Double Bundle Research Articles

To evaluate the accuracy of the femoral tunnel length measurements for acl reconstruction using the endobutton indicator selection device from outside the knee joint and the Transportal endobutton depth probe

Purpose: To evaluate the accuracy of femoral length measurements for ACL reconstruction using the endobutton indicator selection device from outside the knee joint and the transportal endobutton depth gauge. Methods: 50 cases of primary ACL injuries, both single bundle and double bundle reconstructions were evaluated for their intra operative femoral tunnel lengths by using the Endobuttton indicator selection device from outside the knee joint and the transportal Endobuttton depth gauge and were compared with the post-operative CT femoral tunnel lengths obtained using the Osiri X imaging software. Results: The mean femoral tunnel lengths measured intraoperatively using the Endobutton selection device (35.68­±3.99mm for anteromedial tunnel [AM],) significantly longer than the measurements obtained using the Endobutton depth probe. However, there was no statistically significant difference in the posterolateral tunnel [PL] measurements [37.17±3.83mm for Endobutton selection device and 37.22±3.74 for Endobutton depth probe]. Also the measurements obtained using Endobutton depth probe were closer to the CT measurements and better correlation with the longer CT tunnel wall measurements. Conclusion: Measurements by both the Endobutton depth probe and the Endobutton selection device are longer than the actual femoral tunnel length for ACL reconstruction. Even though the difference between the mean measurements obtained by the two devices is statistically significant but the actual difference is so minimal that it barely has any effect in the decision making for the selection of the fixed loop device the graft length in ACL reconstruction. Thereby we suggest that the Endobutton Indicator Device is an easy to use and more convenient alternative to the Endobutton depth probe for measuring the femoral tunnel length in ACL reconstruction.

Midterm clinical and functional outcomes after isolated double bundle anatomic MPFL reconstruction in patients with patellofemoral instability

The purpose of this study was to demonstrate midterm outcomes after isolated double bundle anatomic MPFL reconstruction in a young patient cohort. Between 2014 and 2016; 24 knee joints of 23 patients were operated and evaluated in our retrospective study. The time and duration of the patients' complaints, preoperative and postoperative knee range of motion, extent of patellofemoral pain and episodes of lateral patellofemoral instability were evaluated. Functional outcomes were evaluated with Kujala, IKDC, KOOS-QoL and Tegner activity scores. Patellar height was analysed radiographically using the Caton–Deschamps index. Patients were also asked if they were satisfied with the operation. The mean age of the patients during index surgery was 16.7 ± 8.4 years. 87 % of our patients was satisfied with the surgery. The average Kujala score increased from 72 to 96 (p

Revision Anterior Cruciate Ligament Reconstruction After Primary Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction: A Case Series of 40 Patients

To evaluate the surgical methods according to the status of tunnels at the time of revision anterior cruciate ligament reconstruction (ACLR) and to evaluate clinical outcomes of revision ACLR in patients who underwent primary ACLR with the anatomic 4-tunnel double-bundle (DB) technique. A total of 487 patients who underwent primary anatomic DB ACLR from April 2010 to July 2016 were retrospectively reviewed, and among those knees, the patients who underwent revision ACLR were included in the study. The patients with concomitant posterior cruciate ligament injuries were excluded. Forty patients (40 knees) were identified and enrolled. The surgical methods were reviewed. The range of motion, objective laxity using KT-2000, Lysholm score, Hospital for Special Surgery score, International Knee Documentation Committee subjective score, and Tegner score after revision ACLR were compared with those after primary ACLR in the same patient using paired t-test with Bonferroni correction. The timing of reinjury after primary ACLR and mean interval between primary and revision ACLR were 18months (range 1.5-80months) and 24months (range 4-82months), respectively. Among 40 patients, 38 patients (95%) underwent 1-stage revision with the DB technique using pre-existing tunnels without compromised positioning of the grafts, and the other 2 patients (5%) underwent 2-stage revision. The postrevision range of motion, KT-2000, Lysholm score, Hospital for Special Surgery score, International Knee Documentation Committee subjective score, and Tegner score were 137 ± 7°, 2.4 ± 1.2mm, 91.4 ± 5.8, 98.9 ± 2.2, 78.6 ± 11.5, and 5.5 ± 1.2, respectively, and did not show any differences from those after primary ACLR. In the revision setting after primary anatomic DB ACLR, most of the cases could be managed with 1-stage revision with DB technique using pre-existing tunnels, and the objective laxity and clinical scores after revision DB ACLR were comparable with those after primary DB ACLR. Case series, Level IV.

PCL Transtibial Tunnel Reconstruction.

The keys to successful posterior cruciate ligament (PCL) reconstruction are to identify and treat all pathology, use strong graft material, accurately place tunnels in anatomic insertion sites, minimize graft bending, mechanical graft tensioning, secure graft fixation, and the appropriate postoperative rehabilitation program. Adherence to these technical principles results in successful single and double bundle arthroscopic transtibial tunnel PCL reconstruction based upon stress radiography, arthrometer, knee ligament rating scales, and patient satisfaction measurements. The purpose of this article is to describe the arthroscopic transtibial tunnel PCL reconstruction surgical technique.

Anterior cruciate ligament reconstruction using a double bundle hamstring autograft configuration in patients under 30 years.

BACKGROUNDAnterior cruciate ligament reconstruction (ACLR) has a high incidence of re-tear in younger patients. Despite comparable functional outcomes, the incidence of re-tear using single and double bundle ACLR methods has not been well reported.AIMTo hypothesize that double bundle hamstring ACLR has a lower graft rupture rate compared with single bundle hamstring ACLR grafts in young patients.METHODSOne hundred and twelve patients < 30 years of age at the time of primary double bundle ACLR were eligible for study participation. 91 (81.3%) could be contacted, with a mean age of 20.4 years (range 13-29) and mean post-operative follow-up time of 59 mo (range 25-107). Telephone questionnaires evaluated the incidence (and timing) of subsequent re-tear and contralateral ACL tear, further surgeries, incidence and time to return to sport, and patient satisfaction.RESULTSOf the 91 patients, there were 6 (6.6%, 95%CI: 1.4-11.7) ACL graft re-ruptures, with a mean time to re-rupture of 28 mo (range 12-84). Fourteen patients (15.4%) experienced a contralateral ACL rupture and 14 patients (15.4%) required further surgery to their ipsilateral knee. fifty patients (54.9%) returned to pre-injury level of sport. Of those < 20 years (n = 45), 4 patients (8.9%, 95%CI: 0.4-17.3) experienced a re-rupture, with mean time to re-injury 15 mo (range 12-24). Comparative analysis with existing literature and revealed a non-significant Chi-squared statistic of 2.348 (P = 0.125).CONCLUSIONA trend existed toward lower graft rupture rates in young patients undergoing double bundle ACLR utilizing a hamstring autograft, compared with rates reported after single bundle ACLR.

Single and Double Bundle Arthroscopic Reconstruction of Anterior Cruciate Ligament (Review of Literature)

Researches performed in the past 20 years show the necessity of the restoration of anatomic position of anterior cruciate ligament as the main stabilizing structure of the joint in combination with the restoration of other injured elements and correction of deformities, which affect the outcomes of the treatment. Complexity of the restoration of anatomic position of torn anterior cruciate ligament is caused by its wide area of contact in combination with relatively small sectional area through the joint cavity. More detailed study of topographic anatomy of anterior cruciate ligament allowed the researchers to explain this phenomenon, which pushed them closer to the solution of the problem. Systemic anatomy of anterior cruciate ligament include two bundles - anteromedial bundle and posterolateral bundle. Double bundle plasty of anterior cruciate ligament restored anatomy to its nearly normal condition, but single bundle plasty is used much more often because of its simpler technique. However, the researchers still cannot reach a consensus in the choosing of single or double beam plasty at the restoration of anterior cruciate ligament.

Anteromedial Portal Double-Bundle Anterior Cruciate Ligament Reconstruction Yields Similar Outcomes to Non-AMP Femoral Drilling Double-Bundle Techniques: A Systematic Review of Comparative Studies.

Background:Biomechanical studies have shown double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) to have increased anterior and rotational stability as compared with single-bundle ACLR. Various techniques exist to drill the femoral tunnel, such as anteromedial portal (AMP), outside-in (OI), and transtibial (TT) drilling. However, it is unclear whether one drilling technique is superior to others when a DB graft is used.Purpose:To systematically assess the outcomes and complications in patients undergoing DB ACLR through an AMP technique as compared with other femoral drilling techniques.Study Design:Systematic review; Level of evidence, 3.Methods:PubMed, Medline, and EMBASE databases were searched in April 2018. Nonrandomized studies were assessed with the MINORS (Methodological Index for Nonrandomized Studies), whereas randomized studies were assessed with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.Results:Ten studies comprising 722 patients satisfied the inclusion criteria. A total of 351 patients underwent DB ACLR with AMP drilling (mean ± SD age, 32.7 ± 4.7 years); 318 patients had DB ACLR with OI drilling (age, 31.9 ± 4.1 years); and 53 received a DB ACLR with TT drilling (age, 26.5 ± 2.0 years). Graft types used included hamstring autograft (74.1%; n = 247), tibialis anterior autograft (6.0%; n = 20) and unspecified grafts (19.8%; n = 66). No significant difference in postoperative Tegner and Lysholm scores was found between the AMP and OI groups postoperatively. The AMP group had a lower anterior and posterior graft bending angle as compared with the OI group. Four patients (1.1%) in the AMP group had graft reruptures, as compared with 9 reruptures (2.8%) in the OI group. There were no reports of rerupture in the TT group.Conclusion:DB AMP ACLR results in significantly improved functional outcome scores postoperatively. AMP techniques yield similar functional outcomes to OI ACLR. No direct comparison in functional outcomes scores were available between the AMP and TT techniques. Low overall complication and revision rates were observed for patients undergoing DB AMP ACLR and were found to be similar to those of other femoral drilling techniques. Owing to a steeper graft bending angle in patients undergoing OI or TT ACLR relative to AMP ACLR, patients treated with OI or TT femoral drilling may have increased strain placed on the graft. Based on the various limitations in the available literature, it is not currently possible to make a definite conclusion of whether AMP is superior to non-AMP techniques in the setting of DB ACLR.

The calcaneofibular ligament has distinct anatomic morphological variants: an anatomical cadaveric study.

The purpose of this study was to investigate if the calcaneofibular ligament (CFL) presents morphologic variants and measure the morphometrics of the ligament and its footprints METHODS: An anatomical study of 47 fresh-frozen below-the-knee ankle specimens was performed. Lateral ankle structures were dissected to expose the CFL. Overdissection was avoided to not modify the native morphology. The morphology (number and orientation of CFL bundles) and measurements of CFL insertions were recorded with ankle secured in neutral position. Four distinct morphological-oriented shapes of the CFL were observed. These included single bundle, Y-shape double bundle, V-shape double bundle, and associated with the lateral talocalcaneal ligament. The most frequent CFL morphology observed was the single bundle and the Y-shape double bundle, present in 21 (44.7%) and 13 (27.7%) ankles. The V-shape double bundle and the CFL double bundle associated with the lateral talocalcaneal ligaments were less common, appearing only in eight (17.0%) and five (10.6%) ankles. The CFL length was higher in single bundle and Y-shaped double bundle CFL variants, about 30mm each. Footprint morphometrics were heterogenous amongst the different CFL variants. The CFL presents four distinct morphological-oriented shapes. The double bundle, V-shaped and Y-shaped CFL variants are uncommon and poorly reported in the literature. Their relation to the lateral talocalcaneal ligament and the inferior fascicle of the anterior talofibular ligament requires further research. The CFL morphology provides detailed knowledge of CFL anatomy that can improve diagnostic procedures. Furthermore, this information can fine-tune graft selection and sizing and allow a more precise anatomic placement during surgical reconstruction.

Impact of Surgical Timing on Clinical Outcomes in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Using Hamstring Tendon Autografts.

Background:To date, no studies have analyzed the influence on clinical outcomes of the interval between an anterior cruciate ligament (ACL) injury and double-bundle (DB) reconstruction with hamstring tendon autografts.Hypotheses:(1) Performing ACL reconstruction sooner after an injury will reduce postoperative anterior and rotatory knee instability, (2) postoperative range of knee motion or functional results will not be affected by different intervals between injury and surgery, and (3) preoperative isokinetic peak torque of the quadriceps and hamstring muscles will be lower in patients undergoing surgery earlier, while postoperative muscle strength will not be affected by surgery timing.Study Design:Cohort study; Level of evidence, 3.Methods:This study was conducted on a total of 171 patients who had undergone anatomic DB ACL reconstruction with hamstring tendon autografts. The patients were divided into 3 groups based on the time to surgery: (1) ≤1 month after the injury (group E; n = 25), (2) between 1 and 3 months after the injury (group M; n = 72), and (3) >3 months after the injury (group D; n = 74). Patients were assessed for a minimum of 2 years after surgery.Results:Concerning postoperative anterior laxity, 1-way analysis of variance demonstrated a significant difference (P = .0274) among the 3 groups. Anterior laxity was significantly less in group E than in group D (P = .0206). Spearman rank correlation analysis showed a significant correlation (ρ = 0.200; P = .0327) between anterior knee laxity and time to surgery. Also, a significant correlation (P = .0461) was found between the degree of the pivot-shift phenomenon and time to surgery. There were no significant differences in loss of knee extension or flexion among the 3 groups, nor were there any differences in the Lysholm knee score or International Knee Documentation Committee grade. Postoperatively, there were no significant differences in peak torque of the quadriceps or hamstring muscles among the 3 groups.Conclusion:Early DB reconstruction led to significantly less anterior laxity compared with delayed reconstruction. There were no significant differences in postoperative range of knee motion or functional results among the 3 time intervals between injury and surgery in this study.

Risk factors for residual anterolateral rotational instability after double bundle anterior cruciate ligament reconstruction: Evaluation by quantitative assessment of the pivot shift phenomenon using triaxial accelerometer

BackgroundExact knowledge of risk factors for residual anterolateral rotatinoal instability (ALRI) after anterior cruciate ligament (ACL) reconstruction is limited. The purpose of this study was to analyse possible risk factors for ALRI after ACL reconstruction. MethodsQuantitative assessment of the pivot shift phenomenon by measuring tibial acceleration was performed in 46 patients during primary double-bundle ACL reconstructions. The absolute value of the acceleration of the injured knee after provisional fixation of the ACL grafts (‘absolute residual acceleration’) and the subtraction of the acceleration of the uninjured knee from absolute residual acceleration (‘relative residual acceleration’) were defined as indicators for residual ALRI. The associations between these indicators and nine candidate risk factors were analysed using univariate and multiple regression analyses. ResultsMultiple regression analysis revealed that absolute residual acceleration was positively associated with both preoperative acceleration difference between injured and uninjured knees (β = 0.469, P < 0.001) and tibial acceleration of the uninjured knee (β = 0.597, P < 0.001). Relative residual acceleration was also positively associated with preoperative acceleration difference between injured and uninjured knees (β = 0.446, P< 0.001), but was negatively associated with tibial acceleration of the uninjured knee (β = −0.763, P < 0.001). ConclusionsPatients with larger preoperative side-to-side difference of the pivot shift phenomenon have higher risk for both absolute and relative residual ALRIs after ACL reconstruction, whereas patients with larger pivot shift phenomenon in their uninjured knees are at higher risk for absolute residual ALRI but not for relative residual ALRI.

Quadriceps tendon autograft ACL reconstruction has less pivot shift laxity and lower failure rates than hamstring tendon autografts.

Quadriceps tendon (QT) autograft ACL reconstruction was hypothesized to possess less anterior knee laxity, pivot shift laxity, and lower failure rates than hamstring tendon (HT) autografts. Terms "hamstring tendon autograft" and "ACL reconstruction" or "quadriceps tendon autograft" and "ACL reconstruction" were searched in Embase and PubMed. Inclusion criteria required that studies included patients treated for primary ACL injury with reconstruction using either a QT autograft (Group 1) or a HT autograft (Group 2) and instrumented anterior knee laxity assessment. Extracted information included surgical fixation method, graft type, graft thickness or diameter, single vs. double bundle surgical method, publication year, time between the index knee injury and surgery, % women, initial and final subject number, subject age, follow-up length, side-to-side anterior knee laxity difference, Lysholm Score, Subjective IKDC score, anterior knee laxity side-to-side difference grade, ipsilateral pivot shift laxity grade, and failure rate. The Methodological Index for Nonrandomized Studies was used to evaluate study methodological quality. The QT group (Group 1) had 17 studies and the HT group (Group 2) had 61 studies. Overall, Group 2 had greater pivot shift laxity (OR 1.29, 95% CI 1.05-1.59, p = 0.005). Group 2 suspensory femoral fixation had greater pivot shift laxity (OR 1.26, 95% CI 1.01-1.58, p = 0.02) than Group 1 compression femoral fixation. Group 2 compression femoral fixation also had more anterior knee laxity (OR 1.25, 95% CI 1.03-1.52, p = 0.01) than Group 1 compression femoral fixation and higher failure rates based on initial (OR 1.69, 95% CI 1.18-2.4, p = 0.002) and final (OR 1.89, 95% CI 1.32-2.71, p = 0.0003) subject number. Failure rate for HT compression femoral fixation was greater than suspensory femoral fixation based on initial (OR 2.08, 95% CI 1.52-2.84, p < 0.0001) and final (OR 2.26, 95% CI 1.63-3.16, p < 0.0001) subject number. Overall, QT autografts had less pivot shift laxity and lower failure rates based on final subject number than HT autografts. Compression QT autograft femoral fixation had lower pivot shift laxity than suspensory HT autograft femoral fixation. Compression QT autograft femoral fixation had less anterior knee laxity and lower failure rates than compression HT autograft femoral fixation. Suspensory HT autograft femoral fixation had lower failure rates than compression HT autograft femoral fixation. Greater knee laxity and failure rates may be related to a combination of HT autograft diameter and configuration (tissue quality and dimensions, strands, bundles, and suturing method) variability and fixation mode. Level IV.

L’amplificateur de brillance est-il nécessaire dans les reconstructions double faisceau du ligament croisé antérieur? Une étude prospective randomisée

IntroductionProperly placed tibial and femoral tunnels in anterior cruciate ligament (ACL) reconstruction are important because tunnel misplacement can cause abnormal changes in graft tension patterns, resulting in postoperative knee laxity. To overcome the inaccuracy of tunnel position in ACL reconstruction, intraoperative fluoroscopy has been proven to be a useful method in previous studies focusing on the tunnel position in single-bundle reconstruction, but few studies are available on the efficacy and necessity of intraoperative fluoroscopy for double-bundle (DB) reconstruction. The purpose of this prospective randomized case-control study was to evaluate the effect of intraoperative fluoroscopy on femoral and tibial tunnel position in anatomic DB ACL reconstruction using a postoperative tunnel position in a three-dimensional computed tomography (3D-CT). HypothesisIntraoperative fluoroscopy during ACL DB reconstruction could make an appropriate tunnel position closer to the anatomical center compared to conventional fluoroscopy-free procedure. Material and methodsSixty patients undergoing ACL DB reconstruction (30 fluoroscopy-free reconstruction group and 30 in fluoroscopy-assisted reconstruction group) were included in this prospective study, and randomly allocated into two groups. Mean values of the percentage distance of femoral and tibial tunnel center in a 3D-CT were compared between the two groups. Knee laxity (the anterior translation and pivot-shift grade) and clinical outcomes were also compared at the last follow-up. ResultsThere was a significant difference only in femoral anteromedial (AM) bundle tunnel position, but not in femoral posterolateral (PL) bundle, tibial AM, or PL bundle tunnel position between the two groups. Femoral AM bundle tunnel in the fluoroscopy-assisted reconstruction group showed significantly (p=0.005) deeper position compared to that in the fluoroscopy-free reconstruction group. There was no significant difference in anterior translation, pivot-shift grade, or clinical outcomes between the two groups. DiscussionFluoroscopy-assisted ACL DB reconstruction can make deeper placement of the femoral AM bundle than the conventional ACL DB reconstruction. Level of evidenceII, prospective randomized controlled trial.

Residual remnant preserving anatomic double-bundle anterior cruciate ligament reconstruction using hamstring tendon autografts

Residual remnant tissue preservation of the anterior cruciate ligament (ACL) has attracted notice in ACL reconstruction. There is a possibility that residual remnant tissue preserving technique has several potential advantages to accelerate the graft remodeling, such as improved anterior knee laxity, accelerated cell infiltration and revascularization, increased mechanoreceptors, and reduction of bone tunnel enlargement. Recently, the authors reported a new remnant tissue preserved procedure for anatomic double-bundle (DB) ACL reconstruction using the transtibial tunnel technique. The anterior and rotational knee laxities were significantly less in the remnant-preserved group than in the remnant-resected group. The 2 nd look observation showed that the remnant-preserved group was significantly better than the remnant-resected group. In this article, the authors described the surgical technique and clinical outcomes of the residual remnant preserving DB ACL reconstruction.

The relationship between graft intensity on MRI and tibial tunnel placement in anatomical double-bundle ACL reconstruction.

To determine whether the graft signal intensity of the anteromedial bundle (AMB) on MRI was related to the tibial tunnel placement, anterior-posterior (A-P) stability, and/or cyclops lesion formation following double-bundle (DB) anterior cruciate ligament (ACL) reconstruction. Between January 2010 and August 2016, 65 patients underwent arthroscopic DB-ACL reconstruction and were followed up for a minimum of 2years. Follow-up included 1-week postoperative CT evaluation, 1-year postoperative MRI evaluation, and 2-year postoperative measurement of A-P instability using a KT-2000 arthrometer. Tibial tunnel placement and the location of Parson's knob were expressed as percentages. Patients were divided into two groups according to the graft signal intensity of the AMB on MRI: the high group (grades 2, 3; group H) and the low group (grade 1; group L). There were 23 knees in group H and 42 knees in group L. There was no difference between the two groups regarding the position of Parson's knob. The AMB placement in the tibial tunnel in group H was more anterior than that in group L. The incidence of a cyclops lesion was significantly greater in group H [13 cases (56.5%)] compared with group L [7 cases (16.7%); P = .05]. The arthrometric side-to-side difference was significantly greater in group H (1.67mm) than in group L (0.90mm; P = .019). Group H had a more anterior tunnel location and significantly greater incidence of cyclops lesions than group L. An increased signal intensity of the AMB on MRI indicates A-P instability. Level III retrospective cohort study.

Strain behavior of native and reconstructed medial patellofemoral ligaments during dynamic knee flexion - a cadaveric study

BackgroundSurgical reconstruction of the Medial Patello-Femoral Ligament (MPFL) has been recognized as an effective treatment for patients with instability despite conservative treatment. The purpose of this cadaveric study is to compare the strain patterns within the native and reconstructed single and double-bundle MPFL. This will help ascertain if the native biomechanics are restored with the reconstructions.MethodsTwelve cadaveric knees were dissected and the native MPFL of each specimen was identified. The knees were subjected to dynamic flexion using a customized jig. Continuous strain measurements were taken for each knee from 0 to 120 degrees flexion and then back to full extension using differential variable reluctance transducers (DVRTs). The MPFL was then cut. Six single bundle and six double bundle MPFL reconstructions were performed using hamstring tendon grafts. The DVRTs were reattached to the grafts and strain measurements were retaken. Statistical analysis was performed using a paired t-test.ResultsStrain patterns of the native and reconstructed MPFL showed an increase in strain from 0 to 120 degrees of flexion except for the inferior bundle of the double bundle reconstruction. The strain patterns in the intact specimens were higher than the reconstructed MPFL through different degrees of knee flexion. In the double-bundle group, the superior graft had statistically significantly lower strains compared to the native MPFL with p-value <.05 at all flexion angles. The reconstructed inferior band showed loss of tension as the knee flexed. Higher strain with statistical significance (p-value <.05) was found in the single-bundle compared to the superior band of the double-bundle reconstruction at flexion angles less than 90 degrees.ConclusionThe strain variation at progressive angles of knee flexion is dissimilar between the native and reconstructed MPFL. The reconstructed MPFL exhibited non-physiological biomechanics with the inferior band losing tension. Although the single-bundle reconstruction shows a better strain profile compared to double-bundle reconstruction, the grafts are significantly stiffer than the native MPFL.

Decreased Posterior Tibial Slope Does Not Impact Postoperative Posterior Knee Laxity after Double-Bundle Posterior Cruciate Ligament Reconstruction

Objectives: Recent clinical studies have identified sagittal plane posterior tibial slope as a risk factor for increased postoperative laxity after single-bundle (SB) posterior cruciate ligament reconstruction (PCLR). However, the effect of tibial slope and its role in graft laxity following double-bundle (DB) PCLR has not been investigated clinically. Therefore, the purpose of this study was to retrospectively compare the degree of posterior tibial slope and its impact on posterior tibial translation (PTT) after DB PCLR. It was hypothesized that preoperative tibial slope would not be associated with graft laxity following DB PCLR. Methods: Patients who underwent primary DB PCLR without ACL injury between 2010 and 2017 by a single surgeon were retrospectively analyzed. Measurements of posterior tibial slope were performed using the lateral radiograph and PTT was measured using kneeling PCL stress radiographs, preoperatively and at a minimum of 1-year postoperatively. Linear regression was used to assess the relationship between native posterior tibial slope and postoperative graft laxity, determined by PCL stress radiographs. Results: One hundred three patients with PCL tears and subsequent DB PCL reconstructions were included. Ninety (87.4%) patients reported a contact mechanism at time of injury, while 13 (12.6%) patients reported a noncontact injury mechanism. Sixty-four (62.1%) patients had combined extra-articular ligament injuries that were concurrently reconstructed with the PCL tear, while isolated PCL tears were identified in 39 (37.9%) patients. Forty-nine (47.6%) patients had an acute (less than 6 weeks) injury, 54 (52.4%) patients had a chronic (greater than 6 weeks) injury at time of imaging and evaluation. Four (4%) patients demonstrated failed PCLRs, as defined by SSD in PTT greater than 8 mm on PCL stress radiographs. The mean posterior tibial slope for all PCL injured patients was 5.9 degrees &amp;#177; 2.2 degrees. There was a significant reduction in the amount of mean SSD in PTT between preoperative (10.6 &amp;#177; .7 mm) and postoperative (1.5 &amp;#177; 2.6 mm) PCL stress radiographs following DB PCLR (95% CI [8.4, 9.8], p &lt; 0.001). Linear regression analysis revealed no significant correlation between preoperative posterior tibial slope and the amount of SSD in PTT on postoperative stress radiographs obtained at a mean 18.5 months postoperatively (R = -0.115, p = 0.249). Similarly, when adjusting for combined ligamentous injury, injury chronicity, mechanism of injury, BMI, and age at surgery via multiple linear regression, preoperative tibial slope was not a significant independent predictor of postoperative SSD in PTT (beta = -0.079, 95% CI [-0.308, 0.150], p = 0.496). Combined injury (beta = -1.01, 95% CI [-2.00, -0.01], p = 0.047) was a significant independent predictor of decreased postoperative SSD in PTT on posterior stress radiographs. Conclusion: Graft laxity, determined by PTT in posterior kneeling stress radiographs, was not influenced by decreased posterior tibial slope in patients following DB PCLRs. Combined PCL injury was a significant independent predictor of decreased postoperative SSD in PTT on posterior stress radiographs. Additionally, the majority of patients (96%) demonstrated improved objective posterior knee stability following DB PCLR. Thus, DB PCLR can be recommended as a surgical treatment option for patients with grade III isolated and combined PCL injuries, irrespective of native posterior tibial slope. [Table: see text]

ACL reconstruction with lateral plasty reduces translational and rotatory laxity compared to anatomical single bundle and non-anatomical double bundle surgery: An in vivo kinematic evaluation with navigation system

BackgroundSignificantly better stability may be achieved with a Single Bundle Lateral Plasty (SBLP) reconstruction compared with the Single Bundle (SB) and Double Bundle (DB) procedures. MethodsThe study included 42 patients who underwent ACL reconstruction. Patients were randomly selected for one of the following surgical procedure defining three study groups: Single-Bundle-Lateral-Plasty, Single-Bundle and Double-Bundle procedures. Laxity evaluation was performed with an intraoperative navigation system. Lachman test (AP30), Drawer test (AP90), Varus-Valgus stress test at 0° and 30° knee flexion (VV0, VV30), Internal-External rotation (IE30, IE90), and pivot shift (PS) test are the clinical test executed for the laxity evaluation.Laxity reduction was defined as the difference between laxity before the fixation of the graft used for the reconstruction and the laxity just after its fixation. FindingsFor all the analyzed surgical techniques, the pre-reconstruction laxity values were statistically higher (P < 0.05) than the post-reconstruction values for all the analyzed tests. The analysis of the Drawer test and Internal-External rotation at 30° and 90° of knee flexion, highlighted a significant difference at time zero after surgery among the three study groups. The results showed that the SBLP technique had the highest reduction values compared to SB (PIE90 = 0.001) and DB (PAP90 = 0.012; PIE30 = 0.021; PIE90 = 0.003) techniques. InterpretationSBLP technique showed significantly superior results in terms of antero-posterior and internal-external laxity reduction at time-zero after ACL reconstruction.

Is intraoperative fluoroscopy necessary in anterior cruciate ligament double-bundle reconstruction? A prospective randomized controlled trial

IntroductionProperly placed tibial and femoral tunnels in anterior cruciate ligament (ACL) reconstruction are important because tunnel misplacement can cause abnormal changes in graft tension patterns, resulting in postoperative knee laxity. To overcome the inaccuracy of tunnel position in ACL reconstruction, intraoperative fluoroscopy has been proven to be a useful method in previous studies focusing on the tunnel position in single-bundle reconstruction, but few studies are available on the efficacy and necessity of intraoperative fluoroscopy for double-bundle (DB) reconstruction. The purpose of this prospective randomized case-control study was to evaluate the effect of intraoperative fluoroscopy on femoral and tibial tunnel position in anatomic DB ACL reconstruction using a postoperative tunnel position in a three-dimensional computed tomography (3D-CT). HypothesisIntraoperative fluoroscopy during ACL DB reconstruction could make an appropriate tunnel position closer to the anatomical center compared to conventional fluoroscopy-free procedure. Material and methodsSixty patients undergoing ACL DB reconstruction (30 fluoroscopy-free reconstruction group and 30 in fluoroscopy-assisted reconstruction group) were included in this prospective study, and randomly allocated into two groups. Mean values of the percentage distance of femoral and tibial tunnel center in a 3D-CT were compared between the two groups. Knee laxity (the anterior translation and pivot-shift grade) and clinical outcomes were also compared at the last follow-up. ResultsThere was a significant difference only in femoral anteromedial (AM) bundle tunnel position, but not in femoral posterolateral (PL) bundle, tibial AM, or PL bundle tunnel position between the two groups. Femoral AM bundle tunnel in the fluoroscopy-assisted reconstruction group showed significantly (p=0.005) deeper position compared to that in the fluoroscopy-free reconstruction group. There was no significant difference in anterior translation, pivot-shift grade, or clinical outcomes between the two groups. DiscussionFluoroscopy-assisted ACL DB reconstruction can make deeper placement of the femoral AM bundle than the conventional ACL DB reconstruction. Level of evidenceII, prospective randomized controlled trial.

Anatomical anterior cruciate ligament reconstruction with a flat graft using a new tunnel creation technique

Anterior cruciate ligament (ACL) reconstruction is well established in a single bundle or double bundle technique using hamstrings, quadriceps tendon or patellar tendon. Based on new anatomical findings from the authors about flat ACL and c-shaped tibial insertion, a novel concept was developed to reconstruct the ACL in a more anatomical way. This article describes the new technique of flat ACL reconstruction with graft preparation and creation of flat femoral and tibial bone slits.

Eight-year results of transtibial nonanatomic single-bundle versus double-bundle anterior cruciate ligament reconstruction: Clinical, radiologic outcomes and survivorship.

To compare the long term outcomes of transtibial nonanatomic single-bundle (SB) and double-bundle (DB) anterior cruciate ligament (ACL) reconstruction. Between January 2008 and September 2010, we retrospectively evaluated 377 patients who underwent primary ACL reconstruction and who were available at 8 years of follow-up. Patients who received transtibial nonanatomic SB ACL reconstruction ( n = 263) were assigned to group SB and DB ACL reconstruction ( n = 114) to group DB. The patients were assessed with the International Knee Documentation Committee (IKDC), the Lysholm scores, Tegner activity score, knee joint stability tests, and patellofemoral osteoarthritis (OA) findings using the Kellgren-Lawrence (K-L) classification. Contralateral ACL (CACL) injury was also evaluated. Thirteen patients underwent revision ACL surgery during the follow-up. Ultimately, 256 patients in group SB and 108 patients in group DB were available at the 8-year follow-up. At final follow-up, the IKDC subjective score ( p = 0.04) and Lysholm score ( p = 0.02) showed significantly superior results in group DB compared to group SB. However, there was no significant difference of Tegner activity score ( p = 0.30), range of motion ( p = 0.81), and knee joint stability tests. There was significant progression of patellofemoral OA between preoperative and final follow-up in ipsilateral knee of both groups but not significant progression in contralateral knee. However, there was no significant difference between the two groups at the follow-up. There were 2.7% ipsilateral ACL graft failure in group SB, compared with 5.2% in group DB ( p = 0.12) and 6.4% CACL tear in group SB, compared with 5.2% in group DB ( p = 0.65). The mean survivorship of ACL graft was 9.47 ± 0.05 years (95% confidence interval (CI), 9.36-9.58) in group SB and 9.87 ± 0.16 years (95% CI, 9.54-10.20) in group DB, and there was no significant difference ( p = 0.25). DB ACL reconstruction resulted in significantly better clinical IKDC subjective scores and Lysholm scores. However, most of the differences in clinical scores were small, and the clinical relevance of this difference is unknown. In addition, there was no significant difference in Tegner activity score, knee joint stability tests, patellofemoral OA, and survivor rate of the ACL graft and CACL after reconstruction after a minimum of 8-year follow-up. Level of Evidence: Cohort study; level of evidence, 3.