Bilateral simultaneous anterior cruciate ligament reconstruction: A case series and review of the literature

Bilateral Anterior Cruciate Ligament Reconstruction with All-Inside Technique for Adolescent: A Review of the Literature and Case Report

Introduction

Simultaneous bilateral anterior cruciate ligament (ACL) ruptures are rare, especially in the pediatric population, with very limited evidence. We aimed to review the current literature and present a case study of an adolescent patient who underwent bilateral reconstruction with hamstrings autograft in a single-stage with a partial transphyseal "all-inside" technique.

Literature Review

The limited evidence reports that the incidence of growth disturbance following ACL reconstruction in the skeletally immature is 2.6% with no significant difference between a partial transphyseal and an all-epiphyseal technique. Regarding graft choice in the skeletally immature, no significant difference has been found in function using hamstrings versus bone-to-bone patella autograft. The all-inside technique has shown good outcomes in the skeletally immature with no cases of growth disturbance observed in the literature reviewed. Patients spend less days in hospital and return to sport sooner following simultaneous reconstruction versus staged.

Case Report

A 15-year-old male footballer underwent simultaneous reconstruction of bilateral ACL ruptures through a partial transphyseal "all-inside" technique with hamstrings autografts. He began physiotherapy according to local protocol and was discharged from hospital on Day 4 post-operative. He returned to competitive sports 11 months postoperatively with no intraoperative or post-operative complications.

Conclusion

This case suggests that bilateral simultaneous ACL reconstruction is a safe management strategy in the rare case of bilateral ruptures in the skeletally immature, which adds to the evidence base. The number of required hospital stays was reduced and there was return to sport in a comparative time frame to unilateral ACL reconstruction rehabilitation.

Functional outcomes in single stage bilateral ACL reconstruction with a maximum follow up of 10 years

Background

Bilateral ACL injuries are a rarity and there is no particular consensus on whether this rare problem has to be tackled in stages or in a single stage. There are a few studies and case reports in the literature about the outcomes in single staged bilateral Anterior cruciate ligament reconstruction (ACLR). This study is focused on functional outcomes after a single staged bilateral ACLR, as well as impact of simultaneity of the injury, meniscal tears, notch stenosis and hyperlaxity.

Materials and methods

A retrospective study was conducted from 2013 to 2021. Patients with bilateral ACL injury either simultaneous or non simultaneous, with or without meniscal tears were included in this study. Pre operative diagnosis was made both clinically and by MR imaging. All patients underwent a single staged bilateral ACL reconstruction. Pre operative functional scores (IKDC and Lysholm) were taken at admission and patients were examined at regular follow ups. Final functional scores were collected in a phone interview.

Results

33 patients underwent bilateral ACLR in a single stage during the study period but one patient had revision ACLR in one knee and so was excluded. Of the 32 patients, 25 (78%) had non simultaneous injury and 7 (22%) had a simultaneous injury, meniscus tear was noted in 27 (84.4%), notch stenosis in 19 (59.3%) and hyperlaxity in 12 (37.5%). IKDC and Lysholm scores have improved postoperatively. No statistically significant difference was found with or without simultaneous injury or meniscus tears.

Conclusion

Single stage bilateral ACL reconstruction is a safe, reproducible approach to bilateral ACL injuries whether they were simultaneous or non simultaneous or with or without meniscal tears.

Simultaneous Bilateral Anterior Cruciate Ligament Revision Reconstruction

There are limited studies in the literature regarding the reconstruction of bilateral anterior cruciate ligament (ACL) injuries in a single-stage setting. However, there have been no published studies describing simultaneous revision reconstructions of previously reconstructed bilateral ACLs. We present the case of a 37-year-old male who underwent previous reconstruction of both ACLs at an outside hospital and presented to our outpatient clinic with instability and pain. Simultaneous bilateral ACL revision reconstruction was performed with the use of tibialis anterior allografts. This case report suggests that single-stage bilateral ACL revision reconstruction is a safe procedure that can provide good results for the patient.

Bilateral simultaneous anterior cruciate ligament tears treated with single staged simultaneous primary repair: A case report

Introduction and importance

Simultaneous bilateral anterior cruciate ligament (ACL) injuries are a rare injury pattern within the literature. There is not a consensus optimal management of this injury. Bilateral primary ACL repair in a single stage surgery provides knee stability with a minimally morbid surgery in a single rehabilitation period. This case report offers another option for surgeons to consider in the treatment of this rare injury.

Case presentation

A 45-year-old female skier presented with simultaneous bilateral isolated proximal anterior cruciate ligament injuries. MRI demonstrated bilateral proximal ACL tear patterns which were amenable to primary ACL repair. The patient subsequently underwent acute single-staged arthroscopic primary ACL repair with suture augmentation of both knees. She attained rehabilitation milestones and was fully cleared to return to sporting activities one year post-operatively. Two years post-operatively the patient continues to do well with excellent clinical outcomes.

Clinical discussion

The other treatment modalities reported in the literature were single staged and two staged ACL reconstruction with either autograft or allograft. While single staged procedures are more time and cost efficient, the primary concern is that simultaneous rehabilitation of bilateral ACL reconstructions may lead to severe quadriceps deconditioning. Primary ACL repair poses a potential solution as a minimally morbid surgery with faster rehabilitation from surgery.

Conclusion

Due to the limited invasiveness and morbidity of ACL primary repair with suture augmentation, simultaneous primary repair surgery could be an excellent treatment option for this rare patient population, saving time and cost while providing appropriate knee stability.

Level of evidence

Level IV, Case Report.

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Single-stage bilateral ACL repair is a viable treatment option in a patient with simultaneous bilateral ACL injuries

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ACL repair might be an excellent treatment option for this population due to its minimally morbid nature.

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Simultaneous bilateral ACL repair allows for early return to ambulation and range of motion