Anatomic Double-bundle Anterior Cruciate Ligament Research Articles

Eccentric Graft Positioning Within the Femoral Tunnel Aperture in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Using the Transportal and Outside-In Techniques

Background: Ellipticity of the femoral tunnel aperture, which is considered to better restore the native anterior cruciate ligament (ACL) footprint after ACL reconstruction, is different according to the femoral tunneling technique used. How much of the femoral tunnel aperture is filled with graft in different tunneling techniques has yet to be evaluated. Purpose: The aim of this study was to evaluate and compare the graft filling area and graft position within the femoral tunnel aperture in ACL reconstruction using the transportal (TP) and outside-in (OI) techniques. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 70 patients were randomized to undergo double-bundle ACL reconstruction using either the TP (n = 35) or OI (n = 35) technique. The aperture filling was evaluated by calculating the ratio of the cross-sectional area of the graft to that of the femoral tunnel, and the graft center position within the tunnel was assessed using immediate postoperative magnetic resonance imaging. Results: The cross-sectional area of the femoral anteromedial (AM) tunnel aperture in the TP group (605.5 ± 112.7 mm2) was larger than that in the OI group (537.9 ± 126.8 mm2). The cross-sectional area of the femoral posterolateral (PL) tunnel aperture in the TP group (369.9 ± 88.3 mm2) did not differ significantly from that of the OI group (387.9 ± 87.0 mm2). The grafts filled only 52.0% of the AM tunnel and 55.3% of the PL tunnel in the TP group, compared with 54.9% of the AM tunnel and 54.4% of the PL tunnel in the OI group, but there was no statistically significant difference (P > .05). The AM graft center was positioned 1.7 ± 0.6 mm from the center of the tunnel aperture in the TP group and 1.6 ± 0.5 mm in the OI group, and the PL graft center was positioned 1.4 ± 0.4 mm from the center in the TP group and 1.3 ± 0.4 mm in the OI group, with no significant intergroup differences (P = .406 and P = .629, respectively). In the OI group, the PL graft center was positioned more perpendicular to the Blumensaat line in relation to the tunnel aperture center (−10.8° ± 7.6°) compared with the TP group (−4.0° ± 11.8°) (P = .04). Conclusion: The grafts did not fill the tunnel aperture area in either group, and the centers of the grafts differed slightly from the centers of the tunnel apertures. The finding of eccentric graft positioning in the tunnel with condensation in a particular direction in each technique might suggest the necessity of an underreamed femoral tunnel for graft. In addition, it may be useful to standardize the starting position of the femoral tunnel according to anatomic landmarks.

Relationship between Initial Tension of Fixation and Deterioration of Patellofemoral Joint after Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction

Relationship between Initial Tension of Fixation and Deterioration of Patellofemoral Joint after Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction

Early Postoperative Intratunnel Migration of an EndoButton After Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction: A Case Report.

We report a rare case of early postoperative migration of an EndoButton following anatomic double-bundle anterior cruciate ligament reconstruction with use of the EndoButton for femoral fixation. Although secure fixation of the EndoButton was confirmed during the operation, one-week postoperative radiographs revealed an intratunnel displacement of the posterolateral EndoButton. We performed a reoperation and refixed the EndoButton to the surface of the femoral cortex; we also hooked and tied both ends of the sutures to make a knot in order to prevent remigration. Orthopaedic surgeons should be aware that EndoButton displacement and migration could arise at an early postoperative stage.

Clinical significance of T2*-weighted gradient-echo MRI to monitor graft maturation over one year after anatomic double-bundle anterior cruciate ligament reconstruction: a comparative study with proton density-weighted MRI.

This study examined the feasibility of T2*-weighted imaging (T2*WI) gradient-echo MRI to reflect actual function of the graft after anatomic double-bundle ACL reconstruction. T2*WI and proton density-weighted imaging (PDWI) were compared in the assessment of ACL grafts. Sixty-one patients underwent T2*WI and PDWI at 3, 6, and 12 months postoperatively. Signal intensity of the anteromedial bundle (AMB) or posterolateral bundle (PLB) graft standardized to the intensity of the PCL was defined as signal intensity ratio (SIR). Correlations between degree of knee instability and SIR were assessed for each bundle, each time point, and each sequence. The diagnostic efficacy of T2*WI sequence to detect poorly functioning knee with anteroposterior translation ≥ 4 mm was assessed. Significant correlations were observed between SIR and KT values for both AMB and PLB at 12 months on T2*WI (r=0.39 and 0.53, respectively), but not on PDWI. Notably, 9 of 10 patients with poorly functioning graft showing anteroposterior translation ≥ 4 mm at 12 months formed an isolated group with high T2*WI-SIR. Six of the 10 patients displayed an increase in SIR from 6 to 12 months. Defining anteroposterior translation ≥ 4 mm at 12 months as the diagnostic standard for poorly functioning graft, increasing T2*WI-SIR offered 60% sensitivity and > 90% specificity. ACL graft intensity on T2*WI is more strongly associated with actual function of the graft than that on PDWI. An increasing trend in T2*WI-SIR from 6 to 12 months postoperatively represents a possible surrogate indicator for poorly functioning grafts.

Intratunnel Versus Extratunnel Autologous Hamstring Double-Bundle Graft for Anterior Cruciate Ligament Reconstruction

Background: Anatomic double-bundle anterior cruciate ligament (ACL) reconstruction provides excellent results for restoring normal kinematics to the knee. Nevertheless, strong evidence supporting an ideal method for fixation of the ACL graft is lacking. Hypothesis: Intratunnel femoral fixation of the ACL graft via a cross-pin fixation technique would provide better clinical and objective results than the extratunnel femoral fixation with cortical buttons. Study Design: Randomized clinical trial; Level of evidence, 2. Methods: Seventy patients with a unilateral ACL-deficient knee were randomly assigned to 1 of 2 femoral fixation groups. Group A (35 patients) was fixed with 2 bioabsorbable Rigidfix pins, 1 cross-pin per bundle, while group B (35 patients) was secured with 1 EndoButton cortical button per bundle. All femoral tunnels were created via an anteromedial portal, and a bioabsorbable Biointrafix interference screw was used for tibial fixation for both groups. The evaluation of the patients was performed by history details, clinical examination findings, measurement of the joint laxity by KT-1000 arthrometer, and use of validated patient outcome questionnaires. Statistical analysis was carried out with Fisher exact and Mann-Whitney U tests, with P < .05 considered the cutoff level of significance. Results: At a mean follow-up of 30 months, 34 and 32 patients of group A and B, respectively, were available for evaluation. There were no statistically significant differences between the treatment groups regarding the subjective and objective outcomes, except for KT-1000 arthrometer values. The median KT-1000 value of patients in the cross-pin fixation group was 1.30 mm, while the median value in the cortical button fixation group was 1.95 mm (P < .001). Four patients with ACL grafts that were fixed with cortical buttons demonstrated failure of stability via the instrumented knee laxity testing, while patients from the other group had no failures. Conclusion: Intratunnel femoral fixation of the double-bundle ACL graft from the cross-pin fixation technique provided better instrumented knee laxity results than did the extratunnel femoral fixation with cortical buttons. Future larger studies comparing these 2 techniques should be conducted to ensure the availability of stronger evidence supporting the findings of this study.

The Sagittal Plane Angle and Tunnel-Related Complications in Double-Bundle Anterior Cruciate Ligament Reconstruction Using the Transportal Technique: An In Vivo Imaging Study

To evaluate the relation between the tunnel angle in the 3 orthogonal planes, especially the sagittal plane, which can be influenced by knee flexion during drilling, and the incidence of complications from the transportal technique using in vivo imaging data. Fifty-one patients who underwent anatomic double-bundle anterior cruciate ligament reconstruction by the transportal technique were evaluated retrospectively. A 3-dimensional surface model was made using an axial computed tomography scan obtained after anterior cruciate ligament reconstruction. The tunnel length, posterior cortical damage, proximity between the outer orifice of the tunnel and lateral collateral ligament (LCL) origin, and medial femoral condyle cartilage damage were evaluated on a 3-dimensional computed tomography scan and 3-T magnetic resonance imaging. Correlations between those parameters and the tunnel angle in the coronal, axial, and sagittal planes were analyzed. A tunnel length of less than 30 mm developed in 4 cases (8%) in the anteromedial tunnel and in 1 case (2%) in the posterolateral (PL) tunnel. Posterior cortical damage developed in 12 cases (23%). A distance from the outer orifice of the tunnel to the LCL origin of less than 3 mm occurred in 18 cases (35.2%) in the PL tunnel. Medial femoral condyle cartilage damage was detected in 3 cases (6%). A positive correlation was observed between the sagittal angle and anteromedial tunnel length (P = .002, r = 0.547). The sagittal angle in the group with posterior cortical damage was lower than that in the group with no posterior cortical damage (P = .002). A negative correlation was observed between the distance from the outer orifice of the PL tunnel to the LCL origin and the sagittal angle (P = .002, r = -0.55). Drilling at a higher angle in the sagittal plane decreased the incidence of posterior cortical damage and a short anteromedial tunnel. However, drilling at a higher angle shortened the distance to the LCL origin for the PL tunnel. Level IV, therapeutic case series.

Tibia Rotational Technique to Drill Femoral Bone Tunnel in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

In anatomic anterior cruciate ligament (ACL) reconstruction, several pitfalls in creating the femoral bone tunnels at the correct position are of great concern. Our new method, the tibia rotational (TR) technique, may contribute to resolving these. The purpose of this study is to describe further details about the TR technique in anatomic double-bundle ACL reconstruction. Both anteromedial and posterolateral femoral bone tunnels were drilled through a posterolateral tibial bone tunnel using tibial rotation without deep knee flexion. When it is difficult to reach the mark with the rigid guide pin, the narrow curved TR technique guide and the flexible drill system allow drilling femoral bone tunnels in the correct position. The TR technique offers the technical ease required for widespread acceptance while prioritizing the fundamental goals of an anatomic double-bundle ACL reconstruction.

Three-Dimensional Analysis of Bone Tunnel Changes After Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Using Multidetector-Row Computed Tomography

Background: The femoral and tibial bone tunnel enlargement after anatomic double-bundle anterior cruciate ligament reconstruction (ACL-R) has not been fully documented. Purpose: To evaluate the region-specific bone tunnel volume changes and those transpositions using 3-dimensional multidetector-row computed tomography (MDCT) after anatomic double-bundle ACL-R. Study design: Case series; Level of evidence, 4. Methods: Eleven patients who underwent unilateral double-bundle ACL-R with hamstring tendon autografts were included in this study. MDCT scanning of their knees was performed at 3 weeks and 1 year after surgery. The bone tunnel regions were extracted from the MDCT images, and the longitudinal axis of each bone tunnel was divided into 3 equal sections. The centroids of the outside and the articular thirds were then extracted from the bone tunnel position. Changes in the bone tunnel volume and the transposition of the articular third were calculated and compared. Results: At 1 year postoperatively, as compared with the 3-week postoperative value (set at 100%), the femoral bone tunnel volume of the anteromedial bundle (AMB) and posterolateral bundle (PLB) changed to 77.4% ± 15.3% and 102.3% ± 19.2% in the outside third and 122.3% ± 31.8% and 112.5% ± 34.4% in the articular third, respectively. The tibial bone tunnel volume of the AMB and the PLB changed to 108.6% ± 28.7% and 105.4% ± 22.6% in the tibial articular third and 54.9% ± 25.8% and 52.5% ± 26.9% in the outside third, respectively. The femoral outside third of the AMB and the tibial outside third of both the AMB and PLB were significantly reduced in bone tunnel volume. The centroid of the femoral articular third of the AMB moved 13°, 1.1 ± 0.6 mm posterodistally, and that of the PLB moved 35°, 0.8 ± 0.4 mm anterodistally. Furthermore, the centroid of the tibial articular third of the AMB moved 14°, 2.0 ± 1.6 mm posterolaterally, and that of the PLB moved 72°, 1.0 ± 1.3 mm posterolaterally. Conclusion: Compared with 3 weeks postoperatively, the articular side outlets of the femoral and tibial bone tunnels at 1 year postoperatively had enlarged slightly but statistically maintained their volume, and they had moved a little in the direction that the grafts were pulled.

In Vivo Kinematic Evaluation of Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

Background: There is controversy regarding the functional role of the posterolateral (PL) bundle of the anterior cruciate ligament (ACL). Purpose: To evaluate the in vivo function of the PL and anteromedial (AM) bundles of the ACL during anatomic double-bundle (DB) ACL reconstruction for acute, isolated ACL tears utilizing a computer navigation system to track intraoperative knee kinematics. Study Design: Controlled laboratory study. Methods: Fifteen patients with acute, isolated ACL tears who underwent anatomic DB ACL reconstruction formed the sample for this study. During surgery, knees were examined by a clinician preoperatively, after fixation of the PL bundle, and after fixation of both the PL and AM bundles. An image-free computer navigation system with custom-made software recorded the data during kinematic tests. The examination consisted of the Lachman and anterior drawer tests, internal-external rotation at 30° of knee flexion, and varus-valgus rotation at 30° of knee flexion. Paired Wilcoxon tests were performed to evaluate the effects of each bundle. The comparisons included ACL-deficient to PL bundle–reconstructed knees, ACL-deficient to DB ACL–reconstructed knees, and PL bundle–reconstructed to DB ACL–reconstructed knees. Significance was set at P < .017 to account for the multiple comparisons. Results: Fixation of the PL bundle significantly improved knee laxity during the Lachman and anterior drawer tests as well as internal-external rotation at 30° of knee flexion (P < .017 for all tests). The addition of the AM bundle further improved knee laxity during the Lachman and anterior drawer tests compared with PL bundle fixation as well as during varus-valgus rotation at 30° of knee flexion compared with ACL-deficient knees (P < .017 for all tests). Conclusion: This in vivo study demonstrates that isolated PL bundle reconstruction improves laxity in an ACL-deficient knee and that the addition of the AM bundle improves laxity parameters further. Clinical Relevance: Abnormal knee kinematics is known to be linked to the earlier onset of osteoarthritis and lower rates of return to sport. This study suggests that both the AM and PL bundles are important to stabilize ACL-deficient knees.

Factors Influencing Graft Impingement on the Wall of the Intercondylar Notch After Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

Background: Anatomic placement of the bone tunnel reportedly reduces impingement of the graft with the intercondylar roof, but as a trade-off, the risk of impingement with the lateral wall of the intercondylar notch would increase instead in anatomic double-bundle anterior cruciate ligament (ACL) reconstruction. Purpose: The 2 grafts for the anteromedial bundle (AMB) and posterolateral bundle (PLB) were separately analyzed for the frequency of and risk factors for graft impingement on the wall of the intercondylar notch. Study Design: Case control study; Level of evidence, 3. Methods: A total of 51 patients (53 knees) who underwent primary anatomic double-bundle ACL reconstruction were enrolled. Based on the graft orientation plane reconstructed with 3-dimensional imaging software, graft-wall impingement was defined as overlap between the lateral wall of the notch and the line connecting each center of the intra-articular apertures of the femoral and tibial bone tunnels. The rate of wall impingement was assessed for each bundle. Parameters for bone tunnel positioning in the femur and tibia, notch width index, and knee joint rotation angle were compared between patients with and without wall impingement. The most important risk factors for wall impingement were assessed by logistic regression analysis. Results: Wall impingement for the AMB was observed in 22 knees (42%), whereas no patients exhibited wall impingement for the PLB. Regarding femoral bone tunnel positioning according to the quadrant method, the AMB bone tunnel was placed significantly higher in impingement-positive patients than in impingement-negative patients (P = .03). Regarding tibial tunnel positioning, the tunnel was placed significantly more anteriorly (P = .02) and laterally (P = .02) in the impingement-positive group than in the impingement-negative group. Bone tunnels positioned 48% to 50% from the medial border of the tibia demonstrated a 100% incidence of wall impingement. Based on logistic regression analysis, lateral deviation of the AMB tibial bone tunnel was significantly associated with wall impingement (odds ratio, 1.403; P = .048). Conclusion: The tibial bone tunnel position in the coronal orientation was most likely associated with wall impingement. Considering that tibial bone tunnels are generally created with the knee in 90° of flexion and move laterally as the knee extends because of screw-home movement, the AMB bone tunnel for the tibia should be positioned as medially as possible within its footprint to minimize the risk of wall impingement after anatomic double-bundle ACL reconstruction.

Effect of Notchplasty in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

Background: The effects of notchplasty on the clinical outcome after anatomic double-bundle anterior cruciate ligament (ACL) reconstruction remain unclear. Hypothesis: Anatomic ACL reconstruction with notchplasty would result in less risk of loss of extension and would provide adequate space for better graft healing, leading to better knee stability compared with anatomic ACL reconstruction without notchplasty. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 137 patients who underwent anatomic double-bundle ACL reconstruction were included. Seventy-three patients without notchplasty were classified as the control group, and 64 patients with 2-mm notchplasty were classified as the notchplasty group. The following evaluation methods were used: loss of extension, patient’s subjective feeling of limited extension and pain at passive full extension, muscle strength, manual laxity tests, KT-1000 arthrometer measurement, patellofemoral joint findings, Tegner score, Lysholm score, subjective scores, and time to return to sports. Tearing of the reconstructed ACL and additional synovectomy were recorded. Both tibial and femoral tunnel positions were measured using 2-view radiographs: a Rosenberg and a lateral view. Results: Loss of extension was larger in the notchplasty group compared with controls (at 6 months: 0.8° vs 1.4°, P = .012; at 2 years: 0.4° vs 0.9°, P = .0053). The number of patients with a feeling of limited extension was also larger in the notchplasty group (at 6 months: 13 patients graded 1+ [somewhat limited] and 2 patients graded 2+ [very limited] vs 18 graded 1+ and 6 graded 2+, P = .015; at 2 years: 2 graded 1+ and 0 graded 2+ vs 4 graded 1+ and 5 graded 2+, P = .011). Six patients in the notchplasty group required additional synovectomy because of the prolonged loss of extension, whereas no patient in the control group required additional synovectomy. There were no differences between groups regarding muscle strength, patellofemoral findings, Lysholm score, Tegner score, subjective scores, or time to return to sports. The KT-1000 arthrometer measurement was better in the notchplasty group (1.2 vs 0.4 mm, P = .0017). However, 6 patients in the notchplasty group showed an overconstrained knee (KT-1000 measurement ≤–2 mm), compared with only 1 patient in the control group. There were no differences between groups in the other manual laxity tests or the tunnel positions. Conclusion: In anatomic double-bundle ACL reconstruction, anterior stability was improved and there were no harmful effects on patellofemoral joint findings by 2-mm notchplasty; however, notchplasty likely caused overconstrained knee, leading to a need for additional synovectomy in some patients. In contrast, anatomic double-bundle ACL reconstruction without notchplasty did not increase the incidence of loss of extension or of graft failure.

Outcome of anatomical double-bundle ACL reconstruction using hamstring tendons via an outside-in approach

To evaluate the clinical outcome of anatomical double-bundle anterior cruciate ligament (ACL) reconstruction using multistranded hamstring tendons via an outside-in approach. One hundred and twenty-one patients (mean age 28±10years) who underwent ACL reconstruction were examined. Using an outside-in femoral drill guide, an upper femoral tunnel for the anteromedial (AM) graft was created just below the superior articular cartilage margin of the medial wall of the lateral condyle through a small incision. A lower femoral tunnel for the posterolateral (PL) graft was drilled in the centre of the inferior-posterior half of the attachment area behind the resident's ridge in the same manner. Two tibial tunnels were created at the centre of the AM and PL bundle footprints of a normal ACL. Patients were evaluated at 24months postoperatively. According to the IKDC form, 52 knees (43%) were graded as normal, 64 (53%) as nearly normal, 1 (1%) as abnormal and 4 (3%) as graft rupture due to re-injury. Loss of knee extension of <5° was observed in one patient (1%). Among 111 patients who were directly evaluated, none showed loss of flexion of <5°. Lachman sign was negative in 103 patients (93%), while the pivot shift test result was negative or equivalent to that of the contralateral healthy knee in 103 patients (93%). The mean side-to-side difference in anterior laxity at manual maximum force with the KT-2000 arthrometer(®) was 0.9±1.1mm, and 94% of patients showed a range between -1 and +2mm. The anatomical double-bundle outside-in ACL reconstruction provided a satisfactory short-term outcome. Case series, Level IV.

Anatomic double-bundle reconstruction of the anterior cruciate ligament: midterm results

PurposeThe aim of this study was to investigate the functional outcomes, knee stability, and patient's satisfaction after anatomic double-bundle anterior cruciate ligament (ACL) reconstruction using the three-portal technique.Patients and methodsA prospective case series study on 48 patients (24 were active athletes) with complete tear of the ACL was conducted. All patients underwent anatomic double-bundle ACL reconstruction. Participants were assessed with history taking, clinical examination, International Knee Documentation Committee (IKDC) score, Lysholm scale, and Tegner scale. All assessments were carried out preoperatively and repeated postoperatively every 6 months until a minimum of 2 years. Data were collected and analyzed to detect significant changes.ResultsImprovement was observed in the mean IKDC score from 68.1 to 93.5, in the Lysholm score from 73.8 to 95.5, and in the Tegner scale from 4 to 9.4. All patients showed negative Lachmann and anterior drawer tests at 24 months follow-up; only two (4.2%) patients showed slight glide (one positive), with overall patient satisfaction of 93.8%.ConclusionAnatomic double-bundle ACL reconstruction results in significant improvement in the clinical outcomes and knee stability, with 93.8% satisfaction and return to preinjury level of activity.

Anatomic single- versus double-bundle ACL reconstruction: a meta-analysis

To determine whether anatomic double-bundle anterior cruciate ligament (ACL) reconstruction compared to anatomic single-bundle ACL reconstruction more effectively restored antero-posterior (A-P) laxity, rotatory laxity and reduced frequency of graft rupture. Our hypothesis was that anatomic double-bundle ACL reconstruction results in superior rotational knee laxity and fewer graft ruptures due to its double-bundle tension pattern, compared with anatomic single-bundle ACL reconstruction. An electronic search was performed using the PubMed, EMBASE and Cochrane Library databases. All therapeutic trials written in English reporting knee kinematic outcomes and graft rupture rates of primary anatomic double- versus single-bundle ACL reconstruction were included. Only clinical studies of levels I-II evidence were included. Data regarding kinematic tests were extracted and included pivot-shift test, Lachman test, anterior drawer test, KT-1000 measurements, A-P laxity measures using navigation and total internal-external (IRER) laxity measured using navigation, as well as graft failure frequency. A total of 7,154 studies were identified of which 15 papers (8 randomized controlled trials and 7 prospective cohort studies, n = 970 patients) met the eligibility criteria. Anatomic ACL double-bundle reconstruction demonstrated less anterior laxity using KT-1000 arthrometer with a standard mean difference (SMD) = 0.36 (95% CI 0.214-0.513, p < 0.001) and less A-P laxity measured with navigation (SMD = 0.29 95% CI 0.01-0.565, p = 0.042). Anatomic double-bundle ACL reconstruction did not lead to significant improvements in pivot-shift test, Lachman test, anterior drawer test, total IRER or graft failure rates compared to anatomic single-bundle ACL reconstruction. Anatomic double-bundle ACL reconstruction is superior to anatomic single-bundle reconstruction in terms of restoration of knee kinematics, primarily A-P laxity. Whether these improvements of laxity result in long-term improvement of clinical meaningful outcomes remains uncertain. II.

TransFix およびEndoButton System を用いた解剖学的2 重束前十字靭帯再建術の再鏡視所見の検討と治療成績

TransFix およびEndoButton System を用いた解剖学的2 重束前十字靭帯再建術の再鏡視所見の検討と治療成績

TriLink: Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

Cadaveric and clinical biomechanical studies show improved kinematic restoration using double-bundle anterior cruciate ligament (ACL) reconstruction techniques. These have been criticized in the past for being technically challenging. We present a novel 3-socket approach for anatomic “all-inside” double-bundle reconstruction using a single hamstring tendon fashioned to create a trifurcate graft: the TriLink technique. The semitendinosus alone is harvested, quadrupled, and attached to 3 suspensory fixation devices in a Y-shaped configuration, creating a 4-stranded tibial limb and 2 double-stranded femoral limbs. A medial viewing/lateral working arthroscopic approach is adopted using specifically designed instrumentation. Anatomic placement of the 2 femoral tunnels is performed by a validated direct measurement technique. A single mid-bundle position is used on the tibia. Both femoral and tibial sockets are created in a retrograde manner using outside-to-in drilling. This is a simplified operative technique for anatomic double-bundle ACL reconstruction that maximizes bone preservation. The TriLink construct replicates the 2 bundles of the ACL, conferring native functional anisometry and improving femoral footprint coverage while avoiding the complexities and pitfalls of double–tibial tunnel techniques. Preservation of the gracilis reduces the morbidity of hamstring harvest and allows greater flexibility in graft choice in cases requiring multiligament reconstruction.

Comparing the anatomic single-bundle versus the anatomic double-bundle for anterior cruciate ligament reconstruction: a prospective, randomized, single blind, clinical study

Purpose The aim of this study was to compare the early results of anatomic single bundle versus double-bundle anterior cruciate ligament (ACL) reconstruction.

Clinical outcome of anatomic double-bundle ACL reconstruction and 3D CT model-based validation of femoral socket aperture position

The purpose of this study was to evaluate the clinical results of anatomic double-bundle (DB) anterior cruciate ligament (ACL) reconstruction in which anatomic position of femoral socket apertures was validated using three-dimensional (3D) computed tomography (CT) modelling. Anatomic DB ACL reconstructions with hamstring autografts were performed in 34 patients. Two femoral sockets were created through a far anteromedial (AM) portal behind the lateral intercondylar ridge with the assistance of intraoperative 3D fluoroscopic navigation. Femoral tunnel aperture positioning was investigated postoperatively using 3D CT images in all patients. Clinical results were also evaluated subjectively and objectively at least up to 2 years. Measurement of the AM and the posterolateral (PL) femoral socket locations on the 3D CT images using the quadrant method showed that the centre of the AM socket aperture was located at a depth of 21.0 ± 4.1% and a height of 30.5 ± 9.3% and that of the PL socket aperture was located at a depth of 31.3 ± 5.8% and a height of 57.2 ± 7.7%. The femoral socket locations were considered as anatomic in accordance with previous cadaveric studies examining the positions of ACL femoral insertion site. Subjectively, the mean Lysholm score was 96.9 ± 4.0 points. According to IKDC final objective scores, 26 knees (76%) were objectively graded as normal, 8 (24%) as nearly normal, and 0 (0%) as abnormal or severely abnormal. Postoperative side-to-side anterior translation measured with a KT-2000 arthrometer averaged 0.7 ± 1.2 mm. DB ACL reconstructions in which femoral socket apertures were validated anatomically using 3D CT provided satisfactory short-term results. Case series, Level IV.

Far Anteromedial Portal Technique for Posterolateral Femoral Tunnel Drilling in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction: Effect of Knee Flexion Angle on Femoral Tunnel Characteristics

Far Anteromedial Portal Technique for Posterolateral Femoral Tunnel Drilling in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction: Effect of Knee Flexion Angle on Femoral Tunnel Characteristics

The Accuracy of Femoral Tunnel in Remnant Preserved Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Analyzed Three-Dimensional Computed Tomography

The position of anteromedial and posterolateral bone tunnels in twenty-five knees of anatomical ACL reconstruction were evaluated using quadrant method with three-dimensional computed tomography. Remaining connected ACL remnants were preserved in thirteen of their knees using fluoroscopic assisted surgery. Tunnels of remnant preserved knee were located in anatomic ACL insertion.