Conventional Anterior Cruciate Ligament Reconstruction Research Articles

Comparison of Remnant Preserved versus Conventional Anterior Cruciate Ligament Reconstruction

PURPOSE: Surgical reconstruction of the anterior cruciate ligament (ACL) may reduces knee instability. It has been suggested that the lack of full recovery of knee function following ACL reconstruction is partially the result of a sensory deficit. The remnant preserving technique was developed to preserve the prorioception and to enhance the revasularzation of the reconstructed ACL. Therefore, the purpose of this study was to analyze the clinical results of comparing the remnant preserving technique with the conventional ACL reconstruction. METHODS: We have tested 40 patients ACL reconstruction by auto graft-hamstring tendon, by dividing the subjects into 2 different groups; Trial group (preservation of remnant, Group 1) and control group (no remnant, Group 2). We measured concentric peak torque measurements of the knee extensors and flexors at 60°/sec and 180°/sec on an Isokinetic dynamometry. Proprioceptive functions has been assessed using Joint position sense (JPS) and threshold to detection of passive motion (TDPM). Dynamic postural stability was measured as a stability index in the anterior-posterior and medial-lateral planes with the Biodex Stability System. All tests were measured postoperative 1year. For statistical analysis, we used an independent-sample t test and Pearson correlation and found the results to be statistically significant at p<.05. RESULTS: A significant difference was detected in proprioception. we found significant difference between the group 1 and group 2 for Joint position sense (1.79±0.63° vs 3.14±0.95°. p=0.012) and threshold to detect passive motion (1.73±0.68° vs 2.73±1.15°. p=0.007). In dynamic postural stability test, group 1 showed a significantly improved instability of 10.7±8.5% whereas group 2 resulted that of 17.5±8.8%(p=0.037). But, we found no significant difference between the groups for the test results of knee strength. CONCLUSIONS: We thought that the presence of the proprioceptive nerve fibers in the remnant of the ACL may provide a source for the reinnervation of the graft and restoration of normal proprioception. Therefore, preservation of the remnant ACL reconstruction is helpful in preserving the proprioception and function to stabilize the knee.

The Potential for Primary Repair of the ACL

The objective of this work is to assess the feasibility of successfully repairing the torn anterior cruciate ligament (ACL). Two major motivators for developing a new treatment for ACL injuries are the recently reported high rates of osteoarthritis, after conventional ACL reconstruction, and the problem of how to safely treat skeletally immature patients. A key factor in developing such a technique was the identification of the main inhibitor of intrinsic ACL healing-the lack of clot formation between the 2 torn ends of the ligament. A bioactive and biocompatible scaffold, which could be placed in the wound site to enhance cellular proliferation and biosynthesis, was developed. This biomaterial has shown promising functional outcomes in several large animal models of primary repair of partial and complete ACL transection over 4 to 14 weeks, suggesting potential for a successful, future clinical application.

ACL Reconstruction with Double-Bundle Technique: A Review of Clinical Results

Anatomical and biomechanical studies have shown that the anterior cruciate ligament (ACL) primarily consists of 2 distinct bundles, the anteromedial (AM) and posterolateral (PL), which act separately during the knee's range of motion. Conventional ACL reconstruction techniques have focused on restoration of the AM bundle only, while giving limited attention to the PL bundle. The outcomes of these single-bundle techniques have been relatively good in ACL reconstruction. In recent years, many authors have developed double-bundle ACL reconstruction techniques to better replicate ACL anatomy and its 2 bundles. The purpose of this article is to analyze the clinical results of the double-bundle ACL reconstruction according to the current literature. The review focuses primarily on randomized controlled trials. According to the 14 randomized controlled trials published in the literature and included in this review, 4 (29%) trials did not find any significant differences in the results between double-bundle and single-bundle ACL reconstruction. Ten (71%) trials reported significantly better results with double-bundle technique than with single-bundle technique, of which 7 (50%) reported better rotational stability, 6 (43%) reported better anterior stability, 3 (21%) reported better objective knee scores, 3 (21%) reported better subjective knee scores, 2 (14%) reported fewer graft failures, and 1 (7%) reported less degenerative changes of the knee. In addition, none of the trials found the single-bundle technique to have better results in any of these evaluations when compared with the double-bundle technique. However, 13 (93%) of the 14 trials had only a short-term follow-up (1–3 years), and only 1 (7%) trial conducted long-term follow-up (8–10 years). Therefore, only through long-term follow-up studies will we be able to determine whether the double-bundle reconstruction is really better than the single-bundle technique.

Proprioceptive and Strength Comparison of Remnant Preserved versus Conventional Anterior Cruciate Ligament Reconstruction

Reconstruction of the anterior cruciate ligament (ACL) restores knee stability. The remnant preserving technique was developed to preserve mechanoreceptor function, promote revasularzation and facilitate ligamentation. The purpose of this study was to analyze the clinical results of ACL reconstruction with remnant preserving. Between October in 2008 and September in 2009, 40 patients underwent ACL reconstruction using auto graft-hamstring tendon. On the basis of the ACL’s condition patients were divided into 2 groups. In the trial group (preserved remnant group, PRG; n=20), there were 20 males with an average age of 26.2 years. In the control group (no remnant group, NRG; n=20) were 20 males with an average of age 27.1 years. We measured concentric peak torque of the knee extensors and flexors at 60/s and 180/s on an Isokinetic dynamometry. Proprioceptive functions have been assessed using Joint position sense and threshold to detection of passive motion. Dynamic postural stability was measured as a stability index in the anterior-posterior and medial-lateral planes with the Biodex Stability System. All tests were measured post-operative 1year. We found significant difference between the PRG and NRG for Joint position sense at 15 (2.40±1.00 vs. 3.36±0.95; p=0.0145) and threshold to detect passive motion at 45 (2.02±0.59 vs. 3.12±0.94; p=0.0213). But, we found no significant difference between the groups for the test results of the dynamic postural stability and knee strength. Therefore, preservation of the remnant ACL reconstruction is helpful in preserving the proprioception and function to stabilize the knee.

Transtibial Versus Anteromedial Portal Reaming in Anterior Cruciate Ligament Reconstruction: An Anatomic and Biomechanical Evaluation of Surgical Technique

The purpose of this study was to objectively evaluate the anatomic and biomechanical outcomes of anterior cruciate ligament (ACL) reconstruction with transtibial versus anteromedial portal drilling of the femoral tunnel. Ten human cadaveric knees (5 matched pairs) without ligament injury or pre-existing arthritis underwent ACL reconstruction by either a transtibial or anteromedial portal technique. A medial arthrotomy was created in all cases before reconstruction to determine the center of the native ACL tibial and femoral footprints. A 10-mm tibial tunnel directed toward the center of the tibial footprint was prepared in an identical fashion, starting at the anterior border of the medial collateral ligament in all cases. For transtibial femoral socket preparation (n = 5), a guidewire was placed as close to the center of the femoral footprint as possible. With anteromedial portal reconstruction (n = 5), the guidewire was positioned centrally in the femoral footprint and the tunnel drilled through the medial portal in hyperflexion. An identical graft was fixed and tensioned, and knee stability was assessed with the following standardized examinations: (1) anterior drawer, (2) Lachman, (3) maximal internal rotation at 30°, (4) manual pivot shift, and (5) instrumented pivot shift. Distance from the femoral guidewire to the center of the femoral footprint and dimensions of the tibial tunnel intra-articular aperture were measured for all specimens. Statistical analysis was completed with a repeated-measures analysis of variance and Tukey multiple comparisons test with P ≤ .05 defined as significant. The anteromedial portal ACL reconstruction controlled tibial translation significantly more than the transtibial reconstruction with anterior drawer, Lachman, and pivot-shift examinations of knee stability (P ≤ .05). Anteromedial portal ACL reconstruction restored the Lachman and anterior drawer examinations to those of the intact condition and constrained translation with the manual and instrumented pivot-shift examinations more than the native ACL (P ≤ .05). Despite optimal guidewire positioning, the transtibial technique resulted in a mean position 1.94 mm anterior and 3.26 mm superior to the center of the femoral footprint. The guidewire was positioned at the center of the femoral footprint through the anteromedial portal in all cases. The tibial tunnel intra-articular aperture was 38% larger in the anteroposterior dimension with the transtibial versus anteromedial portal technique (mean, 14.9 mm v 10.8 mm; P ≤ .05). The anteromedial portal drilling technique allows for accurate positioning of the femoral socket in the center of the native footprint, resulting in secondary improvement in time-zero control of tibial translation with Lachman and pivot-shift testing compared with conventional transtibial ACL reconstruction. This technique respects the native ACL anatomy but cannot restore it with a single-bundle ACL reconstruction. Eccentric, posterolateral positioning of the guidewire in the tibial tunnel with the transtibial technique results in iatrogenic re-reaming of the tibial tunnel and significant intra-articular aperture expansion. Anteromedial portal drilling of the femoral socket may allow for improved restoration of anatomy and stability with ACL reconstruction compared with conventional transtibial drilling techniques.

Computer-Navigated Surgery in Anterior Cruciate Ligament Reconstruction: Are Radiographic Outcomes Better Than Conventional Surgery?

The use of computer navigation systems in anterior cruciate ligament (ACL) has been the subject of debate. However, there is a lack of systematic review to analyze the radiographic outcomes after computer-navigated ACL reconstruction. We searched, in duplicate, Medline, Embase, and Web of Science databases for randomized controlled trials (RCTs)/quasi-RCTs comparing conventional versus computer-navigated ACL reconstruction. Two reviewers independently extracted the data. Radiographic outcomes reported in a majority of included trials were meta-analyzed using the Mantel-Haenszel test statistic. After applying our eligibility criteria, we had 5 trials for systematic review and data synthesis. There was no evidence of statistical heterogeneity between all included studies. Both navigated and conventional ACL reconstructions placed the tibial tunnel in acceptable positions. The risk of notch impingement was reduced in the navigated group in comparison with the conventional group. A computer navigation systems may reduce variation from optimal graft alignment and notch impingement. However, there is a need for further high-quality studies with long-term follow-up, so as to prove the clinical significance of these findings. Level II, systematic review of randomized controlled trials.

A long journey to be anatomic

In 1836, Weber and Weber from Gottingen, Germany performed dissection studies and described the anterior cruciate ligament (ACL) as two separate bundles that tension at different knee flexion angles [21, 33]. Many years later in 1912, the first ACL reconstruction was performed by Giertz, the mentor of Palmer, using a single-bundle of tensor fascia lata [5]. In 1917, Hey-Groves used an open ACL reconstruction technique that was ‘‘quite’’ anatomic [9]. He used tunnels to locate the graft, drilling the femoral tunnel inside-out, aiming to place the tunnel aperture on the outer aspect of the notch to produce an oblique graft. In 1938, Palmer proposed the idea of double-bundle reconstruction in his thesis on the ACL [20], though the concept received little attention at the time and his work was not appropriately accredited until many years later. The first arthroscopically assisted ACL reconstruction was performed in 1980 by Dandy [4]. However, arthroscopic surgery was far more challenging than open reconstruction. Arthroscopic anatomic reconstruction of the ACL has a learning curve, as Snow et al. demonstrate in their paper [26]. Surgeons and industry started focusing on developing standardized techniques to facilitate easier and more efficient graft placement, employing techniques such as the o0clock reference, notchplasty, isometry and drill guides. Some of these terms like the o0clock reference and isometry turned into almost mandatory but often misleading technical descriptions. The resulting surgical techniques were indeed fast and efficient, but as Behrend et al. [2] show in their study on the over-the-top guide, unable to place the tunnels in the ACL insertion site. It was such techniques that lead the field away from the teachings of Weber, Palmer and their colleagues. Anatomic tunnel placement was not a priority, and the two-bundle anatomy of the ACL was never considered. This had surgeons asking: ‘‘Does anatomy matter?’’ since the general consensus was that these arthroscopic techniques were effective for restoring knee function. However, as longer-term follow-up data and better kinematic analysis techniques emerged, it has become clear that conventional non-anatomic ACL reconstruction techniques do not prevent the development of early osteoarthritis after ACL injury [6, 14, 16] nor do they restore normal dynamic knee function [27]. These results indicate that our reconstruction techniques need to be improved and restoring anatomy may be the key to success. Therefore, efforts to make reconstruction techniques more anatomic as well as critically evaluate them, such as by Silva et al. [24, 25] and Serrano-Fernandez et al. [23], should be applauded. ‘‘Anatomic’’ ACL reconstruction can be defined as the functional restoration of the ACL to its native dimensions, collagen orientation and insertion sites (Fig. 1) [29]. It is a detailed and meticulous procedure that involves visualization of the native ACL insertion site, measuring ACL and knee dimensions, appropriate graft tensioning and evaluation of graft and tunnel position using MRI and 3D CT scan. It encompasses singleand double-bundle reconstruction and can be applied to primary, revision and augmentation surgery. The development of the anatomic technique has made us take a closer look at the ACL anatomy. Just a few years ago, you would not have seen F. H. Fu Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufman Building Suite 1011, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA

Preliminary Clinical Results of Two Techniques for Addressing Graft Tunnel Mismatch in Endoscopic Anterior Cruciate Ligament Reconstruction

This study reports the initial clinical results of 540 degrees of graft rotation or free tibial bone block to address graft tunnel mismatch in endoscopic anterior cruciate ligament (ACL) reconstruction. The operative reports of patients who underwent endoscopic ACL reconstruction between 1999 and 2001 were reviewed. Nine of 11 patients treated with a free tibial bone block and 14 of 17 patients treated with 540 degrees of graft rotation were evaluated. Mean follow-up was 20 months (range: 13-40 months) for the bone block group and 34 months (range: 18-48 months) for the 540 degrees group. There were statistically significant improvements in physical examination test results postoperatively, and only one patient in the 540 degrees group had a grade one positive pivot shift test. KT-1000 arthrometer testing demonstrated a statistically significant decrease in manual maximum and side-to-side differences at final follow-up. Mean Lysholm and Noyes sports function scores were excellent or good for all patients. One patient required reoperation for flexion contracture, one patient required an arthroscopic irrigation and debridement for a minor infection, and one patient required arthroscopic subtotal medial meniscectomy for failed meniscal repair. No difference was noted between these results and previous results of patients undergoing conventional endoscopic ACL reconstruction. These results demonstrate graft rotation and free bone block techniques are effective in addressing graft tunnel mismatch in endoscopic ACL reconstruction.

Ligamentization of Tendon Grafts Treated With an Endogenous Preparation Rich in Growth Factors: Gross Morphology and Histology

To investigate whether the application of a particular platelet-rich plasma preparation rich in growth factors (PRGF) during anterior cruciate ligament (ACL) surgery gives a potential advantage for better tendon graft ligamentization. This study included 37 volunteers who underwent either conventional (control group, n = 15) or PRGF-assisted (n = 22) ACL reconstruction with an autogenous hamstring and required second-look arthroscopy to remove hardware or loose bodies, treat meniscal tears or plica syndrome, or resect cyclops lesions at 6 to 24 months after ACL surgery. The gross morphologies of the grafts were evaluated on second-look arthroscopy by use of the full arthroscopic score (0 to 4 points) to evaluate graft thickness and apparent tension (0 to 2 points) plus synovial coverage (0 to 2 points). At the same time, biopsy specimens were harvested uniformly from the grafted tendons. In these specimens the histologic transformation of the tendon graft to ACL-like tissue was evaluated by use of the Ligament Tissue Maturity Index, and a score to assess the progression of new connective tissue enveloping the graft was created by use of 3 criteria previously used to characterize changes during ligament healing: cellularity, vascularity, and collagen properties. The overall arthroscopic evaluation of PRGF-treated grafts showed an excellent rating in 57.1% of the knees (score of 4) and a fair rating in 42.9% (score of 2 or 3). In contrast, evaluation of untreated grafts showed an excellent rating in 33.3% of the knees, a fair rating in 46.7%, and a poor rating in 20% (score of 0 or 1). Overall, arthroscopic evaluations were not statistically different between PRGF and control groups (P = .051). PRGF treatment influenced the histologic characteristics of the tendon graft, resulting in tissue that was more mature than in controls (P = .024). Histologically evident newly formed connective tissue enveloping the graft was present in 77.3% of PRGF-treated grafts and 40% of controls. The appearance of the connective tissue envelope changed with increasing time from surgery. On the basis of the histologic findings, we suggest that the remodeling of PRGF-treated grafts involves the formation of synovial-like tissue enveloping the graft. This tissue is eventually integrated in the remodeled tendon graft, conferring a similar appearance to the normal ACL. The use of PRGF influenced the histologic characteristics of tendon grafts, resulting in more remodeling compared with untreated grafts. We have shown temporal histologic changes during the 6- to 24-month postoperative period of graft maturation, with newly formed connective tissue enveloping most grafts treated with PRGF. Level III, case-control study.

Soft-Tissue Reconstruction of the Anterior Cruciate Ligament With the AperFix System

The anterior cruciate ligament (ACL) is composed of 2 bundles: the anteromedial bundle and the posterolateral bundle. Although conventional transtibial ACL reconstruction recreates only the anteromedial bundle, recent data have shown that this may not restore normal knee kinematics. There has been a recent trend for some authors to recommend double-bundle reconstruction. We describe a technique using a unique new implant to reconstruct the ACL that provides for aperture fixation at both the femoral and tibial sides, and offers the surgeon the flexibility to perform either a conventional quadruple bundle soft-tissue reconstruction, or a single-tunnel, double-bundle reconstruction.

The Concept of Anatomic Anterior Cruciate Ligament Reconstruction

Growing interest in double-bundle anterior cruciate ligament (ACL) reconstruction has sparked tremendous research, yielding a better understanding of normal ACL anatomy, kinematics, and function. Recent studies have more accurately defined the size and orientation of the femoral and tibial insertion sites of the anteromedial and posterolateral bundles. At our institution, we have identified specific osseous landmarks to better guide tunnel placement. The goal of anatomic ACL is to use these discoveries, refine technique, and reconstruct the ACL in a manner that most closely mimics normal anatomy. Logically, we believe that anatomic ACL reconstruction will lead to more favorable kinematics and, in turn, improved patient outcomes. This article summarizes our experiences and details our systematic approach to anatomic ACL reconstruction. Finally, we highlight multiple issues with conventional ACL reconstruction to better illustrate the concept of anatomic ACL reconstruction.

Double-Bundle Anatomic Anterior Cruciate Ligament Reconstruction: The Technique and Clinical Experience

Anatomic double-bundle anterior cruciate ligament (ACL) reconstruction has become popular during the last 5 years. This procedure is designed to reconstruct the anatomic insertion of the ACL footprint. Previous biomechanical basic studies and clinical results have demonstrated the advantages of this procedure compared with conventional ACL reconstruction technique. Nonanatomically reconstructed double-bundle ACL surgery has been reported in the past without significant improvement of the outcome; however, the recent reports of anatomic ACL reconstruction are shown to be improving. The outcome measurement of ACL surgery is also one of the important issues to evaluate the efficacy of anatomic ACL surgery. Theoretic background, surgical technique, and instability evaluation in anatomic ACL reconstruction are discussed in this article.

Double-Bundle Anterior Cruciate Ligament Reconstruction Using Hamstring Autografts and Bioabsorbable Interference Screw Fixation

Background Conventional anterior cruciate ligament reconstruction techniques have focused on restoration of the anterome-dial bundle only, which, however, may be insufficient in restoring the rotational stability of the knee. Hypothesis Rotational stability of the knee is better when using a double-bundle technique instead of a single-bundle technique for anterior cruciate ligament reconstruction. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods Seventy-seven patients were randomized into 3 different groups for anterior cruciate ligament reconstruction with hamstring tendons: double-bundle with bioabsorbable screw fixation (n = 25), single-bundle with bioabsorbable screw fixation (n = 27), and single-bundle with metallic screw fixation (n = 25). The evaluation methods were clinical examination, KT-1000 arthrometric measurement, and the International Knee Documentation Committee and Lysholm knee scores. Results There were no differences between the study groups preoperatively. Seventy-three patients (95%) were available at a minimum 2-year follow-up (range, 24–35 mo). The rotational stability of the knee, as evaluated by the pivot-shift test, was the best in the patients in the double-bundle group. In addition, the patients in the single-bundle groups had more graft failures than those in the double-bundle group. Concerning the anterior stability of the knee as measured with the KT-1000 arthrometer, the group differences were not statistically significant. No significant differences were found between the groups in knee scores. Conclusion Rotational stability of the knee is better when using the double-bundle technique instead of the single-bundle technique in anterior cruciate ligament reconstruction.

Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction

ABSTRACT The rapid development of anatomical double-bundle anterior cruciate ligament (ACL) reconstruction techniques is unprecedented, especially given the 80% to 90% success rate that has been reported for conventional single-bundle ACL reconstruction. However, in vitro and in vivo biomechanical evidence of poor transverse plane rotatory knee control and 10% to 30% complication rates associated with conventional single-bundle ACL reconstruction techniques suggest that a better method of restoring ACL function and improving patient outcomes is needed. Selection of which technique to use and its associated learning curve may decrease its desirability for the average knee surgeon who performs fewer than 10 ACL reconstruction procedures a year. This article describes an anatomical double-bundle ACL reconstruction technique that provides reciprocating double-bundle ACL function and that can be performed using a modified conventional single-bundle ACL reconstruction approach. The double-bundle function provided by this ACL reconstruction technique simulates the native ACL more closely than conventional single-bundle ACL reconstruction techniques. In addition to the aforementioned surgical innovations, there is a dire shortage of well-designed patient outcome studies regarding any of these anatomical double-bundle ACL reconstruction techniques. When considering use of a particular anatomical double-bundle ACL reconstruction technique, the knee surgeon must consider its complexity, how the procedure would influence revision surgery should it be needed, appropriate selection of patients who would benefit the most, additional patient education and behavioral change needs, rehabilitation and conditioning program modifications, and how this procedure may better protect the menisci and mitigate the onset and progression of knee osteoarthritis better than conventional single-bundle ACL reconstruction.

Anatomic double bundle ACL reconstruction: a literature review

With the abundance of anatomic double bundle ACL reconstruction techniques that currently exist and limited patient outcome data, one has to ask whether or not they should be used and if so, which one, and what is the learning curve for the average knee surgeon to become competent with the technique that they select? The purpose of this literature review is to summarize existing anatomic double bundle ACL reconstruction surgical and rehabilitation techniques and the clinical and biomechanical study evidence that currently exists. In choosing to perform anatomic double bundle ACL reconstruction we suggest that the knee surgeon should look for evidence of: (1) control of the pivot shift phenomenon, (2) improved transverse plane rotatory knee control during the performance of sports type movements, (3) a decreased likelihood of revision procedures either for ACL reconstruction or for treatment of associated primary or recurrent meniscal injuries, (4) improved patient self-reports of perceived function, satisfaction, and quality of life, and (5) radiographic evidence of a lower incidence and/or magnitude of osteoarthritic changes compared to conventional single bundle ACL reconstruction.

Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective, randomize clinical study

Anatomical observation and biomechanical studies have shown that the anterior cruciate ligament (ACL) mainly consists of two distinct bundles, the anteromedial (AM) bundle and posterolateral (PL) bundle. Conventional single-bundle ACL reconstruction techniques have focused on the restoration of the AM bundle while giving limited attention to the PL bundle. The purpose of this prospective, randomized clinical study is to compare the outcomes of ACL reconstruction when using either double-bundle or single-bundle technique and bioabsorbable interference screw fixation, and similar rehabilitation with both techniques. Sixty-five patients were randomized into either double-bundle (n = 35) or single-bundle (n = 30) ACL reconstruction with hamstring tendons and bioabsorbable screw (Hexalon, Inion Company, Tampere, Finland) fixation in both groups. The evaluation methods were clinical examination, KT-1000 arthrometer measurements, radiographic evaluation, as well as International Knee Documentation Committee and Lysholm knee scores. There were no differences between the study groups preoperatively. For an average of 14 months of follow-up (range 12-20 months), 30 patients of the double-bundle group and 29 patients of the single-bundle group were available (91%). At the follow-up, the rotational stability, as evaluated by pivot shift test, was significantly better in the double-bundle group than in the single-bundle group. However, in anterior stability of the knee, there was no significant difference between the groups. None of the patients in the double-bundle group had graft failure, while four patients in the single-bundle group had. In addition, knee scores were equal at the follow-up, and all the results were significantly better at the follow-up than preoperatively, in both groups.

The effect of graft tensioning in anatomic 2-bundle ACL reconstruction on knee joint kinematics

Recently, double bundle ACL reconstruction, in which the two bundles thought to have different effects on knee kinematics are reconstructed separately, is widely believed to more favorably restore normal knee kinematics than conventional single bundle ACL reconstruction. However, rotational kinematics during physiological movement after double bundle reconstruction has rarely been tested. The purpose of this study was to measure the kinematics of the ACL deficient and reconstructed knees using two different tensioning conditions in double bundle reconstruction, and to examine the effects of each graft on knee kinematics. Six cadaveric knees were used. Six degrees-of-freedom of knee kinematics and the tension of each graft were monitored during simulated knee extension with the ACL intact, resected, and reconstructed under two different tensioning conditions: 50 N on anteromedial bundle and 0 N on posterolateral bundle (AM-favored condition); 0 N on anteromedial bundle and 50 N on posterolateral bundle (PL-favored condition). Tibial translation: After ACL reconstruction, the tibia overcorrected posteriorly in both conditions. Such an overcorrection in the AM-favored condition was larger than in the PL-favored condition. Tibial rotation: The tibia was significantly externally rotated after ACL reconstruction at a low flexion angle in both conditions. However, at a high flexion angle, tibial external rotation was shown only in the AM-favored condition. Graft tension: While total tensions were similar between the two conditions, the AM bundle shared more tension in the AM-favored condition than in the PL-favored condition. A total of 50 N of tension force was assumed to be excessive for normalizing knee kinematics at a low flexion angle even if double bundle reconstruction was used. Additionally, the AM-favored tensioning reconstruction made the tibia rotate externally and translate posteriorly even at a high flexion angle. Further research is needed to normalize knee kinematics after ACL reconstruction, however it is recommended that a moderate tensioning force is applied to the PL bundle and a minimal tensioning force to the AM bundle in double bundle reconstruction to obtain better knee kinematics.

Single Femoral Socket Double-Bundle Anterior Cruciate Ligament Reconstruction Using Tibialis Anterior Tendon: Description of a New Technique

The native anterior cruciate ligament (ACL) has been shown to consist of 2 functional bundles with independent behavior throughout range of knee motion. Conventional arthroscopic ACL reconstruction techniques selectively recreate the anteromedial bundle of the native ACL only. Numerous studies have reported the failure to restore normal knee kinematics in an ACL-deficient knee using a single-bundle reconstruction. It has been suggested that by reconstructing both the anteromedial and posterolateral bundles of the ACL, more normal knee kinematics may be achieved. Several authors have described surgical techniques to recreate the 2 functional bundles and they range from using 2 femoral tunnels to using a single femoral tunnel with the other bundle passed over the top. This article describes a new technique of recreating the 2 functional bundles of the ACL with tibialis anterior tendon allograft using a single femoral socket.

Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Patient

Anterior cruciate ligament (ACL) injuries in skeletally immature patients are being observed with increased frequency. The management of these injuries is controversial. Nonreconstructive treatment of complete tears typically results in recurrent functional instability with risk of injury to meniscal and articular cartilage. A variety of reconstructive techniques have been used, including physeal sparing, partial transphyseal, and transphyseal methods using various grafts. Conventional adult ACL reconstruction techniques risk potential iatrogenic growth disturbance because of physeal violation. Growth disturbances after ACL reconstruction in skeletally immature patients have been reported. In this review, I discuss our approach to ACL injuries in the skeletally immature patient. Specifically, surgical techniques in the prepubescent patient and in the adolescent patient are detailed.

Anatomic fixation in double-bundle anterior cruciate ligament reconstruction

Conventional anterior cruciate ligament reconstruction techniques usually have focused on the restoration of the anteromedial bundle while giving limited attention to the posterolateral bundle. In past years, different surgical techniques addressing both the anteromedial and posterolateral bundle were described. Most of these techniques, however, have used an indirect extra-anatomical fixation technique. Concerns may arise regarding delayed biological incorporation and tunnel enlargement in extra-anatomical fixation techniques by graft-tunnel motion, windshield wipering, and suture stretch-out. Therefore, we present a novel arthroscopic technique that not only reapproximates the native footprints of both the anteromedial and the posterolateral bundle but also allows an anatomic fixation of each bundle close to the joint surface.