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„ ANNOTATION

Double-bundle arthroscopic reconstruction


of the anterior cruciate ligament
DOES THE EVIDENCE ADD UP?

U. G. Longo, There is a trend towards the use of double-bundle techniques for the reconstruction of the
J. B. King, anterior cruciate ligament. This has not been substantiated scientifically. The functional
V. Denaro, outcome of these techniques is equivalent to that of single-bundle methods. The main
N. Maffulli advantage of a double-bundle rather than a single-bundle reconstruction should be a better
rotational stability, but the validity and accuracy of systems for the measurement of
From Keele rotational stability have not been confirmed.
University School of Despite the enthusiasm of surgeons for the double-bundle technique, reconstruction with
Medicine, Stoke on a single-bundle should remain the standard method for managing deficiency of the anterior
Trent, England cruciate ligament until strong evidence in favour of the use of the double-bundle method is
available.

Reconstruction of the anterior cruciate liga- better rotatory stability.10 However, these tech-
ment (ACL) is a common procedure,1,2 with niques have not been shown to be associated
reported clinical success ranging between 80% with an improved functional outcome at a
and 95%.3 Between 75 000 and 100 000 follow-up of two years.9,10,21,22
reconstructions of the ACL are performed In order to assess the success of an ACL
annually in the United States, but 85% of reconstruction, quantitative measurements of
orthopaedic surgeons carry out fewer than ten the pivot shift, rotational laxity in the trans-
„ U. G. Longo, MD, Resident in such procedures per year.3 The ACL consists of verse plane and patient satisfaction must be
Trauma and Orthopaedic
Surgery two major functional bundles, namely the considered.25-29 The long-term outcome of the
„ V. Denaro, MD, Professor of anteromedial and posterolateral2,4 The former reconstruction in terms of preventing or slow-
Trauma and Orthopaedic
Surgery originates more proximally on the femur and ing down the progression of degenerative joint
Department of Orthopaedic and inserts anteromedially on the tibia, while the disease should be taken into account.25-29 This
Trauma Surgery,
Campus Biomedico University, latter originates more distally from the femoral paper considers the evidence for the advan-
Via Alvaro del Portillo 200, site and inserts posterolaterally into the tages of double-bundle as opposed to single-
00128 Trigoria, Rome, Italy.
tibia.2,4,5 Both are nearly parallel when the bundle techniques for the reconstruction of the
„ J. B. King, FRCS, FFSEM
knee is extended and twist around each other ACL.
(UK), Consultant Orthopaedic
Surgeon, as the knee flexes.3
London Independent Hospital,
Stepney Green, London
Many techniques for reconstruction of the Cadaver studies
E1 4NL, UK ACL have been described.3,6-13 There is no true The exact orientation of the different bands of
„ N. Maffulli, MD, MS, PhD, consensus as to the optimal positioning of the the ACL is controversial.23,24 There is no evi-
FRCS (Orth), Professor of femoral tunnel or for determining the land- dence of the histological separation of the indi-
Trauma and Orthopaedic
Surgery marks which best identify its true loca- vidual bands, and two, three or multiple
Department of Orthopaedic and tion.4,14,15 A single-bundle reconstruction is bundles may be seen.18 Generally, as the ten-
Trauma Surgery
University Hospital of North performed using one single femoral and one sion varies among the fibres during flexion and
Staffordshire, Keele University single tibial tunnel.6,10,16-20 extension of the knee, two bands can be distin-
School of Medicine, Stoke on
Trent ST4 7LN, UK. It has been suggested that it is crucial to re- guished.18,23
establish the double-bundle anatomy of the In the absence of a functional ACL the axis
Correspondence should be sent
to Professor N. Maffulli; e-mail: ACL in order to obtain a better restoration of of rotation shifts more medially and tibial rota-
n.maffulli@orth.keele.ac.uk
the normal biomechanics of the knee, and to tion causes a coupled anterior tibial trans-
©2008 British Editorial Society improve the rotatory laxity.9,10,21,22 Such tech- lation, magnifying the movement of the tibial
of Bone and Joint Surgery
doi:10.1302/0301-620X.90B8.
niques aim to reconstruct both bundles, and, plateau.23 The ACL also plays a role in stabili-
20083 $2.00 theoretically, should provide a superior con- sation against rotatory loading.23 Cadaver
J Bone Joint Surg [Br]
struct which would reduce rates of failure and studies have shown that single-bundle recon-
2008;90-B:995-9. improve the functional outcome,1,2,23,24 with struction is successful in limiting anterior tibial

VOL. 90-B, No. 8, AUGUST 2008 995


996 U. G. LONGO, J. B. KING, V. DENARO, N. MAFFULLI

translation in response to anterior loading but cannot fully by the KT-2000 arthrometer (MEDmetric, San Diego, Cal-
control a combined rotatory load of internal and valgus ifornia) with the knee at 20º or 70º of flexion, or with
torque.23,30-34 In single-bundle reconstruction, positioning regard to proprioception.
of the graft at 10 o’clock instead of 11 o’clock has been pro- Yasuda et al13 carried out a prospective, comparative
posed in order to restore knee function in response to both cohort study to compare the clinical outcomes in patients
externally-applied anterior tibial and combined rotatory who had reconstruction of the ACL with single-bundle or
loads.35 double-bundle hamstring autografts. There were 72
The addition of a lateral extra-articular procedure with patients with unilateral ACL-deficient knees who had been
hamstring tendon grafts reduces internal rotation of the assigned to one of three techniques of reconstruction:
tibia in 30º of knee flexion compared with a standard single-bundle, non-anatomical double-bundle or anatomi-
single-bundle reconstruction.36 cal double-bundle. Each group included 24 patients. They
Radford and Amis37 first described the mechanical had a clinical examination before surgery and after two
results of double-bundle reconstruction in cadaver knees years. There were no significant differences in the three
showing restoration of anterior laxity to nearly-normal at groups in regard to muscle torque, range of movement and
20º and 90º of flexion. The force distribution between the the International Knee Documentation Committee (IKDC)
anteromedial and posterolateral bundles in the reconstruc- score, although the side-to-side anterior laxity of the ana-
tion was similar to that found in the normal ACL. There tomical double-bundle was better than that of the single-
was a higher in situ force in the posterolateral bundle at 0º bundle reconstruction.
and 15º, whereas in the anteromedial bundle this force was Aglietti et al10 carried out a prospective, comparative
higher at 90º of flexion. cohort study to evaluate whether one of two techniques of
Yagi et al12 used a robotic/universal force-moment the double-bundle reconstruction was superior to a single-
sensor-testing system to study ten cadaver knees subjected incision single-bundle procedure in controlling anterior
to external loading with an anterior load and a combined tibial translation and reducing pivot shift. The first 25
rotatory load. This showed superior restoration of the bio- patients (group I) had a single-bundle transtibial ACL
mechanics in double-bundle rather than in single-bundle reconstruction, the next 25 (group II) a double-bundle
reconstructions, especially with respect to rotatory loads. single-incision transtibial procedure and a further 25
Sbihi et al,38 investigating cadaver specimens with an (group III) a double-bundle two-incision outside-in opera-
arthrometer, found the double-bundle to be superior to the tion. The mean side-to-side anterior laxity and the amount
single-bundle reconstruction as regards anteroposterior of residual pivot shift were significantly lower in group III
laxity at 20º of flexion, but not at 60º or 90º. than in group I (p < 0.05). The mean IKDC subjective eval-
Ishibashi et al39 showed improvement in anteroposterior uation score was significantly higher in group III than in
laxity in patients who had a double-bundle reconstruction group I (p < 0.05). No significant differences were observed
performed using the OrthoPilot navigation system between groups II and III.
(B. Braun-Aesculap, Tuttlingen, Germany) compared with Yagi et al22 carried out a quasi-randomised trial to eval-
patients who had a single-bundle procedure. uate whether rotational stability differed in three
techniques, namely anteromedial single-bundle and
Single-bundle versus double-bundle techniques posterolateral single-bundle and double-bundle. A total of
As yet there is no clinical evidence to show that the double- 60 patients was allocated into three groups. There were no
bundle is superior to the single-bundle technique in recon- significant differences in the groups in the mean values of
struction of the ACL. Many authors have described a side-to-side anterior laxity, peak isokinetic torque or the
double-bundle technique,3,6-13 and several have reported IKDC score. Patients in whom the ACL had been recon-
outcome studies at two years, but only five randomised, structed with the double-bundle technique had significantly
controlled trials (RCTs), two-quasi-RCTs and two prospec- better control of pivot shift.
tive, comparative cohort studies have compared the two Muneta et al21 conducted a quasi-randomised trial on 68
procedures. All showed a comparable clinical outcome patients with unilateral ACL deficiency to compare the out-
between the two techniques. No study has detected any sta- come between double-bundle and single-bundle ACL recon-
tistically significant differences when using patient-based structions with four-strand semitendinosus tendon. The
outcome measures. patients were assigned to one of two treatment groups
Adachi et al9 prospectively randomised 108 patients with according to their birth date, and were followed up for a
unilateral instability of the knee associated with rupture of mean of 25 months. There were no significant differences
the ACL for arthroscopic single-bundle or double-bundle between the two groups with regard to the mean range of
reconstruction of the ligament using hamstring tendons. movement, girth of the thigh, muscle strength, and the Lysh-
The method of randomisation was not given. The patients olm score. Manual testing showed that positive Lachman and
were followed up for a mean of 32 months (24 to 36). No pivot-shift tests were less common in the double-bundle
significant difference ( p > 0.05) was found between the two group than in the single-bundle group. The KT measure-
groups with regard to the mean anterior laxity as measured ments were statistically significantly different, with better

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DOUBLE-BUNDLE ARTHROSCOPIC RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT 997

results on average in the double-bundle group. Statistical string autograft technique using interference screw fixation.
analysis showed no significant difference regarding all of the There were 77 patients who were randomised into three dif-
modified IKDC categorised data between the two groups. ferent groups: double-bundle with bio-absorbable screw fix-
The authors concluded that double-bundle reconstruction ation (n = 25), single-bundle with bio-absorbable screw
was superior to the single-bundle technique with regard to fixation (n = 27) and single-bundle with metal screw fixation
anterior and rotational stability, but they failed to show any (n = 25). The rotational stability of the knee, as evaluated by
difference between the two techniques when considering sub- the pivot-shift test, was best in the patients in the double-bun-
jective variables. dle group (p = 0.005). Measurement of the anterior stability
Järvelä40 conducted a prospective, randomised clinical of the knee with the KT-1000 arthrometer showed no statis-
study to compare the outcome of ACL reconstruction using tically significant differences in the groups; nor were there
either the double-bundle or single-bundle techniques with significant differences in the knee scores between the groups.
similar regimes for rehabilitation. He randomised 65 patients
into either double-bundle (n = 35) or single-bundle (n = 30) Discussion
groups using hamstring tendons and bio-absorbable screw There is, as yet, no evidence to show that fully anatomical
fixation. Double-bundle reconstruction with hamstring double-bundle reconstruction of the ACL results in a better
grafts using bio-absorbable screw fixation on both tibial and functional outcome.44
femoral sides resulted in better restoration of rotational lax- Many major issues remain in considering reconstruction
ity of the knee than single-bundle ACL reconstruction, when of the ACL, particularly in regard to the indications for this
measured by the pivot-shift test (p < 0.002). procedure such as laxity, or instability. Although there is a
Streich et al41 carried out a randomised trial in male ath- correlation with anteroposterior laxity, not all patients with
letes to compare the clinical results of a single-bundle with a tear of the ACL develop instability. Rotatory laxity seems
that of a double-bundle reconstruction using an autologous to be of greater significance than anteroposterior laxity.
semitendinosus tendon graft with extracortical fixation. A Many patients have anteroposterior and rotatory laxity,
total of 50 men with a mean age of 29.4 years was prospec- but do not develop instability.19,45-53 They do not need a
tively randomised consecutively into one of the two pro- reconstruction. All tears of the ACL do not automatically
cedures. After two years, there was no significant difference produce functional impairment and the patient may be able
in the side-to-side measurement of anterior laxity with the to resume pre-morbid levels of activity without reconstruc-
KT-1000 arthrometer in the groups. As evaluated by the tion. However, others may experience repeated giving-
pivot-shift test, no significant correlation was noted between way.20,49,54,55
rotational stability and the use of either technique. Statistical Measurements of laxity and the IKDC ratings56 are inca-
analysis showed a significant increase in the IKDC and the pable of distinguishing the functional status of the ACL-
Lysholm scores at the final follow-up with no significant dif- deficient patient. Alternatively, the Lysholm,57 Knee Out-
ference between the two methods. come Survey (KOS)-Sport,58 KOS-ADL58 and the global
Siebold, Dehler and Ellert42 conducted a prospective, ran- knee function rating scores59 may be capable of discrimi-
domised clinical study to compare the outcome of ACL nating between symptomatic and asymptomatic defi-
reconstruction using either the double-bundle or the single- ciency.49,55 No single measurement tool is sufficient.
bundle technique. The 70 patients undergoing arthroscopic Measurement of anterior laxity does not correlate with
reconstruction were prospectively randomised to double- measures of functional outcome.60 Assessments which are
bundle (n = 35) or single-bundle (n = 35) groups. Fixation based partially on measures of joint laxity, such as the
was by means of a femoral EndoButton CL (Smith & IKDC score, may artificially overestimate the disability
Nephew, Andover, Massachusetts) and a tibial biodegrad- after rupture of the ACL.20
able interference screw. The subjective results were similar in The main advantage of double-bundle compared with
both groups. There was no significant difference between the single-bundle reconstruction should be better rotational
groups as evaluated by the IKDC-2000 score, the Cincinnati stability, but the validity and accuracy of the measurement
knee score, or the Lysholm score. The objective IKDC score systems for rotational stability have not been con-
was significantly higher for the double-bundle technique firmed,21,22 and this remains the major weakness in
compared with the single-bundle technique. The mean KT- the evaluation of the results of a double-bundle reconstruc-
1000 side-to-side difference was 1.0 mm for double-bundle tion.
and 1.6 mm for single-bundle (p < 0.054) and the pivot-shift Incorrect placement of the femoral and tibial tunnels is
test was negative in 97% of patients for double-bundle and the main reason for technical failure in single-bundle recon-
71% for single-bundle (p < 0.01). struction.15 The question remains as to whether the use of
Järvelä et al43 conducted an RCT to compare the clinical four tunnels in a double-bundle construct rather than two
results of a double-bundle technique using doubled semiten- in a single-bundle repair increases the rate of failure. No
dinosus and doubled gracilis autografts with bio-absorbable study has yet had sufficient power to disprove this. A
interference screw fixation and two tunnels on both the fem- double-bundle procedure may also produce more problems
oral and tibial sides, with a single-bundle, four-stranded ham- at revision surgery.25-29

VOL. 90-B, No. 8, AUGUST 2008


998 U. G. LONGO, J. B. KING, V. DENARO, N. MAFFULLI

Several techniques of double-bundle reconstruction have 2. Zelle BA, Brucker PU, Feng MT, Fu FH. Anatomical double-bundle anterior cruci-
ate ligament reconstruction. Sports Med 2006;36:99-108.
been described,3,6-13 but there is no evidence that one is
3. Crawford C, Nyland J, Landes S, et al. Anatomic double bundle ACL reconstruc-
superior to another. Failure of the graft and requirements tion: a literature review. Knee Surg Sports Traumatol Arthrosc 2007;15:946-64.
for revision procedures should also be considered.25,26 It is 4. Girgis FG, Marshall JL, Monajem A. The cruciate ligaments of the knee joint: ana-
uncertain whether one should depend on instrumented test- tomical, functional and experimental analysis. Clin Orthop 1975;106:216-31.
ing, which does not measure rotational laxity, or accept 5. Dienst M, Burks RT, Greis PE. Anatomy and biomechanics of the anterior cruciate
ligament. Orthop Clin North Am 2002;33:605-20.
functional scores as an accurate assessment of patient out- 6. Zelle BA, Vidal AF, Brucker PU, Fu FH. Double-bundle reconstruction of the ante-
come. rior cruciate ligament: anatomic and biomechanical rationale. J Am Acad Orthop Surg
In order to determine whether a double-bundle recon- 2007;15:87-96.
7. Caborn DN, Chang HC. Single femoral socket double-bundle anterior cruciate liga-
struction is superior to a single-bundle procedure a ran- ment reconstruction using tibialis anterior tendon: description of a new technique.
domised controlled trial would be required. Calculation of Arthroscopy 2005;21:1273.
sample size, based on a power analysis,61 should be included 8. Marcacci M, Molgora AP, Zaffagnini S, et al. Anatomic double-bundle anterior
cruciate ligament reconstruction with hamstrings. Arthroscopy 2003;19:540-6.
in the design of such a trial.61-65 However, there is little agree-
9. Adachi N, Ochi M, Uchio Y, et al. Reconstruction of the anterior cruciate ligament:
ment among surgeons on a suitable outcome measure, so cal- a single- versus double-bundle multistranded hamstring tendons. J Bone Joint Surg
culation of the sample size remains a point of debate; such a [Br] 2004;86-B:515-20.
study would require a large number of patients. 10. Aglietti P, Giron F, Cuomo P, Losco M, Mondanelli M. Single- and double-inci-
sion double-bundle ACL reconstruction. Clin Orthop 2007;454:108-13.
Loss to follow-up after recruitment and attrition are
11. Steckel H, Starman JS, Baums MH, et al. The double-bundle technique for ante-
common in RCTs.64,65 The former occurs when informa- rior cruciate ligament reconstruction: a systematic overview. Scand J Med Sci Sports
tion as to the progress of the patient cannot be obtained, 2007;17:99-108.
12. Yagi M, Wong EK, Kanamori A, et al. Biomechanical analysis of an anatomic ante-
whereas attrition is the exclusion or drop-out of individuals rior cruciate ligament reconstruction. Am J Sports Med 2002;30:660-6.
for a particular reason after randomisation to the interven- 13. Yasuda K, Kondo E, Ichiyama H, Tanabe Y, Tohyama H. Clinical evaluation of
tion or control group.64,65 It forms one of the four predom- anatomic double-bundle anterior cruciate ligament reconstruction procedure using
hamstring tendon grafts: comparisons among 3 different procedures. Arthroscopy
inant biases in clinical trials, as follows: selection, 2006;22:240-51.
performance, attrition and detection.60,61 14. Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BR Jr. Arthroscopic ante-
Considering these aspects, the number of patients required rior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and
hamstring tendon autografts. Am J Sports Med 2003;31:2-11.
to perform a suitable RCT is considerable and it is unlikely
15. George MS, Dunn WR, Spindler KP. Current concepts review: revision anterior
that such a trial will ever be carried out. Given the commer- cruciate ligament reconstruction. Am J Sports Med 2006;34:2026-37.
cial pressures inevitable in this field, we fear that trials involv- 16. Pinczewski LA, Lyman J, Salmon LJ, et al. A 10-year comparison of anterior cru-
ing much smaller numbers of patients will be performed ciate ligament reconstructions with hamstring tendon and patellar tendon autograft:
a controlled, prospective trial. Am J Sports Med 2007;35:564-74.
instead. However, the question remains as to whether it is 17. Aglietti P, Buzzi R, Giron F, Simeone AJ, Zaccherotti G. Arthroscopic-assisted
ethical to carry out such investigations to identify an effect anterior cruciate ligament reconstruction with the central third patellar tendon: a 5-8-
which may be small and not clinically relevant, although sta- year follow-up. Knee Surg Sports Traumatol Arthrosc 1997;5:138-44.
18. Odensten M, Gillquist J. Functional anatomy of the anterior cruciate ligament and
tistically significant and wholly measurable by present tech- a rationale for reconstruction. J Bone Joint Surg [Am] 1985;67-A:257-62.
niques, since a large number of participants would be 19. Roos H, Ornell M, Gärdsell P, Lohmander LS, Lindstrand A. Soccer after anterior
exposed to a potentially less beneficial intervention. cruciate ligament injury: an incompatible combination? A national survey of incidence
and risk factors and a 7-year follow-up of 310 players. Acta Orthop Scand
Currently, there is no evidence that a double-bundle 1995;66:107-12.
reconstruction provides a better clinical outcome than a 20. Snyder-Mackler L, Fitzgerald GK, Bartolozzi AR 3rd, Ciccotti MG. The relation-
single-bundle procedure. A simple single-bundle recon- ship between passive joint laxity and functional outcome after anterior cruciate liga-
ment injury. Am J Sports Med 1997;25:191-5.
struction is a suitable technique, provided that it is per-
21. Muneta T, Koga H, Mochizuki T, et al. A prospective randomized study of 4-strand
formed in a technically correct fashion with up-to-date semitendinosus tendon anterior cruciate ligament reconstruction comparing single-
tunnel placement, using appropriate fixation techniques bundle and double-bundle techniques. Arthroscopy 2007;23:618-28.
and rehabilitation programmes. It should not be aban- 22. Yagi M, Kuroda R, Nagamune K, Yoshiya S, Kurosaka M. Double-bundle ACL
reconstruction can improve rotational stability. Clin Orthop 2007;454:100-7.
doned until stronger scientific evidence in favour of double- 23. Petersen W, Tretow H, Weimann A, et al. Biomechanical evaluation of two tech-
bundle reconstruction can be produced. niques for double-bundle anterior cruciate ligament reconstruction: one tibial tunnel
versus two tibial tunnels. Am J Sports Med 2007;35:228-34.
Supplementary Material 24. Petersen W, Zantop T. Anatomy of the anterior cruciate ligament with regard to its
two bundles. Clin Orthop 2007;454:35-47.
A further opinion by Mr A. Williams is available
25. Eriksson E. Can an ACL reconstruction replicate the normal ACL? Knee Surg Sports
with the electronic version of this article on our web- Traumatol Arthrosc 2005;13:613.
site at www.jbjs.org.uk 26. Eriksson E. Single-bundle, double-bundle or triple-bundle? Knee Surg Sports Trau-
matol Arthrosc 2005;14:503-4.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
27. Eriksson E. Partial ACL injuries. Knee Surg Sports Traumatol Arthrosc 2007;15:1065.
28. Eriksson E. ACL surgery revisited. Knee Surg Sports Traumatol Arthrosc 2004;12:87.
29. Harner CD, Poehling GG. Double bundle or double trouble? Arthroscopy
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