Anatomic Single-bundle Anterior Cruciate Ligament Research Articles

Anatomic single-bundle anterior cruciate ligament reconstruction using the outside-in femoral tunnel drilling technique: a prospective study and short- to mid-term results.

Anatomic positioning of the femoral and tibial tunnels in the native ACL femoral and tibial footprints requires an independent drilling either via an accessory medial portal (trans-portal drilling) or using an outside-in drilling technique. Conventional trans-tibial drilling (dependant drilling) was found to lack the ability to accurately position the femoral tunnel in the native ACL footprint. The purpose of the current study was to evaluate the functional outcome results of anatomic single-bundle ACLR using the OI femoral tunnel drilling technique. Single surgeon single center prospective case series study. 64 patients having complete ACL tears were included in the current study. Average follow-up was 15.8months (range 8-25). Objective and subjective IKDC scores, Lysholm knee score, SF-36 score, VAS for patients' satisfaction, VAS for pain and Kellgren and Lawrence (K/L) classification of osteoarthritis were used for follow-up evaluation. Objective IKDC score revealed that 60 patients had grade ''A'' and 4 had grade ''B'', while no single patient had neither grade ''C'' nor ''D''. The average Lysholm Score was 92.4, average subjective IKDC was 91.5. Average SF-36 score was 96.7. The average VAS for operation satisfaction was 9.7. Average VAS for pain was 0.3. Forty-nine patients were classified as normal K/L classification, 7 were grade ''1'', 8 were grade ''2''. Comparing pre-operative and follow-up Objective IKDC, Subjective IKDC, Lysholm, SF-36 and VAS for pain scores revealed statistically significant differences (P value <0.05). Arthroscopic-assisted ACL reconstruction using the outside-in femoral tunnel drilling technique shows a good and satisfactory functional outcome results at short- to mid-term follow-up. Level IV.

The effect of feedback from post-operative 3D CT on placement of femoral tunnels in single-bundle anatomic ACL reconstruction.

To evaluate the effect of feedback from post-operative 3D CT in the learning process of placing the femoral graft tunnel anatomically using the anteromedial (AM)-portal technique in single-bundle anterior cruciate ligament (ACL) reconstruction. An experienced knee surgeon converting from transtibial to AM-portal technique was offered post-operative feedback on tunnel placement. Three groups of patients were included: transtibial drilling, (AM1) anteromedial drilling without feedback and (AM2) anteromedial drilling with post-operative CT feedback. Intra-articular landmarks were used as the only guidance for tunnel placement. Tunnel position was compared to an ideal anatomical ACL position using the Bernard and Hertel grid and visual feedback was given on tunnel placements. The effect of feedback was measured as the distance from the anatomical centre, and spread of tunnel placements on post-operative CT performed feedback was initiated. When comparing the femoral tunnel placement to an ideal anatomical centre, there was an improvement in the mean tunnel position after (A) changing from a transtibial to an anatomical technique and a further improvement after (B) initializing the radiological feedback. There was a great variation of femoral tunnel localizations when initially only using intra-articular landmarks as guidance for tunnel placement--this variation, however, converged towards the anatomical centre throughout the feedback period and the AM2 group had a femoral tunnel closer (P = 0.001) to the anatomical centre than the AM1 group. Post-operative 3D CT is effective in the learning process of placing femoral tunnels anatomically by giving post-operative feedback on tunnel placement. Bony landmarks and ACL remnants were found unreliable as the only guidance for femoral tunnel placement in the AM-portal technique-therefore, the use of an aid is recommended to reduce unwanted tunnel variations in a learning phase. Cohort Study, Level III.

Comparison of Femoral Tunnel Geometry, Using In Vivo 3-Dimensional Computed Tomography, During Transportal and Outside-In Single-Bundle Anterior Cruciate Ligament Reconstruction Techniques

To compare the transportal (TP) and outside-in (OI) techniques regarding femoral tunnel position and geometry after anatomic single-bundle (SB) anterior cruciate ligament (ACL) reconstruction. This study included 51 patients who underwent anatomic SB ACL reconstruction with the TP (n = 21) or OI (n = 30) technique. All patients underwent 3-dimensional computed tomography 3 days after the operation. The femoral tunnel position (quadrant method), femoral graft bending angle, femoral tunnel length, and posterior wall breakage were assessed by immediate postoperative 3-dimensional computed tomography with OsiriX imaging software. The OI technique had a shallower femoral tunnel position (arthroscopic position) than did the TP technique (P = .005). The mean femoral graft bending angle was significantly more acute with the OI technique (101.3° ± 8.2°) than with the TP technique (107.9° ± 10.0°) (P = .02). The mean femoral tunnel length was significantly greater with the OI technique (33.0 ± 3.5 mm) than with the TP technique (29.6 ± 3.9 mm) (P = .003). Posterior wall breakage occurred in 7 cases (33.3%) with the TP technique and 1 case (3.3%) with the OI technique (P = .02). The mean femoral tunnel position was significantly shallower (arthroscopic position) with the OI technique than with the TP technique. The OI technique resulted in a more acute femoral graft bending angle, longer femoral tunnel length, and lower incidence of posterior wall breakage than did the TP technique. These results might be helpful for anatomic SB ACL reconstruction using TP and OI techniques. Level III, retrospective comparative study.

Knee Moment and Shear Force Are Correlated With Femoral Tunnel Orientation After Single-Bundle Anterior Cruciate Ligament Reconstruction

Background: Increasing evidence has shown that anatomic single-bundle anterior cruciate ligament reconstruction (ACLR) better restores normal knee kinematics and functionality than nonanatomic ACLR. Whether anatomic reconstruction results in better knee kinetics during daily activities has not been fully investigated. Purpose: To assess the relationship between femoral tunnel angle and kinetic parameters of the knee joint during walking after single-bundle ACLR and to compare the radiographic and kinetic results of patients who underwent anatomic ACLR with those of patients who underwent nonanatomic ACLR. Study Design: Controlled laboratory study. Methods: Twenty-one patients who underwent unilateral ACLR were recruited, and 20 healthy subjects from a previous study were used as a control group. All surgical procedures were performed by a single surgeon, 11 using the transtibial (TT) technique and 10 using the anteromedial portal (AMP) technique. Femoral tunnel orientation was measured from posterior-to-anterior radiographs. Dynamic knee joint moments and shear forces during gait were evaluated using 3-dimensional motion analysis and inverse dynamics. Relationships between femoral tunnel angles and kinetic results were evaluated via linear regression. Results were compared between 2 ACLR groups and controls using 1-way analysis of variance. Results: Femoral tunnel angle had significant correlations with peak external knee flexion moment and posterior shear force during early stance. The TT group had a significantly smaller (more vertical) mean femoral tunnel angle (19.4° ± 4.1°) than the AMP group (36.4° ± 5.8°). Significant reductions were found in the normalized peak external knee flexion moment (TT, 0.15 ± 0.12 Nm/kg·m; AMP, 0.25 ± 0.12 Nm/kg·m; control, 0.25 ± 0.16 Nm/kg·m) (P = .032) and posterior shear force (TT, 0.64 ± 0.55 N/kg; AMP, 1.10 ± 0.58 N/kg; control, 1.35 ± 0.55 N/kg) (P = .024) in the TT group compared with controls, but not in the AMP group. Moreover, a significantly greater medial shear force was found in the TT group during the late stance phase (TT, 1.08 ± 0.32 N/kg; AMP, 0.89 ± 0.26 N/kg; control, 0.83 ± 0.22 N/kg) (P = .038). A greater peak external knee adduction moment was found in both ACL groups during the early stance phase (TT, 0.25 ± 0.07 Nm/kg·m; AMP, 0.25 ± 0.07 Nm/kg·m; control, 0.19 ± 0.05 Nm/kg·m) (P < .01). Conclusion: Knee joint kinetic changes are seen within months (~10 months) after ACLR. This study revealed significant relationships between femoral tunnel orientation and postoperative knee joint flexion moment and posterior shear force during walking. The AMP technique provides better restoration of these knee kinetic parameters compared with the TT technique at this postoperative time point. Clinical Relevance: The femoral tunnel angle measured from plain radiographs can be used as an important metric of postoperative knee joint kinetics. This information provides a better understanding of the knee joint’s biomechanical environment after ACLR using commonly used single-bundle techniques.

A Surgical Trick for Adjusting an Inaccurate Guide Pin to the Center of the Tibial Footprint in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction

Anatomic positioning of the graft in anatomic anterior cruciate ligament reconstruction is the key to improved knee stability, restoration of normal knee kinematics, and the prevention of long-term joint degeneration. We have developed a technique for adjusting inaccurate drill guide placement to the center of the tibial footprint in anatomic single-bundle anterior cruciate ligament reconstruction. This technique can solve the inaccurate drill guide placement problems that may be encountered during this surgical procedure.

Effect of tibial drill-guide angle on the mechanical environment at bone tunnel aperture after anatomic single-bundle anterior cruciate ligament reconstruction

The tibial drill-guide angle in anterior cruciate ligament (ACL) reconstruction influences the tunnel placement and graft-tunnel force, and is potentially associated with post-operative tunnel widening. This study aimed to examine the effect of the drill-guide angle on the stress redistribution at the tibial tunnel aperture after anatomic single-bundle ACL reconstruction. A validated finite element model of human knee joint was used. The tibial tunnel with drill-guide angle ranging from 30° to 75° was investigated. The post-operative stress redistribution in tibia under the compressive, valgus, rotational and complex loadings was analysed. Compressive loading played a leading role on the stress redistribution at intra-articular tibial tunnel aperture. After ACL reconstruction, stress concentration occurred in the anterior and posterior regions of tunnel aperture while stress reduction occurred in the lateral and posteromedial regions under the compressive loading. Stress redistribution was partially alleviated by using the drill-guide angle ranging from 55° to 65°. The present study quantified the effect of bone tunnel drill-guide angle on the post-operative stress redistribution. This phenomenon potentially contributed to tunnel widening. A tunnel drill-guide angle ranging from 55° to 65° was proposed based on the biomechanical rationale. It could serve as a helpful surgical guide for ACL reconstruction.

Medial portal technique for single-bundle anatomical Anterior Cruciate Ligament (ACL) reconstruction

The aim of the paper is to describe the medial portal technique for anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. Placement of an ACL graft within the anatomical femoral and tibial attachment sites is critical to the success and clinical outcome of ACL reconstruction. Non-anatomical ACL graft placement is the most common technical error leading to recurrent instability following ACL reconstruction. ACL reconstruction has commonly been performed using a transtibial tunnel technique in which the ACL femoral tunnel is drilled through a tibial tunnel positioned in the posterior half of the native ACL tibial attachment site. ACL reconstruction performed using a transtibial tunnel technique often results in a vertical ACL graft, which may fail to control the combined motions of anterior tibial translation and internal tibial rotation which occur during the pivot-shift phenomenon. The inability of a vertically oriented ACL graft to control these combined motions may result in the patient experiencing continued symptoms of instability due to the pivot-shift phenomenon. The medial portal technique in which the ACL femoral tunnel is drilled through an anteromedial or accessory anteromedial portal allows consistent anatomical ACL tunnel placement. This paper describes the advantages of the medial portal technique, indications for the technique, patient positioning, proper portal placement, anatomical femoral and tibial tunnel placement, graft tensioning and fixation.

Anterior cruciate ligament reconstruction in partial tear: Selective anteromedial bundle reconstruction conserving the posterolateral remnant versus single-bundle anatomic ACL reconstruction: Preliminary 1-year results of a prospective randomized study

Partial tears of the anterior cruciate ligament (ACL) are frequent. Conserving ACL remnants is central to the concept of anatomic, biomechanical and biological reconstruction. The interest of such conservation remains theoretical. The present hypothesis was that selective anteromedial (AM) bundle reconstruction is preferable to the standard single-bundle reconstruction in partial ACL tear. A multicenter prospective randomized study recruited 54 partial ACL tears operated on either by selective AM bundle reconstruction (Group 1, n=29) or by standard anatomic single-bundle reconstruction (Group 2, n=25). All patients were clinically assessed on subjective and objective IKDC, Lysholm and KOOS scores, with a minimum 12 months' follow-up. Comparative pre- to postoperative anterior laxity was measured on the Rolimeter(®) device, with statistical analysis of results. There were no significant preoperative differences between the two groups. All patients were followed-up at 6 months and 1 year. Mean subjective IKDC scores for groups 1 and 2 respectively were 55.8 and 56.8 preoperatively versus 86.2 and 85.7 at 1 year; Lysholm scores were 69.9 and 71.1 versus 90.9 and 91.8. These inter-group differences were non-significant. Differential laxity for groups 1 and 2 respectively was 5.0mm (range, 2-10) and 5.1mm (2-12) preoperatively (P=0.73), versus 1.2mm and 1.9 mm postoperatively (P=0.03). In partial ACL tear, selective AM bundle reconstruction conserving the posterolateral bundle remnant provides clinical results comparable to the standard single-bundle technique, with better control of anterior laxity. Longer follow-up, however, will be needed to compare evolution in anterior and rotational laxity and in subjective results over time.

Comparison of 2 Femoral Tunnel Locations in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction: A Biomechanical Study

To evaluate knee stability after anterior cruciate ligament (ACL) reconstruction using 2 modern clinically relevant single-bundle constructs. Two arthroscopic ACL reconstructions were performed on 6 fresh-frozen human cadaveric knees using bone-patellar tendon-bone autografts. The tibial tunnel was centered in the anatomic tibial footprint. The femoral tunnel was reamed through the anteromedial (AM) portal and centered alternately in either the AM portion of the femoral footprint (center-AM) or the center of the femoral footprint (center-center). Two external loading conditions were applied: (1) a 134-N anterior tibial load and (2) a 10-Nm valgus load combined with a 5-Nm internal tibial torque. Resulting kinematics were determined under 4 conditions: (1) ACL intact, (2) ACL deficient, (3) center-AM reconstruction, and (4) center-center reconstruction. In response to anterior tibial loading, anterior translation was similar in the ACL-intact knee and the 2 reconstructions at 0° to 60° of flexion but was greater in the reconstructed specimens at 90°. In response to the complex rotatory load, internal tibial rotation (ITR) at 30° of flexion was slightly greater in center-AM knees compared with ACL-intact knees (11.0° ± 0.6° v 10.5° ± 0.6°, P = .03). At other angles tested, ITR in both reconstructions was similar to the ACL-intact knee (P > .05). When we compared the 2 reconstruction alternatives, however, center-center knees exhibited greater resistance to ITR at all angles (P < .05). Anatomic single-bundle ACL reconstruction performed with the femoral tunnel placed through the AM portal restores translational and rotational knee stability to an extent that closely approximates the ACL-intact condition. When compared with the AM femoral tunnel position, a femoral tunnel positioned in the anatomic center of the femoral origin of the ACL may further improve rotatory stability without sacrificing anterior stability. This study provides additional biomechanical evidence in support of anatomic single-bundle ACL reconstruction with tunnels positioned in the center of the femoral and tibial footprints.

Effect of Notchplasty in Anterior Cruciate Ligament Reconstruction: A Biomechanical Study in Porcine Knees (SS-74)

Introduction: In anterior cruciate ligament (ACL) reconstruction, notchplasty is frequently performed by many surgeons. It is not well understood how notchplasty may effect tunnel placement and knee kinematics. The purpose of this study is to investigate the biomechanical effects of notchplasty on the ACL reconstructed knee. The hypothesis is that notchplasty will affect knee biomechanics in ACL reconstructed knee. Methods: Twelve (n 12) mature, fresh frozen porcine knees were tested using a robotic/universal force/moment sensor (UFS) testing system. All ACL reconstructions were performed via arthroscopy using a threeportal technique. Four knee states were compared: 1) intact ACL 2) ACL-Deficient 3) Anatomic single bundle (SB) ACL reconstruction and 4) Anatomic SB ACL reconstruction with a 5 mm notchplasty. The same tunnel was used for states 3 and 4. The graft was fixed at 60° of knee flexion and tensioned at 80-N with an Endobutton on the femur and a post-screw on the tibia. All knees were subjected to the following loading conditions: an 89-N anterior tibial load to test anterior tibial translation (ATT) and a 4 N-m internal rotation (IR) and external rotation (ER) tibial torque. The knee kinematics and in situ force obtained from the different knee conditions were compared. The data (mean standard deviation), was analyzed (Prism GraphPad Version 5.0a) using a two-tailed Paired t-test with the level of significance set at P 0.05. Results: There was no significant differences between pre and post notchplasty in ER at 30° (full extension in porcine knee) and 60° of flexion (p 0.05). However, a significant difference was found between pre and post notchplasty in ATT at 30° and 60° of flexion (p 0.05). In-situ force in anatomic single bundle reconstruction with notchplasty was significant lower than intact and anatomic reconstructed ACL pre-notchplasty at 30 °, 60° and 90° flexion of the knee (p 0.05). In response to an IR tibial torque, there were not significant differences between pre and post notchplasty at 30° of knee flexion (p 0.05). However, a significant difference was found between pre and post notchplasty in IR at 60° (p 0.05) of knee flexion. Conclusion: The results of this study showed that notchplasty did not result in an increase in ER at 30° and 60° degrees of knee flexion and IR at 30° degree of knee flexion; but lead to an increase in ATT at 30° and 60° degrees of knee flexion and in IR at 60° degree of knee flexion. Notchplasty had more effect on anterior stability than rotational stability. This change in knee kinematics could be detrimental to a bone healing and graft ligamentization and could lead to graft failure.

Long-term results of arthroscopically assisted anatomical single-bundle anterior cruciate ligament reconstruction using patellar tendon autograft: are there any predictors for the development of osteoarthritis?

The primary purpose of our study was to analyse the long-term outcome of patients treated for anterior cruciate ligament (ACL) tears by anatomical single-bundle ACL reconstruction with patellar tendon autograft. The secondary purpose was to identify predictive factors for good outcome and occurrence of osteoarthritis. Sixty-three patients (m:f = 54:9; mean age at surgery, 27 ± 7 years) treated by ACL reconstruction were evaluated with a mean follow-up of 16 ± 1 years using IKDC2000, the SF36, Lysholm and Tegner score, Knee Society score, visual analogue scale for pain and satisfaction and KOOS. The femoral tunnel position was evaluated according to Sommer. It was also assessed in percentage of the Blumensaat line and the tibial tunnel position in percentage of the total anterior-posterior plateau length. The extent of osteoarthritis was graded according to the Kellgren-Lawrence score. The total IKDC2000 was normal in 20 (32 %), nearly normal in 29 (46 %), abnormal in 12 (19 %) and severely abnormal in 3 (5 %) of patients. The mean total SF-36 was 89 ± 13, the Lysholm score 95 ± 12, the Knee Society score 191 ± 16 and the total KOOS 84 ± 19. The Tegner score decreased from pre-injury 7(4-10) to 6 (2-10) at follow-up. The Kellgren-Lawrence score was normal in 17 (27 %), suspected osteoarthritis in 25 (40 %), minimal osteoarthritis in 5 (8 %), moderate osteoarthritis in 9 (14 %) and severe osteoarthritis in 3 patients (5 %). The femoral tunnel was in zone A in 43 patients (68 %), in zone B in 16 (25 %) and in zone C in 4 patients (7 %). The femoral tunnel position in percentage of the Blumensaat line was 49 ± 3 (range, 44-57), and the tibial tunnel position in percentage of the total anterior-posterior plateau length was 32 ± 6 (range, 21-46). Patients with meniscal lesion at the time of ACL tear showed significantly less favourable outcomes than those without. Patients treated by the proposed ACL reconstruction technique showed on average good to excellent long-term results. A meniscal lesion at the time of ACL tear was highly predictive for less favourable outcome.

Patient selection of anatomical double bundle or traditional single bundle ACL reconstruction

This study was designed as a questionnaire survey to reveal the preference in technique of patients faced with anterior cruciate ligament (ACL) reconstruction. One hundred and ten subjects (35 patients and 75 medical students) were included in this study. A questionnaire survey was conducted, and the following questions were asked: (1) How old are you? (2) Prior to this survey, did you know what the ACL was? (3) Prior to this survey, did you have any knowledge about ACL reconstruction technique? (4) Prior to this survey, did you know the difference between anatomical double bundle (DB) technique and traditional single bundle (SB) technique? (5) If you had to have an ACL reconstruction, which technique would you prefer? In the same questionnaire, between questions (3) and (4), a description of SB and DB was provided. Sixty-nine percent of patients and 100% of medical students knew what the ACL was. Forty-three percent of patients and 85% of medical students had previous knowledge about ACL reconstruction. None of the patients and only 29% of the medical students had prior knowledge about the difference between DB and SB. Six percent of patients selected SB, and 40% selected DB. Nine percent of medical students selected SB, and 67% selected DB. In this study, 46% of patients and 76% of medical students selected one of the operation techniques. The trend in selection of the operation technique was significantly influenced by the subjects' prior medical knowledge. It might be possible to apply the principle of "informed patient choice" to the selection of DB or SB for ACL reconstruction. Decision analysis, Level III.

Knee Laxity Control in Revision Anterior Cruciate Ligament Reconstruction Versus Anterior Cruciate Ligament Reconstruction and Lateral Tenodesis

Background: Rotational laxity control is one of the different options to improve functional results after anterior cruciate ligament reconstruction. Lateral extra-articular tenodesis has been proposed to reduce the rotational laxity, especially in challenging situations such as revision reconstruction after biological failure. We currently lack the practical clinical tools to objectively assess knee rotational laxities. Hypothesis: Addition of a lateral tenodesis to anatomic single-bundle anterior cruciate ligament reconstruction with hamstring tendon graft could improve the knee laxity control, particularly the internal rotation, compared with a standard single-bundle anterior cruciate ligament reconstruction. Study Design: Controlled laboratory study. Methods: Twenty patients underwent navigated anatomic anteromedial bundle revision anterior cruciate ligament reconstruction with addition of percutaneous extra-articular tenodesis using the same hamstring tendon graft. The navigation was used to optimize femoral and tibial tunnel positions and to measure the knee kinematics in response to the anterior drawer test, Lachman test, maximum internal/external rotation test, and pivot-shift test. All patients underwent revision after failure without any technical error found or new trauma. Two sequential reconstruction protocols were used to assess the contribution of the extra-articular tenodesis and single anteromedial bundle anterior cruciate ligament reconstruction to restrain tibial translations and coupled axial rotation occurring with the manually performed clinical laxity tests. In group A, the intra-articular reconstruction was fixed first and then the lateral tenodesis was fixed, and in group B, the protocol was reversed. Measurements were performed before the reconstruction, after the first part was fixed, and after the second part was fixed in each protocol. Results: At 90° of flexion, addition of lateral tenodesis had a significant effect on coupled internal rotation (P = .003). Addition of the intra-articular reconstruction to lateral tenodesis had a significant effect (P = .001) in reducing anterior tibial translation of the medial compartment, and the effect was also significant (P = .0001) in reduction of lateral compartment translation. For the rotational envelope, lateral tenodesis had a significant effect (P = .0001) in reducing maximum internal rotation at 90° of flexion. Conclusion: Addition of an extra-articular procedure provided no significant improvement to anterior tibial translation and improved internal tibial rotation control only at 90° of flexion.

Equal Kinematics Between Central Anatomic Single-Bundle and Double-Bundle Anterior Cruciate Ligament Reconstructions

The purpose of this study was to compare the kinematics of a central anatomic single-bundle anterior cruciate ligament (ACL) reconstruction with a double-bundle ACL reconstruction by use of hamstring grafts and anatomic tunnel placement. Anterior tibial translation and rotation were measured with a computer navigation system in 8 pairs of fresh-frozen cadaveric knees by use of a 133-N anterior force, an internal and external torque of 10 Nm, and an anterior force (133 N) combined with an internal rotation torque (10 Nm). Tests were performed at 30 degrees and 60 degrees of flexion with the ACL intact, the ACL transected, and after reconstruction of one side of a pair with either a single or a double-bundle construct. At 30 degrees of flexion, cutting the ACL increased anterior translation under an anterior force (P < .0001), an internal rotation torque (P = .02), and a combined anterior force plus internal rotation torque (P = .01). At 60 degrees of flexion, transecting the ACL led to increased anterior translation only when an anterior force was used (P < .0001). Both single- and double-bundle reconstructions restored normal kinematics at 30 degrees and 60 degrees of knee flexion. Central anatomic single-bundle ACL reconstruction with tunnels centered within the tibial and femoral insertions and double-bundle ACL reconstruction can restore normal anterior translation to the knee under anterior and rotational loads applied at 30 degrees and 60 degrees of flexion. The primary kinematic effect of an ACL injury is an increase in anterior tibial translation, but there is no significant change in maximum internal or external rotation. Single- and double-bundle ACL reconstructions are equally effective in restoring normal anterior translation to the knee under both anterior and rotational loads.

Prospective Clinical Comparisons of Anatomic Double-Bundle Versus Single-Bundle Anterior Cruciate Ligament Reconstruction Procedures in 328 Consecutive Patients

Prospective Clinical Comparisons of Anatomic Double-Bundle Versus Single-Bundle Anterior Cruciate Ligament Reconstruction Procedures in 328 Consecutive Patients