Knee Rotational Laxity in a Randomized Comparison of Single- Versus Double-Bundle Anterior Cruciate Ligament Reconstruction

Abstract

Background: While single-bundle anterior cruciate ligament reconstruction reduces anterior-posterior laxity, studies have demonstrated residual rotational instability. Improved pivot-shift results have been shown with the double-bundle graft; however, no study has compared rotational laxity outcome of these surgical techniques in vivo under quantified, isolated torsional loading. Hypothesis: The anterior cruciate ligament–deficient knee exhibits greater rotational laxity than the contralateral uninjured knee. The double-bundle reconstruction restores rotational joint stability to a greater extent than single-bundle surgery. Study Design: Controlled laboratory study. Methods: Rotational laxity of 32 patients with unilateral anterior cruciate ligament injury was assessed in both knees at full extension and 30° of flexion using a magnetic resonance imaging–compatible torsional loading device. Patients were randomly allocated either a single- or double-bundle reconstruction and reassessed 5 months after surgery. Results: The anterior cruciate ligament–deficient knees demonstrated greater laxity to internal rotational torque in the extended position, but not in the 30° flexed position. No significant differences in rotational laxity were found between single- and double-bundle reconstructions. In extension, excessive internal rotational laxity of injured compared with contralateral knees was reduced by anterior cruciate ligament reconstruction. The single-bundle reconstruction did not affect internal rotation compared with contralateral or preoperative groups. In response to internal rotational torque in the flexed knee position, the double-bundle reconstruction reduced laxity to 10.8° from the pre-operative value of 15.3° (P = .058); postoperative rotation was also significantly less than the contralateral laxity of 16.4° (P = .022). Conclusion: The ruptured anterior cruciate ligament resulted in increased internal rotational laxity only in the extended position. The single-bundle reconstruction did not affect rotational restraint compared with contralateral or preoperative groups. The double-bundle procedure significantly reduced internal laxity in the flexed position when compared with normal. Clinical Relevance: As the anterior cruciate ligament is not the primary restraint to rotation, its contribution to joint stability is limited under isolated torsional load. While the double-bundle graft demonstrates superior rotational constraint, this may be excessive for isolated anterior cruciate ligament rupture.