Techniques in Double-Bundle Anterior Cruciate Ligament Reconstruction: As Simple as ABC, or Putting the Cart Before the Horse?

Abstract

First, let's review our idioms. ABC are the first three letters of our alphabet, letters we learn as very young children … simple. In addition, the letters are arranged in a formal order, one follows the next. This is similar to surgical techniques where we follow a series of steps to achieve an outcome. Yet we have both the experience and humility to understand that advanced, minimally invasive, reconstructive surgical techniques are rarely simple. Thus, when we introduce the idiom, “as simple as ABC,” which means that something is as easy as following the undemanding steps, we must add a question mark and raise the question: are things really as simple as they appear?In addition, we have a second theme that motivates us to introduce the letters ABC in the context of double-bundle anterior cruciate ligament (ACL) reconstruction. “A” may represent anatomy, “B” may represent biomechanics, and “C” may represent clinical. We believe that when introducing new surgical techniques and comparing them with a previously established gold standard, we must seek support in the anatomic, biomechanical, and clinical realms to justify application of these techniques to our patients—especially when the techniques may not be as simple as they appear.Next, the old expression “putting the cart before the horse” represents the idea of doing things backward or out of order. Just as B and C follow A, the cart must follow the horse. The horse does the pulling, and if we put the cart first, we will go nowhere. In a similar manner, it would seem backward to perform new surgical techniques on patients without being certain that the clinical outcome will be superior. Yet in surgery, we face a paradox: how can we demonstrate clinical superiority of new techniques unless we perform such techniques? Of course, we can't. Yet in our desire to improve outcomes, new techniques must be introduced. Are we putting the cart before the horse? We think not; rather, in arthroscopic and related surgery, we believe that we are able to address the paradox in a manner as simple as ABC. First, we study anatomy; next, we investigate biomechanics. Thus, our A and B provide a logical and ethical series of steps on which to base our C: clinical investigation.Thus, in this issue, we feature a Technical Note Symposium on the topic of double-bundle ACL reconstruction.1Christel P. Sahasrabudhe A. Basdekis G. Anatomic double-bundle anterior cruciate ligament reconstruction with anatomic aimers.Arthroscopy. 2008; 24: 1146-1151Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 2Colombet P.D. Robinson J.R. Computer-assisted, anatomic, double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2008; 24: 1152-1160Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 3Nakagawa T. Takeda H. Nakajima K. et al.Intraoperative three-dimensional imaging-based navigation-assisted anatomic double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2008; 24: 1161-1167Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 4Pombo M.W. Shen W. Fu F.H. Anatomic double-bundle anterior cruciate ligament reconstruction: Where are we today?.Arthroscopy. 2008; 24: 1168-1177Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 5Shino K. Nakata K. Nakamura N. et al.Rectangular tunnel anterior cruciate ligament reconstruction with bone–patellar tendon–bone graft to mimic natural fiber arrangement.Arthroscopy. 2008; 24: 1178-1183Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar, 6Smith P.S. Schwartzberg R.S. Lubowitz J.H. No tunnel 2-socket technique: All-inside anterior cruciate ligament double-bundle retroconstruction.Arthroscopy. 2008; 24: 1184-1189Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 7Volpi P. Denti M. Double-bundle reconstruction of the anterior cruciate ligament using the transtibial technique.Arthroscopy. 2008; 24: 1190-1194Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar The symposium is international and represents authors from Asia, Europe, and North America. In addition, we understand that these authors have collaborated with and been inspired by colleagues from Africa, Australia, and South America. Techniques in double-bundle ACL reconstruction have evolved quickly and internationally in keeping with the globalization and rapid exchange of information we have achieved in the 21st century.Clinical outcomes (“C”) of double-bundle ACL reconstruction may or may not ultimately prove superior to the current gold standard of single-bundle reconstruction. On reviewing the literature as published in Arthroscopy,8Asagumo H. Kimura M. Kobayashi Y. Taki M. Takagishi K. Anatomic reconstruction of the anterior cruciate ligament using double-bundle hamstring tendons: Surgical techniques, clinical outcomes, and complications.Arthroscopy. 2007; 23: 602-609Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 9Jarvela T. Jarvinen M. Double-bundle vs. single-bundle anterior cruciate ligament reconstruction: Prospective, randomized clinical study.Arthroscopy. 2007; 23 (abstr): e5Google Scholar, 10Kondo E. Yasuda K. Second-look arthroscopic evaluations of anatomic double-bundle anterior cruciate ligament reconstruction: Relation with postoperative knee stability.Arthroscopy. 2007; 23: 1198-1209Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 11Muneta T. Koga H. Mochizuki T. et al.A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques.Arthroscopy. 2007; 23: 618-628Abstract Full Text Full Text PDF PubMed Scopus (363) Google Scholar, 12Muneta T. Koga H. Morito T. Yagishita K. Sekiya I. A retrospective study of the midterm outcome of two-bundle anterior cruciate ligament reconstruction using quadrupled semitendinosus tendon in comparison with one-bundle reconstruction.Arthroscopy. 2006; 22: 252-258Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar, 13Muneta T. Sekiya I. Yagishita K. Ogiuchi T. Yamamoto H. Shinomiya K. Two-bundle reconstruction of the anterior cruciate ligament using semitendinosus tendon with EndoButtons: Operative technique and preliminary results.Arthroscopy. 1999; 15: 618-624Abstract Full Text Full Text PDF PubMed Scopus (295) Google Scholar, 14Siebold R. Observations on bone tunnel enlargement after double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2007; 23: 291-298Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar, 15Siebold R. Dehler C. Ellert T. Prospective randomized comparison of double-bundle versus single-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2008; 24: 137-145Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar, 16Yasuda K. Kondo E. Ichiyama H. Tanabe Y. Tohyama H. Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: Comparisons among 3 different procedures.Arthroscopy. 2006; 22: 240-251Abstract Full Text Full Text PDF PubMed Scopus (442) Google Scholar, 17Yonetani Y. Toritsuka Y. Yamada Y. Iwahashi T. Yoshikawa H. Shino K. Graft length changes in the bi-socket anterior cruciate ligament reconstruction: Comparison between isometric and anatomic femoral tunnel placement.Arthroscopy. 2005; 21: 1317-1322Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 18Zhao J. He Y. Wang J. Double-bundle anterior cruciate ligament reconstruction: Four versus eight strands of hamstring tendon graft.Arthroscopy. 2007; 23: 766-770Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar and as meta-analyzed by one of us in the American Journal of Sports Medicine,19Meredick R.B. Vance K.J. Appleby D. Lubowitz J.H. Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: A meta-analysis.Am J Sports Med. 2008; 36: 1414-1421Crossref PubMed Scopus (262) Google Scholar we believe that while double-bundle reconstruction may show subtle, favorable advantages as measured by a few outcome measures, at present we do not believe that clinically significant differences have been established.When it comes to biomechanics (“B”), we believe that the literature, as published in Arthroscopy, does justify further clinical investigation (“C”) of double-bundle reconstruction.20Belisle A.L. Bicos J. Geaney L. et al.Strain pattern comparison of double- and single-bundle anterior cruciate ligament reconstruction techniques with the native anterior cruciate ligament.Arthroscopy. 2007; 23: 1210-1217Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 21Mae T. Shino K. Miyama T. et al.Single– versus two–femoral socket anterior cruciate ligament reconstruction technique: Biomechanical analysis using a robotic simulator.Arthroscopy. 2001; 17: 708-716Abstract Full Text Full Text PDF PubMed Scopus (215) Google Scholar, 22Morimoto Y. Ferretti M. Kaz R. Smolinski P. Fu F.H. Double-bundle ACL reconstruction better restores the tibiofemoral pressure and contact.Arthroscopy. 2007; 23 (abstr): e6-e7PubMed Google Scholar, 23Steckel H. Murtha P. Costic R. Moody J. Jaramaz B. Fu F.H. Computer-assisted evaluation of the kinematics of the AM and PL bundle and the value of parameters according to the IKDC knee ligament examination form.Arthroscopy. 2007; 23 (abstr): e7PubMed Google Scholar, 24Yasuda K. Ichiyama H. Kondo E. Miyatake S. Inoue M. Tanabe Y. An in vivo biomechanical study on the tension–versus–knee flexion angle curves of 2 grafts in anatomic double-bundle anterior cruciate ligament reconstruction: Effects of initial tension and internal tibial rotation.Arthroscopy. 2008; 24: 276-284Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Yet some recent, well-designed biomechanical investigations did not find that double-bundle reconstruction produces a better biomechanical outcome than a well-placed single-bundle construct.25Gardiner A. Ho J. Shah V. Steiner M.E. Knee kinematics after double-bundle versus computer-navigated single-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2008; 24 (abstr): e30Google Scholar, 26Markolf K.L. Park S. Jackson S.R. McAllister D.R. Contributions of the posterolateral bundle of the anterior cruciate ligament to anterior-posterior knee laxity and ligament forces.Arthroscopy. 2008; 24: 805-809Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar It is hypothesized that double-bundle reconstruction results in better control of rotation than single-bundle reconstruction. We believe that the pivot-shift test for rotational laxity is subjective, difficult to quantitate, and challenging to perform on an awake patient; future research must focus on development of objective, practical clinical measures of knee rotational laxity that can be performed on awake patients in an outpatient setting. Despite the current controversy, taken in sum, “B” seems an arguable basis for “C.”We are convinced that the anatomy (“A”) of the native ACL is best reproduced by double-bundle reconstruction. We base our opinion on copious published investigations including many published in Arthroscopy.27Baer G.S. Fu F.H. Shen W. Ekdahl M. Nozaki M. Bonci G. Effect of knee flexion angle on tunnel length and articular cartilage damage during anatomic double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2008; 24 (abstr): e31Google Scholar, 28Buoncristiani A.M. Tjoumakaris F.P. Starman J.S. Ferretti M. Fu F.H. Anatomic double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2006; 22: 1000-1006Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 29Ferretti M. Ekdahl M. Shen W. Fu F.H. Osseous landmarks of the femoral attachment of the anterior cruciate ligament: An anatomic study.Arthroscopy. 2007; 23: 1218-1225Abstract Full Text Full Text PDF PubMed Scopus (412) Google Scholar, 30Ferretti M. Levicoff E.A. Macpherson T.A. Moreland M.S. Cohen M. Fu F.H. The fetal anterior cruciate ligament: An anatomic and histologic study.Arthroscopy. 2007; 23: 278-283Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar, 31Giron F. Cuomo P. Edwards A. Bull A.M.J. Amis A.A. Aglietti P. Double-bundle “anatomic” anterior cruciate ligament reconstruction: A cadaveric study of tunnel positioning with a transtibial technique.Arthroscopy. 2007; 23: 7-13Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 32Kondo E. Yasuda K. Ichiyama H. Azuma C. Tohyama H. Radiologic evaluation of femoral and tibial tunnels created with the transtibial tunnel technique for anatomic double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2007; 23: 869-876Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 33Mochizuki T. Muneta T. Nagase T. Shirasawa S. Akita K. Sekiya I. Cadaveric knee observation study for describing anatomic femoral tunnel placement for two-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2006; 22: 356-361Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar, 34Siebold R. Ellert T. Metz S. Metz J. Tibial insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: Morphometry, arthroscopic landmarks, and orientation model for bone tunnel placement.Arthroscopy. 2008; 24: 154-161Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar, 35Siebold R. Ellert T. Metz S. Metz J. Femoral insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: Morphometry and arthroscopic orientation models for double-bundle bone tunnel placement—A cadaver study.Arthroscopy. 2008; 24: 585-592Abstract Full Text Full Text PDF PubMed Scopus (176) Google Scholar, 36Zantop T. Kubo S. Petersen W. Musahl V. Fu F.H. Current techniques in anatomic anterior cruciate ligament reconstruction.Arthroscopy. 2007; 23: 938-947Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar We particularly acknowledge Dr. Freddie Fu and his colleagues at the University of Pittsburgh Medical Center for their contributions to the majority of our understanding of ACL double-bundle anatomy.27Baer G.S. Fu F.H. Shen W. Ekdahl M. Nozaki M. Bonci G. Effect of knee flexion angle on tunnel length and articular cartilage damage during anatomic double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2008; 24 (abstr): e31Google Scholar, 28Buoncristiani A.M. Tjoumakaris F.P. Starman J.S. Ferretti M. Fu F.H. Anatomic double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2006; 22: 1000-1006Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 29Ferretti M. Ekdahl M. Shen W. Fu F.H. Osseous landmarks of the femoral attachment of the anterior cruciate ligament: An anatomic study.Arthroscopy. 2007; 23: 1218-1225Abstract Full Text Full Text PDF PubMed Scopus (412) Google Scholar, 30Ferretti M. Levicoff E.A. Macpherson T.A. Moreland M.S. Cohen M. Fu F.H. The fetal anterior cruciate ligament: An anatomic and histologic study.Arthroscopy. 2007; 23: 278-283Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar, 34Siebold R. Ellert T. Metz S. Metz J. Tibial insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: Morphometry, arthroscopic landmarks, and orientation model for bone tunnel placement.Arthroscopy. 2008; 24: 154-161Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar, 35Siebold R. Ellert T. Metz S. Metz J. Femoral insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: Morphometry and arthroscopic orientation models for double-bundle bone tunnel placement—A cadaver study.Arthroscopy. 2008; 24: 585-592Abstract Full Text Full Text PDF PubMed Scopus (176) Google Scholar, 36Zantop T. Kubo S. Petersen W. Musahl V. Fu F.H. Current techniques in anatomic anterior cruciate ligament reconstruction.Arthroscopy. 2007; 23: 938-947Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar We agree with Fu: in “concept,” anatomic reconstruction of the ACL should be double-bundle reconstruction.In the past, your Editor-in-Chief has raised the question: will double-bundle reconstruction lead to “double trouble”?37Harner C.D. Poehling G.G. Double bundle or double trouble?.Arthroscopy. 2004; 20: 1013-1014Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar The purpose of our Technical Note Symposium is to address Harner and Poehling's concern.Although surgical complications can never be entirely avoided, proper attention to surgical technique may allow our readers the best possible methods for avoiding double trouble. We caution that at present, single-bundle ACL reconstruction seems the clinical gold standard, and we primarily introduce double-bundle reconstruction techniques for the consideration of experienced, high-volume ACL surgeons. We assure such surgeons that the anatomic and biomechanical concepts of double-bundle ACL reconstruction are based on peer-reviewed publications and presentations. As such, clinical investigation of double-bundle reconstruction does not represent putting the cart before the horse. Rather, clinical investigation of double-bundle ACL reconstruction follows anatomic and (controversial) biomechanical data. As above, we understand and acknowledge that surgical techniques are never simple. Yet, the logical basis for continued investigation of double-bundle ACL reconstruction may be as simple as anatomy, biomechanics, clinical.As ever, we conclude that future prospective, clinical outcomes research of high level of evidence is required to answer our ultimate question: when, if ever, is double-bundle ACL reconstruction clinically indicated? First, let's review our idioms. ABC are the first three letters of our alphabet, letters we learn as very young children … simple. In addition, the letters are arranged in a formal order, one follows the next. This is similar to surgical techniques where we follow a series of steps to achieve an outcome. Yet we have both the experience and humility to understand that advanced, minimally invasive, reconstructive surgical techniques are rarely simple. Thus, when we introduce the idiom, “as simple as ABC,” which means that something is as easy as following the undemanding steps, we must add a question mark and raise the question: are things really as simple as they appear? In addition, we have a second theme that motivates us to introduce the letters ABC in the context of double-bundle anterior cruciate ligament (ACL) reconstruction. “A” may represent anatomy, “B” may represent biomechanics, and “C” may represent clinical. We believe that when introducing new surgical techniques and comparing them with a previously established gold standard, we must seek support in the anatomic, biomechanical, and clinical realms to justify application of these techniques to our patients—especially when the techniques may not be as simple as they appear. Next, the old expression “putting the cart before the horse” represents the idea of doing things backward or out of order. Just as B and C follow A, the cart must follow the horse. The horse does the pulling, and if we put the cart first, we will go nowhere. In a similar manner, it would seem backward to perform new surgical techniques on patients without being certain that the clinical outcome will be superior. Yet in surgery, we face a paradox: how can we demonstrate clinical superiority of new techniques unless we perform such techniques? Of course, we can't. Yet in our desire to improve outcomes, new techniques must be introduced. Are we putting the cart before the horse? We think not; rather, in arthroscopic and related surgery, we believe that we are able to address the paradox in a manner as simple as ABC. First, we study anatomy; next, we investigate biomechanics. Thus, our A and B provide a logical and ethical series of steps on which to base our C: clinical investigation. Thus, in this issue, we feature a Technical Note Symposium on the topic of double-bundle ACL reconstruction.1Christel P. Sahasrabudhe A. Basdekis G. Anatomic double-bundle anterior cruciate ligament reconstruction with anatomic aimers.Arthroscopy. 2008; 24: 1146-1151Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 2Colombet P.D. Robinson J.R. Computer-assisted, anatomic, double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2008; 24: 1152-1160Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 3Nakagawa T. Takeda H. Nakajima K. et al.Intraoperative three-dimensional imaging-based navigation-assisted anatomic double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2008; 24: 1161-1167Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 4Pombo M.W. Shen W. Fu F.H. Anatomic double-bundle anterior cruciate ligament reconstruction: Where are we today?.Arthroscopy. 2008; 24: 1168-1177Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 5Shino K. Nakata K. Nakamura N. et al.Rectangular tunnel anterior cruciate ligament reconstruction with bone–patellar tendon–bone graft to mimic natural fiber arrangement.Arthroscopy. 2008; 24: 1178-1183Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar, 6Smith P.S. Schwartzberg R.S. Lubowitz J.H. No tunnel 2-socket technique: All-inside anterior cruciate ligament double-bundle retroconstruction.Arthroscopy. 2008; 24: 1184-1189Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 7Volpi P. Denti M. Double-bundle reconstruction of the anterior cruciate ligament using the transtibial technique.Arthroscopy. 2008; 24: 1190-1194Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar The symposium is international and represents authors from Asia, Europe, and North America. In addition, we understand that these authors have collaborated with and been inspired by colleagues from Africa, Australia, and South America. Techniques in double-bundle ACL reconstruction have evolved quickly and internationally in keeping with the globalization and rapid exchange of information we have achieved in the 21st century. Clinical outcomes (“C”) of double-bundle ACL reconstruction may or may not ultimately prove superior to the current gold standard of single-bundle reconstruction. On reviewing the literature as published in Arthroscopy,8Asagumo H. Kimura M. Kobayashi Y. Taki M. Takagishi K. Anatomic reconstruction of the anterior cruciate ligament using double-bundle hamstring tendons: Surgical techniques, clinical outcomes, and complications.Arthroscopy. 2007; 23: 602-609Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 9Jarvela T. Jarvinen M. Double-bundle vs. single-bundle anterior cruciate ligament reconstruction: Prospective, randomized clinical study.Arthroscopy. 2007; 23 (abstr): e5Google Scholar, 10Kondo E. Yasuda K. Second-look arthroscopic evaluations of anatomic double-bundle anterior cruciate ligament reconstruction: Relation with postoperative knee stability.Arthroscopy. 2007; 23: 1198-1209Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 11Muneta T. Koga H. Mochizuki T. et al.A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques.Arthroscopy. 2007; 23: 618-628Abstract Full Text Full Text PDF PubMed Scopus (363) Google Scholar, 12Muneta T. Koga H. Morito T. Yagishita K. Sekiya I. A retrospective study of the midterm outcome of two-bundle anterior cruciate ligament reconstruction using quadrupled semitendinosus tendon in comparison with one-bundle reconstruction.Arthroscopy. 2006; 22: 252-258Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar, 13Muneta T. Sekiya I. Yagishita K. Ogiuchi T. Yamamoto H. Shinomiya K. Two-bundle reconstruction of the anterior cruciate ligament using semitendinosus tendon with EndoButtons: Operative technique and preliminary results.Arthroscopy. 1999; 15: 618-624Abstract Full Text Full Text PDF PubMed Scopus (295) Google Scholar, 14Siebold R. Observations on bone tunnel enlargement after double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2007; 23: 291-298Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar, 15Siebold R. Dehler C. Ellert T. Prospective randomized comparison of double-bundle versus single-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2008; 24: 137-145Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar, 16Yasuda K. Kondo E. Ichiyama H. Tanabe Y. Tohyama H. Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: Comparisons among 3 different procedures.Arthroscopy. 2006; 22: 240-251Abstract Full Text Full Text PDF PubMed Scopus (442) Google Scholar, 17Yonetani Y. Toritsuka Y. Yamada Y. Iwahashi T. Yoshikawa H. Shino K. Graft length changes in the bi-socket anterior cruciate ligament reconstruction: Comparison between isometric and anatomic femoral tunnel placement.Arthroscopy. 2005; 21: 1317-1322Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 18Zhao J. He Y. Wang J. Double-bundle anterior cruciate ligament reconstruction: Four versus eight strands of hamstring tendon graft.Arthroscopy. 2007; 23: 766-770Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar and as meta-analyzed by one of us in the American Journal of Sports Medicine,19Meredick R.B. Vance K.J. Appleby D. Lubowitz J.H. Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: A meta-analysis.Am J Sports Med. 2008; 36: 1414-1421Crossref PubMed Scopus (262) Google Scholar we believe that while double-bundle reconstruction may show subtle, favorable advantages as measured by a few outcome measures, at present we do not believe that clinically significant differences have been established. When it comes to biomechanics (“B”), we believe that the literature, as published in Arthroscopy, does justify further clinical investigation (“C”) of double-bundle reconstruction.20Belisle A.L. Bicos J. Geaney L. et al.Strain pattern comparison of double- and single-bundle anterior cruciate ligament reconstruction techniques with the native anterior cruciate ligament.Arthroscopy. 2007; 23: 1210-1217Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 21Mae T. Shino K. Miyama T. et al.Single– versus two–femoral socket anterior cruciate ligament reconstruction technique: Biomechanical analysis using a robotic simulator.Arthroscopy. 2001; 17: 708-716Abstract Full Text Full Text PDF PubMed Scopus (215) Google Scholar, 22Morimoto Y. Ferretti M. Kaz R. Smolinski P. Fu F.H. Double-bundle ACL reconstruction better restores the tibiofemoral pressure and contact.Arthroscopy. 2007; 23 (abstr): e6-e7PubMed Google Scholar, 23Steckel H. Murtha P. Costic R. Moody J. Jaramaz B. Fu F.H. Computer-assisted evaluation of the kinematics of the AM and PL bundle and the value of parameters according to the IKDC knee ligament examination form.Arthroscopy. 2007; 23 (abstr): e7PubMed Google Scholar, 24Yasuda K. Ichiyama H. Kondo E. Miyatake S. Inoue M. Tanabe Y. An in vivo biomechanical study on the tension–versus–knee flexion angle curves of 2 grafts in anatomic double-bundle anterior cruciate ligament reconstruction: Effects of initial tension and internal tibial rotation.Arthroscopy. 2008; 24: 276-284Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Yet some recent, well-designed biomechanical investigations did not find that double-bundle reconstruction produces a better biomechanical outcome than a well-placed single-bundle construct.25Gardiner A. Ho J. Shah V. Steiner M.E. Knee kinematics after double-bundle versus computer-navigated single-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2008; 24 (abstr): e30Google Scholar, 26Markolf K.L. Park S. Jackson S.R. McAllister D.R. Contributions of the posterolateral bundle of the anterior cruciate ligament to anterior-posterior knee laxity and ligament forces.Arthroscopy. 2008; 24: 805-809Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar It is hypothesized that double-bundle reconstruction results in better control of rotation than single-bundle reconstruction. We believe that the pivot-shift test for rotational laxity is subjective, difficult to quantitate, and challenging to perform on an awake patient; future research must focus on development of objective, practical clinical measures of knee rotational laxity that can be performed on awake patients in an outpatient setting. Despite the current controversy, taken in sum, “B” seems an arguable basis for “C.” We are convinced that the anatomy (“A”) of the native ACL is best reproduced by double-bundle reconstruction. We base our opinion on copious published investigations including many published in Arthroscopy.27Baer G.S. Fu F.H. Shen W. Ekdahl M. Nozaki M. Bonci G. Effect of knee flexion angle on tunnel length and articular cartilage damage during anatomic double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2008; 24 (abstr): e31Google Scholar, 28Buoncristiani A.M. Tjoumakaris F.P. Starman J.S. Ferretti M. Fu F.H. Anatomic double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2006; 22: 1000-1006Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 29Ferretti M. Ekdahl M. Shen W. Fu F.H. Osseous landmarks of the femoral attachment of the anterior cruciate ligament: An anatomic study.Arthroscopy. 2007; 23: 1218-1225Abstract Full Text Full Text PDF PubMed Scopus (412) Google Scholar, 30Ferretti M. Levicoff E.A. Macpherson T.A. Moreland M.S. Cohen M. Fu F.H. The fetal anterior cruciate ligament: An anatomic and histologic study.Arthroscopy. 2007; 23: 278-283Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar, 31Giron F. Cuomo P. Edwards A. Bull A.M.J. Amis A.A. Aglietti P. Double-bundle “anatomic” anterior cruciate ligament reconstruction: A cadaveric study of tunnel positioning with a transtibial technique.Arthroscopy. 2007; 23: 7-13Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 32Kondo E. Yasuda K. Ichiyama H. Azuma C. Tohyama H. Radiologic evaluation of femoral and tibial tunnels created with the transtibial tunnel technique for anatomic double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2007; 23: 869-876Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 33Mochizuki T. Muneta T. Nagase T. Shirasawa S. Akita K. Sekiya I. Cadaveric knee observation study for describing anatomic femoral tunnel placement for two-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2006; 22: 356-361Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar, 34Siebold R. Ellert T. Metz S. Metz J. Tibial insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: Morphometry, arthroscopic landmarks, and orientation model for bone tunnel placement.Arthroscopy. 2008; 24: 154-161Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar, 35Siebold R. Ellert T. Metz S. Metz J. Femoral insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: Morphometry and arthroscopic orientation models for double-bundle bone tunnel placement—A cadaver study.Arthroscopy. 2008; 24: 585-592Abstract Full Text Full Text PDF PubMed Scopus (176) Google Scholar, 36Zantop T. Kubo S. Petersen W. Musahl V. Fu F.H. Current techniques in anatomic anterior cruciate ligament reconstruction.Arthroscopy. 2007; 23: 938-947Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar We particularly acknowledge Dr. Freddie Fu and his colleagues at the University of Pittsburgh Medical Center for their contributions to the majority of our understanding of ACL double-bundle anatomy.27Baer G.S. Fu F.H. Shen W. Ekdahl M. Nozaki M. Bonci G. Effect of knee flexion angle on tunnel length and articular cartilage damage during anatomic double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2008; 24 (abstr): e31Google Scholar, 28Buoncristiani A.M. Tjoumakaris F.P. Starman J.S. Ferretti M. Fu F.H. Anatomic double-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2006; 22: 1000-1006Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 29Ferretti M. Ekdahl M. Shen W. Fu F.H. 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Femoral insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: Morphometry and arthroscopic orientation models for double-bundle bone tunnel placement—A cadaver study.Arthroscopy. 2008; 24: 585-592Abstract Full Text Full Text PDF PubMed Scopus (176) Google Scholar, 36Zantop T. Kubo S. Petersen W. Musahl V. Fu F.H. Current techniques in anatomic anterior cruciate ligament reconstruction.Arthroscopy. 2007; 23: 938-947Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar We agree with Fu: in “concept,” anatomic reconstruction of the ACL should be double-bundle reconstruction. In the past, your Editor-in-Chief has raised the question: will double-bundle reconstruction lead to “double trouble”?37Harner C.D. Poehling G.G. Double bundle or double trouble?.Arthroscopy. 2004; 20: 1013-1014Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar The purpose of our Technical Note Symposium is to address Harner and Poehling's concern. Although surgical complications can never be entirely avoided, proper attention to surgical technique may allow our readers the best possible methods for avoiding double trouble. We caution that at present, single-bundle ACL reconstruction seems the clinical gold standard, and we primarily introduce double-bundle reconstruction techniques for the consideration of experienced, high-volume ACL surgeons. We assure such surgeons that the anatomic and biomechanical concepts of double-bundle ACL reconstruction are based on peer-reviewed publications and presentations. As such, clinical investigation of double-bundle reconstruction does not represent putting the cart before the horse. Rather, clinical investigation of double-bundle ACL reconstruction follows anatomic and (controversial) biomechanical data. As above, we understand and acknowledge that surgical techniques are never simple. Yet, the logical basis for continued investigation of double-bundle ACL reconstruction may be as simple as anatomy, biomechanics, clinical. As ever, we conclude that future prospective, clinical outcomes research of high level of evidence is required to answer our ultimate question: when, if ever, is double-bundle ACL reconstruction clinically indicated?