of Osteoarthritis After Double- and Single-Bundle Anterior Cruciate Ligament

Song E, Seon J, Yim J, Woo S, Seo H, &
Lee K. American Journal of Sports
.  Epub ahead of print August 11, 2013; doi:

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?
by: Nicole Cattano
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