KNEE

Simultaneous bilateral anterior cruciate ligament reconstruction:a safe option

Adnan Saithna • Jamie Arbuthnot •

Richard Carey-Smith • Tim Spalding

Received: 28 April 2009 / Accepted: 7 October 2009 / Published online: 22 October 2009

� Springer-Verlag 2009

Abstract When patients present with bilateral anterior

cruciate ligament (ACL) deficiency and require recon-

struction in both knees, a single setting or staged approach

can be adopted. Although single-setting reconstruction has

been described, there are no published case series that

describe simultaneous bilateral ACL reconstruction. We

report a case series of eight patients who underwent

simultaneous bilateral ACL reconstruction. We used two-

camera stack systems to allow for truly simultaneous

bilateral surgery by two surgical teams. At 2 weeks, all

patients were independent in mobility. There was no

difference in pivot shift, Lysholm and Tegner scores at

1 year when compared to published outcomes for unilat-

eral ACL reconstruction. The median duration of follow-

up was 28 months (range 12–50 months). Based on these

small numbers, our results demonstrate that simultaneous

bilateral ACL reconstruction is a safe and clinically

effective option when using either hamstring or patella

tendon graft.

Keywords ACL � Reconstruction � Simultaneous �Bilateral � Rehabilitation

Introduction

When patients present with symptomatic bilateral anterior

cruciate ligament (ACL) deficiency and require recon-

struction in both knees, a single setting or staged approach

can be adopted. With the latter, two periods of rehabilita-

tion are interspersed by a period of several weeks or

months.

Single-setting bilateral ACL reconstruction has been

previously reported using patella tendon grafts and shown

to be successful with no increase in complications when

compared to unilateral surgery [3, 5]. The technique in the

published cases has involved sequential surgery using a

single surgical team. The use of hamstring grafts for

bilateral simultaneous surgery has only been described in a

single case report [7]. We report a series of patients who

underwent simultaneous bilateral ACL reconstruction

using either hamstring or patella tendon autografts fol-

lowed by accelerated rehabilitation.

Methods

Data were collected prospectively for all patients under-

going bilateral simultaneous ACL reconstruction. Patients

were considered for bilateral ACL reconstruction if they

had symptomatic instability of both knees and were willing

to tolerate the rehabilitation. Post-operatively, patients

were clinically reviewed at 2, 6 and 12 weeks and then at

six monthly intervals, recording pivot shift, Lysholm and

Tegner scores.

The operating room set-up included the use of two

exclusion arthroscopy drapes, two-camera stack systems

and a single set of reconstruction instruments to allow for

simultaneous bilateral surgery by two surgical teams. Only

one set of instruments was used in order to reduce clut-

tering of the scrub table. The start of the contra-lateral

procedure was staggered by *5 min in order to reduce the

likelihood of both surgical teams requiring the instruments

at the same time.

A. Saithna (&) � J. Arbuthnot � R. Carey-Smith � T. Spalding

Department of Trauma and Orthopaedic Surgery,

University Hospital Coventry and Warwickshire,

Clifford Bridge Road, Coventry CV2 2DX, UK

e-mail: asaithna@doctors.org.uk

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Knee Surg Sports Traumatol Arthrosc (2010) 18:1071–1074

DOI 10.1007/s00167-009-0971-1

Patients were positioned supine on the operating table

with knees flexed to 90� supported with a foot support and

side post. A Mayo table was clamped to the table at the

level of the groin. Iodine preparation and arthroscopic ACL

drapes were used. Two surgeons (consultant and specialist

knee fellow) performed the surgery with a third as a sur-

gical assistant retracting and preparing the grafts on the

back table. Only one scrub nurse was required. Both sur-

geons stood on the same side as the knee they were oper-

ating upon and looked at the arthroscopic stack system

(containing the camera, pump system and monitor) on the

opposite side of the table.

The choice of graft was based on the standard technique

performed by the senior surgeon and over the time period

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

third patella tendon to four strand double loop semitendo-

nosis and gracilis grafts.

The hamstring tendons were harvested through a cos-

metic transverse incision and were secured on the femoral

side using an Endobutton (Smith & Nephew Endoscopy,

UK). On the tibial side, the Linvatec tensioner system and

an Extralok interference screw (Linvatec, UK) were used,

tensioning the graft to a combined tension of 80 N. Patella

tendon grafts were harvested from the central third of the

tendon with 10-mm-diameter bone plugs from the patella

and tibial tubercle. Fixation was achieved using interfer-

ence fit Bioscrews (Linvatec, UK). A similar single inci-

sion arthroscopic technique was performed for both grafts.

After diagnostic and therapeutic arthroscopy, and prepa-

ration of the notch, a tibial tunnel was drilled using the

Linvatec ACL guide. The femoral tunnel was then drilled

to an appropriate diameter and length for the chosen graft.

This was performed trans-tibially placing the tunnel at a

10:30/1:30 position. The graft was then passed and secured

in place after cycling the knee.

Post-operatively a Cryocuff (�Aircast, DJO, California)

was applied to both knees over a thin bandage. Flexion and

extension exercises were commenced in the morning fol-

lowing surgery, and patients were discharged when safe to

mobilise fully weight bearing with crutches and bending

both knees to 90�. The standard rehabilitation programme

undertaken by patients is described in Table 1. Proprio-

ception and range of motion exercises encouraging full

terminal extension progressed over the first 6 weeks before

starting the strength phase of rehabilitation and finally the

functional phase. No protective braces were used.

Results

Simultaneous bilateral ACL reconstruction was performed

in eight patients (six male, two female) using hamstring

tendon in seven knees and patella tendon in nine. In one

patient, an insufficient hamstring graft was obtained and so

a patella tendon graft was used on the second side. The

median age at surgery was 30 years (range 21–41 years)

and the median time to surgery from the date of first injury

was 6 years (range 4 months to 12 years). The mechanism

of injury was football in nine knees, winter sports in five

and falls unrelated to sport in two knees. One patient sus-

tained simultaneous ACL rupture, and in the remaining

seven patients, the median duration of time between inju-

ries was 5 years (range 1–11 years). The median duration

of surgery (the interval of time between inflating the first

tourniquet and releasing the second tourniquet) was

100 min (range 90–123 min). Five patients also required

meniscal debridement for associated meniscal tears (three

bilateral). No patient required meniscal repair, and no tears

were left untreated. Six patients were discharged from

hospital on the day following surgery, and two patients

stayed in hospital for two nights.

At 2 weeks all patients were able to achieve greater

than 90� flexion, full normal hyperextension and were

independent in mobility. At the latest follow-up (median

Table 1 Summary of six-phase rehabilitation programme undertaken

by patients

Initial post-Op phase (0–2 weeks)

Maintain extension

Active and passive flexion exercises

Patella mobilisation exercises

Mobilise fully weight bearing with crutches

Avoid open chain exercise from 30� flexion to full extension for the

first 6 weeks

Static muscle exercises (quadriceps, gluteal contractions and

hamstring exercises)

Proprioception phase (3–6 weeks)

Weight bearing: full weight bearing off crutches working to

establish normal gait

Start swimming (no breast stroke kick)

Hamstring curls lying on the front using a lightweight or elastic cord

resistance (delayed until 6 weeks if hamstring tendons used for the

graft)

Introduce low resistance closed chain exercises

Strength phase (6–12 weeks)

Start early jog training as control allows

Gait re-education drills: walking fast/slow, side, front and backward

Early sports training (3–6 months)

Hard pivoting and cutting is introduced at this stage providing

satisfactory progress with running training

Functional testing (single leg hop test)

Agility training: shuttle runs, ball dribbling and other sports drills

promoted

Return to sport (6–9 months)

Specific sports training aimed at the individual

1072 Knee Surg Sports Traumatol Arthrosc (2010) 18:1071–1074

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28 months, range 12–50 months), the median Tegner

score had improved from a pre-operative value of 5

(range 2–7) to 7 (range 3–9) and the median Lysholm

score improved from a pre-operative value of 61 (range

52–86) to 94 (range 65–100). For the purpose of this

analysis, the Lysholm score was taken as that of the limb

with the lowest score in order to reflect the overall status

of the patient. Thirteen knees had negative pivot shift

with a glide (Pivot shift grade I) in three. We did not have

any complications of infection, deep vein thrombosis or

pulmonary embolus.

One patient underwent second look arthroscopy of the

right knee for intermittent swelling and discomfort 4 years

after simultaneous bilateral ACL reconstruction. At

arthroscopy, the ACL was found to be satisfactory and the

persistent effusion was attributed to degenerative change

secondary to a deficient lateral meniscus and a medial

meniscal tear. In this patient, the injury to the right knee

occurred 15 years before reconstruction but the patient

became aware of the possibility of reconstructive surgery

only when he sustained injury to the opposite knee

11 years later. This second knee had no meniscal or

chondral secondary injury.

Discussion

The most important finding of this small series is that

simultaneous bilateral reconstruction is a safe and clini-

cally effective treatment modality for patients presenting

with symptomatic bilateral ACL deficiency. None of the

patients in this series suffered any serious complication

such as infection, thromboembolism or graft failure. This is

in agreement with other authors who have reported single-

setting bilateral ACL reconstruction to be safe [3, 5].

Larson et al. [5] reported outcome in 11 patients who

underwent single-setting bilateral ACL reconstruction

using either patella tendon autograft or allograft. They

demonstrated no increased incidence of complications

when compared to a unilateral procedure. Similarly, Jari

and Shelbourne reported a series of 28 patients who

underwent single-setting sequential bilateral ACL recon-

struction using ipsilateral patella tendon graft and com-

pared their results to a group of matched controls

undergoing unilateral procedures [3]. They reported no

significant difference in post-operative pain and analgesic

requirements, and although overall blood loss was higher in

the bilateral group, no patient required transfusion.

Recent meta-analyses have demonstrated good outcome

when using either hamstring tendon or patella tendon graft

for unilateral ACL reconstruction [1, 2, 4, 6]. In our

opinion, a good outcome can be achieved when using

either graft material for simultaneous bilateral ACL

reconstruction though the senior author (TS) currently

favours the use of hamstring tendons. The functional out-

comes reported in this series (Lysholm and Tegner scores)

are comparable to published data for single-setting bilateral

and unilateral ACL reconstruction. These findings concur

with Jari and Shelbourne who found no difference between

the time taken to return to full, unrestricted activity for

patients undergoing unilateral surgery and those undergo-

ing bilateral ACL reconstruction [3]. Patients in our series

were easily able to mobilise fully weight bearing with the

aid of elbow crutches and participated in the same ACL

rehabilitation programme conducted for our unilateral ACL

reconstructions. This rehabilitation strategy when applied

to bilateral reconstructions relies on the concept that whilst

one knee is undergoing rehabilitation the other knee is also

being rehabilitated. Shelbourne has emphasised the

importance of regaining symmetrical knee strength and

function in achieving early return to function [8]. The

rehabilitation programme undertaken by patients in this

series embraces this philosophy.

This study had several limitations. These included the

fact that it was a single centre series with a relatively short

follow-up and no control group. Although we present only

a small series of patients, the clinical relevance of a

potentially reduced period of rehabilitation and reduced

anaesthetic and operating times when compared to staged

or non-simultaneous bilateral ACL reconstruction are

important considerations that require further study.

Conclusion

Simultaneous bilateral ACL reconstruction with either

hamstring or patella tendon graft is clinically effective.

There is no evidence from this small series that simulta-

neous bilateral reconstruction is associated with increased

risk when compared to unilateral or staged ACL recon-

struction. We believe this to be a useful technique for

patients with symptomatic bilateral ACL deficiency.

Conflict of interest The authors declare that they have no conflict

of interest.

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