Multiligamentous knee injuries (MLKI) are rare but devastating injuries to patients. Surgical treatment is often recommended, and the current gold standard is reconstruction of all injured ligaments using autografts or allografts. More recently, there has been interest in primary repair of knee ligaments for proximal or distal avulsion type tears. This has potential benefits, such as no graft usage or donor site morbidity, no tunnel convergence and potentially easier recovery. The goal was to assess the outcomes of arthroscopic primary repair and reconstruction of cruciate ligaments.
A retrospective analysis was performed of all patients with bicruciate knee dislocations undergoing surgical treatment of both ligaments. Proximal or distal avulsed ligaments were repaired, and midsubstance tears underwent primary reconstruction using various grafts. Minimum follow-up was 6 months for physical examination and 2 years for patient-reported outcomes.
Twenty-eight patients were included with age of 32 ± 13 years, 64% male, delay from injury to surgery of 4 ± 7 weeks, BMI of 27 ± 5, and mean follow-up 3.7 ± 2.9 years. Schenck classification was 11% KD-2, 64% KD-3M, 25% KD-3L, 18% had peroneal nerve damage and 7% had poplitear artery damage requiring arterial bypass and external fixation.
Fourteen patients (50%) underwent both ACL and PCL repair, 7 patients (25%) underwent ACL reconstruction with PCL repair and 7 (25%) underwent bicruciate reconstruction. PCL repair resulted in grade 0 posterior drawer in 24% of patients, grade 1 in 57%, and failure (grade 2 or 3 or rerupture) in 19%; PCL reconstruction resulted in 57% of patients in grade 0, 29% grade 1, and 14% failure. ACL repair had grade 0 Lachman and anterior drawer in 83% and failure in 17%, ACL reconstruction had grade 0 in 71% and failure in 29%.
Overall, patients reported good patient-reported outcomes with Lysholm 91±12, modified Cincinnati 84±16, SANE 83±13, Forgotten Joint Score 70±27, ACL-RSI 63±28, preinjury Tegner 6.8±2, and postoperative 5.1±1.6, IKDC subjective 80±14, VAS pain 1.3±2.1.
Bicruciate MLKI are devastating injuries with high morbidity and requiring multiligament reconstructions. Primary repair of distally or proximally avulsed cruciate ligaments is not commonly performed in the literature but could be considered given the high number of grafts and tunnels that are needed in these patients and equivalent failure rates in these patients compared to the current gold standard of ligament reconstruction.
In this heterogeneous group of patients with bicruciate knee dislocations, outcomes of primary repair were not inferior to reconstruction in terms of failure rate and patients reported outcomes similar to the literature. Primary repair of avulsed cruciate ligaments could be considered in patients with multiligamentous knee injuries, although PCL reconstruction seemed to better fully restore the posterior drawer, as more patients had a posterior drawer of <3mm compared to 3-5mm.