Anatomic Double-bundle Technique Research Articles

LONG-TERM CLINICAL OUTCOMES AFTER SINGLE- VERSUS DOUBLE-BUNDLE ACL RECONSTRUCTION: A MATCHED-PAIR ANALYSIS FROM THE SANTI STUDY GROUP

IntroductionIt has been contentious whether an anatomic double-bundle technique for anterior cruciate ligament reconstruction (ACLR)is superior to that of a single-bundle technique. It has been hypothesized in the literature that the double-bundle technique could provide function closer to that of the anatomical knee joint. The purpose of this study was to compare the long-term clinical outcomes after single-bundle ACLR versus double-bundle ACLR. We hypothesized that the double-bundle technique would not be superior to the single-bundle technique.MethodsA retrospective, non-randomized, matched-paired comparative study was performed. Patients undergoing primary anterior cruciate ligament reconstruction, using either a double-bundle or single-bundle technique, between 2003 and 2008 were included and matched 1:1. Matching included age, sex, BMI, time from injury to surgery, side of injury and type of sport. Patients who underwent revision procedures, multiligament reconstruction or other ACLR techniques were excluded. Patients were subsequently followed up, noting occurrence of graft rupture and any other complications.ResultsA total of 1377 ACLRs were performed during the study period. Seven hundred and fifty-six patients were excluded, leaving 396patients to be included in the matching (198 matched pairs). Mean follow-up time was 176.7 +/− 7.7 months (range, 166–211 months). Overall, 40 patients (10.1%) suffered from a graft rupture which consisted of 22 patients (11.1%) in the single-bundle group and 18patients (9.1%) in the double-bundle group. A multivariate analysis was performed using the Cox model and demonstrated that graft failure had no significant association with the surgical technique (hazard ratio (HR), 0.857(0.457;1.609), p=0.6313). (Figure 1) Five patients (2.5%) in the single-bundle group and 7 patients (3.5%) in the double-bundle group underwent secondary surgery for cyclops syndrome(p=0.5637). Three patients (1.5%) in the single-bundle group and 2 patients (1.0%) in the double-bundle group underwent arthrolysis(p=0.6547). Seven patients (3.5%) in the single-bundle group underwent secondary meniscectomy compared to 6 patients (3.0%) in the double-bundle group (p=0.7630).ConclusionDouble-bundle ACLR is not superior to single-bundle ACLR at long-term follow up. Therefore, orthopaedic surgeons do not need to use a double-bundle technique when performing ACL reconstruction.For any figures or tables, please contact authors directly.

Anatomic Double-Bundle and Single-Bundle Reconstructions Yield Similar Outcomes Following Anterior Cruciate Ligament Rupture: A Systematic Review and Meta-analysis

To evaluate outcomes of arthroscopic single-bundle (SB) versus anatomic double-bundle (ADB) anterior cruciate ligament reconstruction (ACLR) in adults through a synthesis of randomized controlled trials (RCTs). We hypothesized that SB and ADB methods would lead to similar outcomes after reconstruction of ACL rupture. The Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist guided our reporting. To identify RCTs that compared SB and ADB reconstructions, a thorough literature search was conducted of PubMed, Embase, Cochrane library, and Web of Science. The methodologic quality of each included study was independently assessed by 2 authors using the Cochrane Collaboration's risk of bias tool. The Anatomic ACL Reconstruction Scoring Checklist (AARSC) was used to screen the eligibility of each study's operative approaches. Twelve clinical outcomes were investigated through pooled analyses conducted using Review Manager 5.3. This meta-analysis synthesized 13 RCTs comparing postoperative outcomes between ADB and SB reconstructions of ACLs. After a minimum follow-up of 12 months, ADB and SB technique resulted in similar subjective clinical outcomes, including the International Knee Documentation Committee subjective score, Lysholm score, Tegner activity score, and Knee injury and Osteoarthritis Outcome Score sports subscale. Similarly, no statistically significant outcomes were found for objective outcomes such as International Knee Documentation Committee objective grade, pivot-shift test, Lachman test, side-to-side difference, extension deficit, flexion deficit, and osteoarthritis change. However, patients who underwent SB reconstruction had significantly greater complication rates than those that underwent ADB reconstruction. When an ACLR approach meets a minimal total AARSC score of 8, ADB and SB techniques may result in similar subjective and objective outcomes, but the ADB technique may lead to lower complication rates following surgery. We recommend that surgeons favor ADB ACLR, as guided by the AARSC. Level I, systematic review and meta-analysis of Level I randomized controlled trials.

Postoperative Evaluation of Knees with Posterior Cruciate Ligament Injury using Patient-Oriented Evaluation Method: Comparison of Single-Bundle and Anatomic Double-Bundle Techniques

Postoperative Evaluation of Knees with Posterior Cruciate Ligament Injury using Patient-Oriented Evaluation Method: Comparison of Single-Bundle and Anatomic Double-Bundle Techniques

Reconstruction of the medial patellofemoral ligament by means of the anatomical double-bundle technique using metal anchors

ObjectiveTo evaluate double-bundle reconstruction of the medial patellofemoral ligament (MPFL) using a graft from the semitendinosus tendon and fixation with metal anchors over the medium term. MethodsThis was a prospective cross-sectional study. After approval from the research ethics committee, 31 patients with patellofemoral instability who underwent MPFL reconstruction by means of the anatomical double-bundle technique, with fixation using metal anchors, were analyzed between May 2010 and January 2015. To evaluate the effectiveness of the MPFL reconstruction surgery, the Kujala scale and the Tegner–Lysholm score were assessed before the procedure and one year afterwards, along with clinical data such as pain levels, range of motion and J sign. The data were tabulated in the Excel® software and were analyzed using the SPSS Statistics® software, version 21. The statistical analysis was performed using the Wilcoxon T test and the McNemar test. ResultsThe mean preoperative score from the Kujala test was 45.64±1.24 and the postoperative score was 94.03±0.79 (p<0.001). The preoperative Tegner–Lysholm score was 40.51±1.61 and the postoperative score was 91.64±0.79 (p<0.001). The preoperative range of motion was 125.96±2.11 and the postoperative range was 138.38±1.49 (p<0.05). ConclusionMPFL reconstruction by means of the anatomical double-bundle technique is easily reproducible, without episodes of recurrence, with satisfactory results regarding restoration of stability and function of the patellofemoral joint.

Volumetric Damage to the Femoral Physis During Double-Bundle Posterior Cruciate Ligament Reconstruction: A Magnetic Resonance Imaging Computer Modeling Study

The purpose of this study was to use computer models to evaluate the volume of femoral physeal disruption in double-bundle posterior cruciate ligament (PCL) reconstruction in patients with open physes. Ten skeletally immature patients (6 girls and 4 boys) were selected for this study. The magnetic resonance imaging scans of each patient were converted into a 3-dimensional model using computer-aided design/computer-aided manufacturing software. The software allowed the users to differentiate the epiphyseal, physeal, and metaphyseal tissues. This allowed for quantification of volume removed of each tissue type. Furthermore, we used the 3-dimensional models to simulate an anatomic double-bundle technique using 6-, 7-, 8-, and 9-mm-diameter tunnels. The software method reflects an inside-out drilling technique. For drill holes of all diameters, the posteromedial tunnels exited the knee inferior to the physis, thus avoiding physeal damage. In contrast, all the anterolateral tunnels perforated the physis. The results for the percent of total physis removed are as follows: 6-mm tunnel, 1.79% ± 0.99%; 7-mm tunnel, 2.23% ± 1.19%; 8-mm tunnel, 3.00% ± 1.54%; and 9-mm tunnel, 3.84% ± 1.73%. This computer modeling simulation of double-bundle PCL reconstruction in skeletally immature knees found that the posteromedial tunnel avoided disruption of the distal femoral physis. In contrast, the anterolateral tunnel did disrupt the physis with all drill hole sizes (6 to 9mm), but all had a less than 4% volume of total physis removed. A clear understanding of the drill hole position may reduce the volume of physeal injury during double-bundle PCL reconstruction. This study shows that physeal disruption of less than the experimental 7% threshold that has been shown to cause physeal arrest may not cause arrest, but this is still speculative.

Early comparision results of anatomical single and double bundle anterior cruciate ligament reconstruction procedures by using autogenous hamstring tendon graft

OZET: On capraz bag lezyonlarinin otojen hamstring tendon grefti kullanilarak anatomik cift band ve tek band teknigi ile rekonstruksiyonu sonrasi karsilastirmali erken donem klinik sonuclarimiz Amac: Bu calismanin amaci on capraz bag yirtigi sonrasinda anatomik cift band yontemi ve anatomik tek band yontemi kullanilarak on capraz bag (OCB) tamiri uygulanan hastalarin ameliyat oncesi ve sonrasi bul- gularini karsilastirmaktir. Gerec ve Yontem: Calismamizda 2007-2009 yillari arasinda anatomik cift band yontemiyle OCB rekons- truksiyonu ameliyati uygulanan ve yeterli takibi olan 20 hasta ile, anatomik tek band yontemiyle OCB rekons- truksiyonu ameliyati uygulanan ve yeterli takibi olan 20 hastanin sonuclari retrospektif olarak degerlendiril- di. Iki grubun Lysholm Skorlamasi sonuclari, Modifiye Cincinnati Skorlamasi sonuclari, IKDC skoru ve aktivite skalasina gore sonuclari, eklem hareket acikligi sonuclari, stabilite test sonuclari, uyluk atrofisi sonuclari, tek bacakla uzun atlama testi sonuclari ve KT-1000 cihazi ile 15, 20, 30 pound kuvvetler uygulanarak yapi- lan olcum sonuclari retrospektif olarak degerlendirildi. Iki grubun karsilastirmasinda student t testi, Mann- Whitney U testi, Anovo testi kullanilarak, p<0.05 degeri anlamli kabul edildi. ABSTRACT: Early comparision results of anatomical single and double bundle anterior cruciate ligament reconstruction procedures by using autogenous hamstring tendon graft Objective: Purpose of this study is to evaluate the results of anatomical single bundle and double bundle anterior cruciate ligament reconstruction procedures and compare the results between two groups. Material and Methods: 20 patients had been treated by anatomical single bundle (group 1) and 20 patients were treated by anatomical double bundle technique (group 2) between 2007 and 2009. The patients'; Lysholm knee scores, Modified Cincinnati scores, knee stability tests, activity scales, examination results of knee range of motion, IKDC scores, thigh atrophy measurement results, one leg hop test scores and examination under 15, 20, 30 pound forces with KT-1000 machine were evaluated and compared between two groups retrospectively. Statistical analysis was performed by using student T test, Mann-Whitney U test and Anovo test, p<0.05 was accepted as significant. Results: For group 1; 17 (85%) of the patients were male and 3 (15%) of them were female, mean age was 26 (16-36) years, 11 (55%) of the lesions were on the right knee and 9 (45%) of them were on the left knee. All of the patients in group 2 were male. For group 2; mean age was 26.7 years (18-35), 14 of the lesions (70%) were on right knee and 6 of them were on the left knee (30%). Anterior translation rates which had been tested by KT-1000 measurements with 20 and 30 pound forces were lesser for group 2 (statistically significant, p<0.05). There were no statistically significant difference for other comparisions. Conclusion: Anterior translation after anatomical double bundle technique was statistically significantly lesser than anatomical single bundle technique when tested with KT-1000 machine under 20-30 pound forces. We believe in that; after evaluating more cases' clinical results which has been treated by anatomical double bundle anterior cruciate ligament reconstruction technique, more orthopaedic surgeon will prefer

Biomechanical evaluation of knee kinematics after anatomic single- and anatomic double-bundle ACL reconstructions with medial meniscal repair.

To evaluate knee laxity after anatomic ACL reconstruction with additional suture repair of a medial meniscus tear. Kinematics of the intact knee were determined in 12 human cadaver specimens in response to a 134-N anterior tibial load (aTT) and a combined rotatory load of 10 Nm valgus and 4 Nm internal tibial rotation (aTTPS) using a robotic/universal force moment sensor testing system. Subsequently, the ACL was resected following the creation of a standardized tear of the medial meniscus, a standard meniscus repair and an ACL reconstruction using an anatomic single-bundle (6) or an anatomic double-bundle technique (6). Knee kinematics were determined following every sub-step. Significant increase of aTT in the ACL-deficient knee was found (p ≤ 0.001) with a further increase in the ACL-deficient knee with additional medial meniscal rupture (p ≤ 0.001). ACL reconstructions significantly decreased aTT compared with the ACL and meniscus-ruptured knee. No significant differences were seen between the intact knee and the ACL-reconstructed knee with additional meniscal repair (p < 0.05). In response to a simulated pivot shift, aTTPS in the intact knee significantly increased in the ACL-deficient knee and meniscus-ruptured knee (p = 0.005). No significant differences in knee kinematics were found between SB as well as DB ACL reconstruction with additional medial meniscal repair compared with the intact knee. Comparison of SB versus DB ACL reconstruction did not reveal any significant differences in a simulated Lachman test or simulated pivot shift test (n.s.). aTT as well as aTTPS significantly increased with ACL deficiency compared with the intact knee; additional medial meniscal rupture further increased aTT. Anatomic ACL reconstruction with medial meniscal repair did not reveal significant differences in knee kinematics compared with the intact knee. Comparison of anatomic SB versus DB ACL reconstruction with additional repair of the medial meniscus did not show significant differences neither in a simulated Lachman nor in a simulated pivot shift test.

Biomechanical Evaluation Of Knee Kinematics After ACL Reconstruction In Anatomic SB- And DB – Technique With Additional Medial Meniscus Suture

Biomechanical Evaluation Of Knee Kinematics After ACL Reconstruction In Anatomic SB- And DB – Technique With Additional Medial Meniscus Suture

Biomechanical Evaluation of Anatomical Double-bundle Coracoclavicular Ligament Reconstruction Secured With Knot Fixation Versus Screw Fixation

Methods to reconstruct the coracoclavicular ligaments anatomically have been described. No clear advantage of 1 technique has been elucidated. The authors' hypothesis was that the biomechanical properties of a modified knot fixation technique would be similar to the anatomical double-bundle technique. Sixteen matched cadaveric shoulders were used for this study, and 1 additional shoulder was used in the knot fixation group only. Shoulders were randomly assigned to the anatomical double-bundle coracoclavicular ligament reconstruction technique (n=8) or a knot fixation technique (n=9). The intact coracoclavicular ligaments were tested to failure with superior displacement at a rate of 2 mm/s. Reconstruction was performed using a semitendinosus tendon allograft, and load to failure was repeated for each construct. Ultimate failure load, stiffness, and failure mode were compared using a paired t test (P<.05). No significant difference existed in load to failure between native and reconstructed ligaments or between reconstruction techniques. Stiffness decreased significantly after reconstruction in the double-bundle group (from 32.5 to 22.5 N/mm; P=.035) and in the modified knot fixation group (from 35.5 to 21.9 N/mm; P=.043). No significant difference existed in stiffness between the 2 reconstruction groups. A significant difference (P=.003) existed between failure modes between the 2 reconstruction techniques. Although less stiff than the native ligament, either technique used to reconstruct the coracoclavicular ligament can be performed to yield a load to failure similar to the intact ligament. The majority of failures in the double-bundle group were by means of the graft slipping at the screw-tendon interface at 1 of the clavicular drill holes. The modified knot fixation technique failed the majority of the time by graft elongation.

Immunohistological analysis of extracted anterior cruciate ligament graft impinged against posterior cruciate ligament

A young female athlete suffered from the residual instability of the knee after anterior cruciate ligament (ACL) reconstruction with hamstring autograft. The 3-dimensional (3-D) CT scan showed the "high noon" positioning of the primary femoral bone tunnel. The revision surgery with anatomic double-bundle technique was performed two years after the primary surgery and the femoral tunnels were created with the assistance of the 3-D fluoroscopy-based navigation. An arthroscopic examination confirmed the ACL graft impingement against posterior cruciate ligament (PCL) when the knee was deeply flexed. The histological analysis of the resected primary ACL graft showed local inflammatory infiltration, enhanced synovial coverage and vascularization at the impinged site. The enhanced expression of vascular endothelial growth factor (VEGF) at the impinged area when compared with non-impinged area was observed on immunohistochemical analysis. Abnormal mechanical stress by the impingement against PCL might have induced chronic inflammation and VEGF overexpression.

A Comparison of the Effect of Central Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction and Double-Bundle Anterior Cruciate Ligament Reconstruction on Pivot-Shift Kinematics

Background: Biomechanical differences between anatomical double-bundle and central single-bundle anterior cruciate ligament reconstruction using the same graft tissue have not been defined. Purpose: The purpose of this study was to compare these reconstructions in their ability to restore native knee kinematics during a reproducible Lachman and pivot-shift examination. Study Design: Controlled laboratory study. Methods: Using a computer-assisted navigation system, 10 paired knees were subjected to biomechanical testing with a standardized Lachman and mechanized pivot-shift examination. The navigation system recorded the 3D motion path of a tracked point at the center of the tibia, center of the medial tibial plateau, and center of the lateral tibial plateau with each maneuver. The testing protocol consisted of evaluation in the intact state, after complete anterior cruciate ligament transection, after medial and lateral meniscectomy, and after anterior cruciate ligament reconstruction with (1) a single-bundle center-center or (2) anatomical double-bundle technique. Repeated-measures analysis of variance with a post hoc Tukey test was used to compare the measured translations with each test condition. Results: A significant difference in anterior translation was seen with Lachman examination between the anterior cruciate ligament– and medial and lateral meniscus–deficient condition compared with both the double-bundle and single-bundle center-center anterior cruciate ligament reconstruction (P < .001); no significant difference was observed between reconstructions. The double-bundle construct was significantly better in limiting anterior translation of the lateral compartment compared with the single-bundle reconstruction during a pivot-shift maneuver (2.0 ± 5.7 mm vs 7.8 ± 1.8 mm, P < .001) and was not significantly different than the intact anterior cruciate ligament condition (2.7 mm ± 4.7 mm, P > .05). Discussion: Although double-bundle and single-bundle, center-center anterior cruciate ligament reconstructions appear equally effective in controlling anterior translation during a Lachman examination, analysis of pivot-shift kinematics reveals significant differences between these surgical reconstructions. An altered rotational axis resulted in significantly greater translation of the lateral compartment in the single-bundle compared with double-bundle reconstruction. Clinical Relevance: A double-bundle anterior cruciate ligament reconstruction may be a favorable construct for restoration of knee kinematics in the at-risk knee with associated meniscal injuries and/or significant pivot shift on preoperative examination.

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction: The University of Pittsburgh Approach

Anterior cruciate ligament tears are a common occurrence and create significant functional limitations for patients sustaining these injuries. Approximately 100,000 reconstructions are performed each year in the United States. Single-bundle reconstructive techniques have been relatively successful; however, concerns remain over pain, degenerative joint disease, residual instability, and failure to return to prior levels of activity. Traditional single-bundle procedures fail to recreate the native anatomy of the knee and, therefore, the natural kinematics of the knee. Intensive research in these areas has created the opportunity for anatomic double-bundle techniques to improve the outcome of traditional reconstruction.

ST/G ACL reconstruction: double strand plus extra‐articular sling vs double bundle, randomized study at 3‐year follow‐up

Several investigators have reported the presence of biomechanical, kinematic, anatomic, fiber orientation patterns and biological differences between the anteromedial bundle and the posterolateral bundle of ACL. The purpose of this prospective randomized study was to compare the clinical, instrumental and X-ray outcome of two ACL reconstruction techniques with hamstring tendons: one with a single intra-articular bundle associated to an extra-articular sling, the second with a more anatomic double-bundle technique that reproduces better the native ACL function. From an initial group of 100 patients who underwent ACL reconstruction, 72 patients (35 single bundle plus lateral plasty and 37 double bundle) were evaluated with IKDC, Tegner score, KT2000 arthrometer, Activity Rating Scale, Psychovitality Questionnaire and Ahlback radiographic score at a mean 3 years follow-up. Double-bundle group showed significantly better results regarding IKDC, ROM, Activity Rating Scale and time to return to sport. Also KT 2000 showed significant differences in objective stability. The double-bundle technique for ACL reconstruction described in this paper has demonstrated significantly better subjective, objective and functional results compared with a double-stranded hamstrings plus extra-articular sling at a minimum 3-year follow-up.

An In Vitro Biomechanical Comparison of Anterior Cruciate Ligament Reconstruction: Single Bundle Versus Anatomical Double Bundle Techniques

Anterior cruciate ligament ruptures are frequent, especially in sports. Surgical reconstruction with autologous grafts is widely employed in the international literature. Controversies remain with respect to technique variations as continuous research for improvement takes place. One of these variations is the anatomical double bundle technique, which is performed instead of the conventional single bundle technique. More recently, there has been a tendency towards positioning the two bundles through double bone tunnels in the femur and tibia (anatomical reconstruction). To compare, through biomechanical tests, the practice of anatomical double bundle anterior cruciate ligament reconstruction with a patellar graft to conventional single bundle reconstruction with the same amount of patellar graft in a paired experimental cadaver study. Nine pairs of male cadaver knees ranging in age from 44 to 63 years were randomized into two groups: group A (single bundle) and group B (anatomical reconstruction). Each knee was biomechanically tested under three conditions: intact anterior cruciate ligament, reconstructed anterior cruciate ligament, and injured anterior cruciate ligament. Maximum anterior dislocation, rigidity, and passive internal tibia rotation were recorded with knees submitted to a 100 N horizontal anterior dislocation force applied to the tibia with the knees at 30, 60 and 90 degrees of flexion. There were no differences between the two techniques for any of the measurements by ANOVA tests. The technique of anatomical double bundle reconstruction of the anterior cruciate ligament with bone-patellar tendon-bone graft has a similar biomechanical behavior with regard to anterior tibial dislocation, rigidity, and passive internal tibial rotation.

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Revision Surgery

With the increasing number of double-bundle anterior cruciate ligament (ACL) reconstructions being performed, revision cases are expected. This report describes the first 3 cases of revision double-bundle ACL surgeries performed at our institution. In 3 athletes in whom the ACL was previously reconstructed with an anatomic double-bundle technique, new traumatic events occurred and an ACL retear was diagnosed. In cases 1 and 2 the anteromedial (AM) bundle was completely torn and the posterolateral (PL) bundle was stretched and nonfunctional. In case 1 both bundles were reconstructed via the previous tunnels, and the AM and PL grafts were tensioned at 60° of flexion and full extension, respectively. In case 2 the PL femoral tunnel was posterosuperior to the PL anatomic position. Therefore we drilled a third femoral tunnel and used the previous PL tunnel as our new AM tunnel. In case 3 the rupture pattern presented an intact and functional PL bundle and a midsubstance AM tear. We decided to revise only the AM bundle using the previous AM tunnels, which were anatomically positioned. This report shows that revision of anatomic double-bundle ACL reconstruction is reasonable to accomplish and that the principles of anatomy are essential as a guide to approaching each case.