Sports Medicine Research: In the Lab & In the Field: Double-Bundle Reconstruction Results in Superior Clinical Outcome than Single-Bundle Reconstruction (Sports Med Res)
Wednesday, July 11, 2012

Double-Bundle Reconstruction Results in Superior Clinical Outcome than Single-Bundle Reconstruction

Double-bundle reconstruction results in superior clinical outcome than single-bundle reconstruction

Zhu Y, Tang R, Zhao P, Shu S, Li Y, & Li J. Knee Surgery, Sports Traumatology, Arthroscopy. 2012; doi 10.1007/s00167-012-2073-8

Injuries to the anterior cruciate ligament (ACL) often necessitate surgical reconstruction.  The debate continues as to whether or not the double-bundle (DB) technique is more beneficial than the single-bundle (SB) technique.  The purpose of this meta-analysis was to analyze the literature and find previous clinical trials that compared the single- and double-bundle ACL surgical reconstruction techniques.  A literature search resulted in 18 trials that met the inclusion criteria (prospective, randomized studies that compared DB vs. SB and included patients over 18 years old) and not the exclusion criteria (without follow-up or had nonclinical outcomes).  Included studies had 1,229 patients who received ACL reconstruction (514 DB, 715 SB).  Studies that followed patients > 24 months were categorized as long-term studies and studies that followed patients < 24 months were short-term studies.  Outcomes of interest were clinical (KT-1000, pivot shift, Lachman) and patient-centered outcomes (Lysholm, IKDC, Tenger activity).  DB ACL reconstruction resulted in better clinical outcomes (KT-1000, Lachman, pivot shift, patient reported outcomes [IKDC]) and fewer complications than SB ACL reconstruction, however, there were no differences found in patient-reported functional capacity.  These results were consistently found in the short-term and long-term studies.

Clinically, it appears that DB ACL reconstruction may be superior to SB ACL reconstruction.  Although the DB technique appears to have better outcomes in clinical measures, there were no differences found in patient functional capacity.    In the short-term and long-term follow-up studies, the DB had better clinical outcomes (KT-1000, Lachman, and Tenger activity) however, there were no differences in functional capacity between the groups.  With this in mind, it is important to consider that DB ACL reconstructions carry the inherent risk of tunnel collapse which could result in extremely poor patient outcomes.  It would be interesting to see what the failure rate of DB and SB ACL reconstructions were in the included studies.  Also, as DB ACL reconstruction becomes more common, it would be interesting to follow these patients for longer than 24 months to determine longer-term outcomes.  Very little is still known about the influence of SB vs. DB ACL reconstruction on the incidence of osteoarthritis, and 24 months may not be enough time to see these changes develop.  This time frame is barely long enough to determine successful return to play as it typically takes an ACL patient up to 1 year until they feel “normal” upon return to play.  Has anyone had any patients undergo DB ACL reconstruction?  What seems to be the clinical/anecdotal evidence that you are seeing?

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

Related Posts:

Ying Zhu, Ren-kuan Tang, Peng Zhao, Shi-sheng Zhu and Yong-guo Li, et al. (2012). Double-bundle reconstruction results in superior clinical outcome than single-bundle reconstruction Knee Surgery, Sports Traumatology, Arthroscopy DOI: 10.1007/s00167-012-2073-8


Megan said...

Since this is my first year being certified, I have not come across any patients receiving a double bundle reconstruction surgery. However, I do think that the long term outcomes of this type of surgery will be better than those of the single bundle. From reading previous research about the technique, we can conclude that this surgery better replicates the original anatomical structure of the ACL by recreating both bundles as opposed to the single bundle surgery. Upon completing my cadaver class in graduate school, I had the opportunity to see an uninjured ACL with my own eyes, and it was incredible to see that there really were two bundles, each with their own lines of pull. It was neat to see each of the bundles become taut when placing the knee into different positions. After seeing this, I realized how important it was to recreate both restraints as opposed to one since each one has different "jobs" when the knee is placed into different positions. Creating a better anatomical reconstruction could have benefits for our patients in the long term because if we can restore the ligament as close as possible to anatomical location and function we can possibly prevent poor surgery outcomes in the long term. I agree that more research on the long term outcomes of this type of surgery is necessary to see if the technique of the surgery has improved and to maybe look at how it can be done better.

Nicole Cattano said...

Megan-thank you for your comment! It is great that you have had a chance to take cadaver. It really does give you a whole new appreciation of any and all anatomy. There are two different schools of thought on this topic: You seem to agree with the one side that close to anatomical replication would have better benefits (utilizing the 2 bundles). However, there is another line of thought as well (that you seemed to touch on) that the only thing that matters is graft placement being closest to anatomical location. Single bundle surgeries have evolved from poor placement to something more anatomical which has resulted in significantly better outcomes. The question remains is it the graft footprint/location that is of most importance, or it replicating the 2 separate bundles. The interesting thing about an uninjured ACL is that it has the 2 bundles, but they are not as distinct and separate as the double bundle graft reconstruction. I tend to lean in favor of graft placement, especially until the double-bundle technique evolves and works out tunnel collapse issues. What school of thought do you find yourself agreeing with?

Kyle Kosik said...

I agree with Megan, my school of thought is that the double-bundle technique would provide more stability compared to the single-bundle. The double-bundle would provide more stability for both rotational and sagital plane motions than the single-bundle would. The ACL doesn't only prevent anterior translation of the tibia, but it also prevents rotational forces. If we can mimic the functionality of the ACL by using a double-bundle technique, then I think we should. For me as a clinician, functional stability in all directions is more important than the risk of a tunnel collapsing.

I also strongly agree that more research needs to done looking at the effects of both double-bundle and single-bundle in the long run. Research has done a good job at reporting the results in the short term and the rate of return-to-play. As athletic trainers, return-to-play is important to us, but I think we need to change our school of thought and research emphasis and begin looking at which technique provides stability 40 years from know. Eventually our athletes are not going to be playing sports anymore, and we need to make sure that when they have grandchildren they can still chase them around the house and not feel as if their knee is going to give out. I know as an athletic trainer our job is to get our athletes back on field as soon as possible, but we also need to keep in mind that our athletes are young adults and we need to really look at the long-term consequences of both techniques.

Jeffrey Driban said...

Kyle: Great point. In sports medicine we need to be concerned about preventing not just the acute and chronic injuries associated with physical activity but also preventing the long-term chronic diseases that our patients may be at greater risk for b/c of their injuries. We're in a unique position to be the voice of reason about the long-term consequences of our choices and need to take ownership of that issue not just with the long-term consequences of concussions but also the long-term consequences like osteoarthritis.

Nicole Cattano said...

I couldn't agree with you all more. ACL tears and meniscal injuries have been linked with early onset and development of osteoarthritis. The double bundle surgical technique is relatively new and I think it will be critical to.follow these patients longer term (at least 10 years). The longest follow up studies are approximately 4 years, so we have no ideas yet as to the effects of this surgery in the long term compared to a traditional single bundle technique. In theory, double bundle would have lower rates of OA than single bundle. But we also also have seen that OA rates are no different in those who have their injured ACL reconstructed (single bundle) when compared to those who never have their injured ACL repaired. So maybe biomechanics is not the only culprit.

JhenC said...

Thanks for this very informative blog. ACL (anterior cruciate ligament) reconstruction is a surgical procedure to repair a torn ligament in the knee. During the procedure a surgeon prepares a tendon graft taken either from the patient’s own body (autograft) or from a deceased person (allograft), who has donated parts or all of his/her body to medical science. ACL reconstruction is major surgery. It is elective surgery; meaning that the patient, in consultation with the surgeon, decides whether or not to proceed with the operation. As with any other surgery there are risks and benefits. To know more what are those visit

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