Does Sequence of Graft Tensioning Affect Outcomes in Combined Anterior and Posterior Cruciate Ligament Reconstructions?
Tóm tắt
Controversy persists regarding the protocol for tensioning and securing the grafts in one-stage reconstruction of combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries. Many authors have reported stability examinations and functional results after reconstruction for this relatively rare injury, and the best sequence for tensioning the grafts is not known. We sought to determine (1) if there are differences in postoperative anteroposterior stability in a protocol of simultaneous tensioning of both grafts and ACL-first fixation compared with a protocol of tensioning and fixation of the PCL first in one-stage reconstruction of combined ACL/PCL injuries; and (2) if there is a difference in postoperative functional outcome scores between the two protocols. Between 2001 and 2011, 29 patients underwent one-stage reconstruction of combined ACL and PCL injuries (the majority with medial collateral ligament [MCL] injuries, posterolateral corner [PLC] injuries, or both, in addition), of whom three patients (10%) were lost to followup before 2 years, and one patient was excluded based on predefined criteria, leaving a total of 25 patients (86%) for retrospective analysis in this report. Fourteen patients underwent one-stage reconstruction of these injuries with tensioning and fixation of the PCL graft first (PCL-first group), and 11 later patients underwent one-stage reconstruction of combined ACL/PCL injuries with simultaneous tensioning of both grafts and fixation of the ACL graft first (simultaneous-tensioning group). During the period in question, the technique used in the PCL-first group was used exclusively for these injuries between August 2001 and August 2008 and that used in the simultaneous-tensioning group was used between September 2008 and August 2011; there was no overlap between groups. The groups were similar in terms of demographics and length of followup. Each patient was assessed for associated injuries, preoperative and postoperative knee stability with anteroposterior stress radiographs, and was evaluated with the Lysholm knee score and International Knee Documentation Committee (IKDC) subjective and objective grading at the last followup after surgery. At the last followup evaluation, patients treated with simultaneous tensioning and ACL-first fixation showed less instability on side-to-side difference of posterior stress radiography (5 ± 1 mm in the simultaneous-tensioning group versus 6 ± 1 mm in the PCL-first group; effect size, 1.2; 95% confidence interval [CI], 0.5–2.3; p = 0.011), but with the numbers available, no difference on anterior stress radiography (3 ± 0.4 mm in the simultaneous-tensioning group versus 3 ± 0.5 mm in PCL-first group; effect size, 0.4; 95% CI, −0.2 to 0.5; p = 443). The simultaneous-tensioning group also had higher Lysholm knee scores (87 ± 5 in the simultaneous-tensioning group versus 80 ± 4 in the PCL-first group; effect size, 1.8; 95% CI, −10.9 to −2.7; p = 0.001), IKDC subjective scores (68 ± 3 in the simultaneous-tensioning group versus 58 ± 3 in the PCL-first group; effect size, 3.4; 95% CI, −14.2 to −8.6; p < 0.001), and IKDC objective grades (p = 0.037). In one-stage reconstruction of combined ACL and PCL injuries, a protocol of simultaneous tensioning both grafts and fixing the ACL graft first may be worth consideration. Arthroscopic reduction landmarks may prove helpful in this technique but require further validation. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Tài liệu tham khảo
Briggs KK, Kocher MS, Rodkey WG, Steadman JR. Reliability, validity, and responsiveness of the Lysholm knee score and Tegner activity scale for patients with meniscal injury of the knee. J Bone Joint Surg Am. 2006;88:698–705.
Edson CJ, Fanelli GC, Beck JD. Rehabilitation after multiple-ligament reconstruction of the knee. Sports Med Arthrosc. 2011;19:162–166.
Fanelli GC, Edson CJ. Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up. Arthroscopy. 2002;18:703–714.
Fanelli GC, Edson CJ, Reinheimer KN. Evaluation and treatment of the multiligament-injured knee. Instr Course Lect. 2009;58:389–395.
Fanelli GC, Giannotti BF, Edson CJ. Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction. Arthroscopy. 1996;12:5–14.
Fanelli GC, Tomaszewski DJ. Allograft use in the treatment of the multiple ligament injured knee. Sports Med Arthrosc. 2007;15:139–148.
Harner CD, Waltrip RL, Bennett CH, Francis KA, Cole B, Irrgang JJ. Surgical management of knee dislocations. J Bone Joint Surg Am. 2004;86:262–273.
Hart JM, Blanchard BF, Hart JA, Montgomery SC, Schoderbek R, Miller MD. Multiple ligament knee reconstruction clinical follow-up and gait analysis. Knee Surg Sports Traumatol Arthrosc. 2009;17:277–285.
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;16:763–769.
Hefti F, Muller W, Jakob RP, Staubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc. 1993;1:226–234.
Irrgang JJ, Anderson AF, Boland AL, Harner CD, Neyret P, Richmond JC, Shelbourne KD, International Knee Documentation Committee. Responsiveness of the International Knee Documentation Committee Subjective Knee Form. Am J Sports Med. 2006;34:1567–1573.
Kim SJ, Choi NH, Shin SJ. Semitendinosus tenodesis for medial instability of the knee. Arthroscopy. 2001;17:660–663.
Kim SJ, Jo SB, Kumar P, Oh KS. Comparison of single- and double-bundle anterior cruciate ligament reconstruction using quadriceps tendon-bone autografts. Arthroscopy. 2009;25:70–77.
Kim SJ, Kim HK, Kim HJ. A modified endoscopic technique for posterior cruciate ligament reconstruction using allograft. Arthroscopy. 1998;14:643–648.
Kim SJ, Moon HK, Kim SG, Chun YM, Oh KS. Does severity or specific joint laxity influence clinical outcomes of anterior cruciate ligament reconstruction? Clin Orthop Relat Res. 2010;468:1136–1141.
Kim SJ, Park IS, Cheon YM, Ryu SW. New technique for chronic posterolateral instability of the knee: posterolateral reconstruction using the tibialis posterior tendon allograft. Arthroscopy. 2004;20(Suppl 2):195–200.
Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC, Stuart MJ, Boyd JL, MacDonald PA, Marx RG. Decision making in the multiligament-injured knee: an evidence-based systematic review. Arthroscopy. 2009;25:430–438.
Liow RY, McNicholas MJ, Keating JF, Nutton RW. Ligament repair and reconstruction in traumatic dislocation of the knee. J Bone Joint Surg Br. 2003;85:845–851.
Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10:150–154.
Margheritini F, Mancini L, Mauro CS, Mariani PP. Stress radiography for quantifying posterior cruciate ligament deficiency. Arthroscopy. 2003;19:706–711.
Mariani PP, Margheritini F, Camillieri G. One-stage arthroscopically assisted anterior and posterior cruciate ligament reconstruction. Arthroscopy. 2001;17:700–707.
Mariani PP, Santoriello P, Iannone S, Condello V, Adriani E. Comparison of surgical treatments for knee dislocation. Am J Knee Surg. 1999;12:214–221.
Markolf KL, O’Neill G, Jackson SR, McAllister DR. Reconstruction of knees with combined cruciate deficiencies: a biomechanical study. J Bone Joint Surg Am. 2003;85:1768–1774.
Noyes FR, Barber-Westin SD. Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Use of early protected postoperative motion to decrease arthrofibrosis. Am J Sports Med. 1997;25:769–778.
Outerbridge RE. The etiology of chondromalacia patellae. J Bone Joint Surg Br. 1961;43:752–757.
Paley D, Herzenberg JE, Tetsworth K, McKie J, Bhave A. Deformity planning for frontal and sagittal plane corrective osteotomies. Orthop Clin North Am. 1994;25:425–465.
Piontek T, Ciemniewska-Gorzela K, Szulc A, Naczk J, Wardak M, Trzaska T, Dudzinski W, Grygorowicz M. Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction with autologous hamstring grafts-isokinetic assessment with control group. PloS One. 2013;8:e82462.
Richter M, Bosch U, Wippermann B, Hofmann A, Krettek C. Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations. Am J Sports Med. 2002;30:718–727.
Rios A, Villa A, Fahandezh H, de Jose C, Vaquero J. Results after treatment of traumatic knee dislocations: a report of 26 cases. J Trauma. 2003;55:489–494.
Schulz MS, Russe K, Lampakis G, Strobel MJ. Reliability of stress radiography for evaluation of posterior knee laxity. Am J Sports Med. 2005;33:502–506.
Shelbourne KD, Porter DA, Clingman JA, McCarroll JR, Rettig AC. Low-velocity knee dislocation. Orthop Rev. 1991;20:995–1004.
Staubli HU, Jakob RP. Posterior instability of the knee near extension. A clinical and stress radiographic analysis of acute injuries of the posterior cruciate ligament. J Bone Joint Surg Br. 1990;72:225–230.
Strobel MJ, Schulz MS, Petersen WJ, Eichhorn HJ. Combined anterior cruciate ligament, posterior cruciate ligament, and posterolateral corner reconstruction with autogenous hamstring grafts in chronic instabilities. Arthroscopy. 2006;22:182–192.
Tzurbakis M, Diamantopoulos A, Xenakis T, Georgoulis A. Surgical treatment of multiple knee ligament injuries in 44 patients: 2–8 years follow-up results. Knee Surg Sports Traumatol Arthrosc. 2006;14:739–749.
Van Tongel A, MacDonald PB. How I manage the multiple-ligament injured knee. Operative Techniques in Sports Medicine. 2010;18:245–249.
Wascher DC, Becker JR, Dexter JG, Blevins FT. Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts. Am J Sports Med. 1999;27:189–196.
Zhao J, He Y, Wang J. Simultaneous arthroscopic reconstruction of the anterior and posterior cruciate ligaments with autogenous hamstring tendons. Arthroscopy. 2006;22:497–504.