Progression of Osteoarthritis After Double- and Single-Bundle Anterior Cruciate Ligament Reconstruction
Song E, Seon J, Yim J, Woo S, Seo H, & Lee K. American Journal of Sports Medicine. Epub ahead of print August 11, 2013; doi: 10.1177/0363546513498998
Take Home Message: Over four years, patients who received a double-bundle ACL reconstruction had better function but no other differences (e.g., osteoarthritis) compared with patients who received a single-bundle ACL reconstruction. However, meniscal status at the time of surgery may be an important risk factor for developing knee osteoarthritis.
Double-bundle anterior cruciate ligament (ACL) reconstruction may better replicate the native biomechanical ACL properties than traditional single-bundle ACL reconstructions, possibly resulting in better short- and long-term outcomes. Several studies have investigated the short-term outcomes after these reconstruction techniques, but few have looked at the long-term outcomes. The authors conducted this randomized trial to compare stability and clinical outcomes between a single- and double-bundle ACL reconstruction over the course of 4 years. One surgeon performed ACL surgery on 130 patients that the authors randomized in alternating order to either double-bundle (65 patients) or single-bundle (65 patients) reconstruction. The authors included patients if they suffered an ACL injury with no concomitant ligamentous instability and had no radiographic knee osteoarthritis or history of knee arthroscopy. Clinical stability (Lachman, pivot-shift), clinical outcome (activities of daily living [Lysholm], physical activity [Tegner], function [IKDC]), and radiographic assessments were done at every follow-up (3 and 6 months, 1, 2, and 4 years) visit. Patients with a double-bundle ACL reconstruction experienced better function (IKDC) after surgery than patients with a single-bundle reconstruction but the authors observed no other differences between groups. Patients with a meniscectomy at the time of their ACL reconstruction (regardless of group) were more likely to have radiographic osteoarthritis at the 4 year follow-up (16%) compared with patients without a meniscectomy (4%).
Clinically, double-bundle ACL reconstruction does not result in any major superior outcomes compared with the traditional single-bundle technique. Short-term outcomes of ACL reconstruction techniques have been previously studied with similar findings (See previous post on Zhu article). However, this is one of the first to compare osteoarthritis incidence after reconstructions. Where reconstruction technique may be inconsequential for short- and long-term outcomes, meniscal status may play a significant role. Over half of the patients in this study had a meniscal injury and they had a higher incidence of osteoarthritis than those that had no meniscal injury. These researchers wish to continue to follow these patients out longer, and I think this may yield interesting results. It could be that the meniscal status accelerates osteoarthritic changes over the first few years, but that the reconstruction technique may have an impact further down the road. While it appears that individuals with a double-bundle ACL reconstruction had minimal benefit (function) above those who received a single-bundle reconstruction, these results should be interpreted with caution. The surgeon involved in this study was more experienced in the traditional single-bundle technique and had only performed 20 double-bundle reconstructions prior to this study. It would be interesting to see how patients compare after each reconstruction technique among surgeons with different experience levels. In conclusion, if an athlete is considering a double-bundle technique they can rest assured that it is equivalent if not a little better than single-bundle reconstructions and we may help them find a surgeon with the most experience to help optimize outcomes.
Questions for Discussion: Do you think that there is value to the double-bundle technique? Does anyone have any ideas of how to manage ACL injuries with concomitant meniscal injuries?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban
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