Sports Medicine Research: In the Lab & In the Field: Is Double (Bundle) Always Better? (Sports Med Res)


Friday, November 1, 2013

Is Double (Bundle) Always Better?

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

Related Posts:
Is Double-Bundle ACL Reconstruction Appropriate for Everybody?

Song EK, Seon JK, Yim JH, Woo SH, Seo HY, & Lee KB (2013). Progression of osteoarthritis after double- and single-bundle anterior cruciate ligament reconstruction. The American Journal of Sports Medicine, 41 (10), 2340-6 PMID: 23959965


Caroline Lisee said...

In this study the results concluded that double-bundle surgery produced greater reported function of the IKDC. Although these results should be taken into consideration, they only express an improvement in function base on self-reported subjective results. It would be interesting to analyze these patients gait patterns or biomechanics during functional tasks. Even if a patient feels better functionally, they may still experience compensatory movements. These compensations could explain the lack of difference between the two surgery and OA outcomes.

Nicole Cattano said...

Great point Caroline! I think that gait analysis and biomechanics would only strengthen these findings. Furthermore, I think investigating the biochemical environment may be another layer of information added as well.

Alexandra DeJong said...

This article brings up an interesting point that a meniscus pathology may be correlated with osteoarthritis. I have seen multiple articles remarking on osteoarthritis associated with ACL reconstruction, but it is rare to find a large group of isolated ACL injury patients to get a good sense of validity. I would be interested to see a study concerning isolated meniscus repairs and associated risks of osteoarthritis development to see if this is potentially a confounding issue in the ACL studies. In terms of double vs. single bundle ACL repair, I agree with the conclusion of this review: it would be beneficial to compare outcomes of patients with single bundle ACL repairs to double bundle ACL repairs from surgeons that are experts in each of the surgical options. Since the surgeon in this study only performed 20 double bundle surgeries, there may be statistically significant differences in cases where hundreds have been performed.

Nicole Cattano said...

Alexandra-thank you for your comment. You are absolutely correct that the meniscus seems to be more of an influence than the general public realizes. The problems with a meniscus tear is that the type of year and location can severely affect the ability to repair it. So while it would be nice to compare the efficacy of meniscus repairs to no would take quite some time to find all similar tears. But it is a great point!

Sandeep said...

Are there any studies available that further investigate the role of meniscal injury in development of OA?

Jeffrey Driban said...

Sandeep, this may be of interest to you...
Also, Claes et al.
There's also plenty of studies linking the role of meniscal injury to OA in the absence of an ACL tear. I hope this helps.

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