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Simultaneous arthroscopic ACL and PCL reconstruction using allograft Achilles tendon
Journal of Clinical Orthopaedics and Trauma 10 (2019) S218eS221
Contents lists available at ScienceDirect
Journal of Clinical Orthopaedics and Trauma journal homepage: www.elsevier.com/locate/jcot
Simultaneous arthroscopic ACL and PCL reconstruction using allograft Achilles tendon Mohsen Mardani-Kivi a, *, Mahmoud Karimi-Mobarakeh b, Keyvan Hashemi-Motlagh c a
Orthopedic Department, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Department, Kerman University of Medical Sciences, Kerman, Iran c Orthopedic Department, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 21 October 2018 Received in revised form 23 December 2018 Accepted 2 January 2019 Available online 2 January 2019
Background: Multi-ligamentous injuries to the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) are uncommon but debilitating injuries. They mostly lead in functional disabilities and further surgeries. Hypothesis: The aim of the present study was to evaluate the outcomes of simultaneous arthroscopic reconstruction of ACL and PCL using allograft Achilles tendon. Study design: Case-series study. Materials and methods: This study was performed on patients with combined ACL-PCL injuries which attended for treatment to a referral center from January 2010 to January 2014. All of them underwent simultaneous arthroscopic reconstruction of ACL and PCL using allograft Achilles tendon. Range of motion (flexion and extension loss), giving way, anterior and posterior knee stability, proximal tibia step off, subjective assessment of knee function and patients satisfaction were evaluated at 3, 6, 12, 24 months and final follow-up. Data were analyzed by SPSS version 21 with consideration of P < 0.05 as significant difference. Results: Among 28 included patients, 21 patients (75%) were male. Mean age of patients was 30.86 ± 7.25 years (range: 18e49 years). The mean follow-up time was 35.7 ± 6.8 months (range: 26e50 months). Our results demonstrated that knee function, stability, and range of motion were improved along the followup periods. At final follow-up none of the patients had giving way and all of them were completely satisfied from the surgery. Conclusion: Simultaneous reconstruction of injured cruciate ligaments using allograft Achilles tendon resulted in appropriate functional outcomes and acceptable range of motion. Level of Evidence: IV © 2019 Delhi Orthopedic Association. All rights reserved.
Keywords: Allograft Simultaneous reconstruction Anterior cruciate ligament Posterior cruciate ligament
1. Introduction Multi-ligamentous injuries to the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) are uncommon but debilitating injuries and involved patients complained from severe pain and lack of knee stability which affect their daily activities and exercise.1,2 This type of injury often causes functional problems and requires surgery for treatment.3 With development of arthroscopic reconstruction, it is considered as an effective and safe method for reconstruction of both ACL
* Corresponding author. Orthopedic Department, Guilan University of Medical Sciences, Poursina hospital, Parastar St., Rasht, Iran. E-mail address: [email protected] (M. Mardani-Kivi). https://doi.org/10.1016/j.jcot.2019.01.001 0976-5662/© 2019 Delhi Orthopedic Association. All rights reserved.
and PCL, but there are certain disagreements about time of surgery, graft type, rehabilitation after surgery and simultaneous or two steps reconstruction.4e6 Another important issue in ACL and PCL reconstruction is graft type. Different grafts such as patellar tendon, hamstring tendon,7 and allografts are used for simultaneous ACL and PCL reconstruction. Use of allografts is preferred by most of surgeons due to more effectiveness, lack of donor site morbidity, shorter surgery time and more stability. However, some problems such as financial burden, the possibility of infection transmission and delay in reconstruction are also existed for this type of graft. Therefore, it cannot say that what graft is better for reconstruction of injured ligaments.4 The aim of the present study is to evaluate the outcomes of simultaneous arthroscopic reconstruction of ACL and PCL using allograft.
M. Mardani-Kivi et al. / Journal of Clinical Orthopaedics and Trauma 10 (2019) S218eS221
2. Material and methods 2.1. Patients This case-series study was performed on patients with combined ACL-PCL tears which attended for treatment to a referral center from January 2010 to January 2014. All 28 included patients were operated by one surgeon (first author). All patients were under physiotherapy for 8 weeks. Range of motion (ROM) of knee was near normal and removed from acute mode. Magnetic resonance imaging (MRI) was used for diagnosis of concurrent lesions of ligaments and meniscus. 2.2. Surgical technique After pre-operative procedures, simultaneous arthroscopic reconstruction by allograft Achilles tendon and using of Endobutton in the femoral side and 3 Bio-interference screws (1 screw for ACL and 2 screws for PCL) in the tibial side was performed. Achilles tendon was divided longitudinally into two halves for applying in ACL and PCL independently. Standard anthrolateral and antromedial portals for ACL reconstruction and these two portals plus auxiliary posteromedial portal for PCL reconstruction were used. The minimum distance of tibial canal input to joint surface was 20 mm in PCL reconstruction. Patients who were not agreed nor had not appropriate medical conditions to participate in the study were excluded. Patient's concomitant comorbidities were also managed intraoperatively. It means that rupture of posterolateral corner (PLC) was reconstructed by modified Larson method. Meniscal repair or partial meniscectomy were performed based on the condition of the meniscus. In case of any chondral lesions, chondroplasty by shave, drilling and microfracture was done during the main surgery. Treatment of medial collateral ligament (MCL) was done nonoperatively. 2.3. Rehabilitation program Rehabilitation program was started at the 2nd post-operative day for all patients equally under direct supervision of physiotherapist. In this program, passive movements between 0 and 40 were started at the first post-operative week for all knees and gradually increased to 90 by the end of the 2nd post-operative week. For better recovery, end of extension was done with stretching and passive movements. As much as weight-bearing which could tolerated by patients was started at the 2nd postoperative day. Brace in the full extension was used to walking in the first month. If possible, walking in water was started after the 2nd post-operative weeks and along with it, hamstring and quadriceps femoris related strengthening exercises were started. Light exercises were allowed 2 months after surgery and hard exercises based on the conditions of hamstring and Quadriceps femoris muscles were allowed 6 months after surgery at appropriate time. 2.4. Follow-up evaluation Patients were followed at 3, 6, 12, 24 months' post-operation and at final follow-up. In these follow-ups, ROM (flexion and extension losses) and giving way were monitored. Lachman and Posterior Drawer tests were also performed by surgeon for evaluation of anterior and posterior knee stability and their results were recorded as score of 0 to þ3. ROM of knee was measured using arthrometer KT-1000. Proximal tibia step off of patients was measured and expressed as millimeter. For subjective evaluations of patient's knee function, Subjective Lysholm Knee Score (S-LKS)
S219
and subjective International Knee Documentation Committee (IKDC) score were used. Visual analogue scale (VAS) was used for assessment of patient's satisfaction subjectively in which 0 means lack of satisfaction and 10 means complete satisfaction. 2.5. Statistical analysis Qualitative data were expressed as frequency and percentage and quantitative data were presented as mean and standard deviation (SD). Friedman test was used to evaluate the trend of proximal tibia step off (PTS) change during follow-ups. Wilcoxon test was used for binary comparison of changes in the PTS, Lysholm and IKDC between two different follow-up times (Due to lack of normal distribution of IKDC and Lysholm based on Kolmogorov-Smirnov test). All statistical analyses were performed using SPSS version 21 and P < 0.05 was considered as significant difference. 3. Results Among 28 included patients, 21 patients (75%) were male and 7 patients (25%) were female. Mean age of patients was 30.86 ± 7.25 years (range: 18e49 years). The mean follow-up time was 35.7 ± 6.8 months (range: 24e50 months). All patients were participated in all follow-ups except 2 patients who were not available at the final follow-up. Ten cases had no concomitant lesions, and in the other 18 patients there were 24 comorbidities (Table 1). In pre-operative ROM assessments, 4 patients had flexion and extension loss with the mean of 5 and it was existed until 6-month follow-up. However, normal ROM was seen in all patients at 12month follow-up remained until the final follow-up. Twenty-two patients (75%) had giving way before surgery, which decreased to 2 patients in 3 and 6 months' follow-ups. There was no case of giving way in 12 and 24 months and final follow-ups. Knee stability was evaluated based on Lachman and Posterior Drawer tests. Knees of all patients were instable before surgery. Lachman test showed that 21 (75%) and 7 (25%) patients were þ3 and þ 2 before surgery. In the 3, 6 and 12 months' follow-ups, 2 patients had þ2 and another two patients had þ1 of Lachman score. In the 24 months, only 3 patients had þ1 of Lachman score. All patients were þ3 based on Posterior Drawer test. After surgery, 2 patients (7.1%) were þ1, 1 patient (3.6%) was þ3 and another 25 patients (89.3%) had normal Posterior Drawer test at 3, 6, 12 and 24 months' follow-ups. However, 2 patients were þ1 based on Posterior Drawer test at final follow-up and all other 24 patients were returned to previous activity level as before trauma. Arthrometric assessment of patients using KT-1000 apparatus showed that 24 patients had 0e2 mm, 3 patients had 3e7 mm and 1 patient had 11 mm side-to-side difference at 3, 6, and 12 months' follow-up. In the 24 months' follow-up, 22 patients had 0e2 mm, 4 patients had 3e7 mm and 2 patients had more than 7 mm (8 and 12 mm) side-to-side difference. At final follow-up, 20 patients had 0e2 mm, 4 patients had 3e7 mm and 2 patients had more than 7 mm side-to-side difference. Significant improvement in PTS (Proximal Tibia Step off) was seen during follow-up times (P < 0.0001). Also, post-operative Table 1 Type of comorbidities in included patients. Comorbidity
N
Posterolateral corner (PLC) rupture Medial collateral ligament (MCL) rupture Meniscus rupture Chondral lesion
11 5 4 4
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M. Mardani-Kivi et al. / Journal of Clinical Orthopaedics and Trauma 10 (2019) S218eS221
Table 2 Changes of subjective IKDC and Lysholm scores. Follow-up times
Before reconstruction 3 months 6 months 12 months 24 months Final
IKDC score
Lysolm score
Mean ± SD
Median (IQR)
Mean ± SD
Median (IQR)
39.46 ± 4.98 72.86 ± 11.54 89.25 ± 11.42 84.00 ± 11.22 89.68 ± 7.37 90.62 ± 7.60
41.50 77.00 89.00 88.50 92.00 93.00
39.97 ± 4.43 75.07 ± 10.16 88.61 ± 10.63 89.54 ± 9.25 92.86 ± 6.47 93.42 ± 5.92
41.43 79.65 92.00 92.00 95.00 94.50
(38.21e42.83) (68.50e81.75) (82.00e91.00) (82.00e91.00) (90.00e94.00) (90.00e94.25)
(39.59e42.49) (72.23e82.13) (87.50e95.75) (90.00e95.00) (92.00e96.75) (92.00e96.50)
IQR, interquartile range. In the follow-up times more than 12 months, the VAS based patient's satisfaction was excellent (one patient had VAS of 1, another one patient had VAS of 2 and other patients were completely satisfied).
functional status of patients based on IKDC subjective and Lysholm scores showed significant improvement in comparison to before surgery (P < 0.0001, Table 2). 4. Discussion Most of our patients (75%) were young men with low mean age. The answer for why more men than women have suffered this type of injury is may be due to the type of men activities in the society which exposed them to such tearing cruciate ligaments traumas more than women. Perhaps the reason that they are more socially active and therefore attended to be treated. Also in the study of Ranajit Panigrahi and colleagues, 17 patients of 20 included patients were male and total mean age was 34 years.8 In the study of Hayashi et al. just one patient of 20 included patients was female and total mean age was 30.5 years.4 One of the controversial topics in the reconstruction of injured ligaments is used surgical technique. We used auxiliary posteromedial portal for reconstruction of PCL. The minimum distance of tibial canal input to joint surface was 20 mm in PCL reconstruction. Also, 2 interference screws in tibial place for PCL fixation and 1 screw for ACL fixation were used. Maybe this is the reason of our good results in patient's stability and performance of the knees. Graft selection is one of the important issues in all ligamentous reconstruction setting. We utilized allograft Achilles tendon in our study for reconstruction of ACL and PCL due to some advantages such as the lack of donor site morbidity, reduction of operating time, and the strength of the large grafts. However, some disadvantages such as higher cost and risk of infection are also existed for allograft.8 About the cost, it can say that although patients who use autograft do not pay the cost to purchase the graft, some of them experienced physical limitations. Therefore, they cannot participate in the physiotherapy and follow-up sections. As a result, they will have absenteeism and they will accept more scathe. While our patients which used allograft were passed rehabilitation courses and returned to activity level as before trauma faster. In addition, higher inactivity rate in these patients increases the possibility of inactivity complications which is important and must be avoided. Another problem of allografts is the risk of transmission of infection such as HIV and hepatitis to patients who used them. We monitored all patients until final follow-up for this issue and evidences of the occurrence of infection were seen in none of them. However, it cannot be said certainly that allograft causes infection transmission or not. It is suggested that this issue is more considered in the future studies. Another controversial topic in reconstruction of injured ligaments which orthopedists don't come to a consensus on it is the simultaneous or two steps reconstruction. We reconstructed ACL and PCL simultaneously and as our results showed in the final follow-up, all patients had recovered their knee stability, 23 of 26 patients (88.4%) returned to activity level as before trauma, had not
giving way, returned to normal knee status and were satisfied about their surgery. Simultaneous reconstruction provides this possibility for the patient to undergo surgery for one time. Therefore, money spending, hospitalization, receiving of anesthesia drug, accepting the risk of surgery, Absence from the work place, time consumption for participation in the rehabilitation program and follow-up are occurred one time and patient returns more rapidly to the daily activity. In addition, this single step reconstruction forces lower manpower and financially cost to the health system. Results of the Panigrahi and collaborators8 which simultaneously reconstructed injured ligaments by autograft of hamstring tendon also indicated the same concepts. They concluded that thus type of reconstruction is an effective and safe method which saved time and money. As they said, patients tolerated this method better and recovered their power and movement after reconstruction and will have well functional outcomes. Hayashi et al.4 and Matteo Denti et al.1 also expressed the single step reconstruction method as an appropriate method for recovering of knee stability and preferred it to two steps method. As Hayashi and colleagues4 said and also mentioned in previous studies, post-reconstruction moderate residual posterior laxity is one of the problem in single step reconstruction. Thus, postoperative rehabilitation program is very important in reconstruction of injured ligaments. This program was similar for all our patients and was started 2 days after surgery under direct supervision of physiotherapist. Passive movements between 0 and 40 were started at the first post-operative week for all knees and increased to 90 by the end of the 2nd post-operative week. The weightbearing was started at the 2nd post-operative day. Brace in the full extension was used to walking in the first month. Our patients started their light and hard exercises from 2 to 6 months' postoperation, respectively. In the final follow-up, 3 of 26 patients (11.53%) had þ1 laxity. In the study of Panigrahi et al.,8 Brace was used for 3 weeks and knee movements were reached from 30 to 90 during 6 weeks. Weight-bearing in the first 6 weeks was done by help of crutches. After the 6 weeks, Brace using was cut and patient's exercises were started and patients could tolerate their weight alone without rod. They started patient's rehabilitation sooner and mostly enforced on the protection of reconstructed PCL. For this reason, they were not engaging patient's Hamstring muscles during the rehabilitative physical exercises to avoid problems for their grafts. In their study, 2 of 20 patients (10%) suffered from mild laxity which was not clearly difference from our findings. Another problem which may be presented after single step reconstruction is occurrence of post-reconstruction artherofibrosis. In the study of Denti et al.1 it has been expressed that based on previous reports simultaneous reconstruction of injured ligaments increased the occurrence of artherofibrosis after reconstruction. Such studies suggested that reconstruction was performed at two steps with appropriate time interval and ACL reconstructed later
M. Mardani-Kivi et al. / Journal of Clinical Orthopaedics and Trauma 10 (2019) S218eS221
than the PCL or other injured ligaments to prevent from this problem. But Denti and colleagues could not find any evidences of post-operative artherofibrosis in their patients with simultaneous reconstruction of injured ligaments and just small number of their patients had laxity. In the study of Panigrahi et al.8 reconstruction of ACL and PCL was performed in single step and their patients showed no artherofibrosis. We also found no arthrofibrosis in our patients. Perhaps developing in the arthroscopic surgical techniques of reconstruction of cruciate ligaments and fast and effective starting of rehabilitation programs are the causes of lack of arthrofibrosis. Despite of our findings, this study had one limitation which is the case-series nature of the study. It is recommended to perform further studies as double blinded comparative studies. 5. Conclusion Simultaneous arthroscopic ACL and PCL reconstruction using allograft Achilles tendon showed acceptable functional outcomes and proper range of motion recovery. Conflicts of interest We have no Conflict of Interest.
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References 1. Denti M, Tornese D, Melegati G, Schonhuber H, Quaglia A, Volpi P. Combined chronic anterior cruciate ligament and posterior cruciate ligament reconstruction: functional and clinical results. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):2853e2858. 2. Fanelli GC, Edson CJ. Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10year follow-up. Arthroscopy. 2002;18(7):703e714. 3. Fanelli GC, Orcutt DR, Edson CJ. The multiple-ligament injured knee: evaluation, treatment, and results. Arthroscopy. 2005;21(4):471e486. 4. Hayashi R, Kitamura N, Kondo E, Anaguchi Y, Tohyama H, Yasuda K. Simultaneous anterior and posterior cruciate ligament reconstruction in chronic knee instabilities: surgical concepts and clinical outcome. Knee Surg Sports Traumatol Arthrosc. 2008;16(8):763e769. 5. Colosimo AJ, Carroll PF, Heidt RS, Carlonas RL. Simultaneous ACL and PCL reconstruction. J Knee Surg. 2003;16(4):191e196. 6. Wajsfisz A, Bajard X, Plaweski S, et al. Surgical management of combined anterior or posterior cruciate ligament and posterolateral corner tears: for what functional results? Orthop Traumatol Surg Res. 2014;100(8):S379eS383. 7. Zhao J, He Y, Wang J. Simultaneous arthroscopic reconstruction of the anterior and posterior cruciate ligaments with autogenous hamstring tendons. Arthroscopy. 2006;22(5):497e504. 8. Panigrahi R, Kumari Mahapatra A, Priyadarshi A, Singha Das D, Palo N, Ranjan Biswal M. Outcome of Simultaneous Arthroscopic Anterior Cruciate Ligament and Posterior Cruciate Ligament Reconstruction With Hamstring Tendon Autograft: a Multicenter Prospective Study. Asian J Sports Med. 2016;7(1), e29287.
Contents lists available at ScienceDirect
Journal of Clinical Orthopaedics and Trauma journal homepage: www.elsevier.com/locate/jcot
Simultaneous arthroscopic ACL and PCL reconstruction using allograft Achilles tendon Mohsen Mardani-Kivi a, *, Mahmoud Karimi-Mobarakeh b, Keyvan Hashemi-Motlagh c a
Orthopedic Department, Guilan University of Medical Sciences, Rasht, Iran Orthopedic Department, Kerman University of Medical Sciences, Kerman, Iran c Orthopedic Department, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 21 October 2018 Received in revised form 23 December 2018 Accepted 2 January 2019 Available online 2 January 2019
Background: Multi-ligamentous injuries to the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) are uncommon but debilitating injuries. They mostly lead in functional disabilities and further surgeries. Hypothesis: The aim of the present study was to evaluate the outcomes of simultaneous arthroscopic reconstruction of ACL and PCL using allograft Achilles tendon. Study design: Case-series study. Materials and methods: This study was performed on patients with combined ACL-PCL injuries which attended for treatment to a referral center from January 2010 to January 2014. All of them underwent simultaneous arthroscopic reconstruction of ACL and PCL using allograft Achilles tendon. Range of motion (flexion and extension loss), giving way, anterior and posterior knee stability, proximal tibia step off, subjective assessment of knee function and patients satisfaction were evaluated at 3, 6, 12, 24 months and final follow-up. Data were analyzed by SPSS version 21 with consideration of P < 0.05 as significant difference. Results: Among 28 included patients, 21 patients (75%) were male. Mean age of patients was 30.86 ± 7.25 years (range: 18e49 years). The mean follow-up time was 35.7 ± 6.8 months (range: 26e50 months). Our results demonstrated that knee function, stability, and range of motion were improved along the followup periods. At final follow-up none of the patients had giving way and all of them were completely satisfied from the surgery. Conclusion: Simultaneous reconstruction of injured cruciate ligaments using allograft Achilles tendon resulted in appropriate functional outcomes and acceptable range of motion. Level of Evidence: IV © 2019 Delhi Orthopedic Association. All rights reserved.
Keywords: Allograft Simultaneous reconstruction Anterior cruciate ligament Posterior cruciate ligament
1. Introduction Multi-ligamentous injuries to the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) are uncommon but debilitating injuries and involved patients complained from severe pain and lack of knee stability which affect their daily activities and exercise.1,2 This type of injury often causes functional problems and requires surgery for treatment.3 With development of arthroscopic reconstruction, it is considered as an effective and safe method for reconstruction of both ACL
* Corresponding author. Orthopedic Department, Guilan University of Medical Sciences, Poursina hospital, Parastar St., Rasht, Iran. E-mail address: [email protected] (M. Mardani-Kivi). https://doi.org/10.1016/j.jcot.2019.01.001 0976-5662/© 2019 Delhi Orthopedic Association. All rights reserved.
and PCL, but there are certain disagreements about time of surgery, graft type, rehabilitation after surgery and simultaneous or two steps reconstruction.4e6 Another important issue in ACL and PCL reconstruction is graft type. Different grafts such as patellar tendon, hamstring tendon,7 and allografts are used for simultaneous ACL and PCL reconstruction. Use of allografts is preferred by most of surgeons due to more effectiveness, lack of donor site morbidity, shorter surgery time and more stability. However, some problems such as financial burden, the possibility of infection transmission and delay in reconstruction are also existed for this type of graft. Therefore, it cannot say that what graft is better for reconstruction of injured ligaments.4 The aim of the present study is to evaluate the outcomes of simultaneous arthroscopic reconstruction of ACL and PCL using allograft.
M. Mardani-Kivi et al. / Journal of Clinical Orthopaedics and Trauma 10 (2019) S218eS221
2. Material and methods 2.1. Patients This case-series study was performed on patients with combined ACL-PCL tears which attended for treatment to a referral center from January 2010 to January 2014. All 28 included patients were operated by one surgeon (first author). All patients were under physiotherapy for 8 weeks. Range of motion (ROM) of knee was near normal and removed from acute mode. Magnetic resonance imaging (MRI) was used for diagnosis of concurrent lesions of ligaments and meniscus. 2.2. Surgical technique After pre-operative procedures, simultaneous arthroscopic reconstruction by allograft Achilles tendon and using of Endobutton in the femoral side and 3 Bio-interference screws (1 screw for ACL and 2 screws for PCL) in the tibial side was performed. Achilles tendon was divided longitudinally into two halves for applying in ACL and PCL independently. Standard anthrolateral and antromedial portals for ACL reconstruction and these two portals plus auxiliary posteromedial portal for PCL reconstruction were used. The minimum distance of tibial canal input to joint surface was 20 mm in PCL reconstruction. Patients who were not agreed nor had not appropriate medical conditions to participate in the study were excluded. Patient's concomitant comorbidities were also managed intraoperatively. It means that rupture of posterolateral corner (PLC) was reconstructed by modified Larson method. Meniscal repair or partial meniscectomy were performed based on the condition of the meniscus. In case of any chondral lesions, chondroplasty by shave, drilling and microfracture was done during the main surgery. Treatment of medial collateral ligament (MCL) was done nonoperatively. 2.3. Rehabilitation program Rehabilitation program was started at the 2nd post-operative day for all patients equally under direct supervision of physiotherapist. In this program, passive movements between 0 and 40 were started at the first post-operative week for all knees and gradually increased to 90 by the end of the 2nd post-operative week. For better recovery, end of extension was done with stretching and passive movements. As much as weight-bearing which could tolerated by patients was started at the 2nd postoperative day. Brace in the full extension was used to walking in the first month. If possible, walking in water was started after the 2nd post-operative weeks and along with it, hamstring and quadriceps femoris related strengthening exercises were started. Light exercises were allowed 2 months after surgery and hard exercises based on the conditions of hamstring and Quadriceps femoris muscles were allowed 6 months after surgery at appropriate time. 2.4. Follow-up evaluation Patients were followed at 3, 6, 12, 24 months' post-operation and at final follow-up. In these follow-ups, ROM (flexion and extension losses) and giving way were monitored. Lachman and Posterior Drawer tests were also performed by surgeon for evaluation of anterior and posterior knee stability and their results were recorded as score of 0 to þ3. ROM of knee was measured using arthrometer KT-1000. Proximal tibia step off of patients was measured and expressed as millimeter. For subjective evaluations of patient's knee function, Subjective Lysholm Knee Score (S-LKS)
S219
and subjective International Knee Documentation Committee (IKDC) score were used. Visual analogue scale (VAS) was used for assessment of patient's satisfaction subjectively in which 0 means lack of satisfaction and 10 means complete satisfaction. 2.5. Statistical analysis Qualitative data were expressed as frequency and percentage and quantitative data were presented as mean and standard deviation (SD). Friedman test was used to evaluate the trend of proximal tibia step off (PTS) change during follow-ups. Wilcoxon test was used for binary comparison of changes in the PTS, Lysholm and IKDC between two different follow-up times (Due to lack of normal distribution of IKDC and Lysholm based on Kolmogorov-Smirnov test). All statistical analyses were performed using SPSS version 21 and P < 0.05 was considered as significant difference. 3. Results Among 28 included patients, 21 patients (75%) were male and 7 patients (25%) were female. Mean age of patients was 30.86 ± 7.25 years (range: 18e49 years). The mean follow-up time was 35.7 ± 6.8 months (range: 24e50 months). All patients were participated in all follow-ups except 2 patients who were not available at the final follow-up. Ten cases had no concomitant lesions, and in the other 18 patients there were 24 comorbidities (Table 1). In pre-operative ROM assessments, 4 patients had flexion and extension loss with the mean of 5 and it was existed until 6-month follow-up. However, normal ROM was seen in all patients at 12month follow-up remained until the final follow-up. Twenty-two patients (75%) had giving way before surgery, which decreased to 2 patients in 3 and 6 months' follow-ups. There was no case of giving way in 12 and 24 months and final follow-ups. Knee stability was evaluated based on Lachman and Posterior Drawer tests. Knees of all patients were instable before surgery. Lachman test showed that 21 (75%) and 7 (25%) patients were þ3 and þ 2 before surgery. In the 3, 6 and 12 months' follow-ups, 2 patients had þ2 and another two patients had þ1 of Lachman score. In the 24 months, only 3 patients had þ1 of Lachman score. All patients were þ3 based on Posterior Drawer test. After surgery, 2 patients (7.1%) were þ1, 1 patient (3.6%) was þ3 and another 25 patients (89.3%) had normal Posterior Drawer test at 3, 6, 12 and 24 months' follow-ups. However, 2 patients were þ1 based on Posterior Drawer test at final follow-up and all other 24 patients were returned to previous activity level as before trauma. Arthrometric assessment of patients using KT-1000 apparatus showed that 24 patients had 0e2 mm, 3 patients had 3e7 mm and 1 patient had 11 mm side-to-side difference at 3, 6, and 12 months' follow-up. In the 24 months' follow-up, 22 patients had 0e2 mm, 4 patients had 3e7 mm and 2 patients had more than 7 mm (8 and 12 mm) side-to-side difference. At final follow-up, 20 patients had 0e2 mm, 4 patients had 3e7 mm and 2 patients had more than 7 mm side-to-side difference. Significant improvement in PTS (Proximal Tibia Step off) was seen during follow-up times (P < 0.0001). Also, post-operative Table 1 Type of comorbidities in included patients. Comorbidity
N
Posterolateral corner (PLC) rupture Medial collateral ligament (MCL) rupture Meniscus rupture Chondral lesion
11 5 4 4
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M. Mardani-Kivi et al. / Journal of Clinical Orthopaedics and Trauma 10 (2019) S218eS221
Table 2 Changes of subjective IKDC and Lysholm scores. Follow-up times
Before reconstruction 3 months 6 months 12 months 24 months Final
IKDC score
Lysolm score
Mean ± SD
Median (IQR)
Mean ± SD
Median (IQR)
39.46 ± 4.98 72.86 ± 11.54 89.25 ± 11.42 84.00 ± 11.22 89.68 ± 7.37 90.62 ± 7.60
41.50 77.00 89.00 88.50 92.00 93.00
39.97 ± 4.43 75.07 ± 10.16 88.61 ± 10.63 89.54 ± 9.25 92.86 ± 6.47 93.42 ± 5.92
41.43 79.65 92.00 92.00 95.00 94.50
(38.21e42.83) (68.50e81.75) (82.00e91.00) (82.00e91.00) (90.00e94.00) (90.00e94.25)
(39.59e42.49) (72.23e82.13) (87.50e95.75) (90.00e95.00) (92.00e96.75) (92.00e96.50)
IQR, interquartile range. In the follow-up times more than 12 months, the VAS based patient's satisfaction was excellent (one patient had VAS of 1, another one patient had VAS of 2 and other patients were completely satisfied).
functional status of patients based on IKDC subjective and Lysholm scores showed significant improvement in comparison to before surgery (P < 0.0001, Table 2). 4. Discussion Most of our patients (75%) were young men with low mean age. The answer for why more men than women have suffered this type of injury is may be due to the type of men activities in the society which exposed them to such tearing cruciate ligaments traumas more than women. Perhaps the reason that they are more socially active and therefore attended to be treated. Also in the study of Ranajit Panigrahi and colleagues, 17 patients of 20 included patients were male and total mean age was 34 years.8 In the study of Hayashi et al. just one patient of 20 included patients was female and total mean age was 30.5 years.4 One of the controversial topics in the reconstruction of injured ligaments is used surgical technique. We used auxiliary posteromedial portal for reconstruction of PCL. The minimum distance of tibial canal input to joint surface was 20 mm in PCL reconstruction. Also, 2 interference screws in tibial place for PCL fixation and 1 screw for ACL fixation were used. Maybe this is the reason of our good results in patient's stability and performance of the knees. Graft selection is one of the important issues in all ligamentous reconstruction setting. We utilized allograft Achilles tendon in our study for reconstruction of ACL and PCL due to some advantages such as the lack of donor site morbidity, reduction of operating time, and the strength of the large grafts. However, some disadvantages such as higher cost and risk of infection are also existed for allograft.8 About the cost, it can say that although patients who use autograft do not pay the cost to purchase the graft, some of them experienced physical limitations. Therefore, they cannot participate in the physiotherapy and follow-up sections. As a result, they will have absenteeism and they will accept more scathe. While our patients which used allograft were passed rehabilitation courses and returned to activity level as before trauma faster. In addition, higher inactivity rate in these patients increases the possibility of inactivity complications which is important and must be avoided. Another problem of allografts is the risk of transmission of infection such as HIV and hepatitis to patients who used them. We monitored all patients until final follow-up for this issue and evidences of the occurrence of infection were seen in none of them. However, it cannot be said certainly that allograft causes infection transmission or not. It is suggested that this issue is more considered in the future studies. Another controversial topic in reconstruction of injured ligaments which orthopedists don't come to a consensus on it is the simultaneous or two steps reconstruction. We reconstructed ACL and PCL simultaneously and as our results showed in the final follow-up, all patients had recovered their knee stability, 23 of 26 patients (88.4%) returned to activity level as before trauma, had not
giving way, returned to normal knee status and were satisfied about their surgery. Simultaneous reconstruction provides this possibility for the patient to undergo surgery for one time. Therefore, money spending, hospitalization, receiving of anesthesia drug, accepting the risk of surgery, Absence from the work place, time consumption for participation in the rehabilitation program and follow-up are occurred one time and patient returns more rapidly to the daily activity. In addition, this single step reconstruction forces lower manpower and financially cost to the health system. Results of the Panigrahi and collaborators8 which simultaneously reconstructed injured ligaments by autograft of hamstring tendon also indicated the same concepts. They concluded that thus type of reconstruction is an effective and safe method which saved time and money. As they said, patients tolerated this method better and recovered their power and movement after reconstruction and will have well functional outcomes. Hayashi et al.4 and Matteo Denti et al.1 also expressed the single step reconstruction method as an appropriate method for recovering of knee stability and preferred it to two steps method. As Hayashi and colleagues4 said and also mentioned in previous studies, post-reconstruction moderate residual posterior laxity is one of the problem in single step reconstruction. Thus, postoperative rehabilitation program is very important in reconstruction of injured ligaments. This program was similar for all our patients and was started 2 days after surgery under direct supervision of physiotherapist. Passive movements between 0 and 40 were started at the first post-operative week for all knees and increased to 90 by the end of the 2nd post-operative week. The weightbearing was started at the 2nd post-operative day. Brace in the full extension was used to walking in the first month. Our patients started their light and hard exercises from 2 to 6 months' postoperation, respectively. In the final follow-up, 3 of 26 patients (11.53%) had þ1 laxity. In the study of Panigrahi et al.,8 Brace was used for 3 weeks and knee movements were reached from 30 to 90 during 6 weeks. Weight-bearing in the first 6 weeks was done by help of crutches. After the 6 weeks, Brace using was cut and patient's exercises were started and patients could tolerate their weight alone without rod. They started patient's rehabilitation sooner and mostly enforced on the protection of reconstructed PCL. For this reason, they were not engaging patient's Hamstring muscles during the rehabilitative physical exercises to avoid problems for their grafts. In their study, 2 of 20 patients (10%) suffered from mild laxity which was not clearly difference from our findings. Another problem which may be presented after single step reconstruction is occurrence of post-reconstruction artherofibrosis. In the study of Denti et al.1 it has been expressed that based on previous reports simultaneous reconstruction of injured ligaments increased the occurrence of artherofibrosis after reconstruction. Such studies suggested that reconstruction was performed at two steps with appropriate time interval and ACL reconstructed later
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than the PCL or other injured ligaments to prevent from this problem. But Denti and colleagues could not find any evidences of post-operative artherofibrosis in their patients with simultaneous reconstruction of injured ligaments and just small number of their patients had laxity. In the study of Panigrahi et al.8 reconstruction of ACL and PCL was performed in single step and their patients showed no artherofibrosis. We also found no arthrofibrosis in our patients. Perhaps developing in the arthroscopic surgical techniques of reconstruction of cruciate ligaments and fast and effective starting of rehabilitation programs are the causes of lack of arthrofibrosis. Despite of our findings, this study had one limitation which is the case-series nature of the study. It is recommended to perform further studies as double blinded comparative studies. 5. Conclusion Simultaneous arthroscopic ACL and PCL reconstruction using allograft Achilles tendon showed acceptable functional outcomes and proper range of motion recovery. Conflicts of interest We have no Conflict of Interest.
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