Fig. 19.1
Anatomy of the ACL. (a) Anterior view of the knee. Both bundles are shown (AM anteromedial, PL posterolateral, PCL posterior cruciate ligament). (b, c) ACL femoral (b) and tibial (c) insertion site. The anatomic femoral insertion site has a deep and low position. ACL insertion site size can vary from individual to individual. Black line demarcates lateral intercondylar ridge (“resident’s ridge”). Asterisk shows insertion sites approximate center (Reprinted with permission from Iriuchishima et al. [27] and Middleton et al. [45])
Fig. 19.2
Clinical case. A 23-year-old male sustained a right knee injury during basketball. Physical exam revealed a 2B Lachman, +2 pivot shift, and 5-mm KT-1000 side-to-side difference. (a) The sagittal and coronal MRI showed a complete ACL tear. Preoperative measurements showed a large insertion site (tibial sagittal length >18 mm). DB ACL reconstruction was indicated. (b) Intraoperative measurements, following the anatomic individualized ACL reconstruction concept, confirmed a large ACL insertion site (tibial sagittal length >18 mm). (c) Hamstrings autograft for DB ACL reconstruction D: DB ACL reconstruction (views from lateral, central and anteromedial portals). (e) Postoperative 3D reconstructed CT showing the anteromedial (AM) and posterolateral (PL) tunnel location (left: tibia; right: femur)
Recently, clinical practice guidelines for management of ACL injuries were published according to the results of a systematic review [58]. Considering “high strength” studies with consistent findings, Carey et al. reported that there is no statistically significant difference between SB and DB reconstruction in postoperative pain, Lysholm score, or IKDC subjective knee score [58]. The clinical practice guideline recommends strongly that the surgeon should use either SB or DB technique, because of the similarity of measured clinical outcomes [58].
Fact Box: Systematic Reviews and Meta-analysis
- 1.
The best evidence from the highest-quality meta-analyses suggests that DB reconstruction yields superior postoperative knee laxity (based on KT arthrometry and pivot-shift testing).
- 2.
Most recent clinical practice guidelines recommend strongly that the surgeon use either SB or DB technique, because of the similarity of measured clinical outcomes.
19.5 Limitations of This Review
The analysis comparing SB and DB reconstruction studies is limited based on the data from the included studies. The statistical power can be affected by small sample size studies, so in this case a small clinical effect may not be statistically significant. Also, much of the available literature comparing SB and DB reconstruction consists of relatively short-term follow-up, such that a significant difference that only manifests itself in long-term follow-up would be missed in this analysis. An additional limitation lies in the heterogeneity of the included studies. These studies combined the analysis of anatomic and nonanatomic ACL reconstruction techniques. This could potentially alter the laxity measures, in particular, rotational laxity [33].
Conclusions
The current highest level of evidence suggests that DB ACL reconstruction provides better postoperative knee laxity by KT arthrometry and pivot-shift testing when compared with SB ACL reconstruction. The effect on clinical outcomes and risk of graft failure have not found to be significantly different in the systematic reviews and meta-analysis. However, heterogeneity of studies, including tunnel positioning and relatively short-term follow-up, is a limitation to be considered when interpreting this evidence.
Future biomechanical and long-term clinical cohort studies with anatomic ACL reconstruction are needed to further examine the improvement in knee laxity and clinical outcomes afforded by DB reconstruction.
References
1.
Adachi N, Ochi M, Uchio Y, Iwasa J, Kuriwaka M, Ito Y (2004) Reconstruction of the anterior cruciate ligament. Single- versus double-bundle multistranded hamstring tendons. J Bone Joint Surg Br 86:515–520PubMed
2.
3.
4.
5.
Allen CR, Giffin JR, Harner CD (2003) Revision anterior cruciate ligament reconstruction. Orthop Clin NA 34:79–98Crossref
6.
7.
8.
9.
Björnsson H, Andernord D, Desai N, Norrby O, Forssblad M, Petzold M, Karlsson J, Samuelsson K (2015) No difference in revision rates between single- and double-bundle anterior cruciate ligament reconstruction: a comparative study of 16,791 patients from the Swedish National Knee Ligament Register. Arthroscopy 31:659–664
10.
Brophy RH, Selby RM, Altchek DW (2006) Anterior cruciate ligament revision: double-bundle augmentation of primary vertical graft. Arthroscopy 22:683.e1–5Crossref
11.
12.
Chhabra A, Starman JS, Ferretti M, Vidal AF, Zantop T, Fu FH (2006) Anatomic, radiographic, biomechanical, and kinematic evaluation of the anterior cruciate ligament and its two functional bundles. J Bone Joint Surg 88(Suppl 4):2–10PubMed
13.
14.
15.
Duthon VB, Barea C, Abrassart S, Fasel JH, Fritschy D, Ménétrey J (2006) Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 14:204–213
16.
17.
18.
19.
Girgis FG, Marshall JL, Monajem A (1975) The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res (106):216–231
20.
Harner CD, Giffin JR, Dunteman RC, Annunziata CC, Friedman MJ (2001) Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect 50:463–474PubMed
21.
22.
23.
Hofbauer M, Valentin P, Kdolsky R, Ostermann RC, Graf A, Figl M, Aldrian S (2010) Rotational and translational laxity after computer-navigated single- and double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 18:1201–1207CrossrefPubMed
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