Abstract
Purpose: The procedure described in 1986 in the Revue de Chirurgie Orthopédique was used for 24 knees operated on since 1982.
Operative technique: A single anterior incision measuring 18 cm and a 28-cm transplant using the patellear tendon, a slit of patellar bone, and the quadriceps tendon. The patellar bloc is fixed in the tunnel bored under the spinous process, using the patellar tendon to reconstruct the posterior cruciate ligament (PCL) and the quadriceps tendon to reconstruct the anterior cruciate ligament (ACL). It crosses the lateral condyle and prolonged to the Gerdy. The bone is blocked but can be fixed with a screw. Since the initial description, a second strand for a lateral plasty has been added from the condyle towards the posterior tibia (six cases). Two strands can be used for the PCL. The tunnel can run oblique upwardly to facilitate passage of the transplant behind the tibia (a 30 cm transplant is needed). Operative time 177±39 minutes.
Material and methods: The series included 24 knees (75% men) (13 right and 3 bilateral procedures). The patients were aged 23±6 years at the time of the accident which was a sports accident in seven and an occupational accident in one. Time from the accident to surgery was 35±41 months. Prior surgery had been performed on fourteen knees (five sutures, five artificial ligaments, two ACL reconstructions). Three patients had fibular nerve palsy. Radiologically, the anterior drawer of the medial and lateral compartments was 124 and 185 mm; the posterior drawer was 174 and 126 mm. Lateral laxity predominated in 17 knees, medial laxity in seven and mixed laxity in eleven. The frontal axe was normal in five knees. Associated procedures depended on the laxity: three procedures to tighten the lateral popliteal ligament, three to tighten the posterior capsule of the femur, and seven to tighten the medial capsule of the femur. There was one meniscal suture and four regularisations. The knee was mobilised postoperatively and weight-bearing with assistance was allowed except in five cases with a weak reconstruction or associated osteotomy.
Results: Mean follow-up was 4.5 years (1–20). Flexion was 130±11° and function was acceptable except for three patients who were able to resume their occupational activities but little sports activity. None of the patients was disappointed. Mean gain in anterior drawer was 5 mm for both compartments; gain for the posterior drawer was 6 mm medially and 3 mm laterally. Peripheral laxity was corrected best.
Discussion: There are no data in the literature on cruciate reconstruction in patients with chronic laxity. This series is small but does have 20 years follow-up and provided precious information for improving results. It would be particularly interesting to use two strands for the PCL reconstruction, to use more peripheral procedures, especially with two lateral plasties and medial plasties, and to use osteotomy.
Conclusion: Cases of double cruciate tears seen late are exceptional and appropriate treatment has not been standardised. Instead of using to distinct incisions with two transplants for the two cruciates, as would be possible with the classical techniques, we propose a single incision and a single transplant with peripheral plasties depending on the radiographic laxity.
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