Prospective comparative study of anterior cruciate ligament reconstruction using the double-bundle and single-bundle techniques

Navigation in anterior cruciate ligament reconstruction: State of the art

Computer navigation (CN) for anterior cruciate ligament (ACL) surgery has been used mainly for two purposes: to enhance the accuracy of tunnel position and to evaluate the kinematics of the ACL reconstruction (ACLR) and the stability achieved by different surgical techniques. Many studies have shown that navigation may improve the accuracy of anatomical tunnel orientation and position during ACL reconstructive surgery compared with normal arthroscopic tunnel placement, especially regarding the femoral side. At the same time, it has become the gold-standard method for intraoperative knee kinematic assessment, as it permits a quantitative multidirectional knee joint laxity evaluation. CN in ACL surgery has been associated with diverse problems. First, in most optic systems additional skin incisions and drill holes in the femoral bone are required for fixation of a reference frame to the femur. Second, additional radiation exposure and extra medical cost to the patient for preoperative planning are usually needed. Third, CN, due to additional steps, has more opportunities for error during preoperative planning, intraoperative registration, and operation. Fourth, soft tissues, including the skin and subcutaneous tissues, are usually not considered during the preoperative planning, which can be a problem for kinematic and stability assessment. Many studies have concluded that ACLR using a CN system is more expensive than conventional surgery, it adds extra time to the surgery and it is not mitigated by better clinical outcomes. This, combined with costs and invasiveness, has limited the use of CN to research-related cases. Future technology should prioritize less invasive intra-operative surgical navigation.

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

BACKGROUND

The purpsose of this study was to evaluate the biomechanical outcomes of patients who underwent ACL reconstruction either with the DB or SB technique. We hypothesized that the DB technique would provide better rotation control of the knee following ACL reconstruction.

METHODS

The study included seventy-five participants (26 DB, 22 SB, and 27 healthy volunteers). Only cases with at least one year of postoperative follow-up were included. The participants performed three different demand tasks: walk task, walk and change direction, and stair descent and change direction, which was tracked using a three-dimensional 4-camera optoelectronic system. The following kinematic data were analyzed: tibial rotation amplitude and maximal internal and external rotation. Knees with ACL reconstruction were compared to contralateral knees with intact ACL and healthy knees. Clinical outcomes were determined using the subjective and objective International Knee Documentation Committee (IKDC) questionnaire and a manual arthrometer (KT 1000).

RESULTS

Both surgical groups exhibited similar clinical outcomes (mean subjective IKDC 91 SB vs. 90 DB, P=0.815; KT 1000 difference: 2mm in both groups, P=0.772). The vertical component of the ground force reaction revealed no differences between the surgical and control groups (P>0.05). Tibial rotation amplitude and maximal internal and external rotation were similar between the control, SB, and DB groups in all three different demand tasks (P>0.05).

CONCLUSION

ACL reconstruction using either the SB or DB technique can restore rotational control to the level of a healthy knee. No clinical or functional differences were found between the SB and DB surgical options.

In vivo knee rotational stability 2 years after the ACL reconstruction using a quadriceps tendon graft with bone block and bone-patellar tendon-bone graft

INTRODUCTION

The aim of this prospective randomised study was to evaluate clinical results and rotational stability at least 2 years after single-bundle anatomic anterior cruciate ligament reconstruction using a quadriceps tendon graft with bone block (BT) and bone-patellar tendon-bone graft (BTB).

MATERIALS AND METHODS

In both groups (BT and BTB), 40 patients selected prospectively at random were evaluated. The mean follow-up after the surgery was 28 months (range 24-33 months). A navigation system was used to measure rotational stability of the knee joint. Cincinnati, Lysholm, and IKDC scores and visual analog score (VAS) were used to evaluate clinical results and the non-parametric Wilcoxon test was used for the statistical analysis.

RESULTS

After the BT reconstruction, the mean internal rotation of the tibia (IR) was 9.5°. In the contralateral healthy knee joint, IR was 8.6° at average. After the BTB reconstruction, the mean IR was 9.9°. In the contralateral healthy knee joint, IR was 8.7° at average. We did not find any statistically significant difference in IR stability between BT and BTB reconstruction. In terms of clinical results, regarding the VAS, patients perceive significantly more pain after the BTB reconstruction (p < 0.05). Kneeling was reported more difficult and painful after BTB reconstruction.

CONCLUSIONS

The BT reconstruction of the ACL provides similar clinical results, less pain, better flexion and the same rotational stability of the knee in comparison with the BTB reconstruction.

Biomechanical comparison of single-bundle versus double-bundle anterior cruciate ligament reconstruction: a meta-analysis

BACKGROUND

Of the many issues regarding surgical techniques related to anterior cruciate ligament reconstruction (ACLR), single-bundle (SB) or double-bundle (DB) ACLR is one of the most debated topics. However, it is unclear which of the techniques yields better outcomes after ACLR for ACL injury. The purpose of this meta-analysis was to compare the benefits of SB versus DB ACLR in terms of biomechanical outcomes.

METHODS

The electronic databases MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and Scopus were searched for relevant articles comparing the outcomes of SB-ACLR versus DB-ACLR that were published until November 2019.

RESULTS

Seventeen biomechanical studies were included. The anterior laxity measured using the anterior drawer test showed significantly better results in DB-ACLR when compared with SB-ACLR. In addition, outcomes of the anterior tibial translation test under a simulated pivot shift presented with better results at low flexion and 30° in DB-ACLR, compared with SB-ACLR. However, there were no significant biomechanical differences between the groups in internal rotation.

CONCLUSIONS

The present study demonstrated that both techniques for ACLR are associated with restoration of normal knee kinematics. DB-ACLR is superior to SB-ACLR in terms of restoration of anteroposterior stability. However, which technique yields better improvement in internal rotation laxity, and internal rotation laxity under a simulated pivot shift at a specific angle, remains unclear.

LEVEL OF EVIDENCE

This is a level II meta-analysis.

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

BACKGROUND

Significantly better stability may be achieved with a Single Bundle Lateral Plasty (SBLP) reconstruction compared with the Single Bundle (SB) and Double Bundle (DB) procedures.

METHODS

The 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.

FINDINGS

For 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 (P_IE90 = 0.001) and DB (P_AP90 = 0.012; P_IE30 = 0.021; P_IE90 = 0.003) techniques.

INTERPRETATION

SBLP technique showed significantly superior results in terms of antero-posterior and internal-external laxity reduction at time-zero after ACL reconstruction.

Double-Bundle Anterior Cruciate Ligament Reconstruction Using Hamstring Tendon Hybrid Grafts in Patients Over 40 Years of Age: Comparisons Between Different Age Groups

Background:

Several recent studies have reported that favorable clinical results and a high level of patient satisfaction can generally be obtained with no increased risk of complications after single-bundle anterior cruciate ligament (ACL) reconstruction performed in patients >40 years of age. However, no studies have yet clarified the age-based differences in clinical outcomes after double-bundle reconstruction.

Purpose:

To compare clinical outcomes after double-bundle ACL reconstruction using hamstring tendon hybrid grafts between patients in 2 different age groups: ≥40 years and <40 years.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective study was conducted using 96 patients (48 men, 48 women ; mean age, 37 years) who underwent unilateral ACL reconstruction between 2008 and 2011. These patients were divided into 2 groups: group M included patients ≥40 years of age (n = 40 patients), and group Y included patients <40 years of age (n = 56 patients). All patients underwent the same anatomic double-bundle ACL reconstruction procedure. Clinical outcomes were evaluated at 2 years after surgery. Tunnel enlargement was also evaluated by computed digital radiography at 1 week and 2 years after surgery.

Results:

Mean postoperative side-to-side differences in anterior laxity were 0.5 ± 1.9 mm and 1.2 ± 1.5 mm in groups M and Y, respectively; there was a significant difference between the 2 groups (P = .039). There were no significant differences between the groups in Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, or peak muscle torque of the hamstring. On the other hand, peak muscle torque of the quadriceps was significantly lower in group M (81%) than in group Y (89%) (P = .025). With respect to femoral tunnel enlargement, the posterolateral tunnel in group M was significantly larger than that in group Y on anteroposterior and lateral radiographs (P = .015 and P = .002, respectively).

Conclusion:

Equivalent clinical outcomes were seen between the 2 age groups after double-bundle ACL reconstruction. Postoperative anterior laxity was significantly less in older patients than in younger patients, however, older patients had significantly less quadriceps muscle strength than younger patients. Surgeons should be aware of residual muscle weakness and tunnel enlargement when performing double-bundle ACL reconstruction in older patients.

In vivo knee rotational stability 2 years after double-bundle and anatomic single-bundle ACL reconstruction

PURPOSE

The objective of this study was to evaluate knee rotational stability at least 2 years after anatomic single-bundle anterior cruciate ligament (ACL) reconstruction (SB) and double-bundle ACL reconstruction (DB) in comparison with the contralateral healthy knee joint. The Cincinnati, Lysholm and IKDC scores were analysed too.

METHODS

There were 40 patients in both groups, the mean follow-up was 27 months. For all measurements, the navigation system OrthoPilot was used. Measurement started with the patient in the standing position in neutral rotation. Then, the patient achieved in 30° knee flexion under weight-bearing maximal external trunk rotation and returned to the neutral position. The same measurement was done for the internal trunk rotation. For the anterior-posterior stability, KT-1000 arthrometer was used. All measurements were repeated three times for each knee joint.

RESULTS

After the DB reconstruction, the mean external rotation of the tibia (ER) was 8.2° and the internal rotation (IR) was 10.2°. In the contralateral healthy knee joint, ER was 8.5° (p = 0.597) and IR was 12.1° (p = 0.064). After the SB reconstruction, ER was 9.4° and IR was 13.1°. In the contralateral healthy knee joint, ER was 7.7° (p = 0.066) and IR was 9.8° (p = 0.005). Anterior-posterior translation was to the same extent for both groups.

CONCLUSIONS

The DB reconstruction of the ACL restores the rotational stability of the knee joint without any significant difference in comparison to the contralateral healthy knee (p > 0.05). The main finding of this study is that the internal rotational stability of the knee joint after the anatomic SB technique is not sufficient.

Double-bundle anterior cruciate ligament reconstruction is superior to single-bundle reconstruction in terms of revision frequency: a study of 22,460 patients from the Swedish National Knee Ligament Register

PURPOSE

Studies comparing single- and double-bundle anterior cruciate ligament (ACL) reconstructions often include a combined analysis of anatomic and non-anatomic techniques. The purpose of this study was to compare the revision rates between single- and double-bundle ACL reconstructions in the Swedish National Knee Ligament Register with regard to surgical variables as determined by the anatomic ACL reconstruction scoring checklist (AARSC).

METHODS

Patients from the Swedish National Knee Ligament Register who underwent either single- or double-bundle ACL reconstruction with hamstring tendon autograft during the period 2007-2014 were included. The follow-up period started with primary ACL reconstruction, and the outcome measure was set as revision surgery. An online questionnaire based on the items of the AARSC was used to determine the surgical technique implemented in the single-bundle procedures. These were organized into subgroups based on surgical variables, and the revision rates were compared with the double-bundle ACL reconstruction. Hazard ratios (HR) with 95% confidence interval (CI) was calculated and adjusted for confounders by Cox regression.

RESULTS

A total of 22,460 patients were included in the study, of which 21,846 were single-bundle and 614 were double-bundle ACL reconstruction. Double-bundle ACL reconstruction had a revision frequency of 2.0% (n = 12) and single-bundle 3.2% (n = 689). Single-bundle reconstruction had an increased risk of revision surgery compared with double-bundle [adjusted HR 1.98 (95% CI 1.12-3.51), p = 0.019]. The subgroup analysis showed a significantly increased risk of revision surgery in patients undergoing single-bundle with anatomic technique using transportal drilling [adjusted HR 2.51 (95% CI 1.39-4.54), p = 0.002] compared with double-bundle ACL reconstruction. Utilizing a more complete anatomic technique according to the AARSC lowered the hazard rate considerably when transportal drilling was performed but still resulted in significantly increased risk of revision surgery compared with double-bundle ACL reconstruction [adjusted HR 1.87 (95% CI 1.04-3.38), p = 0.037].

CONCLUSIONS

Double-bundle ACL reconstruction is associated with a lower risk of revision surgery than single-bundle ACL reconstruction. Single-bundle procedures performed using transportal femoral drilling technique had significantly higher risk of revision surgery compared with double-bundle. However, a reference reconstruction with transportal drilling defined as a more complete anatomic reconstruction reduces the risk of revision surgery considerably.

LEVEL OF EVIDENCE

III.

Current use of navigation system in ACL surgery: a historical review

PURPOSE

The present review aims to analyse the available literature regarding the use of navigation systems in ACL reconstructive surgery underling the evolution during the years.

METHODS

A research of indexed scientific papers was performed on PubMed and Cochrane Library database. The research was performed in December 2015 with no publication year restriction. Only English-written papers and related to the terms ACL, NAVIGATION, CAOS and CAS were considered. Two reviewers independently selected only those manuscripts that presented at least the application of navigation system for ACL reconstructive surgery.

RESULTS

One hundred and forty-six of 394 articles were finally selected. In this analysis, it was possible to review the main uses of navigation system in ACL surgery including tunnel positioning for primary and revision surgery and kinematic assessment of knee laxity before and after different surgical procedures. In the early years, until 2006, navigation system was mainly used to improve tunnel positioning, but since the last decade, this tool has been principally used for kinematics evaluation. Increased accuracy of tunnel placement was observed using navigation surgery, especially, regarding femoral, 42 of 146 articles used navigation to guide tunnel positioning. During the following years, 82 of 146 articles have used navigation system to evaluate intraoperative knee kinematic. In particular, the importance of controlling rotatory laxity to achieve better surgical outcomes has been underlined.

CONLUSIONS

Several applications have been described and despite the contribution of navigation systems, its potential uses and theoretical advantages, there are still controversies about its clinical benefit. The present papers summarize the most relevant studies that have used navigation system in ACL reconstruction. In particular, the analysis identified four main applications of the navigation systems during ACL reconstructive surgery have been identified: (1) technical assistance for tunnel placement; (2) improvement in knowledge of the kinematic behaviour of ACL and other structures; (3) comparison of effectiveness of different surgical techniques in controlling laxities; (4) navigation system performance to improve the outcomes of ACL reconstruction and cost-effectiveness.

LEVEL OF EVIDENCE

IV.

Comparison Between Single- and Double-Bundle Anterior Cruciate Ligament Reconstruction With 6- to 8-Stranded Hamstring Autograft: A Prospective, Randomized Clinical Trial

BACKGROUND

Whether double-bundle (DB) anterior cruciate ligament (ACL) reconstruction with 6- to 8-stranded hamstring autograft (HG) is better than single-bundle (SB) ACL reconstruction remains debatable, as long-term follow-up data are lacking.

PURPOSE

To prospectively investigate and compare the long-term results of DB and SB ACL reconstruction with a 6- to 8-stranded HG.

STUDY DESIGN

Randomized controlled clinical trial;

LEVEL OF EVIDENCE

1.

METHODS

A total of 80 patients with chronic ACL rupture were randomized to SB or DB ACL reconstruction with a 6- to 8-stranded HG. In the SB group, both the semitendinosus tendon (ST) and the gracilis tendon (GT) were prepared in 3 or 4 strands, with a total of 6 to 8 strands. In the DB group, the ST was prepared in 3 or 4 strands used for the anteromedial bundle, and the GT was prepared in the same manner for the posterolateral bundle. Each graft was fixed with an EndoButton, a bioabsorbable interference screw, and a staple. Outcome assessment was performed by a blinded independent observer using International Knee Documentation Committee (IKDC), Tegner, and Lysholm scores, as well as range of motion (ROM), Lachman test, pivot-shift test, KT-2000 arthrometer side-to-side difference, and return-to-sport data.

RESULTS

A total of 68 patients (DB group, 34; SB group, 34) were observed for a mean of 80 months (range, 74-86 months). There were 2 traumatic instability failures and two 5° extension restrictions in the DB group, while no failures or 5° extension restrictions were observed in the SB group. The mean Lysholm, Tegner, and IKDC scores improved significantly in both groups compared with preoperation scores (P < .05). No patient had a positive Lachman test result. No significant differences were found between groups in functional scores, incidence of pivot shift, ROM, Lachman test, KT-2000 arthrometer anterior laxity, or time and level of return to sport.

CONCLUSION

Both SB and DB ACL reconstruction with 6- to 8-stranded HG showed satisfactory results in subjective scores and anteroposterior and rotational stability over a nearly 7-year follow-up; neither technique was superior.

A systematic review of single- versus double-bundle ACL reconstruction using the anatomic anterior cruciate ligament reconstruction scoring checklist

PURPOSE

The aim of this systematic review was to apply the anatomic ACL reconstruction scoring checklist (AARSC) and to evaluate the degree to which clinical studies comparing single-bundle (SB) and double-bundle (DB) ACL reconstructions are anatomic.

METHODS

A systematic electronic search was performed using the databases PubMed (MEDLINE), EMBASE and Cochrane Library. Studies published from January 1995 to January 2014 comparing SB and DB ACL reconstructions with clinical outcome measurements were included. The items from the AARSC were recorded for both the SB and DB groups in each study.

RESULTS

Eight-thousand nine-hundred and ninety-four studies were analysed, 77 were included. Randomized clinical trials (29; 38%) and prospective comparative studies (29; 38%) were the most frequent study type. Most studies were published in 2011 (19; 25%). The most commonly reported items for both SB and DB groups were as follows: graft type (152; 99%), femoral and tibial fixation method (149; 97% respectively), knee flexion angle during graft tensioning (124; 8%) and placement of the tibial tunnel at the ACL insertion site (101; 66%). The highest level of documentation used for ACL tunnel position for both groups was often one dimensional, e.g. drawing, operative notes or o'clock reference. The DB reconstruction was in general more thoroughly reported. The means for the AARSC were 6.9 ± 2.8 for the SB group and 8.3 ± 2.8 for the DB group. Both means were below a proposed required minimum score of 10 for anatomic ACL reconstruction.

CONCLUSIONS

There was substantial underreporting of surgical data for both the SB and DB groups in clinical studies. This underreporting creates difficulties when analysing, comparing and pooling results of scientific studies on this subject.

Single- vs. double-bundle anterior cruciate ligament reconstruction: a new aspect of knee assessment during activities involving dynamic knee rotation

Few studies have compared single-bundle (SB) and double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) in the knee joint during activities involving change-of-direction maneuvers and knee rotation. This study examined whether the type of ACLR contributes to postphysiotherapy outcomes, with an emphasis on knee function assessment during activities involving dynamic knee rotation. Fifteen male patients after SB ACLR and 15 male patients after DB ACLR took part in the same physiotherapy program. Twenty-four weeks after ACLR, both groups underwent anterior laxity measurement, pivot shift tests, range of movement and joint circumference measurements, subjective assessment of pain and stability levels in the knee joint, peak torque measurement of the muscles rotating the tibia toward the femur, and a run test with maximal speed and change-of-direction maneuvers. Comparative analysis did not show any differences between the results of anterior tibial translation, pivot shift test, range of movement and joint circumference, and subjective assessment of pain and knee joint stability levels. No differences were noted between the groups in peak torque values obtained from the muscles responsible for internal and external tibial rotation or results of the run test. The data obtained from this study can be used by research teams to monitor and compare the effectiveness of various study protocols involving surgical and physiotherapy treatment. The data are especially useful when combined with the clinical assessment of patients who would like to return to sport.

Kinematic Analysis of Five Different Anterior Cruciate Ligament Reconstruction Techniques

Several anatomical anterior cruciate ligament (ACL) reconstruction techniques have been proposed to restore normal joint kinematics. However, the relative superiorities of these techniques with one another and traditional single-bundle reconstructions are unclear. Kinematic responses of five previously reported reconstruction techniques (single-bundle reconstruction using a bone-patellar tendon-bone graft [SBR-BPTB], single-bundle reconstruction using a hamstring tendon graft [SBR-HST], single-tunnel double-bundle reconstruction using a hamstring tendon graft [STDBR-HST], anatomical single-tunnel reconstruction using a hamstring tendon graft [ASTR-HST], and a double-tunnel double-bundle reconstruction using a hamstring tendon graft [DBR-HST]) were systematically analyzed. The knee kinematics were determined under anterior tibial load (134 N) and simulated quadriceps load (400 N) at 0°, 15°, 30°, 60°, and 90° of flexion using a robotic testing system. Anterior joint stability under anterior tibial load was qualified as normal for ASTR-HST and DBR-HST and nearly normal for SBR-BPTB, SBR-HST, and STDBR-HST as per the International Knee Documentation Committee knee examination form categorization. The analysis of this study also demonstrated that SBR-BPTB, STDBR-HST, ASTR-HST, and DBR-HST restored the anterior joint stability to normal condition while the SBR-HST resulted in a nearly normal anterior joint stability under the action of simulated quadriceps load. The medial-lateral translations were restored to normal level by all the reconstructions. The internal tibial rotations under the simulated muscle load were over-constrained by all the reconstruction techniques, and more so by the DBR-HST. All five ACL reconstruction techniques could provide either normal or nearly normal anterior joint stability; however, the techniques over-constrained internal tibial rotation under the simulated quadriceps load.

Does Double-Bundle Anterior Cruciate Ligament Reconstruction Improve Postoperative Knee Stability Compared With Single-Bundle Techniques? A Systematic Review of Overlapping Meta-analyses

PURPOSE

Multiple meta-analyses of randomized controlled trials, the highest available level of evidence, have been conducted to determine whether double-bundle (DB) or single-bundle (SB) anterior cruciate ligament reconstruction (ACL-R) provides superior clinical outcomes and knee stability; however, results are discordant. The purpose of this study was to conduct a systematic review of meta-analyses comparing SB and DB ACL-R to discern the cause of the discordance and to determine which of these meta-analyses provides the current best available evidence.

METHODS

We evaluated available scientific support for SB as compared with DB ACL-R by systematically reviewing the literature for published meta-analyses. Data on patient clinical outcomes and knee stability (as measured by KT arthrometry and pivot-shift testing) were extracted. Meta-analysis quality was judged using the Oxman-Guyatt and Quality of Reporting of Meta-analyses systems. The Jadad algorithm was then applied to determine which meta-analyses provided the highest level of evidence.

RESULTS

Nine meta-analyses were included, of which 3 included Level I Evidence and 6 included both Level I and Level II Evidence. Most studies found significant differences favoring DB reconstruction on pivot-shift testing, KT arthrometry measurement of anterior tibial translation, and International Knee Documentation Committee objective grading. Most studies detected no significant differences between the 2 techniques in subjective outcome scores (Tegner, Lysholm, and International Knee Documentation Committee subjective), graft failure, or complications. Oxman-Guyatt and Quality of Reporting of Meta-analyses scores varied, with 2 studies exhibiting major flaws (Oxman-Guyatt score <3). After application of the Jadad decision algorithm, 3 concordant high-quality meta-analyses were selected, with each concluding that DB ACL-R provided significantly better knee stability (by KT arthrometry and pivot-shift testing) than SB ACL-R but no advantages in clinical outcomes or risk of graft failure.

CONCLUSIONS

The current best available evidence suggests that DB ACL-R provides better postoperative knee stability than SB ACL-R, whereas clinical outcomes and risk of graft failure are similar between techniques.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II studies.

Kinematics of Rotation in Joints of the Lower Limbs and Pelvis during Gait: Early Results-SB ACLR Approach versus DB ACLR Approach

It is difficult to find publications comparing rotation kinematics in large joints of the lower limbs and pelvis during gait in patients after single-bundle (SB) reconstruction of the anterior cruciate ligament (ACLR) with double-bundle (DB) ACLR of the knee. The aim of this study was to compare rotation kinematics in ankle, knee, and hip joints and the pelvis during gait in the 14th week after SB and DB ACLR. The subjects were males after SB (n = 10) and DB (n = 13) ACLR and a control group (n = 15). The values of kinematic parameters were recorded during internal (IR) and external (ER) rotation in the joints during gait using the BTS SMART. The SB ACLR group obtained significantly higher values of ER in the involved knee comparing to DB ACLR and controls and excessive IR in the hip comparing to controls. In the DB ACLR group, excessive ER was noted in the involved leg's foot. Comparing with the DB ACLR and control groups, SB ACLR subjects had more substantial disorders of rotation kinematics in the lower limb joints. However, in both ACLR groups, 14 weeks of postoperative physiotherapy were not enough to fully restore rotation kinematics in joints of the lower limbs during gait.

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

PURPOSE

The purpose was to compare revision rates and patient-reported outcomes between single- and double-bundle anterior cruciate ligament (ACL) reconstructions.

METHODS

All patients from the Swedish National Knee Ligament Register from 2005 through 2011 who underwent primary ACL reconstruction with hamstring autografts were included. Patients with concomitant injuries, except meniscal and chondral injuries, were excluded. By December 31, 2011, 16,791 primary isolated ACL reconstructions had been registered, of which 16,281 were single-bundle and 510 were double-bundle. Cumulative revision rates were estimated using Kaplan-Meier analysis. The Knee injury and Osteoarthritis Outcome Score (KOOS) and EQ-5D were calculated at 1- and 2-year follow-ups.

RESULTS

The revision rate showed no statistically significant differences between the groups (P = .30). Over the 7-year observation period, 347 single-bundle (2.1%) and 8 double-bundle (1.6%) ACL reconstructions were revised. No significant differences in the KOOS or EQ-5D were found between the groups postoperatively. In addition, there were no differences in postoperative improvements in the KOOS or EQ-5D at 1- and 2-year follow-ups.

CONCLUSIONS

Revision rates after single- and double-bundle ACL reconstructions were low. No differences were found in revision rates, KOOS, and EQ-5D between the 2 techniques.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Is double-bundle anterior cruciate ligament reconstruction superior to single-bundle? A comprehensive systematic review

PURPOSE

To describe current evidence on single- and double-bundle anterior cruciate ligament (ACL) reconstruction, in terms of differences in knee kinematics, functional outcomes, patient-reported outcomes and graft failures.

METHODS

An electronic search was made using PubMed (MEDLINE), EMBASE and Cochrane Library. Studies published from January 1995 to August 2011 were included, and an updated search was made in PubMed in July 2012. Therapeutic studies, level of evidence I-III, for isolated primary ACL tears written in English comparing single- and double-bundle reconstruction reporting clinical outcome were included. Quality appraisal based on Cochrane Collaboration's tool for assessing risk of bias was performed.

RESULTS

Of 7,154 potentially eligible studies, 60 papers were included (25 randomised controlled trials, 21 prospective comparative studies, 14 retrospective comparative studies), comprising 4,146 patients (2,072 single-bundle, 2,074 double-bundle). Minor differences were found between study types. An analysis of graft failures revealed fewer re-ruptures in double-bundle reconstruction than single-bundle, 19 and 44, respectively. Up to 45 % of the studies reported a superior outcome in double-bundle reconstruction in terms of antero-posterior laxity, measured with the Lachman, anterior drawer, KT-1000/2000 and navigation. Measurements of rotatory laxity revealed superior results in double-bundle reconstruction measured with pivot shift and navigation in 18/42 (8/15 anatomically reconstructed) and 9/20 studies, respectively. Patient-reported outcome measures and functional outcomes did not differ to a large extent; however, differences when identified were almost exclusively in favour of double-bundle reconstruction.

CONCLUSION

Based on current evidence, double-bundle reconstruction appears to have fewer re-ruptures and less antero-posterior and rotatory laxity. Furthermore, no differences were found in short-term patient-reported outcome measures or objective findings. However, detailed statistical analyses of the included studies divided into homogeneous groups are needed to avoid reporting bias and to confirm any statistical difference.

Mid- to long-term results of single-bundle versus double-bundle anterior cruciate ligament reconstruction: randomized controlled trial

PURPOSE

To evaluate the mid-to long-term results of a randomized controlled trial of single-bundle (SB) versus double-bundle (DB) anterior cruciate ligament (ACL) reconstruction using a semitendinosus tendon.

METHODS

Seventy-eight patients who underwent primary ACL reconstruction with an autologous semitendinosus tendon were prospectively randomized into 2 groups: SB reconstruction (n = 39) and DB reconstruction (n = 39). In both groups, grafts were fixed at 30° of flexion with a total tension of 80 N. The following evaluation methods were used: clinical examination, KT-1000 arthrometer (MEDmetric, San Diego, CA) measurement, muscle strength, Tegner activity score, Lysholm score, subjective rating scale regarding patient satisfaction and sports performance level, graft retear, contralateral ACL tear, and additional meniscus surgery.

RESULTS

Fifty-three patients (25 in SB group and 28 in DB group) who were followed up for a minimum of 3 years (mean, 69 months; range, 36 to 140 months) were evaluated. Preoperatively, there were no differences between the groups. Postoperatively, the Lachman and pivot-shift test results were better in the DB group (P = .024 and P < .0001, respectively). KT measurements were better in the DB group (mean, 1.4 mm v 2.7 mm; P = .0023). The Tegner score was also better in the DB group (P = .033). There were no significant differences in range of motion, muscle strength, Lysholm score, subjective rating scale, graft retear, and secondary meniscal tear.

CONCLUSIONS

In ACL reconstruction using the transtibial approach, DB reconstruction was significantly better than SB reconstruction regarding anterior and rotational stability during the 3- to 12-year follow-up. The results of KT measurements and the Lachman and pivot-shift tests were significantly better in the DB group, whereas there was no difference in the anterior drawer test results. The Tegner score was also better in the DB group; however, there were no differences in the other subjective findings.

LEVEL OF EVIDENCE

Level II, lesser-quality prospective randomized trial.

In vivo kinematic evaluation of anatomic double-bundle anterior cruciate ligament reconstruction

BACKGROUND

There is controversy regarding the functional role of the posterolateral (PL) bundle of the anterior cruciate ligament (ACL).

PURPOSE

To evaluate the in vivo function of the PL and anteromedial (AM) bundles of the ACL during anatomic double-bundle (DB) ACL reconstruction for acute, isolated ACL tears utilizing a computer navigation system to track intraoperative knee kinematics.

STUDY DESIGN

Controlled laboratory study.

METHODS

Fifteen patients with acute, isolated ACL tears who underwent anatomic DB ACL reconstruction formed the sample for this study. During surgery, knees were examined by a clinician preoperatively, after fixation of the PL bundle, and after fixation of both the PL and AM bundles. An image-free computer navigation system with custom-made software recorded the data during kinematic tests. The examination consisted of the Lachman and anterior drawer tests, internal-external rotation at 30° of knee flexion, and varus-valgus rotation at 30° of knee flexion. Paired Wilcoxon tests were performed to evaluate the effects of each bundle. The comparisons included ACL-deficient to PL bundle-reconstructed knees, ACL-deficient to DB ACL-reconstructed knees, and PL bundle-reconstructed to DB ACL-reconstructed knees. Significance was set at P < .017 to account for the multiple comparisons.

RESULTS

Fixation of the PL bundle significantly improved knee laxity during the Lachman and anterior drawer tests as well as internal-external rotation at 30° of knee flexion (P < .017 for all tests). The addition of the AM bundle further improved knee laxity during the Lachman and anterior drawer tests compared with PL bundle fixation as well as during varus-valgus rotation at 30° of knee flexion compared with ACL-deficient knees (P < .017 for all tests).

CONCLUSION

This in vivo study demonstrates that isolated PL bundle reconstruction improves laxity in an ACL-deficient knee and that the addition of the AM bundle improves laxity parameters further.

CLINICAL RELEVANCE

Abnormal knee kinematics is known to be linked to the earlier onset of osteoarthritis and lower rates of return to sport. This study suggests that both the AM and PL bundles are important to stabilize ACL-deficient knees.

Comparison of double-bundle anterior cruciate ligament (ACL) reconstruction and single-bundle reconstruction with remnant pull-out suture

PURPOSE

The purpose of this study was to evaluate the stability and functional outcomes of anterior cruciate ligament (ACL) reconstruction by tensioning of the ACL remnant using pull-out sutures compared with ACL double-bundle reconstruction.

METHODS

Forty-four patients were included in single-bundle reconstruction with remnant tensioning group (Group 1), and 56 patients were included in the double-bundle reconstruction group (Group 2). The remnant tissue was tensioned to the direction of posterolateral bundle, which unrelated to the type of remnant bundle. Objective knee stability was evaluated by anterior stress radiography, KT-1000 and lateral pivot shift tests. The Tegner activity scale, International Knee Documentation Committee and OrthopädischeArbeitsgruppeKnie scoring systems were used for clinical evaluation.

RESULTS

No statistically significant intergroup differences were observed in mechanical stability and clinical results (n.s). However, surgical time of remnant tensioning group is shorter than double-bundle reconstruction group (P = 0.005).

CONCLUSION

Remnant tensioning suture with single-bundle reconstruction could be used with positive results as good as double-bundle technique if a good ACL remnant was found bridging the femur and tibia, rather than debride or damage to the remnant tissue during operation.

LEVEL OF EVIDENCE

Retrospective, comparative cohort study, Level IV.

Prospective randomized comparison of anatomic single- and double-bundle anterior cruciate ligament reconstruction

PURPOSE

To determine if anatomic double-bundle anterior cruciate ligament (ACL) reconstruction is superior to anatomic single-bundle reconstruction in restoring the stabilities and functions of the knee joint.

METHODS

A prospective randomized clinical study was done to compare the results of 32 cases of anatomic single-bundle ACL reconstruction and 34 cases of anatomic double-bundle ACL reconstruction with average follow-up of 16.3 ± 3.1 months. Tunnel placements of all the cases were measured on 3D CT. Clinical results were collected after reconstruction; graft's appearance, meniscus status and cartilage state under arthroscopy were compared and analysed too.

RESULTS

Tunnel placements, confirmed with 3D CT, were in the anatomic positions as described in literature both in SB and DB group. No differences were found between SB and DB groups in clinical outcome scores, pivot shift test and KT 1000 measurements (average side-to-side difference for anterior tibial translation was 0.7 mm in SB group and 1.0 mm in DB group). More than 70 % of the single-bundle graft and AM bundle graft in DB group appeared excellent, but only 44.1 % of PL bundle grafts in DB group were excellent and 11.8 % were in poor state. No new menisci tear was found either in SB or DB group, however, in DB group cartilage damages in medial patella-femoral joint occurred in 38.2 % cases. This rate was significantly higher than in the SB group which is only 9.3 %.

CONCLUSION

Both single- and double-bundle anatomic ACL reconstruction can restore the knee's stability and functions very well. However, more incidences of poor PL status and medial patellar-femoral cartilage damage may occur in double-bundle ACL reconstruction.

AM bundle controls the anterior-posterior and rotational stability to a greater extent than the PL bundle - a cadaver study

BACKGROUND

The purpose of this study was to evaluate the influence of both bundles of the anterior cruciate ligament (ACL) on knee stability, anterior-posterior translation (APT) and internal (IR) and external (ER) rotation in cadaveric knees using a computer navigation system.

METHODS

The APT, IR, and ER of the knees were recorded in the intact condition, the anterolateral bundle (AM) or the posterolateral bundle (PL) deficit condition and in the ACL-deficient condition. The KT-1000 arthrometer was used for APT evaluation. The measurement of rotational movements was done using a rollimeter. All tests were performed at 30°, 60° and 90° of flexion.

RESULTS

At 30° of flexion: In the intact knee APT was 5.8mm, IR 12.1°, ER 10.1°. After the AM was cut, the APT increased to 9.1mm, IR to 13.9° and ER to 12.6°. After the PL was cut, the APT was 6.4mm, IR 13.1° and ER 10.6°. After the AM and PL were cut, the APT was 10.8mm, IR 15.7° and the ER was 12.9° on average.

CONCLUSIONS

The AM has a greater impact on the APT than the PL in all knee joint flexion angles. The PL does not resist the rotational stability more than the AM. The rotational stability is better controlled by both bundles of ACL as compared to one bundle of the ACL.

CLINICAL RELEVANCE

This study acknowledges the fact that the both bundles of the ACL are importants for AP and rotational stability of the knee joint.

Progression of osteoarthritis after double- and single-bundle anterior cruciate ligament reconstruction

BACKGROUND

No consensus has been reached on the advantages of double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) over the single-bundle (SB) technique, particularly with respect to the prevention of osteoarthritis (OA) after ACLR.

PURPOSE

To evaluate whether DB ACLR has any advantages in the prevention of OA or provides better stability and function after ACLR compared with the SB technique.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

A total of 130 patients with an ACL injury in one knee were prospectively randomized into a DB group (n = 65) or an SB group (n = 65). For the radiologic evaluation, we determined the degree of OA based on the Kellgren-Lawrence grade before the operation and at the time of the final follow-up and determined the number of patients with progression of OA more than one grade from pre- to postoperation. We evaluated the stability results using the Lachman and pivot-shift tests and stress radiography. We also compared the functional outcomes based on the Lysholm knee score, Tegner activity score, and International Knee Documentation Committee (IKDC) subjective scale.

RESULTS

Six patients (4 in the DB group and 2 in the SB group) suffered graft failure during the follow-up and had ACL revision surgery (P = .06). A total of 112 patients were observed for a minimum of 4 years (DB group, n = 52; SB group, n = 60). Five patients (9.6%) in the DB group and 6 patients (10%) in the SB group had more advanced OA at the final follow-up (P = .75). All patients recovered full range of motion within 6 months from surgery. Stability results of the Lachman test, pivot-shift test, and the radiographic stability test failed to reveal any significant intergroup differences (P = .37, .27, and .67, respectively). In the pivot-shift result, the DB group had 4 patients with grade 2 and the SB group had 3 patients with grade 2 (P = .27). Clinical outcomes, including Lysholm knee and Tegner activity scores, were similar in the 2 groups. Statistical significance was achieved only for the IKDC subjective scale (78.2 in DB group vs 73.1 in SB group; P = .03).

CONCLUSION

The DB technique, compared with SB, was not more effective in preventing OA and did not have a more favorable failure rate. Although the DB ACLR technique produced a better IKDC subjective scale result than did the SB ACLR technique, the 2 modalities were similar in terms of clinical outcomes and stability after a minimum 4 years of follow-up.

Long-term results of arthroscopically assisted anatomical single-bundle anterior cruciate ligament reconstruction using patellar tendon autograft: are there any predictors for the development of osteoarthritis?

PURPOSE

The primary purpose of our study was to analyse the long-term outcome of patients treated for anterior cruciate ligament (ACL) tears by anatomical single-bundle ACL reconstruction with patellar tendon autograft. The secondary purpose was to identify predictive factors for good outcome and occurrence of osteoarthritis.

METHODS

Sixty-three patients (m:f = 54:9; mean age at surgery, 27 ± 7 years) treated by ACL reconstruction were evaluated with a mean follow-up of 16 ± 1 years using IKDC2000, the SF36, Lysholm and Tegner score, Knee Society score, visual analogue scale for pain and satisfaction and KOOS. The femoral tunnel position was evaluated according to Sommer. It was also assessed in percentage of the Blumensaat line and the tibial tunnel position in percentage of the total anterior-posterior plateau length. The extent of osteoarthritis was graded according to the Kellgren-Lawrence score.

RESULTS

The total IKDC2000 was normal in 20 (32 %), nearly normal in 29 (46 %), abnormal in 12 (19 %) and severely abnormal in 3 (5 %) of patients. The mean total SF-36 was 89 ± 13, the Lysholm score 95 ± 12, the Knee Society score 191 ± 16 and the total KOOS 84 ± 19. The Tegner score decreased from pre-injury 7(4-10) to 6 (2-10) at follow-up. The Kellgren-Lawrence score was normal in 17 (27 %), suspected osteoarthritis in 25 (40 %), minimal osteoarthritis in 5 (8 %), moderate osteoarthritis in 9 (14 %) and severe osteoarthritis in 3 patients (5 %). The femoral tunnel was in zone A in 43 patients (68 %), in zone B in 16 (25 %) and in zone C in 4 patients (7 %). The femoral tunnel position in percentage of the Blumensaat line was 49 ± 3 (range, 44-57), and the tibial tunnel position in percentage of the total anterior-posterior plateau length was 32 ± 6 (range, 21-46). Patients with meniscal lesion at the time of ACL tear showed significantly less favourable outcomes than those without.

CONCLUSIONS

Patients treated by the proposed ACL reconstruction technique showed on average good to excellent long-term results. A meniscal lesion at the time of ACL tear was highly predictive for less favourable outcome.

Double-bundle versus single-bundle reconstruction for anterior cruciate ligament rupture in adults

BACKGROUND

Arthroscopic reconstruction for anterior cruciate ligament rupture is a common orthopaedic procedure. One area of controversy is whether the method of double-bundle reconstruction, which represents the 'more anatomical' approach, gives improved outcomes compared with the more traditional single-bundle reconstruction.

OBJECTIVES

To assess the effects of double-bundle versus single-bundle for anterior cruciate ligament reconstruction in adults with anterior cruciate ligament deficiency.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to February 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 2), MEDLINE (1966 to February week 3 2012) and EMBASE (1980 to 2012 Week 8). We also searched trial registers, conference proceedings, and contacted authors where necessary.

SELECTION CRITERIA

Randomised and quasi-randomised controlled clinical trials comparing double-bundle versus single-bundle reconstruction for anterior cruciate ligament (ACL) rupture in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected articles, assessed risk of bias and extracted data. We contacted investigators to obtain missing information. Where appropriate, results of comparable studies were pooled.

MAIN RESULTS

Seventeen trials were included. These involved 1433 people, mostly young physically active adults. All included trials had methodological weaknesses and were at risk of bias, notably selection bias from inadequate or lack of allocation concealment. Data for pooling individual outcomes were available for a maximum of nine trials and 54% of participants.There were no statistically or clinically significant differences between double-bundle and single-bundle reconstruction in the subjective functional knee scores (subjective IKDC score, Tegner activity score, Lysholm score) in the intermediate (six months up to two years since surgery) or long term (two to five years from surgery). For example, the long term results for the Lysholm score (0 to 100: best score) were: mean difference (MD) 0.12, 95% confidence interval (CI) -1.50 to 1.75; 5 trials, 263 participants). The only trial reporting on long term knee pain found no statistically significant differences between the two groups. There were no significant differences between the two groups in adverse effects and complications (e.g. infection reported by nine trials (7/285 versus 7/393; risk ratio (RR) 1.14, 95% CI 0.46 to 2.81); graft failure reported by six trials (1/169 versus 4/185; RR 0.45; 95% CI 0.07 to 2.90).Limited data from five trials found a better return to pre-injury level of activity after double-bundle reconstruction (147/162 versus 208/255; RR 1.15, 95% CI 1.07 to 1.25). At long term follow-up, there were statistically significant differences in favour of double-bundle reconstruction for IKDC knee examination (normal or nearly normal categories: 325/344 versus 386/429; RR 1.05, 95% CI 1.01 to 1.08; 9 trials), knee stability measured with KT-1000 arthrometer (MD -0.74 mm, 95% CI -1.10 to -0.37; 5 trials, 363 participants) and rotational knee stability tested by the pivot-shift test (normal or nearly normal categories: 293/298 versus 382/415; RR 1.06, 95% CI 1.02 to 1.09; 9 trials). There were also statistically significant differences in favour of double-bundle reconstruction for newly occurring meniscal injury (9/240 versus 24/358; RR 0.46, 95% CI 0.23 to 0.92; 6 trials) and traumatic ACL rupture (1/120 versus 8/149; RR 0.17, 95% CI 0.03 to 0.96; 3 trials). There were no statistically significant differences found between the two groups in range of motion (flexion and extension) deficits.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the relative effectiveness of double-bundle and single-bundle reconstruction for anterior cruciate ligament rupture in adults, although there is limited evidence that double-bundle ACL reconstruction has some superior results in objective measurements of knee stability and protection against repeat ACL rupture or a new meniscal injury. High quality, large and appropriately reported randomised controlled trials of double-bundle versus single-bundle reconstruction for anterior cruciate ligament rupture in adults appear justified.

Does the posterolateral bundle influence rotational movement more than the anteromedial bundle in anterior cruciate ligament reconstruction?

The biomechanical function of the anteromedial (AM) and posterolateral (PL) bundles of the anterior cruciate ligament (ACL) remains controversial. Some studies report that the AM bundle stabilises the knee joint in anteroposterior (AP) translation and rotational movement (both internal and external) to the same extent as the PL bundle. Others conclude that the PL bundle is more important than the AM in controlling rotational movement.

The objective of this randomised cohort study involving 60 patients (39 men and 21 women) with a mean age of 32.9 years (18 to 53) was to evaluate the function of the AM and the PL bundles of the ACL in both AP and rotational movements of the knee joint after single-bundle and double-bundle ACL reconstruction using a computer navigation system. In the double-bundle group the patients were also randomised to have the AM or the PL bundle tensioned first, with knee laxity measured after each stage of reconstruction. All patients had isolated complete ACL tears, and the presence of a meniscal injury was the only supplementary pathology permitted for inclusion in the trial. The KT-1000 arthrometer was used to apply a constant load to evaluate the AP translation and the rolimeter was used to apply a constant rotational force. For the single-bundle group deviation was measured before and after ACL reconstruction. In the double-bundle group deviation was measured for the ACL-deficient, AM- or PL-reconstructed first conditions and for the total reconstruction.

We found that the AM bundle in the double-bundle group controlled rotation as much as the single-bundle technique, and to a greater extent than the PL bundle in the double-bundle technique. The double-bundle technique increases AP translation and rotational stability in internal rotation more than the single-bundle technique.

Anterior cruciate ligament graft choices

CONTEXT

Reconstruction of the anterior cruciate ligament (ACL) is a common surgical procedure; however, there is no consensus to what the best graft option is to replace the injured ACL. The main options available consist of allografts and autografts, which include patellar tendon, hamstring tendon, and quadriceps tendon autografts.

EVIDENCE ACQUISITION

The PubMed database was searched in August 2010 for English-language articles pertaining to ACL grafts.

RESULTS

Postoperative outcome variables were analyzed to determine similarities and differences among the different graft options. These variables include stability, strength, function, return to sports, patient satisfaction, complications, and cost.

CONCLUSIONS

Both allografts and the 3 main options for autografts can provide excellent results in ACL reconstruction and lead to a high percentage of satisfied patients. However, differences exist among the graft choices. Both the similarities and the differences are important to discuss with a patient who will be undergoing ACL reconstruction so that he or she has the best information available when making a choice of graft.

Factors affecting anterior knee pain following anatomic double-bundle anterior cruciate ligament reconstruction

PURPOSE

The purpose of this study was to evaluate the prevalence of anterior knee pain in anatomic double-bundle anterior cruciate ligament (ACL) reconstruction and to identify critical factors affecting postoperative anterior knee pain development.

METHODS

Subjects comprised 171 patients (171 knees) who underwent anatomic double-bundle ACL reconstruction with a follow-up period of ≥2 years. The procedure used bone-patellar tendon-bone plus gracilis tendon (BTB-G) in 56 knees, semitendinosus tendon (ST) in 71 knees, and ST-G in 44 knees. Clinical results and prevalence and severity of anterior knee pain were assessed at 3 months and 2 years postoperatively. Clinical variables influencing anterior knee pain development at each postoperative period were subjected to univariate analysis, followed by logistic regression analysis to identify risk factors for anterior knee pain.

RESULTS

Overall prevalences of anterior knee pain at 3 months and 2 years postoperatively were 42.0 and 11.1%, respectively. Use of BTB-G graft represented the highest prevalence of anterior knee pain between the 3 different grafts (P = 0.001); however, this statistical significance disappeared at 2 years postoperatively. Prevalence of postoperative extension deficit was significantly higher in anterior knee pain-positive cohort than in anterior knee pain-negative cohort at 3 months postoperatively. Level of quadriceps strength was significantly lower, and Lysholm score was significantly worse in anterior knee pain-positive cohort than in anterior knee pain-negative cohort at 2 years postoperatively. According to logistic regression analysis, knee extension deficit was a predisposing factor for the development of anterior knee pain at 3 months postoperatively (odds ratio, 2.76; P = 0.004); however, there was no significant predisposing factor for anterior knee pain at 2 years postoperatively.

CONCLUSIONS

Knee extension deficit was an important predisposing factor for postoperative anterior knee pain in the early postoperative period, and anterior knee pain was associated with impaired quadriceps function and inferior subjective results over 2 years postoperatively. Early recovery of full extension may prevent postoperative development of anterior knee pain and achieve successful outcomes for ACL reconstruction.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

A tale of 10 European centres - 2010 APOSSM travelling fellowship review in ACL surgery

The purpose of ESSKA- APOSSM Travelling fellowship is to better understand the epidemiology, management and surgical techniques for sports across continents. There has been a progressive evolution in ACL reconstruction and there is variation in technique in ACL reconstruction amongst the most experienced surgeons in different continents. During this one month fellowship, we saw various ACL reconstruction techniques using different graft sources, with a variety of graft fixation methods, with the common aim of recreating an anatomical ACL reconstruction.

Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective randomized study with 5-year results

BACKGROUND

Surgical technique is essential in anterior cruciate ligament (ACL) reconstruction.

PURPOSE

This randomized 5-year study tested the hypothesis that double-bundle ACL reconstruction with hamstring autografts and aperture screw fixation has fewer graft ruptures and rates of osteoarthritis (OA) and better stability than single-bundle reconstruction.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Ninety patients were randomized: double-bundle ACL reconstruction with bioabsorbable screw fixation (DB group; n = 30), single-bundle ACL reconstruction with bioabsorbable screw fixation (SBB group; n = 30), and single-bundle ACL reconstruction with metallic screw fixation (SBM group; n = 30). The following evaluation methods were used: clinical examination, KT-1000 arthrometer measurement, and International Knee Documentation Committee (IKDC) and Lysholm knee scores. Additionally, radiographic evaluation was made by a musculoskeletal radiologist who was unaware of the patients' clinical and surgical data. A single orthopaedic surgeon performed all the operations, and clinical follow-up assessments were made in a blinded manner by an independent examiner.

RESULTS

Preoperatively, there were no differences between the groups. Eleven patients (7 in the SBB group, 3 in the SBM group, and 1 in the DB group) had a graft failure during the follow-up and went on to ACL revision surgery (P < .043). Of the remaining 79 patients, a 5-year follow-up was performed for 65 patients (20 in the DB group, 21 in the SBB group, and 24 in the SBM group) who had their grafts intact. At 5 years, there was no statistically significant difference in the pivot-shift or KT-1000 arthrometer tests. In the DB group, 20% of the patients had OA in the medial femorotibial compartment and 10% in the lateral compartment, while the corresponding figures were 33% and 18% in the single-bundle groups, again an insignificant finding. Further, no significant group differences were found in the knee scores.

CONCLUSION

The double-bundle surgery resulted in significantly fewer graft failures and subsequent revision ACL surgery than the single-bundle surgeries during the 5-year follow-up. Knee stability and OA rates were similar at 5 years. In view of the size of the groups, some caution should be exercised when interpreting the lack of difference in the secondary outcomes.

Comparison of anterior and rotatory laxity using navigation between single- and double-bundle ACL reconstruction: prospective randomized trial

PURPOSE

To prospectively assess the anterior tibial translation and rotational kinematics of the knee joint as well as the clinical outcome after single-bundle (SB) and double-bundle (DB) anterior cruciate ligament (ACL) reconstruction.

METHODS

Forty-two patients randomly underwent single-bundle (Group SB, n = 21) or double-bundle (Group DB, n = 21) ACL reconstruction using hamstring tendon autografts. Anterior tibial translation and rotatory laxity were measured prior to and after fixation of the graft during reconstruction under the guidance of a navigation system. Clinical outcome measurements included the evaluation of the joint stability and functional status.

RESULTS

Anterior tibial translation and rotatory laxity were improved significantly at all degrees of knee flexion in both groups. The postoperative total rotation (sum of internal and external rotation) at 30° and 60° (26.6° vs. 24.0°; 28.7° vs. 25.1°) as well as postoperative change in external rotation at 60° (-1.4° vs. -4.6°), and a change in total rotation at 30° and 60° (-7.0° vs. -11.5°; -6.1° vs. -8.9°) differed between the two groups, with better stability in the DB group. At 2 years follow-up, IKDC subjective satisfaction score was significantly different between two groups (70.9 vs. 79.6), while manual and instrumented laxity, pivot shift tests, modified Lysholm score, Tegner activity score, thigh muscle strengths were not different. Correlation analysis showed little correlations between anterior laxity tests at follow-up, and the kinematic variables measured by navigation during surgery while pivot shift test, IKDC subjective satisfaction score, modified Lysholm score, and Tegner activity score were mainly correlated with navigation-measured rotations in both groups.

CONCLUSIONS

The kinematic tests in this study found evidence suggesting that the DB ACL reconstruction improved rotatory laxity better than the SB ACL reconstruction at 30° and 60° of flexion, but there was no difference in functional outcome at 2 years follow-up between SB and DB groups.

LEVEL OF EVIDENCE

Prospective comparative study, Level II.

Single- versus double-bundle ACL reconstruction: is there any difference in stability and function at 3-year followup?

BACKGROUND

Despite a number of studies comparing postoperative stability and function after anatomic double-bundle and single-bundle anterior cruciate ligament reconstruction (ACLR), it remains unclear whether double-bundle reconstruction improves stability or function.

QUESTIONS/PURPOSES

We therefore asked whether patients having single- and double-bundle ACLR using semitendinosus (ST) alone differed with regard to (1) postoperative stability; (2) ROM; and (3) five functional scores.

METHODS

We prospectively followed 60 patients with an isolated anterior cruciate ligament (ACL) injury. Thirty patients underwent single-bundle and 30 patients underwent double-bundle ACL reconstruction. Clinically we assessed stability and range of motion (ROM); anteroposterior stability was assessed by Rolimeter and rotational stability by a pivot shift test. Function was assessed by IKDC, Noyes, Lysholm, Marx, and Tegner activity scales. The minimum followup was 36 months (mean, 46.2 months; range, 36-60 months).

RESULTS

Residual anteroposterior laxity at 3 years postoperatively was similar in both groups: 1.4 ± 0.3 mm versus 1.4 ± 0.2 mm, respectively. We observed no difference in the pivot shift test. ROM was similar in both groups, although double-bundle patients required more physical therapy sessions to gain full ROM. IKDC, Noyes, Lysholm, Marx, and Tegner scores were similar at final followup.

CONCLUSION

Double-bundle reconstruction of the ACL did not improve function or stability compared with single-bundle reconstruction.

LEVEL OF EVIDENCE

Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Evaluation of tibial rotational stability of single-bundle vs. anatomical double-bundle anterior cruciate ligament reconstruction during a high-demand activity - a quasi-randomized trial

The purpose of this study was to compare the tibial rotational stability of anatomical double-bundle anterior cruciate ligament reconstructed knees with single-bundle anterior cruciate ligament reconstructed knees during a high-demand activity. Total of 66 subjects, (22 with double-bundle anterior cruciate ligament reconstruction, 22 with single-bundle anterior cruciate ligament reconstruction, and 22 healthy control individuals) were examined in this study. Using a 9-camera motion analysis system, motion subjects were recorded performing during a drop landing and cutting. Using the point cluster technique, the internal-external tibial rotation of both knees was calculated. The mean maximum range of motion for each knee was evaluated for 3 groups (double-bundle group, single-bundle group, and control group). Clinical assessment, including Tegner score, Lysholm score, and knee arthrometric measurement, revealed restoration of the reconstructed knee stability with no differences between the two anterior cruciate ligament reconstruction groups. The results showed that both groups resulted in tibial rotation values that were significantly smaller than those in the intact legs and those in the healthy controls. There were no significant differences in tibial rotation between the DB group and the SB group. Therefore anatomical double-bundle reconstruction restores normal tibial rotation no more than single-bundle reconstruction during this high-demand dynamic activity. These results suggest a trend towards dynamic overcorrection after the ACL reconstruction.

Anatomic double-bundle and over-the-top single-bundle with additional extra-articular tenodesis: an in vivo quantitative assessment of knee laxity in two different ACL reconstructions

PURPOSE

Combinations of intra- and extra-articular procedures have been proposed for anterior cruciate ligament reconstruction with the aim of achieving an optimal control of translational and rotational knee laxities. Recently, the need for better reproducing the structural and functional behavior of the native anterior cruciate ligament led to the definition of anatomic double-bundle surgical approach. This study aimed to quantitatively verify whether the in vivo static and dynamic behavior obtained using over-the-top single-bundle with extra-articular tenodesis reconstruction was comparable to the results achieved by anatomic double-bundle approach.

METHODS

Thirty-five consecutive patients, with an isolated anterior cruciate ligament injury, were included in the study. Standard clinical laxities and pivot-shift test were quantified before and after anterior cruciate ligament reconstruction by means of a surgical navigation system dedicated to kinematic assessment; displacements of medial and lateral compartment during stress tests were also analyzed.

RESULTS

Single-bundle with extra-articular tenodesis approach presented statistically better laxity reduction in varus/valgus stress test at full extension and in internal/external rotation at 90° of flexion; lateral plasty controlled better the lateral compartment during drawer test and varus/valgus stress test both at 0° and 30° of flexion and both the compartments during internal/external rotation at 90° of flexion. On the other hand, pivot-shift phenomenon was better controlled by anatomic double-bundle reconstruction.

CONCLUSIONS

Both the reconstructions worked similarly for static knee laxity. The extra-articular procedure played an important role in better constraining the displacement of lateral tibial compartment, whereas the anatomic double-bundle reconstruction better restored the dynamic behavior of knee joint highlighted under pivot-shift stress test.

STUDY DESIGN

Case series.

Tibial rotation in single- and double-bundle ACL reconstruction: a kinematic 3-D in vivo analysis

PURPOSE

The effect of double-bundle ACL reconstruction on knee kinematics has recently been studied by several authors under controlled laboratory conditions however little evidence has been derived from dynamic in vivo evaluations. This study hypothesized that tibial rotation during pivoting motor tasks would be better restored after double-bundle ACL reconstructions when compared with single-bundle procedures.

METHODS

Twenty patients with a chronic ACL rupture were randomly assigned to receive a single- or double-bundle ACL reconstruction. Both knees were evaluated pre-operatively by kinematic 3-D gait analysis while performing low- and high-demand motor tasks, including pivoting. At 6 months post-operatively, measurements were repeated in 16 patients. Ten healthy, sex- and age-matched subjects with no history of lower limb pathology formed the control group. The tibial rotational excursion was set as the dependent variable.

RESULTS

The results indicate that at 6 months after surgery both "anatomic" single- and double-bundle ACL reconstruction are able to restore tibial rotational excursion when compared with the contralateral knees and with control knees from uninjured subjects. Chronic ACL-deficient patients show an increase in tibial rotation in both knees during high-demand pivoting tasks.

CONCLUSIONS

Both "anatomic" single- and double-bundle ACL reconstruction adequately restore tibial rotational excursion in a human, "in vivo" kinematic model. As knee stability measurements by in vivo kinematic 3-D analysis more accurately represent actual knee loading during activities, the results of this study might better correlate with functional outcome after ACL reconstructions compared with static knee stability tests or ex vivo laboratory experiments. In such, the results of this dynamic study do not support the theoretical advantage of a double-bundle ACL reconstruction over an "anatomic" single-bundle ACL reconstruction.

A matched pairs comparison of single- versus double-bundle anterior cruciate ligament reconstructions, clinical results and manual laxity testing

PURPOSE

To compare the subjective clinical results as well as manual anterior and rotational stability in patients treated with either single- (SB) or double-bundle (DB) anterior cruciate ligament (ACL) reconstructions.

METHODS

Sixty-four patients who had undergone SB or DB hamstring ACL reconstruction with hamstrings were included in a retrospective matched pair analysis. At follow-up IKDC subjective, CKS, KOOS, CKS and a visual analogue satisfaction scale was assessed. A blinded surgeon examined the joint laxity and completed the objective IKDC. The KT-1000 was used to bilaterally test anterior tibial translation. Patients with confounding variables, which statistically influenced the clinical outcome (passive flexion and extension deficits, persistent quadriceps deficit, tibiofemoral osteoarthritis and non-repairable medial meniscus injury), were identified and excluded from the statistical analysis (n = 10).

RESULTS

For all subjective scores, DB patients reported increased scores compared with SB patients. While consistently higher scores were demonstrated, statistical significance was only achieved for the IKDC subjective (P = 0.04) and VAS satisfaction (P = 0.02). Graded stability results of the Lachman, anterior drawer and pivot-shift tests were significantly higher in the DB group and KT-1000 side-to-side difference was significantly better for DB (P = 0.01).

CONCLUSION

DB ACL reconstruction appeared to more consistently result in significantly higher subjective outcome scores and manual tests of joint stability than SB ACL reconstruction. Besides the surgical technique, normal extension and quadriceps strength after surgery were identified to be an essential component in order to provide the patient with a successful outcome.

Double-bundle versus single-bundle anterior cruciate ligament reconstruction: randomized clinical and magnetic resonance imaging study with 2-year follow-up

BACKGROUND

One aspect of the debate over the reconstruction of the anterior cruciate ligament is whether it should be carried out with the single-bundle or double-bundle technique.

HYPOTHESIS

The double-bundle technique results in fewer graft failures than the single-bundle technique in anterior cruciate ligament reconstruction.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 153 patients were prospectively randomized into 2 groups of anterior cruciate ligament reconstruction with hamstring autografts using aperture interference screw fixation: single-bundle technique (SB group, n = 78) and double-bundle technique (DB group, n = 75). The evaluation methods were clinical examination, KT-1000 arthrometric measurement, the International Knee Documentation Committee (IKDC) and the Lysholm knee scores, and magnetic resonance imaging (MRI) evaluation. All of the operations were performed by 1 experienced orthopaedic surgeon, and all clinical assessments were made by 2 blinded and independent examiners. A musculoskeletal radiologist blinded to the clinical data made the MRI interpretation.

RESULTS

There were no differences between the study groups preoperatively. Ninety percent of patients (n = 138) were available at a minimum 2-year follow-up (range, 24-37 months). Eight patients (7 in the SB group and 1 in the DB group) had graft failure during the follow-up and had anterior cruciate ligament revision surgery (P = .04). In addition, 7 patients (5 in the SB group and 2 in the DB group) had an invisible graft on the MRI assessment at the 2-year follow-up. Also, the anteromedial bundle was partially invisible in 2 patients and the posterolateral bundle in 9 patients. Together, the total number of failures and invisible grafts were significantly higher in the SB group (12 patients, 15%) than the DB group (3 patients, 4%) (P = .024). No significant group differences were found in the knee scores or stability evaluations at the follow-up.

CONCLUSION

This 2-year randomized trial showed that the revision rate of the anterior cruciate ligament reconstruction was significantly lower with the double-bundle technique than that with the single-bundle technique. However, additional years of follow-up are needed to reveal the long-term results.

Comparison of rotatory stability after anterior cruciate ligament reconstruction between single-bundle and double-bundle techniques

BACKGROUND

Controversy persists as to whether double-bundle reconstruction of the anterior cruciate ligament (ACL) has any clinical advantage over single-bundle reconstruction. Several studies have used subjective and nonquantitative manual tests to evaluate the rotatory stability of the knee. The authors have developed a method to quantitate the rotatory stability of the ACL-deficient knee using open magnetic resonance imaging (MRI).

HYPOTHESIS

Anatomic double-bundle reconstruction restores rotatory stability significantly better than does single-bundle reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Twenty-three consecutive patients treated with the single-bundle reconstruction (group S) and 25 consecutive patients treated with the anatomic double-bundle reconstruction (group D) were evaluated. Both reconstruction procedures were performed using hamstring tendon autografts. The Slocum anterolateral rotatory instability (ALRI) test was performed 1 year after surgery using open MRI. To assess rotatory stability, we measured the difference in anterior tibial translation between medial and lateral compartments in the sagittal plane and defined this difference as the ALRI value. In addition, clinical examinations consisting of the Lysholm knee score, Tegner activity score, KT-2000 arthrometer anterior translation examination, and the pivot-shift test were carried out.

RESULTS

The mean side-to-side difference in ALRI values was significantly less (P < .001) in double-bundle reconstruction (mean, 1.2 mm) than in single-bundle reconstruction (mean, 4.1 mm). The mean side-to-side difference in KT-2000 arthrometer measurements was significantly less (P = .014) in double-bundle reconstruction (mean, 1.2 mm) than in single-bundle reconstruction (mean, 2.6 mm). The difference in the incidence of positive pivot-shift tests between group S (43%) and group D (16%) did not reach the level of statistical significance (P = .058). No significant differences in Lysholm score or Tegner score between the groups were observed.

CONCLUSION

The rotatory stability of anatomic double-bundle reconstruction was significantly better than the rotatory stability of single-bundle reconstruction.

In vitro and intraoperative laxities after single-bundle and double-bundle anterior cruciate ligament reconstructions

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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 OF EVIDENCE

Level III, meta-analysis.

Activity profile of members of an online health community after articular cartilage repair of the knee

BACKGROUND

Articular cartilage repair (ACR) procedures aim to alleviate pain and restore function for individuals with chondral defects. Rehabilitation is lengthy, and there are limited data on return to sports and exercise activities after ACR in non-elite-athlete populations. The Internet is a growing source of health-related information for patients, and it has resulted in the emergence of online health communities.

PURPOSE

To establish a postoperative activity profile of users of an online health community who have undergone ACR of the knee and to compare this profile with those from the same community who have undergone initial anterior cruciate ligament reconstruction (ACLR).

STUDY DESIGN

Cross-sectional.

METHODS

Tegner Activity Scale ratings were collected via a self-reported online questionnaire from 201 participants of an online health community who had undergone tibiofemoral and/or patellofemoral ACR (n = 75) or ACLR (n = 126).

RESULTS

A higher Tegner activity level was significantly correlated to time from surgery for ACR (P < 0.005) and ACLR (P < 0.01). At a minimum of 24 months' follow-up, the ACR group had a median postoperative Tegner score of 3, compared with 6 for the ACLR group. Tegner score was significantly negatively correlated with age at time of surgery for ACLR (P < 0.05) but not for ACR. Men demonstrated significantly higher Tegner activity levels than did women for both ACLR and ACR (P < 0.05).

CONCLUSIONS

Activity levels after ACR in this population increased with postoperative time but remained lower than expected when compared with current published clinical and normative data.

CLINICAL RELEVANCE

Engagement with an online health community may influence expectations regarding return to sports and exercise activities. Reporting of activity-level data within clinical studies should be differentiated on the basis of sex. Further research is needed to elucidate factors that determine return to sports and exercise activities after ACR.

DOUBLE-BUNDLE ANATOMICAL RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT: A PROSPECTIVE STUDY WITH TWO-YEAR FOLLOW-UP

OBJECTIVE

To prospectively evaluate the results from double-bundle reconstruction of the anterior cruciate ligament, among patients at our clinic, by means of the 2000 protocol of the International Knee Documentation Committee (IKDC).

STUDY DESIGN

Case series; level of evidence IV.

METHODS

Fifty-eight patients who underwent anatomical reconstruction of the anterior cruciate ligament using an autologous flexor tendon graft by means of the double-bundle technique were evaluated in accordance with the IKDC 2000 protocol. The patients' ages ranged from 17 to 58 years, with a mean of 35.2 years. The follow-up ranged from 24 to 37 months (mean of 28.9 months).

RESULTS

Postoperatively, 89.65% of the pivot-shift test findings were negative. In the final evaluation, 44 (75.86%) of the patients' knees were graded as normal, 13 (22.41%) as nearly normal and one (1.72 %) as abnormal.

CONCLUSION

The technique used was effective in promoting restoration of joint stability, without compromising mobility.