ARTHROSCOPIC ANTERIOR CRUCIATE

LIGAMENT REPAIR
SINGLE BUNDLE VS DOUBLE BUNDLE

Presenter : Dr Abhishek Chaudhary (DNB ortho

resident at SGITO)
Moderator: Dr Madan Ballal (professor and head
of dept of sports medicine)
 Applied Anatomy
Biomechanics
ACL tear
Available treatment options
Surgical procedures-single and double
bundle
Journals discussion-single bundle vs double
bundle
Final conclusion
- length of 38 mm (range 25 -41 mm)
- width of 10 mm (range 7 -12 mm)

- made up of multiple collagen fascicles;

- surrounded by an endotendineum
- microspocially: interlacing fibrils (150 to 250 nm in diameter
- grouped into fibers (1 to 20 um in diameter)
- synovial membrane envelvope

- innervation:
- receives its innervation from tibal nerve;
- infiltrates the capsule posteriorly;
- golgi tendon receptors;

- blood supply:
- major blood supply: from middle genicular artery
- bony attachments do not provide a significant source of
blood to distal or proximal ligaments;
 Femoral attachment:
ACL arises from the posteromedial corner of medial aspect of
lateral femoral condyle in the intercondylar notch;
attachment is actually an interdigitation of collagen fibers &
rigid bone thru transitional zone of fibrocartilage and
mineralized fibrocartilage;
femoral attachment of ACL is on posterior part of medial surface
of lateral condyle well posterior to longitudinal axis of the
femoral shaft;
Tibial attachment:
tibial attachment is in a fossa in front of & lateral to anterior
spine, a rather wide area from 11 mm in width to 17 mm in AP
direction;
anterior fibers go forward to level of transverse meniscal
ligament;
inserts into the interspinous area of the tibia;
 Anterior & Posterior Bundles:

ACL is composed of two principal parts: small anteromedial band

and a larger bulky posterolateral portion;

anteromedial bundle is tight in flexion and the posterolateral

bundle is tight in extension;

extension: both bundles are parallel;

flexion:
femoral insertion site of the posterolateral bundle moves
anteriorly
- both bundles are crossed
- anteromedial bundle tightens and
posterolateral bundle loosens
- represents posterior directly directed fibers w/ its attachment just lateral
to midline of the intercondylar eminence and slightly lateral to most lateral
attachement of the intermediate bundle;

- unlike the antermedial portion, the bulkier posterolateral bundle is not

isometric.

- interruption of posterolateral bundle of ACL increases external

rotation recurvatum test of posterolateral after anteromedial and intermediate
bundles are divided;

- - w/ knee extended, resistance to the anterior drawer test is by posterolateral

bulky portion;
- it limits anterior translation, hyperextension, and rotation;
- oblique position of the posterolateral bundle provides more
rotational control than is provided by the anteromedial bundle, which is in a
more axial position;
- hyperextension and internal rotation place the posterolateral bundle
at greater risk for injury;
- rupture cause increases in hyperextension, anterior translation
(extended knee), increase in external and internal rotation (knee extended),
and increases in external rotation with the knee in mid flexion;
 anteromedial bundle:
- femoral insertion of the anteromedial bundle is the center
of rotation of ACL
- anteromedial bundle has isometric behavior;
- is more prone to injury with the knee in flexion
- anteromedial bundle inserts on the medial aspect of the
intercondylar eminence of the tibia and forms the medial corner of
the triangle;
- anteromedial band is primary check against anterior
translation of tibia on femur when anterior drawer test is performed
in usual manner w/ knee flexed;
- cutting this ligament may produce anterolateral
instability;
- limits anterior translation of the tibia on the femur with
the knee in flexion (which requires isometric behavior);
- rupture may cause in an increase in anterior translation in
flexion, minimal increase in hyperextension, and minimal rotational
instability;
- intermediate bundle:
- cutting this ligament produces straight anterior instability;
- when anteromedial band of the ligament is torn,
posterolateral bulk of ligament may remain intact & anterior drawer
sign will be present but surgeon will
have impression that ligament is not torn;
 accounting for approximately 85% of the
resistance to the anterior drawer test when the
knee is at 90 degrees of flexion and neutral
rotation.

Tension in the anterior cruciate ligament is least

at 30 to 40 degrees of knee flexion. The anterior
cruciate ligament also functions as a secondary
restraint on tibial rotation and varus valgus
angulation at full extension.

proprioceptive function
 - ultimate tensile load: 2160 157 N

Or simply we can suspend (2160/9.81=220kg) on the strongest

acl before it breaks.
- stiffness:(force to deform it permanenty)- 242 28 N/mm;
- passive knee extension produces forces along ACL only
during last 10 degrees of knee extension;
- hyper-extension:
- the posterolateral bundle of the ACL is tight in
extension;
- at 5 degrees of hyperextension, anterior cruciate
ligament forces range between 50 and 240 newtons;
- hyperextension of the knee develops much higher
forces in ACL than in the PCL;
- flexion:;
- during isometric quadriceps contraction, ACL strain at
30 deg of knee flexion are significantly higher than at 90 deg
where ligament remain unstrained
with isometric quadriceps activity;
- active extension of knee between the limits of 50 and
110 degrees does not strain the anterior cruciate;
- at 90 deg of knee flexion:
- ACL accounts for approx 85% of resistance to anteior
drawer test
 Sectioning of ACL:
- in unsectioned ACLs in neutral rotation, application of
100 newtons of anterior force produces:
- 2-5 mm of anterior translation at full extension;
- 5-8 mm of translation at 30 deg of flexion;
- as flexion angle increases further, anterior
translation decreases;
- sectioning of ACL results in increased laxity at all flexion
angles;
- 20-30 deg of flexion:
- maximum anterior translation occurs w/ 100-
newton anterior force, 7-9 mm of increased translation is
seen;
- clinically, combined ACL and MCL tears result in large
increases in anterior translation;
- following sectioning of the ACL: anterior restraint derives
from:
- iliotibial band: 24%
- mid medial capsule: 22%
- mid lateral capsule: 20%
- MCL:16%
- LCL: 12%
 Functional Role:
- ACL is the predominant restraint to anterior tibial
displacement;
- ligament accepts 75 % of anterior force at full extension &
approx 85 % at 30 and 90 degrees of flexion;
- deep MCL is a major secondary restraint to anterior
translation;

role in gait: (gait menu and role of knee in locomotion)

- ACL is taut in full knee extension, and tends to
externally rotate tibia;
- tension in ACL is least at 40 to 50 deg of knee
flexion;
- as knee moves from flexion to extension, shorter,
more highly curved lateral condyle exhausts its articular
surface & is checked by ACL;
- larger and less curved medial condyle continues its
forward roll and skids backward, assisted by tightening of PCL;
- towards full extension there is lateral rotation of tibia
& joint is "screwed home;"

consequences of ACL deficient knee

- absence of the normal internal rotation of the
femur during the terminal swing phase
 Isometry:
- anterior cruciate ligament does not
remain an isometric, or constant length,
structure as the knee is flexed and extended;
- ligament increases in strain magnitude as
the lower leg is passively extended, with the
femur in a horizontal plane;
- reconstruction of the ACL should not
strive to achieve an isometric placement of
the graft, but rather reproduce strain
behavior of the normal ACL
 Incidence unknown but estimates It is estimated that
the annual incidence of ACL injury is about 1 in 3,000
amongst the general population in the USA.

Mechanism of injury: non contact inj such as

noncontact deceleration, jumping, or cutting action
accounts for 70 % of ACL tears.

Contact injury (external forces)-30 % of ACL tears

Immidiate Symptoms:-pain swelling,inabilty to walk
normaly or at all ,a pop sound on hyperextention .

Late symptoms: feeling of instability, joint giving up or

leg falling out of knee joint these symptoms increases
on walking down the stairs and when patient is trying
to run
 Signs..knee effusion (haemarthrosis)

The Lachman test is the most sensitive test for anterior

tibial displacement (95% sensitivity)

Increased excursion relative to the opposite knee and

absence of a firm end point suggest an injury to the
anterior cruciate ligament.

The pivot shift test requires a relaxed patient and an

intact medial collateral ligament. When the result is
positive, this test reproduces the pathological motion
in an anterior cruciate ligamentdeficient knee and is
easier to elicit in a chronic anterior cruciate ligament
disruption or in an anaesthetized patient with an acute
anterior cruciate ligament injury
 Knee ligament arthrometers such as the KT-1000/2000

can assist in the diagnosis but are more effective in

evaluating patients with chronic anterior cruciate
ligament disruption

when pain and associated muscle guarding are absent.

These devices also are useful for documentation of
surgical results.

both intraoperatively and postoperatively. With a manual

maximal anterior displacement, the right-left difference
is less than 3 mm in 95% of normal knees. The right-left
difference is 3 mm or more in 90% of knees with an
acute anterior cruciate ligament injury
 incidence of meniscal tears with acute anterior cruciate
ligament injuries to range from 50% to 70%. The lateral
meniscus is more commonly injured with the initial
incident.

As a result of abnormal loading and shear stresses in the

anterior cruciate ligamentdeficient knee, the risk of late
meniscal injury is high and appears to increase with time
from the initial injury.

Most late meniscal tears occur in the medial meniscus

because of its firm attachment to the capsule.

Osteochondral damage also influences prognosis. The

reported incidence ranges from 21% to 31% in patients
examined after the initial injury.
 MRI is the gold standard diagnostic
investigation for ACL injury.

Also gives details of osteochondral damage

and other soft tissue
 History :-

The first recorded description of rupture of the ACL, was

by Stark in 1850 .

Autologous Fascia Lata and Meniscal Grafts In 1912

The Hamstring Graft In 1934 the Italian orthopaedic

surgeon Riccardo Galeazzidescribeda technique forACL
reconstructionusing the semi-tendinosus tendon.

Patellar Tendon Grafts In 1935, Campbell. Marshall et al.

in 1979 also used the central third of the patellar tendon
By the1990s the technique of using a free bone-patellar
tendon-bone graft harvested from the central one-third
of the patella became the Gold Standard of treatment.
 Synthetic Grafts
Benson suggested the potential biological and
biomechanical Significanceofpurecarbonin1971 carbon
fibre graft.

Allograft
During the 1980s a remarkable interest developed in the
use of allograft tissue for ACL reconstruction . freeze
dried grafts used after upto 18 months of preservation.
inferior results compared to autografts

During the 1980s, techniques for arthroscopic ACL

reconstruction were becoming increasingly popular.

The Double-Bundle graft-In 2003 Marcacci et al.

described a double-bundle gracilis and semitendinosus
graft that they claimed guaranteed a more anatomic ACL
reconstruction and avoided the use of hardware for graft
fixation
DB
BACKGROUND:
Surgical technique is essential in anterior
cruciate ligament (ACL) reconstruction.

PURPOSE:
This randomized 5-year study tested the
hypothesis that double bundle ACL
reconstruction with hamstring autografts and
aperture screw fixation has fewer graft
ruptures and rates of osteoarthritis (OA) and
better stability than single bundle
reconstruction.
 STUDY DESIGN:
Randomized controlled trial; Level of evidence, 1.

METHODS:
Ninety patients
bioabsorbable screw fixation (DB group; n = 30),
bioabsorbable screw fixation (SBB group; n = 30),\
metallic screw fixation (SBM group; n = 30).

Evaluation:
clinical examination,
KT-1000 arthrometer measurement, and
International Knee Documentation Committee
(IKDC) and Lysholm knee scores.
radiographic evaluation was made by a
musculoskeletal radiologist who was unaware of the
patients' clinical and surgical data.
A single surgeon.
 Preoperatively, there were no differences.

Eleven patients (7 in the SBB group, 3 in the SBM group, and

only 1 in the DB group) had a graft failure during the follow-
up and went on to ACL revision surgery (P < .043).

Of the remaining 79 patients, a 5-year follow-up was

performed for 65 patients (20 in the DB group, 21 in the SBB
group, and 24 in the SBM group) who had their grafts intact.

At 5 years, there was no statistically significant difference in

the pivot-shift or KT-1000 arthrometer tests.

In the DB group, 20% of the patients had OA in the medial

femorotibial compartment and 10% in the lateral
compartment, while the corresponding figures were 33% and
18% in the single-bundle groups, again an insignificant
finding.
no significant group differences were found in the knee
scores.
 The double-bundle surgery resulted in
significantly fewer graft failures and
subsequent revision ACL surgery than the
single-bundle surgeries during the 5-year
follow-up. Knee stability and OA rates were
similar at 5 years.

In view of the size of the groups, some

caution should be exercised when
interpreting the lack of difference in the
secondary outcomes.
 BACKGROUND:
Arthroscopic reconstruction for anterior cruciate
ligament rupture is a common orthopaedic
procedure. One area of controversy is whether the
method of double-bundle reconstruction, which
represents the 'more anatomical' approach, gives
improved outcomes compared with the more
traditional single-bundle reconstruction.

OBJECTIVES:
To assess the effects of double-bundle versus single-
bundle for anterior cruciate ligament reconstruction
in adults with anterior cruciate ligament deficiency.
 DATA COLLECTION AND ANALYSIS:
independently selected articles,.

MAIN RESULTS:
Seventeen trials .
1433 cases,
outcomes were available for a maximum of nine trials and 54% of
participants.

There were no statistically or clinically significant differences between

double-bundle and single-bundle reconstruction in the subjective
functional knee score) at short term..

At long term followup, there were statistically significant differences in

favour of doublebundle reconstruction for IKDC knee examination.

There were no significant differences between the two groups in adverse

effects and complications .

There were also statistically significant differences in favour of double-

bundle reconstruction for newly occurring meniscal injury.

There were no statistically significant differences found between the two

groups in range of motion (flexion and extension) deficits.
 There is insufficient evidence to determine the
relative effectiveness of double-bundle and single-
bundle reconstruction for anterior cruciate ligament
rupture in adults, although there is limited evidence
that double-bundle ACL reconstruction has some
superior results in objective measurements of knee
stability and protection against repeat ACL rupture or
a new meniscal injury.

High quality, large and appropriately reported

randomised controlled trials of double-bundle versus
single-bundle reconstruction for anterior cruciate
ligament rupture in adults appear justified.
BACKGROUND:
Double-bundle ACL reconstruction popularity is
increasing with the aim to reproduce native ACL
anatomy and improve ACL reconstruction outcome.
However, to date, only a few randomized clinical
studies have been published.

PURPOSE:
The aim of this study was to prospectively compare
the clinical results of single- and double-bundle ACL
reconstruction.

STUDY DESIGN:
Randomized controlled clinical trial; Level of evidence,
1.
 METHODS:
Seventy patients
Outcome assessment visual analog scale (VAS) score,
(IKDC) form, the Knee Injury and Osteoarthritis Outcome
Score (KOOS), and KT-1000 arthrometer evaluation.
RESULTS:
minimum follow-up of 2 years.
No differences between the 2 groups were observed in
IKDC subjective score.
A statistically significant difference in favor of the DB
group was found with the VAS (P < .03). The objective
IKDC final scores showed statistically significantly more
"normal knees" in the DB group than in the SB group (P =
.03).
There was 1 stability failure in the DB group and 3 in the
SB group.
The KT-1000 arthrometer data showed a statistically
significant decrease in the average anterior tibial
translation in the DB group (1.2 mm DB vs 2.1 mm SB; P
< .03). The incidence of a residual pivot-shift glide was
14% in DB and 26% in SB (P = .08).
CONCLUSION:
In the 2-year minimum follow-up, DB ACL
reconstructions showed better VAS, anterior
knee laxity, and final objective IKDC scores
than SB. However, longer follow-up and
accurate instrumented in vivo rotational
stability assessment are needed
 BACKGROUND:
No consensus has been reached on the advantages of
double-bundle (DB) anterior cruciate ligament
reconstruction (ACLR) over the single-bundle (SB)
technique, particularly with respect to the prevention
of osteoarthritis (OA) after ACLR.

PURPOSE:
To evaluate whether DB ACLR has any advantages in
the prevention of OA or provides better stability and
function after ACLR compared with the SB technique.

STUDY DESIGN:
Randomized controlled trial; Level of evidence, 2.
 METHODS:
A total of 130
DB group (n = 65)
SB group (n = 65).
degree of OA based on the Kellgren-Lawrence pre and post
operation.
stability results using the Lachman and pivot-shift tests and
stress radiography.
functional outcomes based on the Lysholm knee score, Tegner
activity score, and International Knee Documentation
Committee (IKDC) subjective scale.

RESULTS:
112 patients were observed for a minimum of 4 years (DB
group, n = 52; SB group, n = 60).
Five patients (9.6%) in the DB group and 6 patients (10%) in the
SB group had more advanced OA at the final follow-up (P = .75)
Six patients (4 in the DB group and 2 in the SB group) suffered
graft failure during the follow-up and had ACL revision surgery
(P = .06).
Other comparisons no difference.
 CONCLUSION:
The DB technique, compared with SB, was not
more effective in preventing OA and did not
have a more favorable failure rate.

Although the DB ACLR technique produced a

better IKDC subjective scale result than did
the SB ACLR technique, the 2 modalities were
similar in terms of clinical outcomes and
stability after a minimum 4 years of follow-
up.
 BACKGROUND:
Double-bundle (DB) anterior cruciate ligament
reconstruction (ACLR) has been reported to yield
better joint stability than single-bundle (SB)
reconstruction. Few studies have compared the 2
techniques with regard to postoperative articular
cartilage changes.

HYPOTHESIS:
Less cartilage damage should occur in the short term
after DB ACLR than after SB ACLR.

STUDY DESIGN:
Cohort study; Level of evidence, 2.
 METHODS:
52 patients (27 in the DB group and 25 in the SB group)
no chondral or meniscus injury at primary ACLR,
Cartilage status at 6 identified regions was evaluated by
second-look arthroscopy .
Other assessments at final follow-up included International
Knee Documentation Committee (IKDC) score, Tegner and
Lysholm scores, side-to-side difference on KT-2000
arthrometer, and range of motion.

RESULTS:
The followup mean time18 months.(short term)
Both groups had cartilage lesions at the patellofemoral joint
(patella, 9 vs 13; trochlea, 5 vs 12) and the medial
compartment (1 vs 2). Significantly less severe lesions were
found in the DB group than in the SB group (mean grade,
0.33 vs 0.96; P < .05).
No significant differences were found between the 2 groups
in terms of cartilage status at other regions, IKDC score,
Lysholm score, Tegner score, KT-2000 arthrometer anterior
laxity, or range of motion.
 CONCLUSION:
Chondral lesions were found postoperatively
in both DB and SB ACLR groups with
hamstring autograft. The DB ALCR led to less
cartilage damage at the femoral trochlea at
short term followup.
PURPOSE:
To prospectively assess the anterior tibial translation and
rotational kinematics of the knee joint as well as the clinical
outcome after singlebundle (SB) and doublebundle (DB)
anterior cruciate ligament (ACL) reconstruction.

METHODS:
Forty two patients randomly underwent singlebundle (Group
SB, n = 21) or double-bundle (Group DB, n = 21) ACL
reconstruction using hamstring tendon autografts.
Anterior tibial translation and rotatory laxity were measured
prior to and after fixation of the graft during reconstruction
under the guidance of a navigation system.
Clinical outcome measurements included the evaluation of
the joint stability and functional status.
 RESULTS:
Stablity increases significantly in both group compared to
preoperative .

The postoperative total rotation (sum of internal and external

rotation) at 30 and 60 (26.6 vs. 24.0; 28.7 vs. 25.1) as well as
postoperative change in external rotation at 60 (-1.4 vs. -4.6),
and a change in total rotation at 30 and 60 (-7.0 vs. -11.5; -6.1
vs. -8.9) differed between the two groups, with better stability in
the DB group.

At 2 years follow-up, IKDC subjective satisfaction score was

significantly different between two groups (70.9 vs. 79.6),

while manual and instrumented laxity, pivot shift tests, modified

Lysholm score, Tegner activity score, thigh muscle strengths were
not different.

Correlation analysis showed little correlations between anterior

laxity tests at follow-up, and the kinematic variables measured by
navigation during surgery while pivot shift test, IKDC subjective
satisfaction score, modified Lysholm score, and Tegner activity
score were mainly correlated with navigation-measured rotations
in both groups.
 CONCLUSIONS:
The kinematic tests in this study found
evidence suggesting that the DB ACL
reconstruction improved rotatory laxity better
than the SB ACL reconstruction at 30 and 60
of flexion, but there was no difference in
functional outcome at 2 years follow-up
between SB and DB groups.

LEVEL OF EVIDENCE:
Prospective comparative study, Level II.
BACKGROUND:
Biomechanical differences between anatomical
double-bundle and central single-bundle anterior
cruciate ligament reconstruction using the same graft
tissue have not been defined.

PURPOSE:
The purpose of this study was to compare these
reconstructions in their ability to restore native knee
kinematics during a reproducible Lachman and pivot-
shift examination.

STUDY DESIGN:
Controlled laboratory study.
 METHODS:
Using a computer-assisted navigation system,
10 paired knees
Lachman and mechanized pivot-shift examination
3D motion path tracking.

RESULTS:
A significant difference in anterior translation was
seen with Lachman examination

The DB construct was significantly better in limiting

anterior translation of the lateral compartment
compared with the SB reconstruction during a pivot
shift maneuver and was not significantly different
than the intact anterior cruciate ligament condition
 DISCUSSION:
Although DB and SB clinically may be same
functional outcome
but An altered rotational axis resulted in
significantly greater translation of the lateral
compartment in the SB compared with DB
reconstruction.

CLINICAL RELEVANCE:
A DB-ACLR may be a favorable construct for
restoration of knee kinematics in the at risk knee
with associated meniscal injuries and/or
significant pivot shift on preoperative
examination.
 PURPOSE:
to compare the clinical outcomes of arthroscopic
anatomical double bundle (DB) anterior cruciate ligament
(ACL) reconstruction with either selective anteromedial (AM)
or posterolateral (PL) bundle reconstruction while
preserving a relatively healthy ACL bundle.

MATERIALS AND METHODS:

98 patients
mean follow-up of 2.7 years
34 DB ACL reconstruction (group A),
34 underwent selective AM bundle reconstruction (group B),
and 30 underwent selective PL bundle reconstructions
(group C).
Pre and post op Lysholm and International Knee
Documentation Committee (IKDC) score,
side-to-side differences of anterior laxity measured by KT-
2000 arthrometer at 14 kg, and stress radiography and
Lachman and pivot shift test results.
 RESULTS:
There were no significant differences between
the three groups in anterior instability
measured by KT-2000 arthrometer, pivot
shift, or functional scores.

CONCLUSION:
Selective bundle reconstruction in partial ACL
tears offers comparable clinical results to DB
reconstruction in complete ACL tears
 Double bundle repair should be reserved for
high demand patients such as contact sports
persons,athletes considering it provides
better stability,less failures and revisions.
however for general population single bundle
repair is sufficient to get good to excellent
functional outcome in majority of cases.
 Acta Orthop. Belgium., 2014, 80, 336-347
The Open Sports Medicine Journal,2010, 4, 51-
57 Damien P. Byrne, Kevin J. Mulhall and Joseph
F. Baker Orthopaedic Research and Innovation
Foundation, Sports Surgery Clinic, Santry, Dublin,
Ireland.
Atlas of Human Anatomy, Sixth Edition- Frank H.
Netter, M.D
Apleys System of Orthopaedics and Fractures
9th Ed
Campbell's Operative Orthopaedics 12th
Pubmed central.