Bicruciate Lesions

James Rand, MD
13400 E Shea Blvd
Scottsdale, AZ 85259, USA
Tel: +1 480 301 8944
Fax: +1 480 301 8674

Philippe Neyret, MD
Hopital de la Criox Rousse - Centre Livet
8 Rue de Margnolles, caluire
Lyon, 69300, FRANCE
Tel: +33 472 071989
Fax: +33 472 072404

Bicruciate lesions are rare but serious. There is no internationally accepted management plan. 

In the published series, either the number of cases was limited or the follow-up was not long enough. In retrospective multi-center series, management is not homogenous. To propose a multicentric study will not solve the problem. We need to clearly identity the questions that must be answered.

In the discussion of bicruciate lesions, problems arise concerning the terminology, definition, and classification. The classical terminology "multiple ligament injury" is very confusing. It doesn't mean that the central pivot (ACL and PCL) is torn. In Europe, several authors, following Albert Trillat, differentiate between pentade and dislocation. In pentade either the medial or lateral ligamentous structures are preserved, and complications are less frequent than in dislocation. Most reports in the literature of complete dislocations are with respect to lesions of either the ACL or PCL. It is important to differentiate two types of peripheral lesions, those resulting from an opening forces which produces rupture of ligaments and those following an osteoperiosteal detachment (or stripping in the manner of a peeled banana) that demonstrate little true ligamentous ruptures. However in these cases of osteoperiosteal stripping, there may be detachment of the capsule, which can start at the level of the epiphysis and extend to the metaphysis.

It is crucial to recognise every elementary ligamentous lesion. The difficulty is not only to make the diagnosis of dislocation that is obvious when the knee is dislocated (the position of the tibia reveals the direction of the dislocation), but also to make the diagnosis after spontaneous reduction. After reduction, movement of the joint can be remarkably free of pain. There will always be considerable instability, which on occasion may allow movement in all directions (a true "flail knee"). Anteroposterior, lateral and axial radiographs are required. A lateral view taken at 20° flexion with the patient lying supine when compared to a film of the contralateral knee taken in the same position may reveal posterior translation. In severe knee injuries dynamic radiographs are essential. They can be taken either with the patient awake, under anaesthesia at the time of reduction or at the start of an operation. It is necessary to perform radiographs with the knee stressed in varus and valgus, as well as with the tibia moved inferiorly and posteriorly. Additional stress views may include medial and lateral translation of the tibia in relation to the femur. Care must be taken not to redislocate the joint. These examinations can help to distinguish between opening lesions and capsular periosteal detachments. Information gained from a MRI taken soon after injury can influence the treatment plan. The site of the rupture of an anterior cruciate ligament will be revealed. MRI is even a greater value with lesions of the posterior cruciate ligament. A MRI can also demonstrate damage of the extensor apparatus, the peripheral capsular ligamentous structures, the menisci, as well as relatively minor osteochondral fractures.

Arthroscopy may be dangerous because of extravasation of fluid from the knee, which can result in a compartment syndrome. However, some surgeons to assess posterolateral lesions use a limited arthroscopic examination.

If we wish to establish a classification, compare results of ligamentous management and make recommendations, identification of every ligamentous lesions is the keystone. However, the management plan (still being debated) of bicruciate lesions will depend not only on the ligamentous damage but also on the real or potential complications. Bicruciate lesions of the knee are over shadowed by the importance of vascular complications. Since arterial lesions are frequent (15%-32% in literature) and are often difficult to diagnose, arteriography with or without MRI is strongly recommended.

The others complications that may influence the management plan include:

- Irreducibility
- Cutaneous complications
- Osseous and osteochondral lesions
- Lesions of the extensor apparatus
- Neurologtical complications
- Veinous complications.

Of course, it is also very important to consider the age and the motivation of the patient. We have several options for management of peripheral ligamentous lesions, non-operative (plaster, external fixation, and patellar tibial fixation) or operative: suture +/+- augmentation, reconstruction, and fixation of bone block. In the selection of a management plan, it is important to consider separately ligamentous lesions produced by opening and those produced by stripping. With stripping and reduction, there is no complete rupture allowing the return of good stability. A different situation occurs with lesions resulting from opening. Every time that a ligament is avulsed with a fragment of bone, this fragment must be replaced and fixed in its original position. If the rupture is in the body of the ligament, an attempt must be made to repair the fibres, which have been torn. When the collateral ligament (particularly the lateral collateral ligament) has been completely torn apart, a graft will be required for replacement.

When there are bicruciate lesions, priority is given to reconstruction of the posterior cruciate ligament. Reconstruction of the anterior cruciate does not take priority when there is also a torn posterior ligament, as simultaneous reconstruction of both ligaments increases the risk of fixing the knee with the tibia in a posteriorly subluxated position. Therefore, there are two options: 1) reconstruction of both ligaments at the earliest possible time or 2) initial reconstruction of only the posterior ligament, with a delayed reconstruction of the anterior cruciate ligament in the future. Some recommendations concerning the timing of reconstruction were established in 1998 during the ESSKA symposium.

1/ As soon as possible reduce the dislocation and treat the arterial complications and open wounds.

2/ Between the first and twenty first days, ligament surgery can be undertaken: however this should be done earlier if there is an articular fracture or rupture of the extensor apparatus. If an operation is done too early the tissues are very oedematous and difficult to dissect.

3/ Non-operative treatment can be considered in an elderly patient or a patient who has low demands for his knee. However, it is important not to leave interposed soft tissues and to obtain a perfect anatomical reduction of the knee.

These lesions are rare, severe and there management controversial. What a wonderful subject for an ISAKOS conference in the future: How to safely manage Bicruciate lesions.

References
Chambat P. Symposium LCP. Rev. Chir. Orthop 1995 ; 81 (suppl II):72

Dejour H. Entorses graves du genou. In : Cahiers d'enseignement de la SOFCOT, Paris : Expansion scientifique française, 1989 ; n° 34 :81-87

Green NE, Allen BI. Vascular injuries associated with dislocation of the knee. J. Bone Joint Surg Am 1977; 59:236

Merril KD. Knee dislocations with vascular injuries. Orthop Clin North Am 1994; 25:707-713

Neyret Ph., Lobenhoffer Ph, ESSKA symposium on pendade and knee dislocation. 8th Congress of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy, Nice, April 29-May 2, 1998.

Neyret Ph., Trojani Ch. Aït Si Selmi T., Versier G., Acute Multiple knee ligament injuries and dislocations in emergency, Ed. Scientifiques et Médicales Elsevier SAS (Paris) Surgical Techniques in Orthopaedic and Traumatology 55-530-E-10, 2000, 6p.

Reckling F., Peltier L., Acute dislocations and their complications. J. Trauma 1969 ; 9 : 181-191.

Trickey EL. Injuries to the posterior cruciate ligament. Diagnosis and treatment of early injuries and reconstruction of late instability. Clin Orthop 1980; 147 / 76-81.