Cutting edge Orthopedics

44 • CUTTING EDGE - ORTHOPEDICS Another alternative is reconstructing the PCL early to restore the central pivot, then delay- ing the ACL and collateral reconstruction for a second stage. In 2002, Ohkoshi and associates published a series of 13 knee dislocations treated with this method [24]. These patients had good range of motion with full extension and a mean of 126.7° active range of motion and 139.5° of passive flexion. These knees were also found to have adequate stability. However, standardized outcome measures were not tested in these patients. Further studies on outcomes of these knees are needed for validation of this method. Open Versus Arthroscopic Cruciate Repair Open ligamentous repair or arthroscopic repair remains controversial. Both approaches offer advantages and disadvantages. An open approach to these injuries is advantageous for addressing bucket handle meniscus tears, patellar tendon avulsions, quadriceps ruptures, displaced collateral avulsions, and capsular tears. One frequent concern for open repair versus arthroscopic recon- struction is postoperative arthrofibrosis. However, a case series with open repair and early aggres- sive modern rehabilitation programs demonstrates acceptable outcomes. Owens and associates published a series of patients repaired primarily in 2007, with a mean arc of motion of 119.3° and no incidence of late loosening that required reconstruction [17]. They retrospectively reviewed 28 acutely dislocated knees in 25 patients undergoing open repair of torn ligaments mostly within 2 weeks of the index injury and, with 2-year follow-up data, demonstrated good mean Lysholm (89) and Tegner (4.4) scores. The main complication of these patients was arthrofibrosis requiring arthroscopic lysis of adhesions in five patients (19%). Other authors have shown good results with arthroscopic treatment of the ACL and PCL in knee dislocations. Some authors advocate that an arthroscopic approach leads to less arthrofi- brosis and fewer wound complications due to less dissection [25], although no definite data have proven that either approach is superior. Fanelli and Edson [26] reported a prospective cohort of 35 combined ACL/PCL injuries with 34 knees with an ACL/PCL/collateral injury. These patients were treated with arthroscopically assisted reconstruction of cruciate ligaments and open recon- struction of collateral ligaments, and all had a minimum of 2-year follow-up. Their cohort of patients had an average Lysholm score of 91.2 and an average Tegner score of 5.3. Kohl and coworkers (2014) have developed a surgical technique for ACL repair as an alterna- tive to conventional arthroscopic repair. Dynamic intraligamentary stabilization (DIS), a method that utilizes a braided wire inserted from the anteromedial aspect of the proximal tibia, through the middle of the torn ACL, anchored to the lateral aspect of the femur [27]. Kohl and coworkers (2015) presented this novel technique, developed at their institution, to determine the clinical and radiological outcomes of knee dislocations surgically treated in this manner. Between 2009 and 2012, 35 patients were surgically treated with the DIS technique and evaluated clinically and radiologically with a mean follow-up of 2.2 years. The cohort experienced a mean Lysholm score of 90.8 and Tegner score of 6, with an IKDC score of B in 29 (83%) patients and C in 6 (17%) of patients. Two of the 35 patients included in the study cohort required a secondary operation. The group concluded that early, single-stage ACL reconstruction utilizing the DIS technique is capable of achieving beneficial results functionally without the requirement for grafting [28].