Double bundle or single bundle plus an extra articular tenodesis?

Abstract

One of the hottest problems in ACL reconstruction today is single bundle or double bundle. As I have pointed out in an earlier editorial, the French school with Dejour and Neyret has always advocated reinforcing the patellar tendon ACL reconstructions with a lateral tenodesis. Neyret also pointed that out during the latest ESSKA 2000 meeting in Innsbruck. Monaco and colleagues from professor Ferretti’s clinic in Rome, Italy have now done an immediate in vivo comparison of the effect of an ACL reconstruction with double bundle versus a single bundle with lateral tenodesis. They used a computer assisted arthroscopic 2 incision technique in a small clinical material of 20 patients, 10 in each group. Interestingly they found that anterior–posterior displacement was the same in both groups but that the prevention of internal rotation was significantly better with the single bundle with lateral tenodesis. I like their study and hope that they will increase their number of patients and that they will follow-up the same patients at a minimum of 2 years post-operatively hopefully with gait analysis to compare how the two different techniques have affected the normal gait pattern and the possible pivotshift. In their discussion they also do point out that their results are solely for time 0. They also know that their material is small. If their results would hold true in a follow-up, single bundle with lateral tenodesis is a much simpler procedure than double bundle ACL reconstruction. I am, however, not sure that the lateral tenodeses really remain tight. There was a comparison between ACL reconstruction with and without lateral tenodesis performed at the Hospital for Special Surgery in New York some years ago. They found no significant difference between the two methods in their follow-up. However, it is evident from the different Scandinavian ACL-registers that 90% of orthopaedic surgeons perform 10 or less ACL reconstructions per year. We also know that even in the best hands, there are 5–10% of failures. As I have said before, I fear the day when all these ‘‘10 or less-ACL surgeons’’ start performing double bundle. I can imagine all the complications that we will see then.