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).

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)

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.

Figure 1

Tibial tunnel for ACL

Figure 2

Femoral tunnel for ACL

Figure 3

ACL graft passing

Figure 4

Bioscrew for ACL

Figure 5

Portals for PCL reconstruction

Figure 6

PCL tunnel preparation

Figure 7

Post operative knee flexion

Figure 8

Post operative knee extension

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