Double-bundle Technique Research Articles

Arthroscopic combined medial and lateral meniscus transplantation after double-tunnel, double-bundle anterior cruciate ligament reconstruction in the same knee

Meniscus transplantation in combination with anterior cruciate ligament (ACL) reconstruction has been used in the treatment of patients with meniscus and ACL deficiency. However, there have been no reports of arthroscopic surgery and the outcome of both medial and lateral meniscus allograft transplantation after double-tunnel, double-bundle ACL reconstruction. Herein, we report the case of a young male who received arthroscopic lateral and medial meniscectomy and ACL tibialis allograft reconstruction performed with the double-tunnel and double-bundle technique approximately 8months after a knee injury. Approximately 4months postoperatively he began to experience pain and weakness in the operated knee and subsequently underwent arthroscopic lateral and medial meniscus allograft transplantation in the same procedure. Second-look arthroscopy and magnetic resonance imaging revealed the meniscal allografts to have normal shape and the ACL grafts to be relatively intact at 18 and 30months after surgery. His knee appeared stable and the range of motion was normal. Our hypothesis was that knee stability could reliably be restored with this combined procedure and the meniscal grafts and ACL graft could provide protection for each other. We suggest that medial and lateral meniscus allografts for one patient should be from the same donor. In the operation, attention must be paid to the direction of the bone tunnels used to fix the horns of the meniscal grafts to avoid communication with other tunnels in the tibial plateau.

Dynamic functional performance and kinematic analysis of the rotational patterns of single- versus double-bundle anterior cruciate ligament reconstruction

BackgroundThe evaluation of anterior cruciate ligament (ACL) reconstruction has typically focused on the restoration of rotatory stability. Some studies have compared single-bundle and double-bundle ACL reconstruction using subjective clinical tests and questionnaires, but these studies only provide limited data on rotational stability. The purpose of this study is to determine the rotational patterns that present during high-demand pivoting tasks and to evaluate any difference in kinematic rotational patterns between patients who have undergone single- or double-bundle ACL reconstruction. Materials and MethodsTwenty-four males were divided into four groups for this study: intact, ACL deficient, single-bundle reconstructed, and double-bundle reconstructed. Kinematic data were collected using a 10-camera optoelectronic motion analysis system while the participants performed high-demand landing and pivoting tasks. The evaluation period was defined as the time from when the tested foot made contact with the ground to takeoff, and the range of tibial rotation was measured. ResultsRotation was significantly reduced in the single-bundle ACL reconstructed knees (7.8° ± 3.4°) and double-bundle ACL reconstructed knees (7.5° ± 2.6°) in comparison with ACL-deficient knees (13.5° ± 3.7°; p < 0.05). There was no significant difference in terms of tibial rotation between the intact knees (6.5° ± 3.5°) and the single-bundle or double-bundle ACL reconstructed knees after >2 years of follow up (p > 0.05). ConclusionBy using a dynamic functional biomechanical assessment, we demonstrate that the single-bundle ACL reconstruction technique using a composite hamstring tendon graft and the double-bundle ACL reconstruction technique can adequately restore excessive tibial rotation during high-demand activities such as landing and pivoting.

Comparison of tunnel placements and clinical results of single-bundle anterior cruciate ligament reconstruction before and after starting the use of double-bundle technique

To investigate whether the locations of the grafts in single-bundle (SB) anterior cruciate ligament (ACL) reconstruction have changed to more anatomical as the double-bundle (DB) method has become more familiar. Operation using anteromedial (not transtibial) portal and freehand technique [Group A (N=25) in 2003, Group B (N=25) in 2007]. The evaluation methods preoperatively and at the 2-year follow-up (two blinded examiners): clinical examination, stability measurement (KT-1000 arthrometer), the International Knee Documentation Committee (IKDC), and the Lysholm knee scores. A musculoskeletal radiologist made tunnel measurements from the magnetic resonance imaging (MRI). The average tunnel placement in the femoral side: from Blumensaat's line 27% (Group A) and 26% (Group B), from the posterior edge of the femur 32% (Group A) and 29% (Group B). The average tunnel placement in the tibial side: from the anterior edge 45% (Group A) and 45% (Group B), from the lateral side 57% (Group A) and 54% (Group B) (P=0.024). Graft failures ending up to revision ACL surgery: 4 (Group A) and 0 (Group B) (P=0.045). Operation time reduced 19min (P=0.001). Tunnel placement at the femoral side was already very low (anatomical) in patients operated in 2003. No significant difference was found when comparing to the patients operated in 2007. There were significantly more graft failures in the Group A, suggesting that the use of the DB method in ACL surgery in 2007 may have also improved the technique and results of the SB ACL reconstruction. Prospective comparative study, Level II.

There is significant load sharing and physical interaction between the anteromedial and posterolateral bundles of the ovine ACL under anterior tibial loads

IntroductionThe ovine stifle joint is an ideal preclinical model to test the ability of double-bundle reconstruction techniques in providing superior joint stability and less osteoarthritis (OA) compared with single-bundle techniques. However, knowledge of the normal ovine ACL and more specifically the load sharing and physical interaction between the two main bundles of the ovine ACL is currently limited. MethodsSix ovine stifle joints were tested using a robotic testing system. Each joint was cyclically loaded to 200N in the anterior tibial direction between 30° and 90° flexion and the force-displacement data were recorded for both the intact ACL, and when the anteromedial (AM, n=3) or the posterolateral bundle (PL, n=3) was transected. ResultsThe load shared by the AM bundle increased from 30° to 75° of flexion at all loading levels (25–200N); whereas, the load shared by the PL bundle decreased between full extension and mid flexion (60°) and then increased again. The load borne by the AM bundle did not change in response to increasing Anterior Tibial Loads (ATL) at each flexion angle, in contrast to the PL bundle (P=0.004). Physical interaction between bundles was greatest at 60° and under 50N ATL. ConclusionThese data will help create double-bundle ACL reconstructions in sheep which are functionally similar to intact native ACL. In turn, this model can be used to examine the success of anatomically accurate double-bundle reconstructions to prevent the development of OA. Level of evidence: III.

Individualized Anatomic Anterior Cruciate Ligament Reconstruction

Arthroscopic anterior cruciate ligament reconstruction (ACL-R) is a technique that continues to evolve. Good results have been established with respect to reducing anteroposterior laxity. However, these results have come into question because nonanatomic techniques have been ineffective at restoring knee kinematics and raised concerns that abnormal kinematics may impact long-term knee health. Anatomic ACL-R attempts to closely reproduce the patient's individual anatomic characteristics. Measurements of the patient's anatomy help determine graft choice and whether anatomic reconstruction should be performed with a single- or double-bundle technique. The bony landmarks and insertions of the anterior cruciate ligament (ACL) are preserved to assist with anatomic placement of both tibial and femoral tunnels. An anatomic single- or double-bundle reconstruction is performed with a goal of reproducing the characteristics of the native ACL. Long-term outcomes for anatomic ACL reconstruction are unknown. By individualizing ACL-R, we strive to reproduce the patient's native anatomy and restore knee kinematics to improve patient outcomes.

Sagittal and rotational knee stability following single- and double-bundle reconstruction of the anterior cruciate ligament: a randomized clinical trial

Propose The aim of this study was to compare the sagittal and rotational stability of anterior cruciate ligament (ACL) reconstructions with anatomic double-bundle and single-bundle techniques.

Single Compared to Double-Bundle PCL Reconstruction Using Allograft Tissue

This study compares the results of arthroscopic transtibial tunnel single-bundle and double-bundle posterior cruciate ligament (PCL) reconstructions using allograft tissue in PCL-based multiple ligament injured knees. Ninety consecutive PCL reconstructions are evaluated: 45 single-bundle and 45 double-bundle reconstructions. All PCL reconstructions were performed using the arthroscopically assisted transtibial tunnel PCL reconstruction technique using fresh frozen allograft tissue from the same tissue bank. Achilles tendon allograft was used for the anterolateral bundle; tibialis anterior allograft was used for the posteromedial bundle. The knees were evaluated postoperatively, comparing the single-bundle results to the double-bundle results, with KT-1000 arthrometer (Medmetric Corporation, San Diego, CA) testing, three different knee ligament rating scales, and Telos stress radiography (Austin Associates, Fallston, MD). Both the single-bundle and the double-bundle PCL reconstruction surgical techniques using allograft tissue provide successful results in the PCL-based multiple ligament injured knee when evaluated with stress radiography, arthrometer measurements, and knee ligament rating scales.

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.

All-Arthroscopic Double-Bundle Coracoclavicular Ligament Reconstruction Using Autogenous Semitendinosus Graft: A New Technique

We present our novel arthroscopic anatomic double-bundle coracoclavicular ligament reconstruction technique using a semitendinosus tendon autograft. The dorsal limb of the graft is positioned around the dorsal edge of the clavicle, re-creating the conoid ligament. The anterior limb proceeds superiorly and re-creates the trapezoid ligament. The solution effectively stabilizes the acromioclavicular joint and prevents anterior posterior translation. This new arthroscopic double-bundle coracoclavicular joint reconstruction is an effective and reliable method in stabilizing the clavicle and neutralizing the anterior-posterior translation, and we find it to be technically practical for the surgeon.

A new technique in double-bundle anterior cruciate ligament reconstruction using implant-free femoral fixation

The study is a prospective case-series analysis to demonstrate a new double bundle technique for anterior cruciate ligament (ACL) reconstruction with the use of hamstring tendons through a single tibial tunnel, a double femoral socket with implant-free femoral fixation and interference screw for tibial fixation. Twenty-one patients were treated with the same technique. Hamstring tendons were not removed from the tibial side, and using a single tibial and a double femoral tunnel of 8 and 6mm, respectively, anatomic ACL reconstruction was performed. Graft passage was performed from the tibial side to the posterolateral femoral tunnel and was looped back to the anteromedial femoral tunnel to be fixed on the tibial tunnel with an interference screw and additional extracortical fixation. Follow-up of the study group was performed for a two-year period, documenting standard clinical and radiographic parameters. Post-operative follow-up (mean 24months) revealed radiological widening of tibial tunnel (mean 133.6%) in all patients and minor femoral tunnels widening (119.4% and 117.5%). Clinical evaluation showed no signs of instability, and knee evaluation using the IKDC score was performed. The manuscript describes a novel technique in ACL reconstruction, and reports the radiographic results of tunnel widening and clinical scores. Implant-free femoral fixation led to minor tunnel widening similar to previously published data. Further studies need to be performed to compare the long-term results with different published techniques of cost-effective implant-free ACL reconstruction.

Clinical outcomes of double‐ vs single‐bundle anterior cruciate ligament reconstruction: A systematic review of randomized control trials

Clinical outcomes of anterior cruciate ligament (ACL) reconstruction with double-bundle and single-bundle techniques are still controversial. We therefore performed a systematic review to compare postoperative outcomes between the two techniques. Randomized control trials comparing the outcomes between the two techniques were identified from Medline and EMBASE since inception to April 27, 2011. Data were independently extracted by two reviewers. Thirteen of 318 studies were eligible; 9, 11, 7, and 8 studies were pooled for rotation, translation, function, and complication outcomes, respectively. The double-bundle technique was approximately four times (95% CI: 2.65, 11.99) and two times (95% CI: 1.16, 5.21) more likely to show a normal pivot shift and normal International Knee Documentation Committee (IKDC) grading compared with the single-bundle technique. However, there were nonsignificant differences in KT grading (OR = 1.66, 95% CI: 0.77, 3.82), IKDC score (0.29, 95% CI: -1.17, 1.75), Lysholm knee score (-0.87, 95% CI: -2.66, 0.93), Tegner activity score (0.37, 95% CI: -0.05, 0.79), and complications (OR = 1.11, 95% CI: 0.48, 2.57). Heterogeneity was present in some outcomes but there was no evidence of publication bias for any outcome. The double-bundle may be better than the single-bundle ACL reconstruction technique in rotational stability but not for function, translation, and complications.

Double-Bundle Posterior Cruciate Ligament Reconstruction Technique with Use of Endoscopic Femoral Graft Placement

As the varied results seen after posterior cruciate ligament (PCL) reconstructions might be due to surgical techniques that fail to reconstruct both functional bundles of the PCL and that injure the vastus medialis obliquus muscle, we developed a technique to address these problems and thus improve patient outcomes. Assess range of motion and patellofemoral stability; perform stress tests, Lachman and pseudo-Lachman tests, pivot shift test, drawer tests, reverse pivot shift test, and dial test. Preserve any remnants of PCL at anterolateral and posteromedial bundle attachment sites to promote vascular healing. Guidepin enters tibia at, roughly, 45° angle and 6 cm distal to joint line, midway between anterior tibial crest and posteromedial tibial border. Use Achilles tendon allograft for anterolateral bundle and semitendinosus or tibialis anterior allograft for posteromedial bundle. Guidepin position should be slightly lateral to midline between apices of medial and lateral tibial eminences on anteroposterior radiograph and approximately 7 mm proximal to "champagne-glass drop-off" on lateral radiograph. Tug hard on grafts through anterolateral arthroscopic portal to verify that they are secured within the femoral tunnel. Manage knee motion for first six weeks by prone knee flexion to counteract deleterious effects of gravity on reconstruction. In a cohort of thirty-nine total patients, thirty-three males and six females, with an average age of thirty-three years, seven isolated PCL reconstructions and thirty-two combined knee reconstructions were performed. IndicationsContraindicationsPitfalls & Challenges.

Prospective evaluation of patients with anterior cruciate ligament reconstruction using a patient-based health-related survey: comparison of single-bundle and anatomical double-bundle techniques

To compare the treatment outcomes of single-bundle and anatomical double-bundle anterior cruciate ligament (ACL) reconstructions, we used the patient-based health-related QOL questionnaire SF-36 to evaluate patients with ACL injury who underwent surgical reconstruction using the two techniques. A prospective study was performed on patients who were diagnosed with ACL injury and underwent ACL reconstruction. Eighty-four male patients who were followed for at least 2years were analyzed in this study. Forty-four patients were operated by single-bundle technique, and 40 by double-bundle technique. SF-36, Lysholm score, anterior tibial translation, and pivot shift were assessed before surgery and 6, 12 and 24months after surgery. In the preoperative SF-36 survey, the scores of almost all the subscales were lower than the national standard scores in both groups. After operation, the scores of all the subscales improved to the national standard values in all patients, but no difference was observed between two groups. Lysholm score, distance of anterior tibial translation and pivot shift positive rate improved significantly after operation in all patients, but there were no significant differences between two groups. Although good clinical results have been reported for double-bundle ACL reconstruction, some studies reported no clear difference compared to the conventional single-bundle technique. In the present study, significant improvements were achieved after operation in both groups, confirming the usefulness of both techniques. No clear merit of one method over the other was found, not only from the conventional objective assessments but also from the patient-based subjective evaluation.

Double-bundle versus single-bundle anterior cruciate ligament reconstruction—Is the double bundle technique really better?

Background: The traditional surgical treatment for ACL rupture is single-bundle reconstruction. Over the past few years there has however been a shift in interest toward double-bundle reconstruction which more closely restores the native ACL anatomy. This study examined the clinical outcomes of single-bundle (SB) and double-bundle (DB) ACL reconstruction procedures.

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

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

Mechanical stability of the femoral fixation for single‐ and double‐bundle ACL reconstruction in an in vitro experimental model

Anterior cruciate ligament ACL reconstruction using the double-bundle (DB) technique is gaining popularity. A possible weak link in the DB technique could be that two tendon grafts of smaller diameters are used. The purpose of this study was to test different femoral fixation methods and graft diameters representing single-bundle (SB) and DB ACL reconstructions and compare their biomechanical properties. We hypothesized that SB 6-mm graft constructs had inferior biomechanical properties than SB 9-mm grafts or DB 2 × 6-mm grafts. Furthermore, we hypothesized that interference (IF) screw fixation would demonstrate less elongation and a higher stiffness than Endobutton (Smith & Nephew®, Inc., Andover, Massachusetts, USA) fixation (EBF). We performed an in vitro study using porcine knees and extensor tendons. The mechanical test consisted of a cyclic test followed by a load-to-failure test. We found that 6-mm graft constructs had an ultimate failure load that was up to 40% less than both the 9-mm and 2 × 6-mm graft constructs, despite the fixation method (P-values ≥ 0.004). Comparing fixation methods, EBF was superior to IF concerning maximum load to failure (P < 0.001); IF resulted in a higher stiffness of the femur/graft complex than the EBF (P < 0.001) but no significant difference in elongation between fixation methods. Since the two graft strands are subjected to different loads in different knee flexion angles, the reduced strength of the individual graft strands in DB ACL reconstruction could be a concern.

Paper # 260: Winner of the Albert Trillat Young Investigators Award Double Bundle versus Single Bundle Anterior Cruciate Reconstruction – Is the Double Bundle Technique Really Better?

Paper # 260: Winner of the Albert Trillat Young Investigators Award Double Bundle versus Single Bundle Anterior Cruciate Reconstruction – Is the Double Bundle Technique Really Better?

Paper # 130: Should All Patients Receive a Double Bundle ACL Reconstruction? A Prospective Comparison of Double versus Single Bundle Techniques in Indian Patients

Paper # 130: Should All Patients Receive a Double Bundle ACL Reconstruction? A Prospective Comparison of Double versus Single Bundle Techniques in Indian Patients

Volumetric Injury of the Distal Femoral Physis During Double-Bundle ACL Reconstruction in Children

Double-bundle anterior cruciate ligament (ACL) reconstruction was developed to produce a more "anatomic" reproduction of the anteromedial and posterolateral bundles of the ACL. The purpose of this study was to determine the volume of injury to the physis during double-bundle ACL reconstruction in children with open physes. Magnetic resonance images (MRIs) of ten knees of children were converted into three-dimensional models. Computer-aided design/computer-aided manufacturing software placed drill-holes of 6, 7, 8, and 9 mm in diameter in these models, simulating tunnels in the femur used for anatomic double-bundle ACL reconstruction. Computer-aided design/computer-aided manufacturing software was used to calculate the total physeal volume and the volume of physis that was removed by creation of the tunnels. The ratio of the physeal volume that had been removed to the total physeal volume was subsequently determined. With use of 6, 7, 8, and 9-mm-diameter drill-holes in the femur, the average physeal volume removed, as a percentage of the total physeal volume, was 1.5%, 2.0%, 2.5%, and 2.9%, respectively, for the anteromedial tunnels; 2.2%, 2.9%, 3.6%, and 4.2% for the posterolateral tunnels; and 3.7%, 4.8%, 5.7%, and 6.5% for the anteromedial and posterolateral tunnels combined. The volume of physeal damage caused by the posterolateral drill-holes was greater than that produced by the anteromedial drill-holes in all subjects. Drill-hole placement during ACL reconstruction produces a zone of physeal injury. Double-bundle techniques substantially increase the volume of injury to the physis, which appears to increase the risk of abnormal growth in the distal femoral physis following this surgical procedure.

In Vitro and Intraoperative Laxities After Single-Bundle and Double-Bundle Anterior Cruciate Ligament Reconstructions

The purpose of this study was to objectively evaluate whether double-bundle anterior cruciate ligament (ACL) reconstruction can better restore the normal translational and rotational laxities than the conventional single-bundle ACL reconstruction among the reported biomechanical studies. A systematic literature search was conducted to identify in vitro and in vivo (intraoperative) biomechanical studies that compared the laxities (anterior or anteroposterior or rotational) between single- and double-bundle ACL reconstructions. Because of large variability among the loading conditions and testing methods used to determine the rotational laxities among the studies, a meta-analysis of rotational laxities was not feasible. Seven in vitro and three in vivo studies were included in this analysis based on the predefined inclusion criteria. The overall mean differences calculated by the random effects model in anteroposterior laxity between the single-bundle and double-bundle ACL reconstruction techniques at 0°, 30°, 60°, and 90° of flexion were 0.99 mm, 0.38 mm, 0.34 mm, and 0.07 mm, respectively. No statistically significant difference was noted between the 2 treatments at all flexion angles. Among the 9 studies that compared the rotational laxity of single-bundle and double-bundle ACL reconstructions, 4 reported that double-bundle reconstruction can provide better rotational control than single-bundle reconstruction. The other 5 studies could not identify any significant difference between the 2 reconstructions in terms of rotational laxity. Both single- and double-bundle treatment options for ACL injury result in similar anteroposterior knee joint laxity at time 0. No conclusive evidence on the superiority of 1 reconstruction technique over the other in terms of rotation laxity can be obtained because of several variations in the experimental protocol and the kinematics used to measure the rotational laxity among the studies. Level III, meta-analysis.