The association of an anterior cruciate ligament (ACL) tear and a posterior cruciate ligament (PCL) injury is rare in athletes, and to our knowledge it has never been described in a professional rugby player. We report the case of a 27-year-old international professional rugby player who presented with an ACL tear associated with chronic posterior laxity on a former PCL tear. The procedure associated arthroscopic ACL and PCL reconstruction in a one-stage operation with two autografts, bone-patellar tendon-bone and hamstring tendon, respectively. At 7 months postoperatively, the patient had returned to playing rugby at the same level of play. The therapeutic strategy successfully met the established goals of returning to sports at the same level of play with excellent functional results after 2 years of follow-up. A literature review was performed via PubMed. The inclusion criteria were the studies in English language, assessing the return-to-sport after bicruciate ligament reconstruction in athletes. Eight studies were included in analysis. Only one study has focused on the return-to-sport in 24 competitive athletes and two other studies have included 1 professional athlete each. The overall rate of the return-to-sport after bicruciate reconstruction varied between 100% and 50%.
Anterior (ACL) and posterior (PCL) cruciate ligament tears are frequent and severe in professional rugby players [
A 27-year-old patient who was an international professional rugby player consulted for a knee sprain that occurred during training after landing from a jump without player contact. He had a history of a sports injury in the same knee 8 years before during a rugby match. Since then he occasionally experienced patellofemoral pain syndrome during periods of rest from sports or when he stopped performing quadriceps strengthening exercises. The contralateral knee had been treated by arthroscopic meniscectomy for a meniscal lesion.
The patient measured 1 m91 and weighed 105 kg with a varus morphotype. The clinical examination showed a positive Lachman test with a soft end point (++), a clearly positive pivot shift test in internal valgus rotation, a posterior drawer test at 70° and 90° with a lack of end feel, spontaneous disappearance of the anterior tibial tubercle in the resting position, and tibial retraction during isometric contraction of the hamstrings at 90°, with no other anomalies.
MRI showed a recent full-thickness ACL tear, a lateral meniscal lesion, and an abnormal signal of the PCL. Laximetry with the GNRB (GeNouRoB) arthrometer [
Preoperative anterior laximetry: graph of GNRB measurements.
Telos stress radiography performed with the knee in 90° flexion with and without hamstring contraction showed maximum posterior laxity of 13 mm in the right knee with a differential of 8.6 mm compared to the left knee (Table
Preoperative posterior laximetry on X-rays at 90° flexion with and without hamstring contraction.
Right (injured) | Left (healthy) | |
---|---|---|
|
7.5 mm | 3 mm |
|
13 mm | 4.4 mm |
Differential rest/contraction | 5.5 mm | 1.4 mm |
Differential right/left knee |
|
Following a preoperative physical reeducation protocol, the procedure was performed 23 days after the injury on a dry, mobile, and pain-free knee. The procedure was performed in a single-stage operation (Figure
Installation of patient for fluoroscopy guided bicruciate reconstruction.
The semitendinosus and gracilis (STG) tendons were harvested from a single vertical parapatellar portal and prepared as a single bundle with four strands. The middle part of the patellar ligament was harvested for the bone-patellar tendon-bone (BTB) graft. Arthroscopic evaluation showed ICRS (International Cartilage Repair Society) stage 2 chondropathies on the lateral facet of the patella and the lateral and medial condyles. The lateral meniscus presented with a complex tear including a radial tear at the junction of the middle posterior segment, freeing a displaced 7 mm fragment into the joint space and a horizontal cleavage tear separating the meniscus in two to the popliteal hiatus. A resection of the minimum necessary amount of meniscal tissue was performed (Figure
(a) Lateral meniscus complex lesion. (b) Lateral meniscus after minimal resection.
The blind femoral tunnel for BTB reconstruction was drilled in the lateral condyle through an anteromedial portal. The femoral tunnel for STG reconstruction of the LCP was drilled in the medial condyle by outside-in drilling. The tibial tunnel for STG reconstruction of the PCL was performed under fluoroscopic control through an accessory posteromedial portal, and then the tibial tunnel for BTB reconstruction of the ACL was drilled. After distal to proximal insertion of the STG graft, femoral fixation was obtained using an interference screw (Biosure, Smith & Nephew, USA) and then at 70° flexion by reducing posterior drawer under fluoroscopic control, tibial fixation was obtained with an interference screw and a ligament staple (Orthomed SAS, France). The BTB transplant was then inserted distally and attached in the femoral (SoftSilk, Smith & Nephew, USA) and tibial (Biosure, Smith & Nephew, USA) tunnels with interference screws (Figure
Perioperative view of the intracondylar notch after bicruciate reconstruction.
Postoperatively, the patient had an articulated brace and the knee was immediately free from 0 to 80° with full weight bearing. No PCL brace was used to control posterior laxity. The postoperative outcome was uneventful. The postoperative protocol was the same as ACL-type rehabilitation with closed kinetic chain exercises maintained for 5 full months. Protection of posterior drawer was not proposed, as in isolated PCL reconstruction.
Recovery was satisfactory at postoperative month 5. Isokinetic assessment of muscles was excellent. Concentric isokinetic knee extension tests at 90 and 240°/second and eccentric flexion isokinetic exercises at 30°/second were symmetric for both knees [
An electronic search of the literature was performed in Medline via PubMed using the key words
Flowchart of the systematic review.
The main evaluation criterion was the return-to-sport (yes/no). Eight studies were included in analysis. Only one study has focused on the return-to-sport in 24 competitive athletes [
Review of the literature.
Authors | Year | Athletes | Age (years) | Sex | Sport | Level of sport | Surgical technique | Follow-up | Return-to-sport | Level of return-to-sport |
---|---|---|---|---|---|---|---|---|---|---|
Sisto and Warren [ |
1985 | 13/19 | 37.7 | NR | Baseball 1 |
Professional 1 |
Open |
24 m | 8/13 |
Same 8/8 |
|
||||||||||
Noyes and Barber-Westin [ |
1997 | 8/11 | 17–42 | 10 M |
Jumping 4 |
NR | Arthroscopy |
2.5–9 y | 7/8 |
Increased 1/7 |
|
||||||||||
Wascher et al. [ |
1999 | 11/13 | 27.5 |
NR | NR | NR | Open 11 |
38.4 m |
10/11 |
Same 6/10 |
|
||||||||||
Xie et al. [ |
2007 | 10/10 | 34 |
8 M |
NR | NR | Arthroscopy |
18 m |
10/10 |
Same 8/10 |
|
||||||||||
Zhao et al. [ |
2008 | 2/21 | 27 |
15 M |
NR | NR | Arthroscopy |
24 m | 2/2 |
Same 2/2 |
|
||||||||||
Shi et al. [ |
2008 | 4/15 | 24 |
11 M |
Judo 1 |
Professional 1 |
Arthroscopy |
38 m |
2/4 |
Same 2/2 |
|
||||||||||
Hirschmann et al. [ |
2010 | 24/24 | 24 |
24 M | Soccer 16 |
Competitive |
Open |
8 y |
19/24 |
Same 8/19 |
|
||||||||||
Cartwright-Terry et al. [ |
2014 | 22/25 | 34 |
22 M |
NR | NR | Arthroscopy |
5 y | 23/25 |
NR |
This case study shows that ACL and PCL reconstruction in a single-stage operation with two autografts in an international professional rugby player makes possible a safe return-to-sports rapidly at the same level of play with excellent functional results after 2 years of follow-up.
In the present study several aspects were considered when determining the therapeutic strategy: whether to perform PCL reconstruction or not, in a one- or two-stage procedure, the type of reconstruction to be used, and the postoperative physical therapy protocol.
Certain arguments support functional physical therapy for the treatment of the PCL tear. Adding PCL reconstruction complicates the surgical procedure and can increase the risk of infection, which is already high in a professional athlete [
The second therapeutic decision to be made was the type of reconstruction. For the ACL the autograft can be either the patellar tendon if the STG has already been harvested, the fascia lata [
The third therapeutic decision was the choice of physical rehabilitation protocol. Because the goal was rapid recovery, we chose a rehabilitation protocol without posterior drawer protection, without restriction on the rehabilitation program or the use of a PCL brace. This compromise favors recovery of joint range of motion and muscular strength at the expense of residual posterior laxity. The articulated brace was immediately free from 0 to 80° with full weight bearing.
Although the clinical and functional results were satisfactory, persistent laxity remained. Extra-articular tenodesis would have been useful.
A bicruciate ligament tear in a professional athlete practicing a pivot sport is not frequent. There is no consensus on the therapeutic strategy in this case. The therapeutic decisions that were made resulted in an uneventful postoperative outcome, return-to-sports at a professional level after a short recovery period, and excellent functional results more than 2 years after surgery. The systematic review has shown a lack of data for professional athletes.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from the participant included in the study.
All authors declare they have no conflict of interests.