Double-bundle Technique Research Articles

Anatomic Double-Bundle Transtibial Anterior Cruciate Ligament Reconstruction With Ligament Advanced Reinforcement System

It has been reported that anterior cruciate ligament reconstruction (ACLR) with the Ligament Advanced Reinforcement System (LARS) could obtain similar clinical outcomes to ACLR with autograft. However, in most related reports, single-bundle ACLR was performed. Given that double-bundle ACLR is more favorable than single-bundle ACLR biomechanically, it is reasonable to try double-bundle ACLR with the LARS clinically. Thus, we introduce an anatomic double-bundle transtibial ACLR technique with the LARS, in which the most critical step is to create a shallow tibial tunnel for the anteromedial bundle to further create the corresponding femoral tunnel in a transtibial manner, as well as to fix both bundles in full extension of the knee.

Anterior Cruciate Ligament Over-The-Top Plus Lateral Plasty and Minimally Invasive Double-Bundle Posteromedial Corner Reconstruction

The medial collateral ligament (MCL) and the posteromedial corner (PMC) of the knee are essential structures for maintaining medial knee stability. Chronic MCL instability is infrequent but can necessitate surgical intervention. Various surgical techniques have been described, but they often involve the use of tibial tunnels, which may complicate concurrent ligament reconstructions. This study aims to present a minimally invasive double-bundle PMC reconstruction technique that avoids the use of tibial tunnels. Knee evaluation was performed using standard clinical tests and 1.5-Tesla magnetic resonance imaging. Patients with grade III Hughston MCL injuries were considered for surgery. The technique employs either an autologous semitendinosus graft or a fresh-frozen allograft, usually tibialis anterior, to reconstruct both the superficial MCL and the posterior oblique ligament. The technique described avoids the use of tibial tunnels, preserving tibial bone stock for any future procedures. The graft is secured at the femoral and tibial insertions using bioabsorbable interference screws and titanium staples, respectively. Our minimally invasive double-bundle PMC reconstruction technique offers a feasible and effective solution for patients with chronic medial knee instability. It is particularly beneficial for patients requiring multiple ligament reconstructions, as it avoids tunnel collision and preserves tibial bone stock.

Double and Single Bundle in Athletes: A Comparison in Medium and Long-Term Rates to Return to Sport and Re-Injury.

Compare, retrospectively, the medium- and long-term of return to sport rates and re-injury of the anterior cruciate ligament (ACL) in patients submitted to single-bundle (SB) compared to double-bundle (DB) technique reconstruction. Athletes operated by SB or DB ACL reconstruction, with at least five years of follow-up at a single center, were included. The following data were collected: demographic data; competitive sports practice before the injury; previous surgery; injury/surgery to the contralateral knee; return to sports and level of the return; re-injury (time of the re-injury after the first surgery; mechanism of trauma for the re-injury; necessity of operative treatment); signs and complaints related to the knee the last clinical consultation. Seventy-six athletes (27 SB and 49 DB) were included. The return to sport rate (98%) was the same for both groups, and the return to the previous level rate showed an improvement in the DB group but without statistical significance (63% vs. 79%; P = 0.173). However, other outcomes showed higher results for the DB group: lower re-injury rate throughout the follow-up period (41% vs. 18%; P = 0.034) and during the first year of follow-up (22% vs. 4%; P = 0.021), and less stiffness (0% vs. 22%, P = 0.001). While in primary reconstruction cases, there was not a higher re-injury rate using SB (P = 0.744), in the revision cases, SB was correlated with more re-injuries than DB (P = 0.002). The overall re-injury in the medium- and long-term and the return to practice sports at the same level as before surgery in athletes submitted to DB reconstruction were slightly better than those submitted to SB reconstruction, especially in the cases that were asecond time lesion ( revisioned knees).

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.

Outcome Analysis of Posterior Cruciate Ligament Injuries: A Narrative Review.

The primary posterior stabilizer of the knee is the posterior cruciate ligament (PCL), the largest intra-articular ligament in the human knee. One of the four primary ligaments of the knee joint, the PCL, serves to support the tibia on the femur. An extreme force applied anteriorly to the proximal tibia of the flexed knee results in trauma to the PCL. Dashboard injuries, which occur when the knee is driven into the dashboard after a collision with a motor vehicle, are frequent causes. Grade 1 and 2 acute injuries are often addressed conservatively due to the PCL's natural capacity for mending. If a grade 3 injury occurs, a cautious trial can be conducted on elderly or low-demand patients. When standard treatment for isolated grade 3 injuries has failed, surgery is advised. Single-bundle or double-bundle techniques using either transtibial tunnel or tibial inlay techniques are among the reconstruction approaches. Restoring the natural kinematics of the knee and forestalling persistent posterior and mixed rotatory knee laxity are the ultimate goals of treating PCL injuries through a personalized strategy. These injuries may become more common in the future as more people participate in sports. As a result of ongoing instability, discomfort, diminished function, and the emergence of inflammatory and degenerative disorders of joints, PCL rips are becoming more well-acknowledged as a cause of morbidity and decreased function.

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Using the Anatomic Double-Bundle 2-in-1 Guide System

Background: In double-bundle anterior cruciate ligament (ACL) reconstruction, tunnel coalition may occur intraoperatively or during the postoperative course. Tibial tunnel coalition is more common compared with femoral tunnel coalition. Once tunnel coalition occurs on the tibial side, rotatory knee laxity may not be controlled as expected. We have developed a new device to avoid tibial tunnel coalition with consistency. The purpose of this video is to present the surgical technique for double-bundle ACL reconstruction using a new drill guide. Indications: The novel guide may be used in all cases with confirmed ACL tear in a physically active patient, identical to indications for current ACL reconstruction using the double-bundle technique. Technique Description: The hamstring tendon is harvested for the ACL grafts. Two guide pins for the anteromedial bundle and posterolateral bundle for the tibial tunnel are inserted through the Anatomic Double-Bundle 2-in-1 Guide System. Cannulated drills and dilators are used to create the tunnel to the final diameter. Next, femoral tunnels are created by the outside-in technique using the Anatomic Double-Bundle 2-in-1 Guide System. Grafts are inserted from the tibia and passed through the femur. The grafts are fixed with a post screw and/or interference screw. Results: Two weeks after surgery, no tibial or femoral coalition (0/20 cases) were confirmed and tibial bony bridge at the intraarticular surface was measured 2.7 ± 0.9 mm using computed tomography (CT). One year after surgery, tibial coalition was confirmed in 13.3% (2/15 cases), and femoral coalition in 6.7% (1/15 cases) on CT image mainly due to tunnel widening. The 2 cases with tibial coalition had tibial bony bridge of less than 2 mm on immediate postoperative CT. Discussion/Conclusion: Using the novel guide, 2 tibial tunnels were created easily and accurately compared with the conventional independent drilling technique. The 2 tunnels can also be created simultaneously with single placement of the guide. Two separate tunnels help maintain expected rotatory knee stability after double-bundle ACL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Trends of Publications on Single- and Double-Bundle ACL Reconstructions over the Last 20 Years: A Bibliometric Analysis of the PubMed Literature

PurposeTo improve the clinical outcomes of anterior cruciate ligament reconstruction (ACLR), there have been attempts to reproduce anatomic reconstruction by modifying the single-bundle (SB) and double-bundle (DB) techniques. Although DB ACLR restores better rotational control compared to SB ACLR, it is still debatable whether there are higher clinical outcomes in favor of DB ACLR. We aimed to study the trends of publications on SB and DB ACLR techniques over the last 20 years.MethodsFor this bibliometric study, we performed a PubMed search on 31/05/2022 with a well-defined search strategy. The articles were downloaded into Excel software, and citations were determined from the iCite website for PubMed. The analysis was performed using SPSS software version 28.0.1. Data mining was performed using Orange software, Mac version 3.32.0, from the titles of all articles and each group of SB and DB ACLR. The output is presented as word clouds.ResultsA total of 10,530 publications were identified, of which 9699 publications (92.1%) pertained to SB-ACLR and 831 publications (7.9%) to DB-ACLR. There was a steady increase in the publications on SB-ACLR until 2012, followed by a steep increase that peaked in 2021. The highest number of publications on DB-ACLR was in 2012 (n = 76; 9.1%). The mean citations per year for SB-ACLR and DB-ACLR were 2.87 ± 4.31 and 2.74 ± 3.17, respectively. The most prolific journals publishing on this topic were Knee Surgery Sports Traumatology Arthroscopy, American Journal of Sports Medicine, and Arthroscopy. The top three articles that received the maximum number of citations were from Japanese authors.ConclusionThe number of publications related to SB-ACLR was significantly higher than that related to DB-ACLR in the last 20 years. The publications related to DB-ACLR have decreased in the recent past, after reaching a peak in 2012. The citations per year of SB-ACLR and DB-ACLR were similar.

Onlay Technique for Posterior Cruciate Ligament Reconstruction: The Paccola's Technique

The primary function of the posterior cruciate ligament (PCL) is to restrict the posterior translation of the tibia, and its secondary function is to limit the tibial external rotation, mainly at 90° and 120° of knee flexion. The prevalence of PCL rupture ranges between 3% and 37% of patients with knee ligament tears. This ligament injury often is associated with other ligament injuries. Surgical treatment is recommended for acute PCL injuries associated with knee dislocations or when stress radiographs show a tibial posteriorization greater than or equal to 12 mm. The techniques classically described for the surgical treatment are inlay and transtibial, which can be performed in a single- or double-bundle fashion. Biomechanical studies suggest that the double-bundle technique is superior to the single femoral bundle, suggesting less postoperative laxity. However, such superiority has not yet been proven in clinical studies. This paper will describe the step-by-step technique for PCL surgical reconstruction. The tibial fixation of the PCL graft is performed by using a screw and spiked-washer, and the femoral fixation can be done with a single- or double-bundle technique. We will explain the surgical steps in detail, with tips to perform them simply and safely.

Biomechanical considerations for graft choice in anterior cruciate ligament reconstruction.

Injury to the anterior cruciate ligament (ACL) of the knee is common and often requires surgical reconstruction. There are numerous graft options available to the operating surgeon, to each of which a growing body of dedicated literature exists. Each of these potential choices of ACL graft specimen has a distinctive set of biomechanical properties, clinical outcome profiles, and other special considerations (e.g., autograft versus allograft, harvest site factors, and operating time). The purpose of this review is to discuss the biomechanical characteristics of the native ACL alongside those of several of the most commonly used ACL graft specimens based on a current review of the biomechanical literature. In doing so, this review will also briefly discuss the biomechanical implications for allograft versus autograft usage and single-bundle versus double-bundle repair techniques. This review lists and discusses the stress, strain, stiffness, Young's modulus, and ultimate load to failure of the native ACL, several common autografts [patellar bone-tendon-bone (BTB), hamstring tendon (HT), and quadriceps tendon (QT)], and several common allografts. Given the important biomechanical role of the ACL in stabilizing the knee to translational and rotational forces, it is crucial that the operating surgeon make a decision on graft choice that is informed in the biomechanical implications of ACL graft selection.

Comparison of Outcomes Between All-Inside Single-Bundle and Double-Bundle Anterior Cruciate Ligament Reconstruction: A Retrospective Study.

ACL rupture is the most common type of knee injury. The All-inside ACL reconstruction procedure features some distinguished components including closed-socket tunnels with less bone expulsion, double suspensory fixation, and smaller incisions. We aimed to compare the outcomes between the All-inside Single-bundle and the Double-bundle ACL reconstruction techniques. This study was a retrospective study which analysed the patient-reported and the clinical outcomes on patients who underwent ACL reconstruction between January and December 2020 at Dr Kariadi General Hospital Semarang, Indonesia. We compared the patient-reported and the clinical outcomes at 6- and 12-month follow-ups between the All-inside Single-bundle and the Double-bundle groups. The patient-reported outcomes were determined using the IKDC and Tegner-Lysholm scores while the clinical outcomes included the measurement of Thigh Circumference, Single Hop test, Anterior Drawer test, Lachman test, Range of motion, and the patient's level of return to sport. A total of 24 subjects were divided into two groups, namely the All-inside Single-bundle and the Double-bundle groups, consisting of 12 subjects in each group. Most of the subjects were male in both groups, including 9 (75%) subjects in the All-inside Single-bundle group, and 11 (91.67%) subjects in the Double-bundle group. The mean age of the subjects were 25.75±7.57 years old in the All-inside Single-bundle group, and 24.5±6.87 years old in the Double-bundle group. In terms of the side of the knee that suffered the most injuries in both groups were the right knees. The result of the patient-reported outcomes using IKDC and Tegner-Lysholm scores showed no statistically significant differences in both groups at 6- and 12-month follow-ups (p=0.864; p=0.293 and p=0.589; p=0.233, respectively). The results of clinical assessments at 6- and 12-month follow-ups also showed no statistically significant differences in both groups. Our study showed no significant differences in the patient-reported and the clinical outcomes between the All-inside Single-bundle and the Double-bundle ACL reconstruction techniques at 6- and 12-month follow-ups.

Single bundle vs double bundle for anterior cruciate ligament reconstruction evaluated with T2 mapping: A case series.

ACL reconstruction is needed to restore the stability and biomechanics properties of the injured knee joints in order to reproduce the function of the native ACL. The single-bundle (SB) and double-bundle (DB) techniques are most commonly used to reconstruct the injured ACL. However, its superiority upon each other is still controversial. This study presented a case series of six patients underwent ACL reconstruction, consisted of three patients with SB ACL reconstruction and three patients with DB ACL reconstruction with further T2 mapping for joint instability evaluation. Only two DB patients showed consistent decreased value in every follow-up. ACL tear can generate joint instability. Joint instability is resulted from two mechanisms of relative cartilage overloading. First, there is an abnormal load distribution due to shifting of the center of pressure of the tibiofemoral force, resulting in increased stresses on the articular cartilage of the knee joint. There is also an increase of translation between articular surfaces, resulting in increased shear stresses on the articular cartilage. A trauma of knee joint causes cartilage damage and increased oxidative and metabolic stress of chondrocytes, resulting in chondrocyte senescence acceleration. This case series showed inconsistent results to determine either SB or DB has a better outcome in joint instability, thus further larger studies are needed.

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

A Comprehensive Meta-analysis of Clinical and Biomechanical Outcomes Comparing Double-Bundle and Single-Bundle Posterior Cruciate Ligament Reconstruction Techniques

Background: Posterior cruciate ligament (PCL) reconstruction techniques have historically focused on single-bundle (SB) reconstruction of the larger anterolateral bundle without addressing the codominant posteromedial bundle. The SB technique has been associated with residual laxity and instability, leading to the development of double-bundle (DB) reconstruction techniques. Purpose: To perform a meta-analysis of comparative clinical and biomechanical studies to differentiate the pooled outcomes of SB and DB PCL reconstruction cohorts. Study Design: Meta-analysis and systematic review: Level of evidence, 3. Methods: Six databases were queried in February 2022 for literature directly comparing clinical and biomechanical outcomes for patients or cadaveric specimens undergoing DB PCL reconstruction against SB PCL reconstruction. Biomechanical outcomes included posterior tibial translational laxity, external rotational laxity, and varus laxity at 30° and 90° of knee flexion. Clinical outcomes included the side-to-side difference in posterior tibial translation during postoperative stress radiographs, risk of a major complication, and the following postoperative patient-reported outcome measures: Lysholm, Tegner, and International Knee Documentation Committee (IKDC) subjective and objective scores. A random-effects model was used to compare pooled clinical and biomechanical outcomes between the cohorts. Results: Fifteen biomechanical studies and 13 clinical studies were included in this meta-analysis. The DB group demonstrated significantly less posterior tibial translation at 30° and 90° of knee flexion (P < .00001). Additionally, the DB group demonstrated significantly less external rotation laxity at 90° of knee flexion (P = .0002) but not at 30° of knee flexion (P = .33). There was no difference in varus laxity between the groups at 30° (P = .56) or 90° (P = .24) of knee flexion. There was significantly less translation on stress radiographs in the DB group (P = .02). Clinically, there was no significant difference between the groups for the Lysholm score (P = .95), Tegner score (P = .14), or risk of a major complication (P = .93). DB PCL reconstruction led to significantly higher odds of achieving “normal” or “near normal” objective IKDC outcomes for the included prospective studies (P = .04) and higher subjective IKDC scores (P = .01). Conclusion: DB PCL reconstruction leads to superior biomechanical outcomes and clinical outcomes relative to SB PCL reconstruction. Re-creating native anatomy during PCL reconstruction maximizes biomechanical stability and clinical outcomes.

Double-bundle versus single-bundle anterior cruciate ligament reconstruction in preventing the progression of osteoarthritis: A protocol for systematic review and meta-analysis of randomized controlled trials.

The knee has a high incidence of osteoarthritis (OA) following the anterior cruciate ligament (ACL) injury, which was reduced by ACL reconstruction including double-bundle (DB) techniques and single-bundle (SB) techniques. However, the effectiveness of preventing the progression of OA after the ACL reconstruction using DB and SB techniques is controversial. This meta-analysis was performed following the preferred reporting items for systematic reviews and meta-analyses guidelines. The databases, including PubMed, Embase, and Cochrane Library, were searched. Randomized controlled trials comparing DB with SB ACL reconstruction and reporting clinical outcomes of radiological OA were included. Quality of the included studies was assessed using the Cochrane Collaboration's risk of bias tool. The outcome was analyzed using the risk ratio (RR) and its corresponding 95% confidence interval (CI). Ten Randomized controlled trials studies were included in this meta-analysis (accounting 1062 knees: 475 SB and 587 DB). The rate of radiological OA after the ACL reconstruction was 39% in SB group and 34% in DB group. The results of meta-analysis showed no difference in the occurrence of radiological OA between DB group and in SB group (RR, 1.05; 95% CI, 0.85-1.30, P = .63), including subgroup of radiological scores of OA (subgroup of Minimal OA: RR, 0.95; 95% CI, 0.61-1.48; P = .82; subgroup of Notable OA: RR, 1.16; 95% CI, 0.75-1.78; P = .51), subgroup of follow-up time in 5 years and more than 5 years (RR, 0.98; 95% CI, 0.80-1.20; P = .85), and subgroup of autograft graft for ACL (RR, 0.97; 95% CI, 0.79-1.19; P = .77). However, the DB group had less incidences of knee OA than the SB group in subgroup of less than 5 years (RR, 1.48; 95% CI, 1.13-1.92; P = .004) and subgroup of allograft type (RR, 1.42; 95% CI, 1.06-1.91; P = .02). Overall, this meta-analysis showed that the DB technique was no more effective in preventing the progression of OA than the SB technique in ACL reconstruction at midterm follow-up.

Double-bundle ACL reconstruction versus anatomic single-bundle ACL reconstruction combined with anterolateral ligament reconstruction: a comparative study of clinical outcome.

Recent studies showed increasing evidences of anterolateral ligament (ALL) reconstruction in conjunction with anterior cruciate ligament (ACL) reconstruction that proves to be more superior to the previous double-bundle (DB) ACLR technique especially in improving knee stability in biomechanic studies. However to date, there have been no studies evaluating the functional outcome of DB-ACLR vs single-bundle (SB) with ALL in ACLR. A total of 138 patients with ACL deficient knee were enrolled to the study. Double-bundle ACL reconstruction (DB-ACLR) was performed in 75 patients and single-bundle ACL reconstruction with anterolateral ligament reconstruction (SB + ALL) ACLR was performed in 63 patients. Surgical outcomes were compared with The International Knee Documentation Committee Subjective Knee Form (IKDC) and the Kujala score at the 3rd, 6th and 9th month post-operative. The IKDC score in the 3rd and 6th month was superior in the SB + ALL group compared to the DB group. However, this difference was not statistically significant. In the meantime, there were no statistically significant difference between the Kujala Score at the 3rd, 6th, and 9thmonths consecutively. There were no statistically significant differences in the functional outcomes of DB-ACLR and SB + ALL groups at the 3rd, 6th, and 9thmonths post-operative period. The functional outcome comparison showed non-superiority of SB + ALL group compared to the DB-ACLR group. The patellar pain was less found in DB-ACLR group at 6- and 9-months post-operative period.

Functional evaluation of the double-bundle vs single-bundle anterior cruciate ligament ligamentoplasty. Prospective com-parative study.

Background: The anatomical reconstruction of the anterior cruciate ligament is of great interest because its function is directly related to its anatomy. The aim of the study was to compare dou-ble-bundle with single-bundle ligamentoplasty of the anterior cruciate ligament using a biome-chanical analysis of gait and balance. Methods: Prospective comparative experimental clinical study on 64 people, 27 health subjects and 37 patients with anterior cruciate ligament injury. 19 injured subjects were assigned to single-bundle and 18 to double-bundle technique. Gait biomechanical analysis in all individuals were performed by means of four test and injured subjects ones were repeated at 3, 6 and 12 months after surgery: 1) kinematic test, to characterize gait pattern; 2) kinetic test, to characterize forces against floor, du-ration of treads, symmetry of both legs, and the reproducibility of the gait; 3) pivot-shift gait test, to analyze the rotational stability of the knee in the sagittal axis; and 4) equilibrium test. Results: The two surgical techniques achieved an improvement of the functional alteration (gait pattern, changes in the forces against floor, duration of treads, symmetry of both legs, and the re-producibility of the gait, and changes in bipedal standing equilibrium), with little differences be-tween the two techniques, with neither being superior to the other. Conclusion: Reconstruction of the anterior cruciate ligament with the double-bundle technique offered very similar improvement in functional recovery than the single-bundle technique. At 12-months after surgery, double-bundle technique did not result in better rotational stability of the knee.

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Is Not Superior to Anatomic Single-Bundle Reconstruction at 10-Year Follow-up: A Randomized Clinical Trial

Background: The anatomic double-bundle (DB) technique is purported to be a superior technique due to its mimicking of the double-stranded anatomic formation of the anterior cruciate ligament (ACL). Previous studies with 2-, 5- and 10-year follow-up are conflicted as to whether this technique is superior to the previous gold standard method of ACL reconstruction, the anatomic single-bundle (SB) reconstruction. Purpose/Hypothesis: The aim of this prospective randomized study was to compare the outcomes of the anatomic DB technique and anatomic SB technique with independent drilling at 10 years after anterior cruciate ligament (ACL) reconstruction. We hypothesized that DB ACL reconstruction would result in a better outcome in terms of the pivot-shift test. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 105 patients (33 women, 72 men; median age, 27 years [range, 18-52 years]) were randomized and underwent ACL reconstruction (DB group: n = 53; SB group: n = 52). All reconstruction procedures were performed anatomically by identifying the ACL footprint, using the anteromedial portal for femoral tunnel drilling, and utilizing interference screws for tibial and femoral fixation. One blinded observer examined the patients both preoperatively and at follow-up (median, 120 months [range, 112-134 months]). Multiple subjective and objective clinical evaluations were used to assess the outcomes. Radiographic assessments of osteoarthritis were performed using the Ahlbäck, Kellgren-Lawrence, and Fairbank classification systems early postoperatively and at the final follow-up. Results: Preoperatively, no differences were found between the study groups. Overall, 70 patients (67%; DB group: n = 39; SB group: n = 31) were available for analysis at 10-year follow-up. No significant difference could be shown between the groups in terms of the pivot-shift grade, knee laxity measurements using the KT-1000 arthrometer, manual Lachman grade, single-leg hop test result, range of motion measurements, Lysholm knee score, Tegner activity score, and Knee injury and Osteoarthritis Outcome Score (KOOS) score. Correspondingly, no differences were found between the groups regarding the presence of radiographic osteoarthritis at follow-up. Both groups improved at follow-up compared with preoperatively in terms of the pivot-shift grade, knee laxity measurements using the KT-1000 arthrometer, manual Lachman grade, Lysholm knee score, and KOOS score (P < .05 [highest P value for any comparison]). Conclusion: The anatomic DB technique was not superior to the anatomic SB technique with independent drilling at 10-year follow-up in regard to objective and subjective measurements. As such, one could argue that there is no need for the continued use of the anatomic DB technique in an unselected population.

The proximal posterior cartilage of the lateral femoral condyle can be used as a reference for positioning the femoral tunnel in ACL reconstruction.

To describe the femoral insertion of the ACL using the posterior proximal cartilage of the lateral femoral condyle as the anatomical reference. Twenty knees were dissected. The X-axis (deep-shallow) and Y-axis (high-low) were determined using the femoral diaphysis and the proximal cartilage of the lateral femoral condyle (point C) as a reference, which were easily identified by direct visualization through the anteromedial portal. The distances to the center of the anteromedial and posterolateral bands and to the center of the ACL were measured. The mean distances were 7.2mm (SD: 0.7) between the center of the anteromedial bundle and the Y-axis (AM-Y), 9mm (SD: 1.1) between the center of the ACL and the Y-axis (M-Y), and 12.7mm (SD: 0.9) between the center of the posterolateral bundle and the Y-axis (PL-Y). Regarding the distance (from point C to the distal cartilage along the X-axis), the center of the anteromedial bundle (AM) was 35% (SD: 4.9%), the center of the posterolateral bundle was 62% (SD: 3.7%), and the center of the ACL (M) was 44% (SD: 7%) of the CD distance on average. Given the similarity among the specimens in terms of the height of the ACL on the Y-axis in relation to the proximal posterior cartilage of the femoral lateral condyle (point C), this point can be used as an arthroscopic intraoperative parameter to define the position of the femoral tunnel in ACL reconstruction for single- or double-bundle techniques.

Arthroscopic-Assisted Double-Bundle Coracoclavicular Ligament Reconstruction Using Cortical Fixation Buttons With Suture Tape Provides Superior Vertical Stability Than the Single-Bundle Reconstruction for Acute Acromioclavicular Joint Dislocation

This study aimed to compare clinical and radiologic outcomes between single- and double-bundle arthroscopic-assisted coracoclavicular (CC) ligament reconstruction using cortical fixation buttons with suture tapes for acute acromioclavicular (AC) joint dislocation. Patients who underwent arthroscopic-assisted CC ligament reconstruction using cortical fixation buttons with suture tapes for acute AC joint dislocation from July 2014 to March 2019 were identified. This study included patients treated for acute AC joint dislocation within 2 weeks after an injury, with a Rockwood classification of III or V and at least 2 years of follow-up. Patients were divided into 2 groups based on the reconstruction technique: group I (single-bundle technique) and group II (double-bundle technique). The clinical outcomes were compared using the American Shoulder Elbow Surgeons (ASES) score, Constant score, and visual analog scale for pain score between the 2 groups. On the plain radiograph, the CC interval ratio (CCIR) was measured to evaluate maintenance of CC interval fixation. Postoperative complications, including reduction failure, were also documented. Fifty-eight patients (26 in group I, 32 in group II) were enrolled. There were no significant differences in CCIR between the 2 groups preoperatively and 3 months postoperatively. However, the CCIR of group I was significantly greater than that of group II 6 months postoperatively (group I: 160.5% ± 48.5%, group II: 125.4% ± 38.9% at 6 months postoperatively, P= .01; group I: 164.0% ± 57.3%, group II: 123.2% ± 35.9% at the last visit, P= .01). Despite radiologic differences, the clinical outcomes demonstrated no significant differences between 2 the groups (ASES score: 93.5 ± 5.2 in group I, 94.4 ± 4.5 in group II, P= .54; Constant score: 92.9 ± 5.3 in group I, 94.8 ± 4.3 in group II, P= .16). Reduction failure occurred in 4 patients (15.3%) in group I and in 1 patient (3.2%) in group II (P= .16). Arthroscopic-assisted double-bundle CC ligament reconstruction using cortical fixation buttons with suture tapes provided superior vertical stability than the single-bundle technique. Level III, retrospective comparative study.

Rotational Stability of the Knee in a Comparative Study of Anterior Cruciate Ligament Reconstruction Using the Double-Bundle and Single-Bundle Techniques.

The purpsose of this study was to evaluate the biomechanical outcomes of patients who underwent ACL reconstruction either with the DB or SB technique. We hypothesized that the DB technique would provide better rotation control of the knee following ACL reconstruction. The study included seventy-five participants (26 DB, 22 SB, and 27 healthy volunteers). Only cases with at least one year of postoperative follow-up were included. The participants performed three different demand tasks: walk task, walk and change direction, and stair descent and change direction, which was tracked using a three-dimensional 4-camera optoelectronic system. The following kinematic data were analyzed: tibial rotation amplitude and maximal internal and external rotation. Knees with ACL reconstruction were compared to contralateral knees with intact ACL and healthy knees. Clinical outcomes were determined using the subjective and objective International Knee Documentation Committee (IKDC) questionnaire and a manual arthrometer (KT 1000). Both surgical groups exhibited similar clinical outcomes (mean subjective IKDC 91 SB vs. 90 DB, P=0.815; KT 1000 difference: 2mm in both groups, P=0.772). The vertical component of the ground force reaction revealed no differences between the surgical and control groups (P>0.05). Tibial rotation amplitude and maximal internal and external rotation were similar between the control, SB, and DB groups in all three different demand tasks (P>0.05). ACL reconstruction using either the SB or DB technique can restore rotational control to the level of a healthy knee. No clinical or functional differences were found between the SB and DB surgical options.