Prospective evaluation of patients with anterior cruciate ligament reconstruction using a patient-based health-related survey: comparison of single-bundle and anatomical double-bundle techniques
Ochial S, Hagino T, Segna S, Saito M, & Haro H. Archives of Orthopaedic Trauma Surgery. 2011 December 9. [Epub ahead of print] doi: 10.1007/s00402-011-1443-x
Anterior cruciate ligament (ACL) reconstruction is commonly performed on the athletic population to restore function and return to pre-injury sporting activities. There is much debate on the optimal surgical technique to restore kinematics and subjective findings. The purpose of this prospective randomized study was to compare the subjective and objective outcomes of the single-bundle and anatomical double-bundle ACL reconstruction techniques. A total of 84 males were included in the study and evaluated pre-reconstruction, and at 6-months, 12-months, and 24-months post ACL reconstruction. Patients were evaluated objectively for knee stability (i.e., pivot shift and anterior tibial translation using a Telos SE stress device) and subjectively for function (i.e., Lysholm and Short Form-36 questionnaires). There were significant improvements in subjective and objective outcomes between pre- and post-ACL reconstruction, however there were no significant differences found between ACL reconstruction groups at any of the time points.
Patients oftentimes ask clinicians what surgical technique they would choose for ACL reconstruction. It would appear that, between these two surgical approaches, there is no superior answer. There was a high level of patient satisfaction in both groups. The authors limited the inclusion criteria to males only due to the difficulties of performing the double-bundle technique on females who have smaller intercondylar notches. It is interesting that the double-bundle technique was performed on a group unlikely to have any complications and it still failed to show superiority. It would appear that the single-bundle reconstruction technique provides the same outcomes as the double-bundle reconstruction technique, without the added risk of complications. The authors noted that their placement of the single-bundle graft was similar to anatomic placement of the original ACL compared to traditional single-bundle techniques. Furthermore, an anatomic single-bundle reconstruction has been demonstrated to improve rotational instability better than traditional surgical approaches. However, in the current study the authors did not compare their graft placement in the single-bundle technique to the original single-bundle graft placement. Rather than replicating the two bundles of the ACL through a more complicated surgery, it may be that research needs to focus on improving anatomical placement of the new graft. Beyond surgical techniques we may also need to pay more attention to the rehabilitation processes and return-to-play criteria. The idea of treating the “whole patient” and not just the patient’s knee seems to be gaining support. I fear that surgical techniques have gotten so advanced that return to play is borderline rushed and that while the patient may be physically healed, they may not be ready to return to play. In making return to play decisions it may be beneficial to not just look at strength, function, and physical healing, but also possibly looking at criteria such as neuromuscular patterns and mental status (e.g., confidence, fear, anxiety). Does anyone have any experience evaluating these criteria or thoughts on these examples or other criteria that should be evaluated?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban
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Ochiai S, Hagino T, Senga S, Saito M, & Haro H (2011). Prospective evaluation of patients with anterior cruciate ligament reconstruction using a patient-based health-related survey: comparison of single-bundle and anatomical double-bundle techniques. Archives of Orthopaedic and Trauma Surgery PMID: 22160514
Nice post Nicole. I think trying to determine the optimal time to return to play is an important question. I don't think it's clearly understood how the surgical technique, rehab approach, or patient characteristics interact to influence return to play criteria. For that matter, as you point out, it's not clear what the optimal outcome measures for determining clearance for return to play. There's considerable evidence that based on biochemical outcomes and neuromuscular outcomes that the knee might not return to normal during the first two years post-op and some knees may not return to normal. So in addition to determining an optimal time for return to play it's also important for us to look for new treatment strategies that will promote a true recovery that promotes the long-term health of the joint.
We're very proficient in sports medicine at achieving good quick outcomes (returning a person back to activity as quickly and safely as possible) and we often examine how our return to play criteria influences the person's reinjury rate or the level of activity the person maintains after they return but we need to learn more about how our return-to-play decisions influence the long-term health outcomes.
Jeff- i could not agree with you more. As clinicians in the area of sports medicine, we sometimes get more focused on the sports than the long-term health of the patients. If the biochemistry and neuromuscular aspects are still abnormal two years post injury, we really should be looking at how these variables relate to patient outcome measures as well as if there is anything that we can intervene with to help mitigate these longer term derivations from normal.