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.
CasagrandaBU, MaxwellNJ, KavanaghEC, TowersJD, ShenW, FuFH. Normal appearance and complications of double-bundle and selective-bundle anterior cruciate ligament reconstructions using optimal MRI techniques. AJR Am J Roentgenol.2009; 192(5): 1407–1415.
5.
EdwardsA, BullAM, AmisAA. The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament, part 1: tibial attachment. Knee Surg Sports Traumatol Arthrosc.2007; 15(12):1414–1421.
6.
EdwardsA, BullAM, AmisAA. The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament, part 2: femoral attachment. Knee Surg Sports Traumatol Arthrosc.2008; 16: (1):29–36.
7.
FerrettiA, MonacoE, LabiancaL, ConteducaF, De CarliA. Double-bundle anterior cruciate ligament reconstruction: a computer-assisted orthopaedic surgery study. Am J Sports Med.2008; 36: 760–766
8.
FerrettiA, MonacoE, LabiancaL, De CarliA, MaestriB, ConteducaF. Double-bundle anterior cruciate ligament reconstruction: a comprehensive kinematic study using navigation. Am J Sports Med.2009; 37(8): 1548–1553.
9.
FerrettiM, ShenW, FuFH, EkdahlM. Osseous landmarks of the femoral attachment of the anterior cruciate ligament: an anatomic study (SS-30). Arthroscopy.2008; 24(Suppl 1):e17.
10.
GardinerA, HoJ, ShahV, SteinerME. Knee kinematics after double bundle versus computer-navigated single-bundle anterior cruciate ligament reconstruction (SS-52). Arthroscopy.2008; 24(Suppl 1):e30.
11.
HoJY, GardinerA, ShahV, SteinerME. Equal kinematics between central anatomic single-bundle and double-bundle anterior cruciate ligament reconstructions. Arthroscopy.2009; 25(5): 464–472.
12.
HofbauerM, ValentinP, KdolskyRRotational and translational laxity after computer-navigated single- and double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc.2010; 18(9): 1201–1207.
13.
IshibashiY, TsudaE, FukudaA, TsukadaH, TohS. Stability evaluation of single-bundle and double-bundle reconstruction during navigated ACL reconstruction. Sports Med Arthrosc.2008; 16(2): 77–83.
14.
IshibashiY, TsudaE, YamamotoY, TsukadaH, TohS. Navigation evaluation of the pivot-shift phenomenon during double-bundle anterior cruciate ligament reconstruction: is the posterolateral bundle more important?Arthroscopy.2009; 25(5):488–495.
15.
JärveläT. Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective, randomize clinical study. Knee Surg Sports Traumatol Arthrosc.2007; 15: 500–507
16.
JärveläT, MoisalaAS, SihvonenR, JärveläS, KannusP, JärvinenM. Double-bundle anterior cruciate ligament reconstruction using hamstring autografts and bioabsorbable interference screw fixation: prospective, randomized, clinical study with 2-year results. Am J Sports Med.2008; 36: 290–297
17.
KanayaA, OchiM, DeieM, AdachiN, NishimoriM, NakamaeA. Intraoperative evaluation of anteroposterior and rotational stabilities in anterior cruciate ligament reconstruction: lower femoral tunnel placed single-bundle versus double-bundle reconstruction. Knee Surg Sports Traumatol Arthrosc.2009; 17(8): 907–913.
18.
KimSJ, JoSB, KumarP, OhK. Comparison of single- and double-bundle anterior cruciate ligament reconstruction using quadriceps tendon-bone autografts. Arthroscopy.2009; 25(1): 70–77.
19.
KondoE, MericanAM, YasudaK, AmisAA. Biomechanical comparisons of knee stability after anterior cruciate ligament reconstruction between 2 clinically available transtibial procedures: anatomic double bundle versus single bundle. Am J Sports Med.2010; 38(7): 1349–1358.
20.
KondoE, YasudaK, AzumaH, TanabeY, YagiT. Prospective clinical comparisons of anatomic double-bundle versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients. Am J Sports Med.2008; 36(9): 1675–1687.
21.
MeredickRB, VanceKJ, ApplebyD, LubowitzJH. Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament, a meta-analysis. Am J Sports Med.2008; 36(7): 1414–1421.
22.
MeyersAB, HaimsAH, MennK, MoukaddamH. Imaging of anterior cruciate ligament repair and its complications. AJR Am J Roent-genol.2010; 194: 476–484
23.
MillerTT. MR imaging of the knee. Sports Med Arthrosc Rev.2009; 17(1):56–67.
24.
MunetaT, KogaH, MochizukiTA prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques. Arthroscopy.2007; 23(6): 618–628.
25.
PalmerI. On the injuries to the ligaments of the knee joint. Acta Chir Scand.1938; 91: 282.
26.
ParkSJ, JungYB, JungHJOutcome of arthroscopic single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a preliminary 2-year prospective study. Arthroscopy.2010; 26(5): 630–636.
27.
SalmonL, RussellV, MusgroveT, PinczewskiL, RefshaugeK. Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy.2005; 21(8): 948–957.
28.
SamuelssonK, AnderssonD, KarlssonJ. Treatment of anterior cruciate ligament injuries with special reference to graft type and surgical technique: an assessment of randomized controlled trials. Arthros-copy.2009; 25(10): 1139–1174.
29.
SastreS, PopescuD, NúñezM, PomesJ, TomasX, PeidroL. Double-bundle versus single-bundle ACL reconstruction using the horizontal femoral position: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc.2010; 18(1): 32–36.
30.
SeonJK, ParkSJ, LeeKB, YoonTR, SeoHY, SongEK. Stability comparison of anterior cruciate ligament between double- and single-bundle reconstructions. Int Orthop.2009; 33(2): 425–429.
SieboldR, DehlerC, EllertT. Prospective randomized comparison of double-bundle versus single-bundle anterior cruciate ligament reconstruction. Arthroscopy.2008; 24(2): 137–145.
33.
SieboldR, EllertT, MetzS, MetzJ. Femoral insertions of the antero-medial and posterolateral bundles of the anterior cruciate ligament: morphometry and arthroscopic orientation models for double-bundle bone tunnel placement, a cadaver study. Arthroscopy.2008; 24(5): 585–592.
34.
SongEK, OhLS, GillTJ, LiG, GadikotaHR, SeonJK. Prospective comparative study of anterior cruciate ligament reconstruction using the double-bundle and single-bundle techniques. Am J Sports Med.2009; 37(9): 1705–1711.
35.
SonodaM, MorikawaT, TsuchiyaK, MoriyaH. Correlation between knee laxity and graft appearance on magnetic resonance imaging after double-bundle hamstring graft anterior cruciate ligament reconstruction. Am J Sports Med.2007; 35(6): 936–942.
36.
StockleU, HoffmannR, SchwedkeJAnterior cruciate ligament reconstruction: the diagnostic value of MRI. Int Orthop.1998; 22: 288–292
37.
StreichNA, FriedrichK, GotterbarmT, SchmittH. Reconstruction of the ACL with a semitendinosus tendon graft: a prospective randomized single blinded comparison of double-bundle versus single-bundle technique in male athletes. Knee Surg Sports Traumatol Arthrosc.2008; 16(3): 232–238.
38.
TakedaY, SatoR, OgawaT, FujiiK, NaruseA. In vivo magnetic resonance imaging measurement of tibiofemoral relation with different knee flexion angles after single- and double-bundle anterior cruciate ligament reconstructions. Arthroscopy.2009; 25(7): 733–741.
39.
TsaiAG, WijdicksCA, WalshMP, LaPradeRF. Comparative kinematic evaluation of all-inside single-bundle and double-bundle anterior cruciate ligament reconstruction, a biomechanical study. Am J Sports Med.2010; 38(2): 263–272.
40.
TsudaE, IshibashiY, FukudaA, TsukadaH, TohS. Comparable results between lateralized single- and double-bundle ACL reconstructions. Clin Orthop Relat Res.2009; 467(4): 1042–1055.
41.
WuJL, SeonJK, GadikotaHRIn situ forces in the anteromedial and posterolateral bundles of the anterior cruciate ligament under simulated functional loading conditions. Am J Sports Med.2010; 38(3):558–563.
