Double-bundle reconstruction cannot restore intact knee kinematics in the ACL/LCL-deficient knee

Introduction  

The aim of this study was to evaluate the effect of single-bundle (SB) and anatomic double-bundle (DB) anterior cruciate ligament (ACL) reconstruction on the resulting knee kinematics in a simulated clinical setting with ACL rupture and associated extra-articular damage to the lateral structures. It was hypothesized that anatomic DB ACL reconstruction restores the intact knee kinematics in ACL/LCL-deficient knees, whereas SB ACL reconstruction fails to restore the intact knee kinematics.     

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction: Where Are We Today?

The anatomic approach to anterior cruciate ligament (ACL) reconstruction has been a growing trend in orthopaedics. Progress made over the last 7 years has led to a greater understanding of the ACL anatomy and its 2 bundles. Surgeons are now more equipped to restore the native anatomy and knee kinematics than ever before. The University of Pittsburgh experience and technique have been described and have evolved to include several key principles. These include the restoration of native ACL anatomy, insertion sites, and double-bundle tension patterns with the utilization of an accessory medial portal to provide an individualized approach to ACL reconstruction. The purpose of this technical note is to provide surgeons with a technical update regarding the anatomic approach to ACL surgery. Most of this article will be focused on anatomic double-bundle ACL reconstruction, but it must be emphasized that this is a concept rather than just a technique and should be applied to all ACL reconstructions to provide a more anatomic and individualized result.     

Editorial Commentary: Chronic Anterior Cruciate Ligament Injury Requires Reconstruction Plus Lateral Tenodesis to Control Rotational Instability: Additional Technical Complexity May Result in Complications Without Improved Outcomes

How to restore native knee kinematics following complex knee injuries is still debated and under investigation. To better reproduce the native anterior cruciate ligament (ACL), surgeons have a host of different options, including graft choice, technique, fixation method, and single-, double-, and triple-bundle techniques, etc. Isolated ACL reconstruction alone is not effective in controlling complex instability patterns, especially regarding internal and external rotations. Several techniques have been described to address such instabilities, like single- or double- bundle ACL reconstruction plus lateral extra-articular tenodesis. In truth, chronic ACL injury requires reconstruction plus lateral tenodesis to control rotational instability. Additional technical complexity may result in complications without improved outcomes. Neither single-bundle nor double-bundle techniques are “truly” anatomic. Keep it simple; keep it safe.     

Hybrid Anterior Cruciate Ligament Reconstruction: Introduction of a New Technique for Anatomic Anterior Cruciate Ligament Reconstruction

Recently, anatomic or double-bundle reconstruction of the anterior cruciate ligament (ACL) has been presented in an effort to more accurately restore the native anatomy. These techniques create 2 tunnels in both the femur and tibia to reproduce the bundles of the ACL. However, the increased number of tunnels, particularly on the femoral side, has raised some concerns among authors and surgeons. We describe a technique to reconstruct the 2 distinct bundles of the ACL by using a single femoral tunnel and 2 tibial tunnels, the “hybrid” ACL reconstruction. The femoral tunnel is drilled through an anteromedial arthroscopy portal, which allows placement in a more anatomic position. Fixation in the femur is achieved with a novel device that separates a soft-tissue graft into 2 independently functioning bundles. Once fixed in the femur, the anteromedial and posterolateral bundles of the graft are passed through respective tunnels at the anatomic footprint on the tibia. These bundles are independently tensioned, which creates a reconconstruction that is similar to the native ACL. The technique presented provides surgeons with an alternative to other double-bundle techniques involving 4 tunnels.     

Kinematic study following double-bundle, anterior cruciate ligament reconstruction

The purpose of this study was to evaluate tibiofemoral kinematics after double-bundle anterior cruciate ligament (ACL) reconstructions and compare them with those of successful single-bundle reconstructions and contralateral normal knees using open MR images. We obtained MR images based on the flexion angle without weight-bearing, from 20 patients with successful unilateral single-bundle (10 patients) and double-bundle (10 patients) ACL reconstructions with tibialis anterior allografts and a minimum 1-year follow-up. The MR images of the contralateral uninjured knees were used as normal controls. Sagittal images of the mid-medial and mid-lateral sections of the tibiofemoral compartments were used to measure the translation of the femoral condyles relative to the tibia. The mean translations of the medial femoral condyles on the tibial plateaus during knee joint motion showed no significant differences among normal, single-bundle, and double-bundle ACL reconstructed knees (all p>0.05). The mean translations of the lateral femoral condyles showed a significant difference between normal and single-bundle reconstructed knees, or between single-bundle and double-bundle reconstructed knees (p<0.05). However, there was no significant difference between normal and double-bundle reconstructed knees (p=0.220). These findings suggest that double-bundle ACL reconstruction restores normal kinematic tibiofemoral motion better than single-bundle reconstruction.     

Dynamic functional performance and kinematic analysis of the rotational patterns of single- versus double-bundle anterior cruciate ligament reconstruction

BackgroundThe evaluation of anterior cruciate ligament (ACL) reconstruction has typically focused on the restoration of rotatory stability. Some studies have compared single-bundle and double-bundle ACL reconstruction using subjective clinical tests and questionnaires, but these studies only provide limited data on rotational stability. The purpose of this study is to determine the rotational patterns that present during high-demand pivoting tasks and to evaluate any difference in kinematic rotational patterns between patients who have undergone single- or double-bundle ACL reconstruction.Materials and MethodsTwenty-four males were divided into four groups for this study: intact, ACL deficient, single-bundle reconstructed, and double-bundle reconstructed. Kinematic data were collected using a 10-camera optoelectronic motion analysis system while the participants performed high-demand landing and pivoting tasks. The evaluation period was defined as the time from when the tested foot made contact with the ground to takeoff, and the range of tibial rotation was measured.ResultsRotation was significantly reduced in the single-bundle ACL reconstructed knees (7.8° ± 3.4°) and double-bundle ACL reconstructed knees (7.5° ± 2.6°) in comparison with ACL-deficient knees (13.5° ± 3.7°; p < 0.05). There was no significant difference in terms of tibial rotation between the intact knees (6.5° ± 3.5°) and the single-bundle or double-bundle ACL reconstructed knees after >2 years of follow up (p > 0.05).ConclusionBy using a dynamic functional biomechanical assessment, we demonstrate that the single-bundle ACL reconstruction technique using a composite hamstring tendon graft and the double-bundle ACL reconstruction technique can adequately restore excessive tibial rotation during high-demand activities such as landing and pivoting.     

The “Footprint” Anterior Cruciate Ligament Technique: An Anatomic Approach to Anterior Cruciate Ligament Reconstruction

To address the technical limitations of the conventional transtibial technique and the steep learning curve associated with double-bundle anterior cruciate ligament (ACL) reconstruction, we have defined a novel “footprint” technique that reliably allows for anatomic single-bundle ACL reconstruction with minimal technical complications. The technique merges the principles of carefully defining the ACL footprint anatomy with the use of a modified anteromedial portal reaming technique with a flexible guidewire and reaming system. The procedure offers the advantages of an anatomic ACL reconstruction by use of anteromedial portal reaming techniques while avoiding the significant technical risks and pitfalls associated with double-bundle reconstruction. Our experience in over 100 footprint ACL reconstructions has been met with excellent clinical success with minimal intraoperative or postoperative complications. The purpose of this article is to outline the key steps of our defined procedure that are critical to achieving a successful outcome.     

Indications and contraindications for double-bundle ACL reconstruction

Over recent years, double-bundle reconstruction has gained popularity after studies showed significant advantages of adding a second bundle with regard to outcomes and biomechanics; in particular, it resulted in less rotational instability than after reconstruction with a traditional single-bundle technique. As the focus shifted further towards the restoration of the native anatomy, both single-bundle and double-bundle ACL reconstruction were performed in an anatomical fashion and yielded similar results. To date, no consensus has developed as to whether double-bundle reconstruction is better than single-bundle reconstruction or vice versa. However, after surgeons started to individualise their surgical approach to the patient, it has been found that both the anatomical single- and double-bundle techniques have their own set of indications and contraindications. Reconstruction of the ligament should focus on restoration of the native functional and anatomical properties and should take the size, shape and orientation of the ACL into account. When indications and contraindications for the technique used are based on native anatomical characteristics, either a single-bundle or a double-bundle procedure can be performed according to the same double-bundle concept.     

关节镜下双束重建与单束重建膝前交叉韧带的效果比较

目的比较双束重建与单束重建膝前交叉韧带(ACL)的临床效果。方法分别对31例和30例膝前交叉韧带损伤患者行双束重建与单束重建手术,通过关节稳定性试验、Tegner体育量表评分和术后满意度来评价疗效。结果双束组和单束组Lachman试验阳性分别为1例和7例(P<0.05);边对边差异<3 mm分别为27例和19例(P<0.05);Tegner体育量表评分双束组优于单束组。结论双束重建符合正常膝ACL的空间结构,更能满足膝关节伸直位和扭转位时的生物力学要求。     

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures performed by orthopaedic surgeons. The procedure has improved significantly since its inception in 1900 and continues to be intensively studied with outcomes receiving considerable attention. Traditional ACL reconstruction techniques have focused on one portion of the ACL—the anteromedial bundle. Single-bundle ACL reconstruction is the criterion standard and has provided good to excellent results, with many athletes being able to return to sports; however, recently, some authors have noted persistent instability with functional testing and degenerative radiographic changes after single-bundle ACL reconstruction. As a result, several centers have attempted to improve upon the single-bundle technique by reconstructing both the anteromedial and posterolateral bundles of the ACL. This article will present the embryologic, anatomic, and biomechanical rationale for double-bundle ACL reconstruction. In addition, the latest outcomes of double-bundle ACL reconstruction will be presented.     

Editorial Commentary: Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction Makes More Sense Than Triple-Bundle: Three’s a Crowd

Recent research reports impressive patient-reported and objective stability outcomes after triple-bundle anterior cruciate ligament (ACL) reconstruction with hamstring autograft. However, the results are similar to those reported in the orthopaedic literature for single-bundle ACL reconstruction. If the triple-bundle technique does not reduce graft failure rates, and bearing in mind that it is more complex, more expensive, and more difficult to revise, then an anatomically-positioned single-bundle ACL reconstruction makes more sense. If the data supporting double-bundle ACL reconstruction is inconclusive, then why add a third bundle?     

关节镜下个体化前交叉韧带单束与双束解剖重建的近期疗效比较

目的 探讨关节镜下个体化单束与双束解剖重建前交叉韧带(ACL)的技术,并比较二者的近期疗效.方法回顾性分析2007年3月到2009年9月行ACL个体化单、双束解剖重建且获得随访的117例ACL损伤患者资料,根据不同解剖重建方法分为两组:A组(个体化单束解剖重建)35例,男31例,女4例;平均年龄(28.6±5.1)岁.B组(个体化双束解剖重建)82例,男73例,女9例;平均年龄(27.6±5.4)岁.两组患者术前一般资料比较差异均无统计学意义(P>0.05),具有可比性.采用Lachman试验、轴移试验、KT-2000、国际膝关节评分委员会(IKDC)评分及Lysholm评分比较两组患者的疗效.结果 117例患者术后获11～25个月(平均15个月)随访.末次随访时Lachman试验结果:与健侧比较,A组完全正常者占88.6%(31/35),B组占95.1%(78/82);轴移试验结果:与健侧比较,A组完全正常者占88.6%(31/35),B组占96.3%(79/82);Lysholm评分:A组平均为(93.4±8.2)分,B组平均为(93.7±7.0)分,以上指标两组比较差异均无统计学意义(P>0.05).而KT-2000检测结果:A组平均为(1.4±0.6)mm,B组平均为(1.1±0.5)mm;A组IKDC评分正常者(A级)占71.4%(25/35),B组占93.9%(77/82),两组比较差异均有统计学意义(P<0.05).结论采用个体化解剖位双束重建能更好地恢复患者膝关节的稳定性.双束解剖重建术中ACL股骨与胫骨足迹、髁间窝宽度的判断对手术的设计至关重要,3入路技术、测量尺的应用是个体化ACL双束解剖重建的关键所在.

Abstract：

Objective To compare clinical outcomes of double-bundle and single-bundle in individualized arthroscopic anatomical reconstruction of anterior cruciate ligament (ACL) . Methods The clinical data of 117 patients were reviewed who had received double-bundle or single-bundle arthroscopic ACL reconstruction from March 2007 through September 2009 in our hospital and had undergone complete follow-up. Of them, 35 cases had single-bundle ACL reconstruction and 82 double-bundle reconstruction. In the single-bundle group(group A), there were 31 men and 4 women, aged 28. 6 ±5. 1 years. In the double-bundle group(group B), there were 73 men and 9 women, aged 27. 6 ±5. 4 years. The 2 groups were comparable in the preoperative demographic data ( P > 0. 05). To evaluate the outcomes, Lachman and Pivot Shift exams , KT-2000, Lysholm and IKDC (International Knee Documentation Committee) scores, were adopted. Results The 117 patients received a mean follow-up of 15 months (from 11 to 25 months). The Lachman test showed 88. 6% (31/35) were normal in group A and 95. 1% (78/82) were normal in group B.The pivot-shift test showed 88. 6%(31/35) were normal in group A and 96. 3% (79/82) were normal in group B. Group A had a mean Lysholm score of 93. 4 ± 8. 2 and group B a mean Lysholm score of 93. 7 ±7. 0. There were no significant differences between the 2 groups in the above indexes ( P > 0. 05). By IKDC score, 71. 4% (25/135) were normal in group A and 93. 9% (77/82) were normal in group B. The KT-2000 test showed a mean of 1. 4 ± 0. 6 mm in group A and a mean of 1. 1 ± 0. 5 mm in group B. These 2 values were significantly different between the 2 groups ( P < 0. 05). Conclusions The individualized arthroscopic double-bundle anatomical reconstruction of ACL can maximally restore the anteroposterior and rotational stability. Arrangement of the ACL insertion site on the femoral and tibial side, three-portal technique and ruler application are keys for individualized anatomical double-bundle ACL reconstruction.     

All-Inside Anterior Cruciate Ligament Graft-Link Technique: Second-Generation, No-Incision Anterior Cruciate Ligament Reconstruction

We describe an anatomic, single-bundle, all-inside anterior cruciate ligament (ACL) graft-link technique using second-generation Flipcutter guide pins (Arthrex, Naples, FL), which become retrograde drills, and second-generation cortical suspensory fixation devices with adjustable graft loop length: femoral TightRope (Arthrex) and tibial ACL TightRope-Reverse Tension (Arthrex). The technique is minimally invasive using only four 4-mm stab incisions. Graft choice is no-incision allograft or gracilis-sparing, posteriorly harvested semitendinosus material. The graft is sutured 4 times through each strand in a loop and linked, like a chain, to femoral and tibial adjustable TightRope graft loops. With this method, graft tension can be increased even after graft fixation. The technique may be modified for double-bundle ACL reconstruction.     

Application of a computerised navigation technique to assist arthroscopic anterior cruciate ligament reconstruction

Purpose

Based on biomechanical cadaver studies, anatomical double-bundle reconstruction of the anterior cruciate ligament (ACL) was introduced to achieve better stability in the knee, particularly in respect of rotatory loads. Previously, the success of ACL reconstruction was believed to be mainly dependent on correct positioning of the graft, irrespective of the number of bundles for which computer-assisted surgery was developed to avoid malpositioning of the tunnel. The aim of this study was to compare rotational and translational stability after computer-navigated standard single-bundle and anatomical double-bundle ACL reconstruction.

Methods

The authors investigated 42 consecutive patients who had undergone the single-bundle or double-bundle ACL reconstruction procedure using autogenous hamstring tendon grafts and ENDOBUTTON fixation in patients who had been followed up for a minimum of 24 months. Post-operative anteroposterior and rotational laxity was measured with the KT3000 and compared between groups.

Results

Both surgical procedures significantly improve rotational and translational stability compared to the preoperative ACL-deficient knee (P<0.05). No significant differences were registered between groups with regard to anteroposterior displacement of the tibia. The International Knee Documentation Committee (IKDC) and Lysholm scores were significantly higher in the double-bundle group. However, the results were excellent in both groups.

Conclusions

The use of computer-assisted ACL reconstruction, which is a highly accurate method of graft placement, could be useful for inexperienced surgeons to avoid malposition. Long-term results of at least five years are needed to determine whether double-bundle ACL reconstruction, which was associated with improved rotational laxity and significantly better IKDC and Lysholm scores compared to the standard single-bundle ACL reconstruction procedure, exerts an influence in terms of avoiding osteoarthritis or meniscus degeneration.     

Single-bundle versus double-bundle arthroscopic reconstruction of the anterior cruciate ligament: what does the available evidence suggest?

Abstract The introduction of the double-bundle technique as a surgical option for primary anterior cruciate ligament (ACL) surgery stems from the hypothesis that replicating the double-bundle anatomy of the native ACL improves knee kinematics by supplying better rotational control. We performed a systematic review of the literature comparing double-bundle with standard single-bundle reconstruction methods. One RCT and three quasi-RCTs with a one-to two-year follow-up were included in this review. On the basis of these studies, ACL reconstruction with a double-bundle technique leads to less residual pivot-shift as assessed on manual and instrumented tests. Conflicting results exist as to whether the double-bundle technique leads to less side-to-side anterior tibial translation, and no significant differences were found regarding proprioception, flexorextensor peak torque and knee function as assessed with the International Knee Documentation Committee score. On the other hand, better subjective knee functionwas found in one quasi-RCT. However, there is a lack of correlation between these kinematic differences and an as yet unproven clinical effect. Uncertainties also exist regarding the mid- and long-term performances of the ACL reconstructed with a double-bundle technique. Comparison between the single-bundle and double-bundle techniques should be expanded to cover unresolved issues such as the rate of complications from a more challenging surgical technique, the risk of complicating revision surgery due to the presence of two tunnels, and the cost-effectiveness of a procedure with a higher consumption of fixation devices. The doublebundle technique should be further investigated by experienced knee surgeons in studies with higher methodological quality.     

Anatomic double-bundle posterior cruciate ligament reconstruction using hamstring tendons

Recent biomechanical studies have shown that an anatomic double-bundle posterior cruciate ligament (PCL) reconstruction is superior in restoring normal knee laxity compared with the conventional single-bundle isometric reconstruction. We describe a modification of an endoscopic PCL reconstruction technique using a double-bundle Y-shaped hamstring tendon graft. A double- or triple-bundle semitendinosus-gracilis tendon graft is used and directly fixed with soft threaded biodegradable interference screws. In the medial femoral condyle, 2 femoral tunnels are created inside-out through a low anterolateral arthroscopic portal. First, in 80° of flexion, the double-stranded gracilis graft is fixed with an interference screw inside the lower femoral socket, representing the insertion site of the posteromedial bundle. In full extension the combined semitendinosus-gracilis graft is pretensioned and fixed inside the posterior aspect of the single tibial tunnel. The double- or triple-stranded semitendinosus tendon is inserted in the higher femoral tunnel, presenting the insertion site of the anterolateral bundle. Finally, pretension is applied to the semitendinosus bundle in 70° of flexion and a third screw is inserted. Using this technique, the stronger semitendinosus part of the double-bundle graft, which mimics the anterolateral bundle of the PCL, is fixed in flexion, whereas the smaller gracilis tendon part (posteromedial bundle) is fixed in full extension. Thus, a fully arthroscopic anatomic PCL reconstruction technique is available that may better restore normal knee kinematics as compared to the single-stranded isometric reconstruction.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 1 (January), 2001: pp 88–97     

A modified arthroscopic anterior cruciate ligament double-bundle reconstruction technique with autogenous quadriceps tendon graft: remnant-preserving technique

Several techniques of anterior cruciate ligament (ACL) double-bundle reconstruction have been introduced to improve the functional outcome and restore normal kinematics of the knee. Meanwhile, a remnant-preserving technique was developed to preserve the proprioception and to enhance the revascularization of the reconstructed ACL. We developed double-bundle ACL reconstruction technique using autogenous quadriceps tendon graft while preserving the remnant. With this technique, two femoral sockets and one tibial tunnel are made. To preserve the remnant of the ACL, the rotational direction of the reamer was set to counterclockwise just before perforation of the tibial tunnel. To pass the graft more easily without disturbance of the remnant, the graft passage was achieved through the tibial tunnel. We suggest that the remnant-preserving technique could be an effective alternative considering its mechanical stability as well as the proprioception and vascularization recovery in arthroscopic double-bundle ACL reconstruction.     

Arthroscopic double-bundle posterior cruciate ligament reconstruction surgical technique

The keys to successful posterior cruciate ligament (PCL) reconstruction are to identify and treat all pathology, use strong graft material, accurately place tunnels in anatomic insertion sites, minimize graft bending, use a mechanical graft tensioning device, use primary and back-up graft fixation, and use the appropriate postoperative rehabilitation program. Adherence to these technical principles results in successful single-bundle and double-bundle arthroscopic transtibial tunnel PCL reconstruction based on stress radiography, arthrometer, knee ligament rating scales, and patient satisfaction measurements.     

自体腘绳肌腱单、双束重建前交叉韧带临床比较研究

目的 比较自体腘绳肌腱单、双束重建前交叉韧带的临床效果.方法 2005年5月至12月采用双束重建前交叉韧带患者33例(双束组),单束重建患者41例(单束组),均采用自体半腱肌腱和股薄肌腱.双束组4例失访,随访时间14～22个月,平均18个月;单束组8例失访,随访时间14-21个月,平均18个月.采用国际膝关节评分委员会评分标准(IKDC),Lysholm和Tegner评分、KT-2000及Biodex肌力测试评价.结果 双束组IKDC,Lysholm和Tegner评分分别由术前的60、66、4分显著上升至术后的85、94、6分.KT-2000在134 N下30°和90°位移情况由术前的5.8和2.4 mm减少为术后1.2和1.1 mm(P＜0.01).双束组伤侧膝关节伸膝及屈膝的峰力矩在60°/s下,相对于正常侧分别为81%和87%,120°/s下为76%和85%.各项值均显著低于对侧(P＜0.01).尽管在30°位KT-2000测量值和伸膝肌力的恢复方面,双束重建较单束重建表现出了更好的趋势,但功能评分,KT测量值和BIODEX测量的结果,单、双束组差异无统计学意义.结论 自体胭绳肌腱单、双束重建前交叉韧带均可以恢复膝关节稳定,改善关节功能,双束重建患者在30°位前后稳定性和伸膝肌力方面表现出了较单束重建更好的趋势.