One-stage bilateral anterior cruciate ligament reconstruction

KNEE

One-stage bilateral anterior cruciate ligament reconstruction

Matjaz Sajovic • Saska Demsar • Romana Sajovic

Received: 9 May 2012 / Accepted: 19 November 2012

� Springer-Verlag Berlin Heidelberg 2012

Abstract

Purpose The ideal treatment for patients presenting with

bilateral anterior cruciate ligament (ACL) deficiency

remains controversial. The purpose was to evaluate cost

and functional results after one-stage bilateral ACL

reconstruction using either hamstring or patella tendon

autograft.

Methods This prospective comparative study was com-

pared the mid-term outcome of 7 patients (14 knees) who

had one-stage bilateral ACL reconstruction with that of a

matched group of patients who had unilateral reconstruc-

tion (21 patients).

Results The median length of hospital stay was 4 (3–5)

nights for the bilateral group and 2 (1–4) nights for the

control group. The duration of rehabilitation process in

patients from control group with unilateral ACL recon-

struction was one week shorter (9 vs 8 weeks). In the

bilateral group, the median Lysholm score was 96

(85–100), and in the control group, the median score was

93 (81–100). The median time to return to full-time work

and to full sports was 9 weeks and 7 months for the one-

stage group and 8 weeks and 6 months for the unilateral

group. Six patients (86 %) in the bilateral group and 17

patients (81 %) in the control group were still performing

at their pre-injury level of activity. National Health Insti-

tution saved 2925 EUR when we performed one-stage

bilateral reconstruction instead of two-stage ACL

reconstruction.

Conclusions Mid-term clinical results suggested that one-

stage bilateral ACL reconstruction using either hamstring

or patella tendon autograft is clinically effective. For

patients presenting bilateral ACL-deficient knees, one-

stage bilateral ACL reconstruction is reproducible, cost

effective and does not compromise functional results.

Level of evidence II.

Keywords Anterior cruciate ligament (ACL) �Reconstruction � Bilateral � Rehabilitation � Cost

comparison

Introduction

Anterior cruciate ligament (ACL) rupture is the most

common serious injury of the knee. In the general popu-

lation in the United States, an estimated 1 in 3,000 indi-

viduals per year sustains an ACL injury, corresponding to

an overall injury rate of approximately 100,000 injuries

annually [6]. Among patients presenting with ACL-defi-

cient knees, the incidence of bilaterality is reported to be

between 2 and 4 % [1, 14]. Mechanism of injury rarely

causes simultaneous bilateral ACL tear. Usually unilateral

injury of the knee has occurred and later on one during

further sports activity contra-lateral knee injury has taken

place.

Several risk factors for tearing the ACL have been

evaluated in the literature. The highest incidence is in

individuals 15–25 years old who participate in pivoting

sports. Seventy percentage of ACL injuries occur in non-

contact situations. The risk factors for non-contact ACL

injuries fall into four distinct categories: environmental,

M. Sajovic (&) � R. Sajovic

General Teaching Hospital Celje, Celje, Slovenia

e-mail: [email protected]

S. Demsar

Sports Rehabilitation Center Celje, Celje, Slovenia

e-mail: [email protected]

123

Knee Surg Sports Traumatol Arthrosc

DOI 10.1007/s00167-012-2320-z

anatomic, hormonal, and biomechanical [4]. Inadequate or

compromised conditioning, experience, muscle recruitment

patterns [5], and proprioception [10] have been described

as partially controllable, trainable characteristics [9]. It has

also been suggested that an increased posterior tibial slope

and narrow notch width index increase the risk of ACL

injury [13]. Familial predisposition could be associated

factor for the ACL tear [3]. The ACL injury rates are

reported to be two-to-eight times higher in women than in

men participating in the same sports [6]. With the growing

participation of women in athletics and the debilitating

nature of ACL injuries, a better understanding of mecha-

nisms of injury in women sustaining ACL injuries is

essential. Published studies strongly support noncontact

mechanisms for ACL tears in women, which make these

injuries even more perplexing. Speculation on the possible

aetiology of ACL injuries in women has centred on ana-

tomic differences, joint laxity, hormones, and training

techniques.

ACL reconstruction is a common procedure that usually

allows predictable and timely return to function for the

patient. The goals of ACL reconstructions are to decrease

symptoms, improve function, and return patients to their

pre-injury level of activity. When ACL reconstruction is

indicated for both knees, surgeons have the choice of per-

forming staged or simultaneous procedures. A review of the

literature revealed just a few previous reports on the results

of one-stage bilateral ACL reconstruction [7, 8, 11, 16].

The purpose of this prospective study was to present our

experience and clinical outcome after one-stage bilateral

ACL reconstruction. The hypothesis for this study was that

functional results of patients with bilateral ACL-deficient

knees who underwent one-stage bilateral ACL recon-

struction are not significantly different from those of mat-

ched control group of patients who underwent unilateral

ACL reconstruction. Another purpose of our study was to

quantify, whether there are any total cost savings by per-

forming bilateral ACL reconstruction as a single procedure

rather than two separate surgeries.

Materials and methods

From 2002 to 2008, 723 primary ACL reconstructions were

performed by the senior author at our institution. The

indication for operation was symptomatic ACL-deficient

knee in patients who desired to return to pre-injury level of

activity. During this period, 7 patients (14 knees) under-

went one-stage bilateral ACL reconstructions. In one

patient with multiligamentar injury in one of the knees, we

have performed staged bilateral ligament reconstruction.

Data were collected prospectively for all patients under-

going one-stage bilateral ACL reconstruction. All patients

signed an informed consent form. This group included six

men and one woman with a median age of 25 (17–36) years

who had symptomatic instability in both knees because of

bilateral ACL tears. All of them had bilateral chronic ACL-

deficient knees, meaning that they had experienced at least

one additional giving-way episode of the knee after the

initial injury. The median time from initial injury to sur-

gery was 24 (11–35) months in the bilateral injured group

and 12 (2–16) months in the control group. One patient

sustained simultaneous bilateral ACL tear while skiing. In

another six patients, unilateral injury of the knee had

occurred and later on during further sports activity contra-

lateral knee injury had taken place.

For the purpose of comparison, a control group was

derived from our database of patients who underwent

unilateral ACL reconstruction. The patients were matched

for sex, age, time from surgery and choice of graft.

A control group consisting of 21 patients was obtained.

Their median age was 29 (16–37) years.

All patients in both groups underwent a period of pre-

operative rehabilitation to eliminate effusion, regain full

motion, and develop good leg control and a normal gait

pattern before surgery. The patients were also informed

about the operation and the post-operative rehabilitation

and its goals.

The operating room set-up included the use of two

exclusion arthroscopy drapes, one-camera stack system,

and a single set of reconstruction instruments to allow one-

stage bilateral surgery by one surgical team. Both knees

were prepared and draped separately. An arthroscopy was

performed on the first knee to evaluate and treat any

meniscal tears following with ACL reconstruction, after

which the tourniquet was released, and the knee was

wrapped with an elastic bandage. Then, an arthroscopy and

ACL reconstruction were performed on the other leg. The

choice of graft was based on the standard technique per-

formed by the senior surgeon, and over the period of time

of this study, graft choice changed from use of central third

patella tendon to four strand double loop semitendinosus

and gracilis grafts. In first two patients, the surgeon used

patellar tendon autografts for one-stage bilateral ACL

reconstruction. Later hamstring tendons autografts were

used in the next five patients.

All patients underwent the same post-operative reha-

bilitation programme [12], which was not altered for the

bilateral group, except to include simultaneous rehabilita-

tion of both legs. In bilateral group, first 2–3 weeks, full

weight bearing with use of crutches was recommended.

Rehabilitation braces were not used postoperatively. Pro-

prioceptive exercises were started from the very first day of

rehabilitation. It is reasonable to consider the principle of

progression. At first, these are less demanding exercises on

the balance mat, board, and plate. The use of various aids


123

with different visual effects depends on patient’s ability to

participate in the rehabilitation. The patients from both

groups concluded their post-operative rehabilitation after

they achieved full active ROM, the knee/knees was/were

not swollen and after they were comfortable with day-to-

day activities (8 weeks controlled group, 9 weeks bilateral

group). The patients whose job activities included light

functional activities, such as walking, jogging, and agility

drills (without pivoting and shifting), could at that time

return to work. While, sports active patients began with the

sports rehabilitation programme.

Data collection and follow-up evaluations

Patients returned for regular follow-up visits at 2 and

9 weeks and 4 and 6 months after surgery. For research

purposes and mid-term follow-up data, patients were asked

to return for evaluation every year after surgery. The

Lysholm knee score questionnaire [15] was sent to the

patients by mail and completed in their home environment

prior to clinical control. An additional subjective ques-

tionnaire was used to determine when patients returned to

full-time work, to low-level sports activities, and to full

sports activity. Senior author had performed all surgical

procedures and clinical evaluations at regular follow-ups.

At final follow-up, an independent examiner performed

clinical ligament testing by means of the Lachman test,

anterior drawer test, and pivot-shift test, with side-to-side

differences recorded. Objective anteroposterior knee laxity

was determined by using the KT-1000 arthrometer

(MEDmetric, San Diego, Calif.) at manual maximum ten-

sion (over 134 N) and a knee flexion angle of 25� [2]. All

measurements were taken by physiotherapist who was

involved in pre- and post-operative rehabilitation. In both

groups, preoperative total AP laxity of the involved knee

has been compared with post-operative total AP laxity

measured at follow-ups. Clinical controls and KT-1000

arthrometer measurements were performed in the General

Teaching Hospital Celje. Intraoperative and post-operative

complications such as wound complications, graft failures,

arthrofibrosis, and unexpected inpatient stay were also

tabulated.

Because of changes in currency and costs over the

11-year study period, total costs per patient were tabulated

in current euros (2012). A current formula for intraopera-

tive and perioperative charges was obtained from the

hospital billing department. Most of the hospital charges

were based on the type of operative surgery, time spent in

hospital, and potential ancillary services provided. Anaes-

thesiologist fees were calculated according to hospital fee

scale. Current mean surgeon fee reimbursement for uni-

lateral and bilateral ACL reconstruction was also calcu-

lated according to hospital fee scale. Information about

operative, perioperative, and aesthesia time was obtained

from medical records of each patient. Current charges for

physical therapy were provided by physical therapy bill-

ing office of Rehabilitation Center Celje and Spa Zrece,

where they underwent the rehabilitation programme.

Physical therapy records and bills were tabulated based on

services provided and the number and length of physical

therapy visits. All the charges were generated in the same

hospital and the same physical therapy department and

Spa.

Statistical analysis

Median (range) values are presented, except for the total

AP KT-1000 arthrometer laxity measurements, for which

mean (SD) values are presented. The unpaired t test was

used for the normally distributed numerical data (KT-1000

arthrometer). A nonparametric analogue (Mann–Whitney

test) was used to compare the difference of Lysholm score

between the groups. The v2 test was used to compare

categorical variables (IKDC scores). A P value less than

0.05 was considered statistically significant.

Results

Mid-term subjective and objective follow-up after surgery

were obtained for 7 patients (14 knees) in the bilateral

group at a median 88 (45–115) months and for 21 patients

in the unilateral group at a median 85 (47–114) months. At

the final follow-up, there were no statistically significant

differences between the groups with respect to Lysholm

knee scores. In the bilateral group, the median Lysholm

score was 96 (85–100), and in the control group, the

median score was 93 (81–100). Six patients (86 %) in the

bilateral group and 17 patients (81 %) in the control group

were still at their pre-injury level of activity. Table 1 rep-

resents the distribution of patients according to IKDC

activity level (n.s.). There was no significant difference in

time taken to return to full-time work, low-level athletic

activity, or full athletic participation between the unilateral

and bilateral groups.

Preoperative mean value of total AP laxity measured

with the KT-1000 arthrometer at manual maximum ten-

sion was 11.6 ± 2.0 mm for the bilateral group and

12.4 ± 1.7 mm for the control group (n.s.). On clinical

examination at final follow-up, there was a positive pivot-

shift test (2?) in one patient in the unilateral group (n.s.).

Table 2 represents post-operative clinical evaluation and

KT-1000 arthrometer measurements. Post-operative mean

value of total AP laxity was 4.0 ± 1.1 mm for the bilat-

eral group and 4.9 ± 1.2 mm for the unilateral group

(n.s.).


123

Cost comparison

Cost analysis reveals that there is a big cost saving when

the surgeon performs one-stage bilateral ACL recon-

struction instead of two-stage operative procedures. Nor-

mally, the total savings are broken down according to

operating room time, material costs, anaesthesiology fees,

surgeon fees, equipment fees, hospital days, and rehabili-

tation costs. Table 3 shows that the said costs for unilat-

eral surgery amounts in total to 3,798 EUR. In two-stage

bilateral ACL reconstruction procedures, the costs would

therefore amount to 7,596 EUR. However, in one-stage

bilateral ACL reconstruction, the total cost amounts to

4,670 EUR. This shows that the total saving amounts to

2,925 EUR.

With one-stage bilateral ACL reconstruction, all further

costs regarding sick leave are approximately cut in half,

since post-operative rehabilitation is carried out simulta-

neously for both legs. Simultaneous bilateral ACL recon-

struction with adequate and proper rehabilitation shortens

the time of absence from sports arenas in professional

athletes.

Discussion

The most important finding of the present study is that

simultaneous bilateral ACL reconstruction is clinical and

cost effective treatment for patients presenting symptom-

atic bilateral ACL deficiency. None of the patients in this

study had suffered any serious complication. Despite the

otherwise abundant literature regarding ACL reconstruction,

Table 1 Post-operative level of

activity

a IKDC international knee

documentation committee

Activity level (IKDC)a Bilateral group Unilateral group P

Number % Number %

Functional category n.s.

I. Daily living activities

II. Straight running 1 14 4 19

III. Agility sports 3 43 9 43

IV. Cut and jump 3 43 8 38

Intensity n.s.

Work 1 14 2 9

Light recreational sports 2 29 10 48

Vigorous recreational/competitive 4 57 9 43

Table 2 Outcomes of clinical and KT-1000 evaluation at final follow-up

Bilateral group Unilateral group

No. of knees (14) % No. of knees (21) %

Manual Lachman test

A (negative) 11 79 16 76

B (positive with firm endpoint-1+) 3 21 4 19

C (soft endpoint-2+) 0 0 1 5

Manual pivot-shift

A (negative) 12 86 15 72

B (glide-1+) 2 14 5 24

C (clunk-2+) 0 0 1 4

Total AP laxity measured with KT-1000 arthrometer in

mm at manual max tension

P

Preoperatively 11.6 ± 2.0 12.4 ± 1.7 n.s

Postoperatively 4.0 ± 1.1 4.9 ± 1.2 n.s

Table 3 Cost comparison

Unilateral Bilateral

Cost comparison Cost in EUR Cost in EUR

Perioperative care 65 65

Operative procedure

Anaesthesia fees 255 255

Cost of surgery 799 1,301

Post-operative hospital care 827 1,127

Total hospital charges 1,948 2,750

Post-operative physical therapy 1,850 1,920

Total 3,798 4,670


123

there is very little information regarding strategies for

patients with bilateral ACL-deficient knees. The incidence

of bilaterality for ACL ruptures is reported to be between 2

and 4 % [1, 14]. In spite of reports on simultaneous

bilateral ACL ruptures in the literature [11, 16], the vast

majority of patients presenting with bilateral ACL-deficient

knees sustain non-simultaneous bilateral ruptures [14].

To our knowledge, Jari and Shelbourne [7] were the first

to publish results concerning the bilateral ACL recon-

struction as a single procedure. Their results showed that,

in the short term, there was no statistically significant

difference in post-operative results between patients who

had simultaneous bilateral ACL reconstructions and

patients who had unilateral ACL reconstruction. These

results indicate that there might be an advantage to per-

forming simultaneous ACL reconstructions to stage pro-

cedures, which would involve two operations and

rehabilitation programmes. In our study, we had come to

the same conclusions. Post-operative hospitalization of

patients in whom bilateral ACL reconstruction has been

performed was on average 2 days longer, while the dura-

tion of rehabilitation process in patients from control group

with unilateral ACL was only one week shorter. In study of

Jari and Shelbourne [7], the mean KT-1000 arthrometer

side-to-side comparative values appeared to show a dif-

ference between groups, with apparent increased laxity in

the unilateral group. Side-to-side comparative values that

are usually presented in the literature compare results from

an injured or reconstructed knee with those from a normal

uninjured knee. In their group of patients who had bilateral

reconstructions, both knees were ACL-deficient, and so

there was no base line normal value for post-operative

comparison. What the data from their bilateral group

indicate was that both knees were reconstructed to a similar

degree of stability on average. However, the advantage of

our study is that we measured total AP laxity of the knee

preoperatively and postoperatively. In this way, we could

objectively evaluated post-operative stability of the knees.

The retrospective Larson study [8] did not represent the

results on post-operative pain, return to full ROM and

muscles strength, or return to work and sports. However,

they performed a more comprehensive analysis of costs

incurred both on the day of surgery and during rehabilita-

tion. They found that performing bilateral ACL recon-

struction at a single setting resulted in a total cost savings of

more than $3,750 per knee. They found that day-of-surgery

charges made up the majority of savings, post-operative

rehabilitation accounted for nearly 15 % of the total. On the

other side, we have a completely different situation in our

country. We found that rehabilitation charges totalled

nearly 50 % of savings because the surgery fees are very

low. In Larson study [8], the majority of patients (80 %

overall) underwent allograft ACL reconstruction. Although

it was initially felt that patients may tolerate a bilateral

procedure using an allograft tissue better, they recognized

no difference in perioperative morbidity or early functional

or objective results between allograft and autograft for

bilateral ACL reconstruction at a single setting. In our

study, the majority of patients (70 % overall) underwent

hamstring tendons autograft ACL reconstruction. In the rest

of the patients, we used patella tendon autograft.

The main limitation of our study is the small number of

patients who underwent one-stage bilateral ACL recon-

struction. Low incidence of bilaterality for ACL ruptures is

the reason why we did not present more patients. In order to

obtain more reliable results, a multicentre study should be

made in the future. The results of our study indicate that there

might be an advantage to performing one-stage bilateral ACL

reconstruction as opposed to staged procedures, which would

involve two operations and two rehabilitation programmes.

Economic aspects play a significant role in health care

delivery. In addition to lower costs, only one period of work

and one period of rehabilitation are needed, which results in

less disruption to the lives of the patients and caregivers.

Conclusion

One-stage bilateral ACL reconstruction with either ham-

string or patella tendon autograft is clinically effective.

Based on this small series, there is no evidence that

simultaneous bilateral ACL reconstruction is associated

with an increased risk when compared to unilateral ACL

reconstruction. For patients presenting symptomatic bilat-

eral ACL-deficient knees, one-stage bilateral ACL recon-

struction is reproducible, cost effective and does not

compromise functional results.

References

1. Anderson AF, Lipscomb AB, Liudah KJ et al (1987) Analysis of

the intercondylar notch by computed tomography. Am J Sports

Med 15:547–552

2. Daniel DM, Malcolm LL, Losse G et al (1985) Instrumented

measurement of anterior laxity of the knee. J Bone Joint Surg Am

67:720–726

3. Flynn RK, Pedersen CL, Birmingham TB et al (2005) The

familial predisposition toward tearing the anterior cruciate liga-

ment. A case control study. Am J Sports Med 33:23–28

4. Griffin LY, Agel J, Albohm MJ, Arendt EA et al (2000) Non-

contact anterior cruciate ligament injuries: Risk factors and pre-

vention strategies. J Am Acad Orthop Surg 8(3):141–150

5. Harmon KG, Ireland ML (2000) Gender differences in noncon-

tact anterior cruciate ligament injuries. Clin Sports Med 19:

287–302


123

6. Huston LJ, Greenfield ML, Wojtys EM, Griffin LY, Garrick JG

(2000) Anterior cruciate ligament injuries in the female athlete:

potential risk factors. Clin Orthop Relat Res 372:50–63

7. Jari S, Shelbourne KD (2002) Simultaneous bilateral anterior

cruciate ligament reconstruction. Am J Sports Med 30:891–895

8. Larson CM, Fischer DA, Smith PJ, Boyd JL (2004) Bilateral

anterior cruciate ligament reconstruction as a single procedure.

Evaluation of cost and early functional results. Am J Sports Med

32(1):197–200

9. Lephart SM, Kocher MS, Harner CD et al (1993) Quadriceps

strength and functional capacity after anterior cruciate ligament

reconstruction. Patellar tendon autograft versus allograft. Am J

Sports Med 21:738–743

10. Ochard J, Seward H, McGiven J et al (2001) Intrinsic and

extrinsic risk factors for anterior cruciate ligament injury in

Australian footballers. Am J Sports Med 29:196–200

11. Sanchis-Alfonso V, Tinto-Pederol M (2000) Simultaneous bilat-

eral anterior cruciate ligament tears in a female beginner skier.

Knee Surg Sports Traumatol 8(4):241–243

12. Shelbourne KD, Gray T (1997) Anterior cruciate ligament

reconstruction with autogenous patellar tendon graft followed by

accelerated rehabilitation. A two-to nine-year follow-up. Am J

Sports Med 25:786–795

13. Sonnery-Cottet B, Archbold P, Cucurulo T, Fayard MJ et al

(2011) The influence of the tibial slope and size of the interc-

ondylar notch on rupture of the anterior cruciate ligament. J Bone

Joint Surg 93-B:1475–1478

14. Souryal TO, Moore HA, Evans JP (1988) Bilaterality in anterior

cruciate ligament injuries: associated intercondylar notch steno-

sis. Am J Sports Med 16(5):449–454

15. Tegner Y, Lysholm J (1985) Rating systems in the evaluation of

the knee ligament injuries. Clin Orthop Relat Res 198:43–49

16. Tifford CD, Jackson DW (2001) Simultaneous bilateral anterior

cruciate ligament ruptures in a cheerleader. Arthroscopy 17(4):

E17


123

Documents

One-stage bilateral anterior cruciate ligament reconstruction