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

Abstract

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.

Keywords: Anterior cruciate ligament; Bilateral anterior cruciate ligament injury; Case report; Primary repair; Skiing injuries.

Fig. 1

MRI of the same patient with bilateral ACL injuries. (A) Sagital T1 imaging of the right knee shows a proximal avulsion type 1 complete ACL tear (arrowhead). (B) Sagital magnetic resonance image T1 of the left knee shows a proximal type 2 complex complete ACL tear (arrowhead).

Fig. 2

Arthroscopy of the ACL tear in the right and left knee of the same patient. (A) Arthroscopic view of a right knee viewed from the anterolateral portal with the patient supine and the knee in 90° flexion. A proximal avulsion tear with excellent tissue quality is seen. (B) Arthroscopic view of a left knee viewed from the anterolateral portal with the patient supine and the knee in 90° flexion shows a complex tear pattern of the ACL.

Fig. 3

Arthroscopic evaluation after reattachment of bilateral ACLs in the same patient. (A) Arthroscopic view of a right knee viewed from the anterolateral portal with the patient supine and the knee in 90° flexion. Shown is the completed ACL repair with suture augmentation (arrowhead). (B) Arthroscopic view of a left knee viewed from the anterolateral portal with the patient supine and the knee in 90° flexion. Shown is a completed ACL repair with suture augmentation (arrowhead). Note that there is an extra horizontal stitch at the midsubstance of the ligament (asterisk).