Arthroscopic Double-bundle Anterior Cruciate Ligament Research Articles

Review of Cha et al. (2005) on “Arthroscopic Double Bundle Anterior Cruciate Ligament Reconstruction: An Anatomical Approach”

This classic discusses the original publication ‘Arthroscopic double-bundle anterior cruciate ligament reconstruction (ACL): An anatomical approach’, the first detailed description of the surgical technique popularised by Dr Freddie Fu. The technique, in which the anteromedial and posterolateral bundles of the ACL are reconstructed individually using two grafts with independent bone tunnels, was designed to more closely recreate the function of the native ACL by more closely reproducing the functional anatomy. This reconstruction was biomechanically superior to single-bundle reconstruction, particularly with regards to rotational control, leading to great interest from ACL surgeons around the world. Clinical superiority was more difficult to demonstrate; however, and the technical difficulty of the procedure has limited its use. Nevertheless, the pursuit of improved patient outcomes through attention to functional anatomical detail continues. ‘Recreating the functional anatomy of the intact ACL remains the cornerstone of ACL reconstruction’.

A CT based evaluation of femoral and tibial tunnel widening after double bundle ACL reconstruction

IntroductionAmong the postoperative phenomenon of ACL reconstruction, tunnel enlargement has been reported consistently, regardless of the technique used. It could be clinically relevant in post operative follow up and revision surgery. This study evaluated the magnitude of tibial and femoral bone tunnels enlargement after arthroscopic double-bundle anterior cruciate ligament (ACL) reconstruction by the Computed Tomography Scan. MethodsForty patients undergoing arthroscopic double-bundle ACL reconstruction using multistranded hamstring graft, were included in the study. CT scan was performed on second postoperative day and at follow-up of 6 month. Tunnels were evaluated by digitally measuring the widths, perpendicular to the long axis of the anteromedial (AM) and posterolateral (PL) tunnels, on an oblique coronal, saggital and axial plane at 3 levels: aperture, midway, and suspension point. Bony bridge thickness at aperture and minimum distance between two tunnels to anticipate communication was also computed. ResultsFemoral tunnel measurement showed statistically significant enlargement at aperture and midway. At the aperture, enlargement of AM and PL tunnel was 21.95% and 26.16% whereas at midway, enlargement was 20.05% and 24.5%. At the suspension point, enlargement was 3.97% and 7.1%. On tibial side, order of significant enlargement was midway of AM = 21.16% and PL = 31.78% followed by aperture of AM = 18.9% and PL = 28.84% and finally suspension point of AM = 17.84% and PL = 25.21%. Average bony bridge thickness at femoral and tibial aperture was 0.291 ± 0.059 and 0.231 ± 0.105 cm respectively with 10% of the patients showed merging of tunnels at aperture. ConclusionCT scan is an effective way to determine the tunnel position and enlargement after ACL reconstruction. There is a significant widening of femoral and tibial tunnels at 6 months follow-up of arthroscopic double bundle anterior cruciate ligament reconstruction. Tunnel widening could be a serious problem after double-bundle ACL reconstruction.

Comparison of Tunnel Enlargement and Clinical Outcome Between Bioabsorbable Interference Screws and Cortical Button-Post Fixation in Arthroscopic Double-Bundle Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Study With a Minimum Follow-Up of 2 Years

To investigate the tunnel enlargement rate and clinical function by comparing double-bundle anterior cruciate ligament reconstruction (ACLR) using different fixation devices. Patients receiving primary arthroscopic double-bundle ACLR were screened and divided into 2 groups on the basis of the method of graft fixation: bioabsorbable interference screw (BS) group and cortical button (CB) group. Bone tunnel size was assessed digitally using magnetic resonance imaging, which was performed a minimum of 2years postoperatively. Clinical evaluations were performed using the Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee score, and KT-1000 arthrometer 2years postoperatively. Sixty patients receiving primary arthroscopic double-bundle ACLR were included. Overall, the BS group showed greater tunnel enlargement than the CB group, as well as a significantly increased rate of tunnel communication (P= .029). The average anteromedial tunnel enlargement rates for the BS and CB groups were 50% and 28%, respectively. The enlargement rate of the posterolateral (PL) femoral tunnel was similar in both groups. In the PL tibial tunnel, the CB group showed a significant increase in enlargement compared with the BS group (64% vs 45%, P= .0001). Both groups showed functional improvement in the Knee Injury and Osteoarthritis Outcome Score and International Knee Documentation Committee score. No significant difference in postoperative functional outcomes was found between the 2 groups. The BS group showed significantly greater tunnel enlargement in anteromedial tunnels and an increased tunnel communication rate compared with the CB group. On the other hand, the CB group showed greater tunnel enlargement in tibial PL tunnels. Tunnel communication was observed mostly on the tibial side in the BS patients. Equivalent clinical function outcomes were noted at 2years after surgery in both groups of patients. Level II, randomized controlled clinical trial.

Capsulotomy as a measure to control pain and reducing hemarthrosis in arthroscopic DB ACL reconstruction surgery: a prospective randomized control study.

The aim of the study was to evaluate the effect of capsulotomy as a measure of pain relief and hemarthrosis prevention in the arthroscopic double-bundle anterior cruciate ligament reconstruction. This was a case control study conducted between April 2013 and Dec 2013, in which 64 patients were enrolled. Capsulotomy was done at the end of the procedure in 31 patients, who were compared with a control group. Pain score (VAS) and grade of hemarthrosis on post-op day 1 and post-op day 2 were compared between the two groups and patients followed up to a minimum of 24months. There was a statistically significant difference (p value<0.05) in the pain scores and hemarthrosis grade of the capsulotomy group compared to the control group. The mean pain score on post-op day 1 in the capsulotomy group was 2.71±0.97, whereas it was 4±1.22 in the non-capsulotomy group. The difference between the two groups was statistically significant both at day 1 of post-op and day 2 of post-op (p value<0.05). The difference between the two groups in terms of hemarthrosis grading was statistically significant both at day 1 of post-op and day 2 of post-op (p value<0.05). The difference between the two groups in terms of thigh circumference measurements was statistically significant both on day 1 and day 2 of post-op (p value<0.05). We conclude that capsulotomy is a safe and effective measure of pain relief and hemarthrosis management in arthroscopic ACL reconstruction surgeries.

Outcome of double bundle anterior cruciate ligament reconstruction using crosspin and aperture fixation

Background:Double bundle anterior cruciate ligament (DBACL) reconstruction is said to reproduce the native anterior cruciate ligament (ACL) anatomy better than single bundle anterior cruciate ligament, whether it leads to better functional results is debatable. Different fixation methods have been used for DBACL reconstruction, the most common being aperture fixation on tibial side and cortical suspensory fixation on the femoral side. We present the results of DBACL reconstruction technique, wherein on the femoral side anteromedial (AM) bundle is fixed with a crosspin and aperture fixation was done for the posterolateral (PL) bundle.Materials and Methods:Out of 157 isolated ACL injury patients who underwent ACL reconstruction, 100 were included in the prospective study. Arthroscopic DBACL reconstruction was done using ipsilateral hamstring autograft. AM bundle was fixed using Transfix (Arthrex, Naples, FL, USA) on the femoral side and bio interference screw (Arthrex, Naples, FL, USA) on the tibial side. PL bundle was fixed on femoral as well as on tibial side with a biointerference screw. Patients were evaluated using KT-1000 arthrometer, Lysholm score, International Knee Documentation Committee (IKDC) Score and isokinetic muscle strength testing.Methods:Out of 157 isolated ACL injury patients who underwent ACL reconstruction, 100 were included in the prospective study. Arthroscopic DBACL reconstruction was done using ipsilateral hamstring autograft. AM bundle was fixed using Transfix (Arthrex, Naples, FL, USA) on the femoral side and bio interference screw (Arthrex, Naples, FL, USA) on the tibial side. PL bundle was fixed on femoral as well as on tibial side with a biointerference screw. Patients were evaluated using KT-1000 arthrometer, Lysholm score, International Knee Documentation Committee (IKDC) Score and isokinetic muscle strength testing.Results:The KT-1000 results were evaluated using paired t test with the P value set at 0.001. At the end of 1 year, the anteroposterior side to side translation difference (KT-1000 manual maximum) showed mean improvement from 5.1 mm ± 1.5 preoperatively to 1.6 mm ± 1.2 (P < 0.001) postoperatively. The Lysholm score too showed statistically significant (P < 0.001) improvement from 52.4 ± 15.2 (range: 32-76) preoperatively to a postoperative score of 89.1 ± 3.2 (range 67-100). According to the IKDC score 90% patients had normal results (Category A and B). The AM femoral tunnel initial posterior blow out was seen in 4 patients and confluence in the intraarticular part of the femoral tunnels was seen in 6 patients intraoperatively. The quadriceps strength on isokinetic testing had an average deficit of 10.3% while the hamstrings had a 5.2% deficit at the end of 1 year as compared with the normal side.Conclusion:Our study revealed that the DBACL reconstruction using crosspin fixation for AM bundle and aperture fixation for PL bundle on the femoral side resulted in significant improvement in KT 1000, Lysholm and IKDC scores.

Double-bundle anterior cruciate ligament reconstruction: a short-term study

Background In recent years, there is an increasing interest in double-bundle (DB) anterior cruciate ligament (ACL) reconstruction to improve the anatomical, biomechanical, and clinical outcome of the procedure. Objectives The aim of the study was to evaluate the outcome of arthroscopic DB ACL reconstruction using the four-tunnel technique with autograft hamstring tendons for athletic patients. Patients and methods Fifteen athletic male patients suffering from ACL injury with a mean age at the time of operation of 24.3 years (average 18-34 years) were operated upon using four-tunnel technique, and fixation was carried out by two femoral end buttons and two tibial interference screws. Results After a mean follow-up period of 26 months (range 12-42 months), according to the International Knee Documentation Committee score, 14 patients (93.3%) became normal and near normal, whereas one patient (6.7%) was abnormal. The Lysholm score changed from 56 points preoperative (range 30-72) to 93 points (range 45-100) at the end of follow-up. Thirteen patients (86.6%) had normal Lachman and anterior drawer tests results. Twelve patients had negative pivot shift test. Nine patients (60%) had near normal thigh girth in comparison with the healthy side. All 15 patients reached 100% range of motion in comparison with the other healthy side at the end of follow-up. Conclusion ACL reconstruction with the DB technique is good for stability of the knee. Long-term studies should be performed and the number of patients should be increased.

The Position of the Posterolateral Bundle Femoral Tunnel During Arthroscopic Double-Bundle Anterior Cruciate Ligament Reconstruction: A Cadaveric Study

The purpose was to find a simple guideline to help establish accurate positioning of the posterolateral bundle (PLB) femoral bone tunnel during double-bundle anterior cruciate ligament reconstruction by measuring the distance between the center of the PLB femoral footprint to the shallow and the deep articular cartilage borders of the lateral wall of the intercondylar notch. The femoral insertions of the anteromedial bundle and PLB of the anterior cruciate ligament were dissected in 22 male cadaveric knees, aged 25 to 45 years. By use of the intercondylar notch as the landmark, the distances between the center of the PLB femoral footprint and the shallow and the deep articular cartilage borders of the lateral wall of the intercondylar notch were measured with the knees flexed at 90°. The measured data (mean ± standard deviation) were evaluated and compared. The center of the PLB was positioned 8.60 ± 1.52 mm and 8.65 ± 1.54 mm from the shallow and the deep cartilage borders of the lateral wall of the intercondylar notch, respectively (P = .95). The distance between the center of the PLB footprint to the low cartilage border of the lateral intercondylar wall was 5.05 ± 0.76 mm. The findings suggest that the position of the center of the PLB femoral footprint is at the middle of the line joining the shallow and the deep borders of the femoral cartilage. Surgeons can use our results as a guideline and use the PLB footprint remnant as a reference at the same time to locate the femoral PLB tunnel in a simple, easy, and repeatable way.

Anatomic double-bundle ACL reconstruction using a bone–patellar tendon–bone autograft: a technical note

This article describes an original arthroscopic double-bundle anterior cruciate ligament (ACL) reconstruction technique using a bone-patellar tendon-bone autograft. A rectangular patellar bone block, with a double strand patellar tendon, and a double tibial bone block is harvested. The femoral anteromedial tunnel is made using an all-inside technique by the anteromedial portal. The femoral posterolateral (PL) tunnel is created with an outside-in technique, with a 30 degrees divergence between both tunnels. A single tibial tunnel is drilled, the graft is then passed through the tibial tunnel, and the bundles are separately tensioned and fixed with three bioabsorbable interference screws. The femoral AM bone block is fixed by the anteromedial portal, the tibial bone block is then fixed in an oblique manner in order to mimic the ACL orientation with the knee at 30 degrees of flexion. The femoral PL bone block is fixed at the end with the knee in full extension.

Anatomical analysis of the anterior cruciate ligament femoral and tibial footprints

BackgroundThe current trend in anterior cruciate ligament (ACL) reconstruction has shifted to anatomical double-bundle (DB) reconstruction, which reproduces both the anteromedial bundle (AMB) and the posterolateral bundle (PLB) of the ACL. Navigation systems have also been recently introduced to orthopedic surgical procedures, including ACL reconstruction. In DB–ACL reconstruction, the femoral and tibial tunnel positions are very important, but a representation of the ACL footprint under an arthroscopic view has not been established even though navigation systems have been introduced. The purpose of this study was to evaluate the anatomical footprints of both the AMB and the PLB using the representation method for application to arthroscopic DB–ACL reconstruction using a navigation system, and to evaluate the validity of the currently determined footprint position compared with other representation methods. MethodsThirty-six cadaveric knees were used for an anatomical evaluation of footprints of the AMB and PLB. On the tibial side, the ACL footprints were evaluated using an original method. On the femoral side, the ACL footprints were evaluated using Watanabe’s method and three other methods: (1) the quadrant method, (2) Mochizuki’s method, and (3) Takahashi’s method. ResultsThe central points of the ACL footprints were represented almost constantly. The present data is in accordance with previous measurement data. ConclusionThis study showed that the anatomical data of the ACL femoral and tibial footprints determined with Watanabe’s method at the femoral side and our original method at the tibial side were both applicable to arthroscopic surgery with a navigation system.