Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up

Hussein M, van Eck CF, Cretnik A, Dinevski D, & Fu FH. American Journal of Sports Medicine. 2011 November 15. [Epub ahead of print] doi: 10.1177/036546511426416

Rupture of the anterior cruciate ligament (ACL) can result in decreased function, knee stability, and an increased likelihood of meniscal and cartilage damage. ACL reconstruction is often performed to restore stability/function, and includes various surgical techniques focused on restoring pre-injury joint kinematics. The purpose of this prospective randomized study was to compare the results of 3 unique ACL reconstruction techniques (i.e., conventional single bundle-graft focused to limiting anterior translation of tibia, anatomic single bundle-graft placed closer to anatomic position of the original ACL, and anatomic double bundle-two separate and distinct graft bundles to replicate the anatomic position and composition of the original ACL) among 281 patients. The analyses included 72 patients that were assigned to the conventional single bundle, 78 patients to the anatomical single bundle, and 131 patients to the anatomic double bundle group. There were no pre-operative differences between the 3 groups in all subjective and objective measures (i.e., Lachman, pivot shift, anterior drawer, KT-1000, International Knee Documentation Committee [IKDC] form). Average post-surgery follow up was 51 months (range 39 to 63 months). Anatomic single bundle reconstructions resulted in better anteroposterior and rotational stability than the conventional single bundle technique, despite having similar patient outcomes (Lysholm & IKDC). Anatomic double bundle technique resulted in better anteroposterior and rotational stability than the anatomic single bundle technique with no differences in patient outcomes as well.

This study is the first to take a look at the graft placement in addition to the surgical technique performed. Restoration of joint kinematics to pre-injury function seems to be dependent on replicating the original ACL as closely as possible. The results of this study reinforce the concept that graft placement may be one of the most critical components of an ACL reconstruction. Even though the anatomic double bundle was found to be statistically superior to the anatomic single bundle technique for stability outcomes, the clinical relevance remains unclear, as there were no differences found in patient outcomes among any of the surgical techniques. This may indicate that patient outcomes are not solely dependent upon restoration of joint kinematics. While it is evident that physicians and clinicians need to be concerned with correct anatomic graft placement, we also need to figure out what else is influencing patient reported outcomes. It may be that we need to focus on other aspects (e.g., psychological) throughout the rehabilitation process as well. It is important to remember to treat the whole patient, as opposed to just the injury. In regard to patient centered approaches, the authors also introduced the notion of future studies investigating an individualized approach to patient ACL reconstruction based on their anatomic architecture. This is an interesting concept, and I wonder what features would determine anatomic single bundle versus double bundle surgical techniques. Does anyone have any opinions on what else may influence patient outcomes post-ACL reconstruction?

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

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Hussein M, van Eck CF, Cretnik A, Dinevski D, & Fu FH (2011). Prospective Randomized Clinical Evaluation of Conventional Single-Bundle, Anatomic Single-Bundle, and Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction: 281 Cases With 3- to 5-Year Follow-up. The American Journal of Sports Medicine PMID: 22085729