Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Was Superior to Conventional Single-Bundle Reconstruction

Question: In patients having anterior cruciate ligament (ACL) reconstruction, how does the anatomic double-bundle tech- nique compare with the anatomic single-bundle technique, and how do both techniques compare with the conventional single- bundle technique?

Design: Randomized (allocation concealed), blinded (outcome assessor), controlled trial with a mean follow-up of 51 months.

Setting: The Artros Center for Orthopaedic Surgery and Sports Medicine in Ljubljana, Slovenia.

Patients: 330 active patients with a closed growth plate who had an ACL rupture. Exclusion criteria were multiligamentous injuries, severe arthritic changes, total or subtotal meniscectomy, contralat- eral ACL-deficient knee, or partial ACL rupture. 281 patients (mean age thirty-three years, 61% men) were included in the analysis.

Intervention: Patients were allocated to 3 different techniques of ACL reconstruction: anatomic double-bundle (n 5 160), anatomic single-bundle (n 5 85), or conventional single-bundle (n 5 85). Anatomic double-bundle reconstruction involved use of an accessory medial portal with placement of the posterolateral socket at the center of the posterolateral femoral insertion site. The anteromedial femoral tunnel was done in a similar way. For the tibial tunnels, the guide was placed in the insertion site of the posterolateral bundle with use of anatomic landmarks. The starting point of the anteromedial tibial tunnel was more anterior and central than the starting point of the posterolateral tunnel was During anatomic single-bundle reconstruction, the femoral tunne was placed in the center of the marked insertion sites and the tibial- tunnel director guide was placed in the center of the ACL tibial insertion site. For conventional single-bundle reconstruction, the tibial guide was placed at the center of the most posterior aspect of the ACL insertion between the medial and lateral tibial eminence The femoral tunnel was created with use of the transtibial tunnel technique. All grafts were fixed with EndoButton fixation devices (Smith & Nephew, Andover, Massachusetts) on the femur and with bioabsorbable interference screws on the tibia.

Main outcome measures: Subjective outcomes were mea- sured with use of the Lysholm score (0 to 100; ,65 5 poor and .90 5 excellent) and the International Knee Documentation Committee (IKDC) subjective score. Objective outcomes were the side-to-side difference for anteroposterior stability as mea- sured with the KT-1000 arthrometer, the pivot-shift test for rotational stability (category 0 indicated the best result), and the IKDC objective score.

Main results: The anatomic double-bundle reconstruction was associated with better results than the conventional single- bundle technique for the Lysholm score, anteroposterior sta- bility, rotational stability, and the IKDC objective score; the groups did not differ with regard to subjective IKDC score (Table). Compared with the anatomic single-bundle tech- nique, the anatomic double-bundle had better results for anteroposterior and rotational stability (Table). The anatomic single-bundle reconstruction was better than the conventional single-bundle reconstruction for anteroposterior and rota- tional stability (Table).

Conclusion: In patients having ACL reconstruction, the anatomic double-bundle technique was superior to both the conventional and anatomic single-bundle techniques for re- storing anteroposterior and rotational stability. The double- bundle technique also had better results than the conventional technique on the Lysholm score and the IKDC objective score.

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