Summary

The results showed the effectiveness and safety of simultaneous ACL and PCL reconstruction using ‘hybrid’ tendon autografts of combined ligamentous injuries of the knee that can adequately restore satisfactory stability.

Abstract

Introduction

Combined rupture of both ACL and PCL often results in significant functional disability and requires surgical treatment. However, the treatment strategy for combined ligamentous injuries of the knee remains controversial. Because achievement of normal anterior-posterior (A-P) laxity and normal range of knee motion is often difficult. We have treated the multiple knee ligament injuries with both ACL and PCL ruptures using ‘hybrid’ tendon autografts, which is composed the multistrand tendons and polyester tapes (KSSTA 2008). The purpose of this study is to clarify clinical outcomes of our surgical treatment for the multiple knee ligament injuries with both ACL and PCL ruptures.

Methods

Between 2000 and 2017, 36 patients (36 knees) who sustained the multiple knee ligament injuries with both ACL and PCL ruptures were enrolled in this study. There were 32 men and 4 women with a mean age of 30 (16–60) years at the time of surgery. 5 patients were surgically treated during the acute phase, and the remaining 31 patients were treated in the chronic phase. In the acute cases, we selected the two-stage procedure. First, we performed repair of the grade III medial or posterolateral structures or avulsion fracture. Simultaneous ACL and PCL-reconstruction (R)s were performed in the second stage. In the chronic cases, we performed simultaneous ACL and PCL reconstructions. 14 cases required both ACL and PCL-Rs using the semitendinosus (Semi-T) and gracilis tendons hybrid autografts, and the others had the following additional ligament reconstruction associated with ACL and PCL-Rs according to our previous reported techniques (Arthroscopy 2004, KSSTA 2008, AJSM 2013); 12 of cases required the superficial MCL-R using the Semi-T tendon hybrid autograft, and 5 cases required posterolateral corner-R using biceps tendon hybrid autograft. The patients were examined at more than 2 years after surgery. This study design had been accepted by the institutional review board clearance in our hospital. Statistical analyses were made using a Student t-test. The significance level was set at p=0.05.
Result: At the last follow-up, 3 patients who had the common peroneal nerve palsy showed functional recovery. No patients showed a loss of knee extension more than 5°, while 4 patients revealed a loss of flexion more than 15°. The side-to-side difference in the A-P translation measured at 20° and 70° averaged 2.2 (SD, 1.9) mm and 2.3 (2.8) mm, respectively. Varus and valgus, A-P stress radiographs showed no significant differences in comparison with that of the uninjured knee. The Lysholm score averaged 90.1 (10.2) points. In the International Knee Documentation Committee (IKDC) evaluation, 16, 14, and 6 patients were graded as A, B, and C, respectively. 3 patients who had acute intraarticular infections were treated by synovectomy and continuous irrigation treatment without the graft removal.

Discussion

The results showed the effectiveness and safety of simultaneous ACL and PCL reconstruction using hybrid tendon autografts of combined ligamentous injuries of the knee that can adequately restore satisfactory stability. However, in the IKDC rating, 6 patients were abnormal, and some of them had post-operative infections and loss of knee flexion. Since the infections were due to long operative time, the surgical technique will be needed to reduce the operative time. Since a loss of range of knee motion had existed before surgery in chronic cases, the initial treatment and rehabilitation in the acute stage after injury are of critical importance for the following surgery.