Neyret, S Lustig, E Servien, C Batailler, N Darwich (Lyon)
Bicruciate lesions are rare but serious. There is no internationally accepted management plan. It is crucial to recognise every elementary ligamentous lesion.
The difficulty is not only to make the diagnosis of dislocation that is obvious when the knee is dislocated but also to make the diagnosis after spontaneous reduction.
It is necessary to perform radiographs with the knee stressed in varus and valgus, as well as with the tibia moved inferiorly and posteriorly. Additional stress views may include medial and lateral translation of the tibia in relation to the femur. Care must be taken not to redislocate the joint. These examinations can help to distinguish between opening lesions and capsular periosteal detachments. Information gained from a MRI taken soon after injury can influence the treatment plan. If we wish to establish a classification, compare results of ligamentous management and make recommendations, identification of every ligamentous lesions is the keystone. However, the management plan (still being debated) of bicruciate lesions will depend not only on the ligamentous damage but also on the real or potential complications. Bicruciate lesions of the knee are over shadowed by the importance of vascular complications. Since arterial lesions are frequent (15%-32% in literature) and are often difficult to diagnose, Angio MRI or Angio CT Scan is strongly recommended.
The others complications that may influence the management plan include: Irreducibility, Cutaneous complications, Osseous and osteochondral lesions, Lesions of the extensor apparatus, Neurologtical complications, Veinous complications.
Of course, it is also very important to consider the age and the motivation of the patient. it is important to consider separately ligamentous lesions produced by opening and those produced by stripping. When there are bicruciate lesions, priority is given to reconstruction of the posterior cruciate ligament. Reconstruction of the anterior cruciate does not take priority when there is also a torn posterior ligament, as simultaneous reconstruction of both ligaments increases the risk of fixing the knee with the tibia in a posteriorly subluxated position.
Non-operative treatment can be considered in an elderly patient or a patient who has low demands for his knee. However, it is important not to leave interposed soft tissues and to obtain a perfect anatomical reduction of the knee.
Conclusion : These lesions are rare, severe and there management still controversial.