Amrut Borade Rajiv Gupta Combined Anterior Cruciate Ligament, Posterior Cruciate Ligament, and Posterolateral Corner / Medial Collateral ligament reconstruction with autogenous Hamstring Grafts in Chronic multi ligamentous injured knee Amrut Borade Rajiv Gupta

INTRODUCTION Treatment of patients with closed dislocation of knee joint is a matter of debate? Factors influencing treatment: Healing potential of injured structures Natural history of these injuries.

Fewer studies for PCL reconstruction and Numerous studies have shown Arthroscopic ACL reconstruction as a safe and reliable procedure. Fewer studies for PCL reconstruction and There are very few studies reporting the results of arthroscopically assisted ACL/PCL with PLC / MCL reconstruction. 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. Combined posterior cruciate ligamentposterolateral reconstructions with Achilles tendon allograft and biceps femoris tendon tenodesis: 2- to 10-year follow-up. Arthroscopy 2004;20:339-345. Mariani PP, Margheritini F, Camillieri G. One-stage arthroscopically assisted anterior and posterior cruciate ligament reconstruction. Arthroscopy 2001;17:700-707.

PURPOSE OF STUDY To determine the clinical results after a minimum followup of 2 years for a group of patients who underwent arthroscopically assisted ACL & PCL with PLC/MCL reconstruction using autogenous Hamstring grafts.

Material & Methods INCLUSION CRITERIA: Presence of both cruciate ligament insufficiency with additional posterolateral rotatory instability / MCL insufficiency based on clinical examination and confirmed by MRI and Arthroscopy. Chronic Injured Knees Age group 16-45 years

Exclusion criteria: MATERIALS METHODS Acute knee dislocations / Fractures Age <16 and >45 years Ligamentous Bony avulsions Exclusion criteria: We have limited this study group to chronic multilig deficient knees.

MATERIAL METHODS During 2009-2010 , 15 patients underwent arthroscopic ACL & PCL reconstruction with either PLC or MCL reconstruction. Mode of Fixation for ACL/PCL : Endobutton CL for femoral fixation and Bioscrew for Tibial fixation. Graft Choice : Autogenous semitendinosus and gracilis tendons from both sides. PCL – Semitendinosus and Gracilis. ACL – Semitendinosus MCL – Ipsilateral Gracilis PLC - Free Gracilis

MATERIAL METHODS All reconstruction were performed by a single surgeon using same surgical technique. Pre-op and post-op evaluation using LYSHOLM and IKDC knee scores to measure symptoms , function and activity level. Post-op evaluation was performed by an independent examiner who was not part of surgical procedure.

MATERIAL METHODS DISTRIBUTION OF CASES ACL & PCL 5 cases ACL & PCL with PLC 6 cases ACL & PCL with MCL 4 cases

Surgical technique

Diagnostic Arthoscopy PCL femoral tunnel created by Transportal technique ACL tibial tunnel and femoral tunnel created by Transportal technique PCL tibial tunnel created appx. 2 cm below joint line using posteromedial portal PCL graft introduced and fixed on femoral side with Endobutton CL ACL graft introduced and fixed on femoral side with Endobutton CL PLC/MCL reconstruction performed

Femoral graft fixation of PLC reconstruction was performed with interference screw with knee flexed 30 with internal tibial rotation and applied anterior nad valgus force to knee joint. PCL tibial fixation done with knee in 70 flexion and applied anterior force to restore the anatomical step-off ACL tibial fixation done with knee in 30 flexion with tension applied to distal end of ACL graft. MCL reconstruction performed and tensioned with knee in 30 flexion with leg in figure of 4 position.

Surgical Technique PLC reconstruction: Free graft figure of 8 technique using semitendinosus graft. Tunnel created in fibular head in anterior to posterior direction. Peroneal nerve is protected during drilling. Free graft is passed through fibular head and secured to lateral femoral epicondyle in a figure of 8 fashion with a screw. Free graft is passed beneath biceps femoris and iliotibial band.

Surgical technique PLC reconstruction is needed if- Dial test shows > 10 degree difference Reverse Pivot shift is positive Varus external rotation recurvatum appears on lifting the leg by great toe. Anterior drawer’s test is increased in Internal rotation.

Soft tissue reconstruction: Surgical technique MCL reconstruction: Ipsilateral gracilis is harvested with open tendon stripper leaving its insertion at tibia in situ. Soft tissue reconstruction: Remnant of superficial MCL is made taut on either side. Posteromedial capsule is double breasted Semimembranosus tenodesis.

POSTOPERATIVE REHAB Knee kept in full extension using PTS brace for 6 weeks. Progressive ROM exercises started after 2 weeks with patient prone to prevent tibial drop back. Strict avoidance of active Hamstring exercises. Strengthening exercises started after 10 weeks. Return to sports and heavy labour after 9 months. Residual laxity in pcl- stretching of graft during rehab To minimize pcl graft forces during healing phase and in initial rehab period, knee is placed in full extension in PTS brace 6 wks day and night.

RESULTS All patients in study were Males. Right: left :: 6:9 Mean age at time of injury:28.54 years Mean time from injury to reconstructive procedure: 21 months MOI : 13 RTA(8- motorcycle , 4 car and 1 others) and 2 sports injury.

RESULTS – MODE OF INJURY Majority of the cases (86.67%) were due to Road Traffic Accidents

POST-OPERATIVE LYSHOLM SCORE 40% 13.33%

POST-OPERATIVE IKDC GRADE

Mean LYSHOLM SCORE Mean Preop Lysholm score- 26.93 Mean Postop Lysholm score- 81.27 Improvement in Lysholm Score was Statistically significant with a p- value of based on Wilcoxon signed rank test

MEAN IKDC KNEE SCORE Mean Preop IKDC Knee score- 28.79 Mean Postop IKDC Knee score- 70.87 Improvement in IKDC score was Statistically significant with a p- value of based on Wilcoxon signed rank test

Complications Anterior Knee pain 8(53.33%) Knee stiffness 2(13.33%) Anterior Knee pain 8(53.33%) Residual Posterior laxity 8(53.33%) Loss of Terminal Flexion 2(13.33%) Persistent Aseptic Discharge 1(6.67%)

RESULTS Statistically significant improvement of knee function was noted with both subjective criteria (Lysholm and IKDC knee scores) and objective criteria (IKDC knee Grade). No correlation was found between subjective IKDC knee score and anterior –posterior laxity of knee. Although NOT Normal , BUT Functionally stable knee can be achieved.

CONCLUSION Combined chronic ACL & PCL instabilities with MCL/PLC injury can be treated with 1 stage Arthroscopic Bicruciate ligament reconstruction along with reconstruction of PLC/MCL structure using Autogenous Hamstring grafts Present reconstruction techniques doesn’t reliably restore normal tibiofemoral kinematics in complex instabilities But most patients recover a functionally stable knee with considerable improved subjective knee function

DRAWBACKS Small Study Population Selection Bias Lack of stress X-rays to assess Posterior Laxity Lack of KT -1000 Arthrometer testing Small study populaton because of rarity of injury. Selection bias because surgery was only performed in motivated patients with severe subjective instability

Case 1 : Sanjay 22 yr Male