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The American Journal of Sports Medicine

http://ajs.sagepub.com/content/40/3/512The online version of this article can be found at:

DOI: 10.1177/0363546511426416 2012 40: 512 originally published online November 15, 2011Am J Sports Med

Mohsen Hussein, Carola F. van Eck, Andrej Cretnik, Dejan Dinevski and Freddie H. Fu5-Year Follow-up

and Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction : 281 Cases With 3- to Prospective Randomized Clinical Evaluation of Conventional Single-Bundle, Anatomic Single-Bundle,

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What is This?

- Nov 15, 2011OnlineFirst Version of Record

- Mar 5, 2012Version of Record >>

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Hughston Award

Prospective Randomized ClinicalEvaluation of Conventional Single-Bundle,Anatomic Single-Bundle, and AnatomicDouble-Bundle Anterior CruciateLigament Reconstruction

281 Cases With 3- to 5-Year Follow-up

Mohsen Hussein,*yz MD, Carola F. van Eck,§ MD, PhD, Andrej Cretnik,z MD, PhD,Dejan Dinevski,z PhD, and Freddie H. Fu,§ MD, DSc, DPsInvestigation performed at Artros Center for Orthopaedic Surgery and Sports Medicine,Ljubljana, Slovenia

Background: Three different techniques of anterior cruciate ligament (ACL) reconstruction—conventional (transtibial) single bun-dle (CSB), anatomic single bundle (ASB), and anatomic double bundle (ADB)—have been described.

Purpose: To determine if double-bundle reconstruction is needed to restore rotational stability or if anatomic placement of a sin-gle bundle can yield similar results.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: From December 2005 to December 2007, 320 patients were prospectively randomized into 3 groups: ADB, ASB, andCSB reconstruction. The average follow-up was 51.15 months (range, 39-63 months). At the final follow-up, 281 patients wereavailable. In all groups, hamstring tendons were used with suspensory fixation on the femoral side and bioabsorbable interferencescrew fixation on the tibial side. The outcomes were evaluated by an independent blinded observer using the Lysholm score andsubjective International Knee Documentation Committee (IKDC) form. The KT-1000 arthrometer was used to evaluate anteropos-terior stability, and the pivot-shift test was used to determine rotational stability.

Results: Anatomic single-bundle reconstruction resulted in better anteroposterior and rotational stability than CSB reconstruction(average side-to-side difference for anterior tibial translation was 1.6 mm in the ASB group vs 2.0 mm in the CSB group; P = .002).Negative pivot shift was 66.7% vs 41.7% (P = .003). In other parameters, the differences between groups were not statistically sig-nificant. The results of the ADB group were also superior to the ASB group for anteroposterior and rotational stability (average side-to-side difference for anterior tibial translation was 1.2 mm in the ADB group vs 1.6 mm in the ASB group; P = .002). Negative pivotshift was 93.1% vs 66.7%, respectively (P\ .001), and range of motion was also significantly different (P = .005). The Lysholm scorewas 90.9, 91.8, and 93.0 in the CSB, ASB, and ADB groups, respectively. The difference was significant only when we comparedADB and CSB (P = .025). Subjective IKDC scores were 90.2, 90.6, and 92.1 in the CSB, ASB, and ADB groups, respectively. Thedifference was not significant.

Conclusion: Anatomic double-bundle ACL reconstruction is significantly superior to conventional single-bundle ACL reconstruc-tion and better than anatomic single-bundle reconstruction. Anatomic single-bundle reconstruction was superior to conventionalsingle-bundle reconstruction. However, these differences are small and may not be clinically relevant.

Keywords: ACL; anatomic; reconstruction; single bundle; double bundle

Complete anterior cruciate ligament (ACL) rupture can leadto recurrent knee instability, meniscal tears, and articularcartilage degeneration. The ACL does not heal when torn,

and surgical reconstruction is the standard treatment.6,12

Reconstruction aims at restoring the kinematics and stabil-ity of the injured knee to prevent future degenerativechanges.22 Reconstruction of the ACL has become a com-monly performed procedure, and good to excellent resultshave been reported. However, a critical review of the litera-ture reveals that the success rates vary between 69% and95%.6,7,13,45,48 Conventional reconstruction techniques are

The American Journal of Sports Medicine, Vol. 40, No. 3DOI: 10.1177/0363546511426416� 2012 The Author(s)

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mostly successful in limiting anterior tibial translation butmay be insufficient in controlling combined rotatory loadsof internal and valgus torque.8,30 In addition, a significantportion of patients with ACL reconstruction will not returnto their previous level of sporting activity.8,10-12,14,46 Thissuggests that there remains considerable room for improve-ment in ACL reconstruction.

It has been well described in the literature that the ACLcan be divided into 2 major functional bundles: the anterome-dial (AM) bundle and the posterolateral (PL) bundle.9,16 Bio-mechanical investigations have indicated that anatomic ACLdouble-bundle reconstruction restores knee stability closer tonormal than conventional single-bundle ACL reconstruc-tion.13,15,42,43 In a cadaveric study, Musahl et al31 foundthat double-bundle reconstruction offers better anterior androtational stability than single-bundle. However, they com-pared an anatomic double-bundle technique with a single-bundle technique using traditional transtibial tunnelpositions. These anatomic and biomechanical considerationshave recently sparked an interest in double-bundle recon-struction techniques and anatomic ACL reconstruction meth-ods.9,21,29,33,39 Many prospective comparative clinical studieswith level I or II evidence reported superior results of ana-tomic double-bundle reconstructions compared with single-bundle reconstructions.|| On the other hand, some studiesreported that there is no difference between single-bundleand double-bundle ACL reconstruction.1,38 Also a meta-analysis performed by Meredick et al28 showed that thereis no significant statistical subjective clinical differencebetween the patients treated with either method. However,for all the aforementioned studies, it remains unclear ifboth the single- and double-bundle ACL reconstructions per-formed in these studies were anatomic. In many studies, thesurgeon drilled the femoral tunnels transtibially, in both thesingle-bundle reconstructions and the anteromedial bundlein double-bundle reconstructions. Tunnel mismatch is com-mon when the femoral (AM) tunnel is drilled in a transtibialfashion and can result in tunnel placement outside of thenative insertion site, which can result in abnormal knee kine-matics, limited range of motion, higher than physiologic grafttension, and, ultimately, graft failure. Biological healing ofthe graft-bone interface may also be affected.{

This study compares results of 3 different techniques ofACL reconstruction: conventional single bundle, anatomicsingle bundle, and anatomic double bundle. The aim of thisstudy is to determine if double-bundle reconstruction isneeded to restore rotational stability or if anatomic place-ment of a single bundle can yield similar results. Our

hypothesis is that anatomic single-bundle ACL reconstruc-tion is superior to conventional single-bundle ACL and thatanatomic double-bundle ACL reconstruction is superior toboth conventional and anatomic single-bundle.

METHODS

From December 2005 to December 2007, we performed a pro-spective randomized clinical study to evaluate the results ofthese 3 different methods of ACL reconstruction. Ethicalapproval was obtained from the institutional review boardand from the national medical ethics committee. Patientswere randomized into 3 groups during their office visit: con-ventional single-bundle group (CSB group; n = 85), anatomicsingle-bundle group (ASB group; n = 85), anatomic double-bundle group (ADB group; n = 160). Randomization was per-formed using a computer with randomization software. Twiceas many patients were identified for the last group as it wasuncertain whether these patients had a 1-bundle ruptureand only needed augmentation surgery. If this was thecase, patients were excluded from the study (Figure 1).

Inclusion criteria were an ACL rupture in activepatients with a closed growth plate. Exclusion criteriawere multiligamentous injuries, severe arthritic changes(grade 3 or greater), total or subtotal meniscectomy, con-tralateral ACL-deficient knee, and patients with partialACL rupture. Patients were excluded for the following rea-sons: in the conventional single-bundle group, 3 patientswere undergoing revision ACL reconstruction, 2 had con-tralateral ACL injury and reconstruction, and 3 were mov-ing out of the region. In the anatomic single-bundle group,1 patient was undergoing revision ACL reconstructionbecause of injury, and 1 patient had contralateral ACLinjury and reconstruction. In the anatomic double-bundlegroup, 2 patients were undergoing revision ACL recon-struction, 3 had contralateral ACL injury and reconstruc-tion, 5 patients were moving out of the area, and 19suffered only a 1-bundle tear and underwent augmentationsurgery. All these patients were excluded from the study,and a total of 281 patients were randomized for the 3 pro-cedures: 72 patients in the CSB group, 78 in the ASBgroup, and 131 patients in ADB group (Figure 1).

Preoperatively, all patients had complete examinationto exclude multiligamentous injuries and other pathologicchanges. All patients underwent preoperative examina-tion, including Lachman, anterior drawer, pivot-shift test-ing, and KT-1000 arthrometer with the knee flexed 30� at134 N and manual maximum force (MEDmetric, SanDiego, California). We examined the injured and the con-tralateral knees. All patients were evaluated objectivelyand subjectively. The objective International Knee

||References 2, 3, 20, 23-25, 30, 36, 41, 45.{References 4, 17, 18, 26, 35, 37, 39, 47.

*Address correspondence to Mohsen Hussein, MD, Artros Center for Orthopaedic Surgery and Sports Medicine, Tehnoloski Park 21, 1000 Ljubljana,Slovenia (e-mail: mhussein@artros.si).

yArtros Center for Orthopaedic Surgery and Sports Medicine, Ljubljana, Slovenia.zFaculty of Medicine, University of Maribor, Maribor, Slovenia.§Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.

One or more of the authors has declared the following potential conflict of interest or source of funding: The Department of Orthopaedic Surgery fromthe University of Pittsburgh receives funding from Smith & Nephew to support research related to reconstruction of the ACL. Dr Fu has a family memberwho is employed by Stryker.

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Documentation Committee (IKDC)5 form was completed by1 orthopaedic surgeon who was blinded to the group of thesubject. All patients completed the questionnaires necessaryto calculate the IKDC subjective score and Lysholm score.27

Standard radiographs and magnetic resonance imaging(MRI) had been obtained for all patients. There were nodemographic differences between the 3 groups, and the pre-operative examination was similar, as can be seen in Tables1 and 2. All procedures were performed by the first author.

Operative Techniques

The knee was prepared and draped in the standard fash-ion, and arthroscopic portals were established. The antero-lateral portal was placed a little above the inferior pole ofthe patella at the lateral border of the patellar tendon.The anteromedial portal was placed just below the inferiorpole of the patella, approximately 1 cm medial to themedial edge of the patellar tendon. Finally, an accessoryinferior medial portal was marked medial and distal tothe inferomedial portal slightly above the meniscus andwas established later in the procedure.

The semitendinosus and gracilis tendons were har-vested with a closed tendon stripper through a longitudinalanteromedial incision on the medial side of the proximaltibia, over the insertion of the pes anserinus. Graft prepa-ration was initiated on the back table. Each graft was

trimmed to the appropriate diameter. Before graft passage,an EndoButton CL (Smith and Nephew, Andover, Massa-chusetts) was attached, with a loop length based on meas-urements of tunnel lengths.

Before assessment of the ACL, any meniscal or chondralinjuries were addressed.

Next, the accessory medial portal was established usingan 18-gauge spinal needle under direct visualization. Thisportal was essential to allow improved visualization of thelateral wall of the intercondylar notch and achieve correctplacement of the PL femoral tunnel. Next, the rupture pat-tern of the AM and PL bundle was carefully evaluatedusing a thermal device. Special attention was given tothe remaining fibers of each bundle, and the insertion sitesof the AM and PL bundle were very carefully visualizedthrough the lateral and medial portals. This was notalways possible, especially in chronic cases. Then we visu-alized and identified the bony landmarks, especially thelateral intercondylar ridge and the lateral bifurcate ridge.Then we marked the location of the native femoral and tib-ial footprint, corresponding to their positions in the normalACL (Figure 2). We performed no notchplasty.

Anatomic Double-Bundle Reconstruction

With the scope in the medial portal, a 3/32 Steinman pinwas introduced through the accessory medial portal and

Figure 1. Consort diagram of this study. ACLR, anterior cruciate ligament reconstruction; ADB, anatomic double-bundle group;ASB, anatomic single-bundle group; CSB, conventional single-bundle group; R, reconstruction.

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was placed at the center of the PL femoral insertion site. Inchronic cases, we placed it below the lateral intercondylarridge and anterior to the bifurcate ridge. This was approx-imately 6 mm arthroscopically posterior to the anteriorarticular cartilage border and 3 mm superior to the inferiorborder. The knee was held in 90� of flexion for this stepbecause the position of the femoral insertion sites changeswith the knee flexion angle. After verification of correct pinposition, the knee was flexed to 120�, and the pin was mal-leted into place. An acorn reamer was inserted over theguide wire with special attention taken to avoid injury tothe articular surface of the medial femoral condyle. ThePL tunnel was drilled to a depth of 25 mm and, dependingon overall tunnel length, may later be hand-drilled toa final length. The far cortex was breached using a 4.5-mm EndoButton drill (Smith and Nephew), and total tun-nel length was measured with a depth gauge. The AM fem-oral tunnel was established in a similar way. In chroniccases, we placed it below the lateral intercondylar ridgeand posterior to the bifurcate ridge. This is approximately2 mm posterior to the posterior rim of the PL tunnel, ina horizontal or slightly superior position.

Next, attention was turned to the tibial tunnels. An ACLtibial tunnel director guide (DePuy Mitek, Raynham, Mas-sachusetts) set at 55� was placed in the insertion site ofthe PL bundle, based on anatomic landmarks and previous

marking. The position of the director guide on the tibial cor-tex was just anterior to the superficial fibers of the medialcollateral ligament. After PL guide pin placement, the guidewas set to 45� and was positioned in the AM tibial footprint.The starting point of the AM tunnel on the tibial cortex wasmore anterior, central, and proximal than the starting pointof the PL tunnel. The AM tibial guide pin was placed, andboth pin positions were verified before tunnel drilling.

For PL graft passage, a beath pin with a long loopsuture attached was passed through the accessory medialportal, femoral PL tunnel, and lateral thigh, with theknee hyperflexed to protect the peroneal nerve. The suturewas retrieved through the PL tibial tunnel using an arthro-scopic suture grasper. The PL graft was passed, and theEndoButton was flipped in the standard fashion to achievefemoral fixation. The AM graft sutures were passed in a sim-ilar fashion. The crossing pattern of the 2 bundles of the ACLcan be observed by taking the knee from flexion to extension.The AM graft was then passed and the EndoButton was flip-ped in the standard fashion for femoral fixation (Figure 3).

The knee was cycled from 0� to 120� approximately 25times for preconditioning of grafts. Each graft was fixedwith a bioabsorbable interference screw (DePuy Mitek).The PL graft was tensioned with the knee held in 0�, andthe AM graft was tensioned with the knee in 60� of flexionby manual tensioning. After fixation, the knee was tested

TABLE 2Preoperative Results of Subjective and Objective Evaluation Between All Groupsa

CSB (n = 72) ASB (n = 78) ADB (n = 131) P Value

Lysholm score, mean 6 SD 71.5 6 12.8 73.6 6 12.8 73.9 6 12.4 .418Subjective IKDC, mean 6 SD 63.7 6 14.9 67.7 6 14.0 67.0 6 14.9 .204SSD, mean 6 SD 6.8 6 2.0 6.7 6 1.5 6.8 6 2.0 .912IKDC, No. (%) .326

A 0 0 0B 0 0 0C 55 (76.4) 67 (85.9) 105 (80.1)D 17 (23.6) 11 (14.1) 26 (19.8)

Pivot shift, No. (%) .9990 0 0 01 13 (18.1) 14 (17.9) 25 (19.1)2 58 (80.6) 63 (80.8) 104 (79.4)3 1 (1.4) 1 (1.3) 2 (1.5)

aADB, anatomic double-bundle group; ASB, anatomic single-bundle group; CSB, conventional single-bundle group; IKDC, InternationalKnee Documentation Committee; SSD, side-to-side difference for anterior tibial translation determined with KT-1000.

TABLE 1Demographic Data and Characteristics of Study Sample (N = 281) Patientsa

CSB (n = 72) ASB (n = 78) ADB (n = 131) P Value

Mean age, y (range) 32.6 (16-60) 34.2 (16-63) 32.3 (16-74) .409Follow-up, mo (range) 52 (39-63) 50.5 (39-63) 51 (39-63) .843Sex, male/female 45/27 46/32 80/51 .905Side, right/left, No. 43/29 46/32 68/63 .395Cartilage injury, No. (%) 4 (5.5) 9 (11.5) 7 (5.3) .202Meniscal injury, No. (%) 18 (25.0) 22 (28.0) 29 (22.0) .612

aADB, anatomic double-bundle group; ASB, anatomic single-bundle group; CSB, conventional single-bundle group.

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for range of motion and stability, and the wounds wereclosed in the standard fashion.

Anatomic Single-Bundle Reconstruction

The procedure of anatomic single-bundle reconstructionwas similar to anatomic double-bundle reconstruction.We addressed the femoral tunnel first and performed itthrough the accessory medial portal, but we placed thefemoral tunnel in the center of the marked insertion sites.The position of the femoral tunnel was between the targetpoint of the AM bundle and PL bundle in the double-bundle ACL reconstruction. In chronic cases, we placedit below the lateral intercondylar ridge, at the lateralbifurcate ridge. If these bony landmarks could not beidentified, we placed it in the lower third of the medialwall of the lateral femoral condyle. Next, attention was

turned to the tibial tunnels. An ACL tibial tunnel directorguide (DePuy Mitek) set at 55� was placed in the center ofthe ACL tibial insertion site, based on anatomic land-marks and previous marking. The position of the directorguide on the tibial cortex was 3 cm medial to the tibialtubercle (Figure 4). The graft was then passed and theEndoButton was flipped in the standard fashion for femo-ral fixation. The knee was cycled from 0� to 120� approx-imately 25 times for preconditioning of the graft. Thegraft was fixed using a bioabsorbable interference screw(DePuy Mitek) with the knee at full extension witha forced posterior drawer.

Conventional Single-Bundle Reconstruction

The tip of the tibial guide was introduced through themedial infrapatellar portal and put at the center of themost posterior aspect of the normal ACL insertion between

Figure 3. Arthroscopic view of the left knee in 90� of flexion.(A) Lateral portal view of the anatomic double-bundle tunnelposition of the anteromedial (AM) and posterolateral (PL) tib-ial tunnels. (B) Central portal view of the anatomic double-bundle position of the AM and PL femoral tunnels. Notethat the pull sutures in the AM and PL tunnels cross eachother when the knee is in 90� of flexion. (C) End results afteranatomic double-bundle ACL reconstruction showing the AMand PL bundle grafts.

Figure 4. Arthroscopic view of the left knee in 90� of flexion.(A) Lateral portal view of the anatomic single-bundle positionin the middle of the anteromedial (AM) and posterolateral (PL)bundle insertion site. (B) Central portal view of the anatomicsingle-bundle position in the middle of the AM and PL bundleinsertion site.

Figure 5. Arthroscopic lateral portal view of the left knee in90� of flexion showing the conventional single-bundle recon-struction technique. (A) Tibial tunnel position. (B) The guidewire is placed through the tibial tunnel to determine femoraltunnel location. (C) Tibial and femoral tunnel position usingthe transtibial drilling technique. (D) End results after the con-ventional single-bundle technique.

Figure 2. Arthroscopic view of the left knee in 90� of flexion.(A) Lateral portal view showing marking of the anteromedial(AM) and posterolateral (PL) bundle tibial insertion site.(B) Central portal view showing marking of the AM and PLbundle insertion site as well as the lateral intercondylar ridge(LIR) and lateral bifurcate ridge (LBR).

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the medial and lateral tibial eminence. A guide wire wasinserted into the tibia through the sleeve. A tibial tunnelwas created with a cannulated drill with a diametermatched to the width of the prepared graft. A Kirschnerwire was then drilled into the lateral femoral condyle atthe 1:30-o’clock (or 10:30-o’clock) position, using the trans-tibial tunnel technique. We used a 5- or 6-mm offset guidesystem (DePuy Mitek). Then the drill system for EndoBut-ton fixation was used to create a femoral tunnel. Graft pas-sage and fixation was performed in the same way as in theanatomic single-bundle reconstruction group (Figure 5).

Rehabilitation

Postoperative management followed our standard ACLprotocol for all groups. Continuous passive motion stretch-ing was initiated on the first postoperative day. Crutcheswere used for 1 week, but patients were allowed to bearweight as tolerated. Return to full activities was typicallyallowed at 9 months postoperatively.

Follow-up

In the first 2 hours after the surgery, an anteroposteriorand lateral radiograph of the knee was performed. Allfollow-up examinations were performed by a blinded inves-tigator who was not involved in the surgery. The initialand follow-up examinations were performed by the sameobserver. International Knee Documentation Committeesubjective and Lysholm scores were used to evaluate thesubjective outcomes. The skin incisions were identical forall 3 techniques, so the investigator did not know to whichgroup the patients were assigned. The patients were notblinded because the surgeon informed them about detailsof the operative technique they had.

Statistics

Statistical analysis was done using the SPSS 15.0 softwarepackage (SPSS, Inc, Chicago, Illinois). The calculationsbetween the differences of means were done by analysisof variance (ANOVA) and an independent samples t test,and those of the frequencies were done by the x2 test. Fordeficit of flexion and deficit of extension, the Mann-Whitney U test was employed. The significance level wasset at P \ .05.

Before the investigation was initiated, the sample sizewas estimated on the basis of the hypothesis that therewas no difference between the treatment groups. Thepower analysis was done on the basis of the preliminaryanticipation that the pivot-shift category ‘‘0’’ for anatomicdouble-bundle treatment would improve in a range of25%, from approximately 50% to approximately 75% suc-cess. The initial 50% success rate in the pivot-shift cate-gory 0 for anatomic single-bundle treatment was setaccording to our previous experience. The expectedimprovement between control and test group in pivot-shiftcategory 0 is statistically estimated as a medium effectsize. For a x2 test at a = 0.05 and 3 degrees of freedom,

to achieve 0.8 power, we needed a sample size of 120patients.10 The 25% improvement in pivot-shift category0 for anatomic double-bundle treatment would not onlyresult in a statistical significance but also representa meaningful clinical significance.

RESULTS

The average follow-up in this study was 51 months, rang-ing from 39 to 63 months. The results of last follow-up eval-uation are outlined in Table 3.

Comparing the outcomes in single-bundle groups showsthat at the final evaluation, the outcome of anatomic singlegroup was better than the conventional single-bundlegroup for anteroposterior and rotation stability (Table 3).The side-to-side difference for anteroposterior stabilitywas 1.6 mm in the ASB group and 2.0 mm in the CSBgroup (P = .002). Rotational stability indicated that66.7% of the ASB group and 41.7% of the CSB group hada 0 pivot-shift result (P = .003). The Lysholm score was90.9 in the CSB group and 91.8 in the ASB group. This dif-ference was not significant (P = .366). The subjective IKDCscore was 90.2 in the CSB group and 90.6 in the ASBgroup, which was also not significant (P = .688). In addi-tion, there was no difference in the objective IKDC scorebetween the groups (P = .224).

Comparing the outcomes between conventional single-bundle and anatomic double-bundle reconstruction showedthat the outcome of the anatomic double-bundle group wasbetter than the conventional single-bundle group for allmeasured parameters except objective IKDC (Table 3).The side-to-side difference for anteroposterior stabilitywas 1.2 mm in the ADB group and 2.0 mm in the CSBgroup (P \ .001). Rotation stability indicated that 93.1%of the ADB group and 41.7% of the CSB group hada 0 pivot-shift result (P \ .001). The Lysholm score was90.9 in the CSB group and 93.0 in the ADB group. This dif-ference was significant (P = .025). The subjective IKDCscore was 90.2 in the CSB group and 92.1 in ADB group.This difference was again not significant (P = .06). The dif-ference according to the objective IKDC score was signifi-cant (P = .009).

Comparing the outcomes between anatomic single-bundle and anatomic double-bundle reconstruction showedthat the results of the anatomic double-bundle group werebetter than the anatomic single-bundle group for antero-posterior and rotation stability and knee range of motion(Table 3). The side-to-side difference for anteroposteriorstability was 1.2 mm in the ADB group and 1.6 mm inthe ASB group (P = .002). Rotational stability indicatedthat 93.1% of the ADB group and 66.7% of the ASB grouphad a 0 pivot-shift result (P \ .001). The Lysholm scorewas 91.8 in the ASB group and 93.0 in the ADB group.This difference was not significant (P = .051). The subjec-tive IKDC score was 90.6 in the ASB group and 92.1 inthe ADB group. This difference was not significant (P =.087). In addition, the difference according to the objectiveIKDC score was not significant (P = .245).

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DISCUSSION

This study compared conventional single-bundle, anatomicsingle-bundle, and anatomic double-bundle reconstructionfor ACL rupture. Preoperatively, there were no significantdifferences in demographics between the 3 groups. However,the rate of cartilage injury in the ASB group was twice ashigh as that in the other 2 groups. The most important find-ing of the present study was that the results of anatomicsingle-bundle reconstruction were superior to conventionalsingle-bundle reconstruction for anteroposterior and rota-tional stability. Anatomic double-bundle reconstruction wassuperior to both conventional and anatomic single bundle.When comparing anatomic double bundle to conventionalsingle bundle, it resulted in superior outcome for all objectiveand subjective outcome measurements, except subjectiveIKDC. When comparing the anatomic double-bundle groupto the anatomic single-bundle group, there were significantdifferences in anteroposterior and rotation stability and rangeof motion. However, most of these differences were small, andthe clinical relevance of this difference is not known.

Most of the published clinical studies comparing single-and double-bundle reconstruction do not present a fair com-parison because often one or both surgical techniques were

not performed anatomically. For example, some studiescompared transtibial single-bundle reconstruction with ana-tomic double-bundle reconstruction.# In contrast with otherstudies, in our study, we looked at the results of the conven-tional single-bundle reconstruction group separately fromthe anatomic single-bundle group and compared themwith each other and with those of an anatomic double-bundle group. Another issue is that anatomic ACL recon-struction has not yet been well defined. Some authorshave attempted to provide guidelines, definitions, and crite-ria,39 but none of these is generally accepted.

Yasuda et al44 performed a prospective comparativestudy on anatomic double-bundle, single-bundle, and non-anatomic double-bundle procedures in 72 patients. Theyreported that the results of anatomic double bundle aresignificantly better than single bundle based on anteropos-terior and rotation stability. There was no significant dif-ference between the single-bundle and nonanatomicdouble-bundle groups. Also, they found no significant dif-ference between the 3 groups in the IKDC evaluation,range of motion, and muscle torque. In our study, we

TABLE 3Comparison of Conventional Single-Bundle Group, Anatomic Single-Bundle Group, and Anatomic Double-Bundle Groupa

CSB (n = 72) ASB (n = 78) ADB (n = 131) P Value

Lysholm score, mean 6 SD 90.9 6 7.0 91.8 6 4.3 93.0 6 4.0 CSB vs ASB = .366CSB vs ADB = .025ASB vs ADB = .051

Subjective IKDC, mean 6 SD 90.2 6 7.6 90.6 6 6.4 92.1 6 5.5 CSB vs ASB = .688CSB vs ADB = .063ASB vs ADB = .087

SSD, mean 6 SD 2.0 6 0.9 1.6 6 0.8 1.2 6 0.9 CSB vs ASB = .002CSB vs ADB \ .001ASB vs ADB = .002

DE, mean 6 SD 0.6 6 1.0 0.6 6 1.1 0.2 6 0.7 CSB vs ADB = .782ASB vs ADB \ .001CSB vs ASB = .005

DF, mean 6 SD 1.9 6 2.8 1.7 6 3.2 1.2 62.6 CSB vs ASB = .728CSB vs ADB = .020ASB vs ADB = .187

IKDC, No. (%) CSB vs ASB = .224CSB vs ADB = .009ASB vs ADB = .245

A 57 (79.2) 69 (88.5) 122 (93.1)B 14 (19.4) 9 (11.5) 9 (6.9)C 1 (1.4) 0 0D 0 0 0

Pivot shift, No. (%) CSB vs ASB = .003CSB vs ADB \ .001ASB vs ADB = .001

0 30 (41.7) 52 (66.7) 122 (93.1)1 35 (48.6) 25 (32.1) 9 (6.9)2 7 (9.7) 1 (1.3) 03 0 0 0

aADB, anatomic double-bundle group; ASB, anatomic single-bundle group; CSB, conventional single-bundle group; DE, deficit of exten-sion; DF, deficit of flexion; IKDC, International Knee Documentation Committee; SSD, side-to-side difference for anterior tibial translationdetermined with KT-1000.

#References 2, 3, 23-25, 30, 36, 39-41, 45.

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compared anatomic double bundle to conventional andanatomic single bundle, which will help us to conclude ifbetter results are due to 4 tunnels, to a more anatomicposition of the tunnels, or both. Kondo et al,25 in a prospec-tive comparative study of 328 patients, reported that ana-tomic double bundle is superior to single bundle. Thedouble-bundle group had significantly better results interms of anterior laxity and pivot shift. But there wereno significant differences in terms of IKDC, subjectivescores, range of knee motion, muscle torque, and rate ofreturn to sports activities between the 2 procedures. How-ever, this study was not randomized. In addition, they useda transtibial technique to place the femoral tunnels.Aglietti et al,3 in a randomized single-blinded study witha minimum follow-up of 24 months, reported that doublebundle showed significantly better results in terms of ante-roposterior stability measured with the KT-2000, visualanalog scale, and objective IKDC. But there was no signif-icant difference between the 2 groups in the pivot shift andsubjective measurements. A limitation of this study wasthat only 70 patients were included, with a follow-up ofonly 24 months, which is shorter than in the present study.

Some studies show that there is no significant differencein any of their clinical evaluations between single-bundleand double-bundle groups.20 Park et al,32 in prospectivestudy with 113 patients, found that double-bundle recon-struction of the ACL using 2 tibial tunnels and 2 femoraltunnels showed no differences in stability results or anyother clinical aspects in terms of patient satisfactionwhen compared with single-bundle reconstruction. Inboth studies, they used a transtibial technique and the‘‘o’clock’’ method to place the femoral tunnels.

Recent studies have shown that using transtibial dril-ling leads mostly to nonanatomic, consistently anteriorlypositioned femoral tunnels.26,37 In addition, with the trans-tibial tunnel technique, there is some difficulty in obtain-ing the correct femoral anatomic position for the PLbundle. Furthermore, using the ‘‘o’clock’’ method can oftenlead to misconceptions because of the 3-dimensional natureof the intercondylar notch, where the clock face can be putanywhere along the anterior-to-posterior axis.19,35 In con-trast with the studies performed by Ibrahim et al20 andPark et al,32 the present study showed a significant differ-ence between groups. One possible explanation for this dif-ference could be that we separated the conventional andanatomic single-bundle groups. In addition, the femoraltunnels in our anatomic double-bundle group were drilledfreehand and, as such, independent of the respective tibialtunnel position, without use of the ‘‘o’clock’’ reference. Thefixation on the femur was the same for all groups, in con-trast with their studies, in which they used hybrid fixation.

Sastre et al,34 in a randomized prospective study with20 patients in each single- and double-bundle group, putthe femoral tunnels more horizontal in both groups andfound no significant differences between them. Theauthors concluded that placing the femoral tunnel ina more horizontal position in the single-bundle group pro-duced similar rotatory and anteroposterior laxity control tothat obtained with the double-bundle technique in patientswith low functional demands. In contrast, in our study, we

did find a significant difference between anatomic singleand double-bundle groups probably because in our study,we put the femoral anteromedial tunnel in a more ana-tomic position through the accessory portal, whereas theydrilled it through the tibial tunnel. Also, they had a smallnumber of patients (n = 40).

Our study has some limitations. The first limitation isthat we had different numbers of patients in the groups,especially in the ADB group. We did not individualize oursurgery (to determine the type of reconstruction, graft type,and size depending on patients’ individual measurements ofthe ACL insertion sites and intercondylar notch) becausethe patients were randomized to 1 of 3 reconstruction meth-ods before the surgery, regardless of the intra-articular anat-omy. The anatomy can be very different between individuals,but individualization cannot be performed because of the ran-domized nature of the study design. There is a need forfuture studies that will individualize the surgery and proba-bly will be more anatomic than ours.

CONCLUSION

Anatomic double-bundle ACL reconstruction is superior toboth conventional single-bundle ACL reconstruction andanatomic single-bundle reconstruction. Anatomic single-bundle reconstruction is superior to conventional single-bundle reconstruction. This implies it is most importantto perform ACL reconstructions anatomically. Addinga second bundle may also provide additional stability.

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