reconstructionKnee1998542556010.1016/s0968-0160(98)00015-5

8 

RYL Liow MJ. McNicholas JF Keating RW Nutton Ligament repair and reconstruction in traumatic dislocation of the kneeJ Bone Joint Surg200385-B68455110.1302/0301-620x.85b6.13972

9 

A R Taylor G P Arden H A Rainey Traumatic dislocation of the knee. A report of forty-three cases with special reference to conservative treatmentJ Bone Joint Surg Br197254196102

10 

CH Wong JL Tan HC Chang LW Khin CO Low Knee dislocations-a retrospective study comparing operative versus closed immobilization treatment outcomesKnee Surg Sports Traumatol Arthrosc20041265404

11 

SL Kan ZF Yuan GZ Ning B Yang HL Li JC Sun Autograft versus allograft in anterior cruciate ligament reconstruction: a meta-analysis with trial sequential analysisMedicine2016954936

12 

PP Mariani F Margheritini G Camillieri One-stage arthroscopically assisted anterior and posterior cruciate ligament reconstructionArthroscopy2001177700710.1053/jars.2001.25335



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