No difference was found between double-bundle and single-bundle anterior cruciate ligament reconstructions in terms of osteoarthritis at 15-year follow-up.

PURPOSE: The purpose of the study was to determine whether the grade of osteoarthritis (OA) is higher with single-bundle (SB) or double-bundle (DB) anterior cruciate ligament (ACL) reconstruction. The hypothesis was that there will be no difference in the grade of OA between the techniques. METHODS: This study was a randomised controlled trial (RCT) with a follow-up period of 15 years. Patients were randomly assigned to either the SB group (n = 78) or the DB group (n = 75). Surgical techniques were anatomic, and the rehabilitation protocol was standardised. Evaluation included Kellgren-Lawrence (KL) difference and absolute OA results. OA was defined as a KL grade of at least 2. RESULTS: At 15-year follow-up, information was available on 101 patients (66%), of whom 56 (37%) were accepted in the final statistical analysis. No difference was found between the SB and DB techniques in terms of KL difference or absolute OA results. Significantly less OA was found in the contralateral knee (21%) than in the reconstructed knee (59%) (p < 0.001). Patients with meniscal tears who underwent partial meniscal resection during ACL reconstruction had a significantly higher rate of OA changes (82%) compared with patients with isolated ACL tears (33%) (p < 0.001). A longer delay between initial injury and surgery did not appear to affect the severity of the KL classification. CONCLUSION: At 15-year follow-up, no difference was found between the DB and SB techniques in terms of OA. LEVEL OF EVIDENCE: Level I.

Double-bundle anterior cruciate ligament reconstruction resulted in better International Knee Documentation Committee objective grading at fifteen year follow-up compared to single-bundle reconstruction.

PURPOSE: The aim of this prospective randomized study was to evaluate whether the use of the anatomic double-bundle (DB) method for anterior cruciate ligament (ACL) reconstruction results in better clinical outcomes and a lower incidence of graft failure compared with the anatomic single-bundle (SB) method. The hypothesis was that DB ACL reconstruction would result in a lower incidence of graft failure. METHODS: Patients were randomly assigned to either the SB group (n = 78) or the DB group (n = 75). Evaluation included clinical testing, subjective assessments, functional testing, and International Knee Documentation Committee (IKDC) objective grading. Surgical techniques were anatomic, and the rehabilitation protocol was standardized. RESULTS: At 15-year follow-up, information was available on 100 patients (65%), of whom 55 (36%) were accepted in the final statistical analysis. There were almost three times as many graft failures in the SB group, but the result wasn´t statistically significant. Subjective assessments, knee stability (KT -1000 and pivot shift), range of motion (ROM), and functional one leg hop test showed no statistically significant differences between the groups. However, DB ACL reconstruction resulted in better International Knee Documentation Committee objective grading (P < 0.001). CONCLUSION: At the 15-year follow-up, double-bundle surgery resulted in significantly better International Knee Documentation Committee objective grading compared to single-bundle surgery.

Suprapatellar tibial fracture nailing is associated with lower rate for acute compartment syndrome and the need for fasciotomy compared with the infrapatellar approach.

BACKGROUND: Intramedullary tibial nailing (IMN) is the gold standard for stabilizing tibial shaft fractures. IMN can be performed through an infra- or suprapatellar approach. PURPOSE: The aim of this study is to compare the rate of fasciotomies for acute compartment syndrome between infra- and suprapatellar approaches. METHODS: A total of 614 consecutive patients who were treated with IMN for tibial fracture between October 2007 and February 2020 were included in the study. The approach used for IMN was determined by the operating surgeon. Infrapatellar IMN was performed with the knee in deep flexion position, with or without calcaneal traction. Suprapatellar IMN was performed in straight or semiflexed position. The diagnosis of compartment syndrome was based on clinical analysis, but for some patients, a continuous compartment pressure measurement was used. The primary outcome was the rate of peri- and postoperative compartment syndrome treated with fasciotomies. RESULTS: The study sample included 513 patients treated with infrapatellar IMN and 101 patients treated with suprapatellar IMN technique. The mean age of the patients was 44.7 years (infrapatellar technique) and 48.4 years (suprapatellar technique). High energy trauma was seen in 138 (27%) patients treated with infrapatellar technique and in 39 (39%) patients treated with suprapatellar technique. In the suprapatellar group (n = 101), there were no cases of peri- or postoperative compartment syndrome treated with fasciotomies. In the infrapatellar group (n = 513), the need for fasciotomies was stated in 67 patients, 31 patients (6.0%) perioperatively and in 36 patients (7.0%) postoperatively. The rate of fasciotomies (0/101 versus 67/513 cases) differed significantly (p < 0.001). There were no significant differences in the fracture morphology or patient demographics between the study groups. CONCLUSIONS: The suprapatellar technique is recommended over the infrapatellar approach in the treatment of tibial shaft fractures. The rate of peri- and postoperative compartment syndrome and the need for fasciotomies was significantly lower with the suprapatellar technique. The major cause of increased rate of peri- or postoperative acute compartment syndrome with infrapatellar IMN technique is presumably associated with the positioning of the patient during the operation.

Implementing an orthoplastic treatment protocol for open tibia fractures reduces complication rates in tertiary trauma unit.

INTRODUCTION: Open tibia fracture (OTF) causes a considerable increase in morbidity and risk for complications compared to closed fractures. The most significant OTF complication leading to morbidity is commonly considered to be fracture-related infection (FRI). In September 2016, Tampere University Hospital (TAUH) introduced a treatment protocol for OTFs based on the BOAST 4 guideline. The aim of this study is to investigate the outcomes before and after implementation of the OTF treatment protocol. MATERIALS AND METHODS: A retrospective cohort study was conducted using handpicked data from the patient record databases of TAUH from May 1, 2007, to May 10, 2021. For patients with OTF, we collected descriptive information, known risk factors for FRI and nonunion, bony fixation method, possible soft tissue reconstruction method, information about the timing of internal fixation and soft tissue coverage, and timing of primary operation. As outcome measures, we collected information on FRI, reoperation due to non-union, flap failure, and secondary amputation. We then compared the incidence of complications before and after the implementation of the OTF treatment protocol at TAUH. RESULTS: After predefined exclusions, a total of 203 patients with OTF were included. Of these, 141 were treated before and 62 after the implementation of the OTF treatment protocol. The FRI rate in the pre-protocol group was significantly higher compared to the protocol group (20.6% vs 1.6%, p = 0.0015). The incidence of reoperation due to nonunion was also significantly higher in the pre-protocol group (27.7% vs 9.7%, p = 0.0054). According to multivariable analysis, definitive fixation and soft tissue coverage performed in separate operations was an independent risk factor for both FRI and reoperation due to nonunion. CONCLUSIONS: After implementation, the BOAST 4 based OTF treatment protocol reduced the rate of FRI and reoperation due to nonunion in patients with OTF treated at TAUH during the study period. We, therefore, recommend the implementation of such a treatment protocol in all major trauma centers treating patients with OTF. Furthermore, we also recommend the immediate referral of patients with complex OTF from hospitals lacking the preconditions to provide BOAST 4 based treatment to specialized centers.

Double bundle ACL reconstruction leads to better restoration of knee laxity and subjective outcomes than single bundle ACL reconstruction.

PURPOSE: The purpose of this meta-analysis is to compare arthroscopic single bundle (SB) and double bundle (DB) anterior cruciate ligament (ACL) reconstructions in the light of all available randomised controlled trials (RCTs). A meta-analysis of this well-researched topic was performed and subgroup analyses of the medial portal (MP) technique and the transtibial technique (TT) were added as a new idea. The hypothesis was that the DB technique is superior to the SB technique also in subgroup analyses of the MP and TT techniques. METHODS: Instructions of the PRISMA checklist were followed. Systematic literature search from electronic databases, including PubMed, Cochrane library and Scopus was performed to find RCTs that compared the SB and DB techniques. Nine outcomes were used to compare these two techniques. Each study was assessed according to the Cochrane Collaboration's risk of bias tool and three subgroup analyses (minimum 2-years' follow-up, TT technique and MP technique) were performed. RESULTS: A total of 40 studies were included in this meta-analysis. When analysing all the included studies, the DB technique was superior to the SB technique in KT-1000/2000 evaluation (p < 0.01), IKDC subjective evaluation (p < 0.05), Lysholm scores (p = 0.02), pivot shift (p < 0.01) and IKDC objective evaluation (p = 0.02). Similar results were also found in the subgroup analyses of minimum 2-years' follow-up and the TT technique. However, there were no differences between the two techniques in a subgroup analysis of the MP technique. CONCLUSION: Generally, DB ACL reconstruction leads to better restoration of knee laxity and subjective outcomes than SB ACL reconstruction. The subgroup analysis of the MP technique revealed that surgeons can achieve equally as good results with both techniques when femoral tunnels are drilled through the medial portal. LEVEL OF EVIDENCE: II.

Does the shoe-lace technique aid direct closure of fasciotomy wounds after acute compartment syndrome of the lower leg? A retrospective case-control study.

BACKGROUND AND OBJECTIVE: Tibia fractures are relatively common injuries that are accompanied with acute compartment syndrome in approximately 2% to 20% of cases. Although the shoe-lace technique, where vessel loops are threaded in a crisscross fashion and tightened daily, has been widely used, no studies have compared the shoe-lace technique with the conventional one. The aim of this study was to compare the shoe-lace technique with the conventional technique. METHODS: We identified 359 consecutive patients with intramedullary nailed tibia fracture and complete medical records including outpatient data between April 2007 and April 2015 from electronic patient database of our institute. The use of the shoe-lace technique was compared to conventional one (in which wounds were first left open with moist dressings). Main outcome measurement is direct closure of fasciotomy wounds. RESULTS: From 359 consecutive patients with intramedullary nailed tibia fracture, fasciotomy was performed on 68 (19%) patients. Of these, the shoe-lace technique was used in 47 (69%) patients while in 21 (31%) patients, the shoe-lace technique was not applied. Side-to-side approximation was successful in 36 patients (77%) in the shoe-lace+ group and 7 patients (33%) in the shoe-lace- group (p = 0.002). CONCLUSIONS: The main finding of our comparative study was that the shoe-lace technique seems to ease direct closure of lower leg fasciotomy wounds, and thus reduces the frequency of free skin grafts. Our finding needs to be confirmed in a high-quality randomized controlled trial.

Double-Bundle Versus Single-Bundle Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Study With 10-Year Results.

BACKGROUND: A long-term follow-up comparing double-bundle and single-bundle techniques for anterior cruciate ligament (ACL) reconstruction has not been reported before. HYPOTHESIS: Double-bundle ACL reconstruction may have fewer graft ruptures, lower rates of osteoarthritis (OA), and better stability than single-bundle reconstruction. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Ninety patients were randomized for double-bundle ACL reconstruction with bioabsorbable screw fixation (DB group; n = 30), single-bundle ACL reconstruction with bioabsorbable screw fixation (SBB group; n = 30), and single-bundle ACL reconstruction with metallic screw fixation (SBM group; n = 30). Evaluation methods consisted of a clinical examination, KT-1000 arthrometer measurements, International Knee Documentation Committee (IKDC) and Lysholm knee scores, and a radiographic examination of both the operated and contralateral knees. RESULTS: Eighty-one patients (90%) were available at the 10-year follow-up. Eleven patients (1 in the DB group, 7 in the SBB group, and 3 in the SBM group) had a graft failure during the follow-up and went on to undergo revision ACL surgery ( P = .043). In the remaining 70 patients at 10 years, no significant group differences were found in the pivot-shift test findings, KT-1000 arthrometer measurements, or knee scores. The most OA findings were found in the medial compartment of the knee, with 38% of the patients in the operated knee and 28% of the patients in the contralateral nonoperated knee. However, no significant group difference was found. The most severe OA changes were in the patients who had the longest delay from the primary injury to ACL reconstruction ( P = .047) and in the patients who underwent partial meniscal resection at the time of ACL reconstruction ( P = .024). CONCLUSION: Double-bundle ACL reconstruction resulted in significantly fewer graft failures than single-bundle ACL reconstruction during the follow-up. Knee stability and OA rates were similar at 10 years. The most severe OA changes were found in the patients who had the longest delay from the primary injury to ACL reconstruction and in the patients who underwent partial meniscal resection at the time of ACL reconstruction.

Femoral and Tibial Tunnel Diameter and Bioabsorbable Screw Findings After Double-Bundle ACL Reconstruction in 5-Year Clinical and MRI Follow-up.

BACKGROUND: Tunnel enlargement is frequently seen in short-term follow-up after anterior cruciate ligament reconstruction (ACLR). According to new evidence, tunnel enlargement may be followed by tunnel narrowing, but the long-term evolution of the tunnels is currently unknown. HYPOTHESIS/PURPOSE: The hypothesis was that tunnel enlargement is followed by tunnel narrowing caused by ossification as seen in follow-up using magnetic resonance imaging (MRI). The purpose of this study was to evaluate the ossification pattern of the tunnels, the communication of the 2 femoral and 2 tibial tunnels, and screw absorption findings in MRI. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty-one patients underwent anatomic double-bundle ACLR with hamstring grafts and bioabsorbable interference screw fixation and were followed with MRI and clinical evaluation at 2 and 5 years postoperatively. RESULTS: The mean tunnel enlargement at 2 years was 58% and reduced to 46% at 5 years. Tunnel ossification resulted in evenly narrowed tunnels in 44%, in conical tunnels in 48%, and fully ossified tunnels in 8%. Tunnel communication increased from 13% to 23% in the femur and from 19% to 23% in the tibia between 2 and 5 years and was not associated with knee laxity. At 5 years, 54% of the screws were not visible, with 35% of the screws replaced by a cyst and 19% fully ossified. Tunnel cysts were not associated with worse patient-reported outcomes or knee laxity. Patients with a tibial anteromedial tunnel cyst had higher Lysholm scores than patients without a cyst (93 and 84, P = .03). CONCLUSION: Tunnel enlargement was followed by tunnel narrowing in 5-year follow-up after double-bundle ACLR. Tunnel communication and tunnel cysts were frequent MRI findings and not associated with adverse clinical evaluation results.

High blood metal ion levels in 19 of 22 patients with metal-on-metal hinge knee replacements.

Background and purpose - There has been increasing alarm regarding metal-on-metal (MoM) joint replacements leading to elevated levels of metal ions and adverse reactions to metal debris (ARMDs). There is little information available concerning the prevalence of and risk factors for these adverse reactions, except with MoM hip joint replacements. We determined the levels of metal ions in blood and the rate of revision due to ARMDs in patients treated with MoM hinge total knee arthroplasty (TKA). Patients and methods - 22 patients with TKAs and MoM hinge connecting mechanisms were studied for whole-blood chromium and cobalt levels at 6 months, 1 year, and/or ≥2 years after surgery. Possible ARMDs were investigated by MRI. 12 patients with TKAs and metal-on-polyethylene (MoP) connecting mechanisms served as controls. Results - The cobalt levels were over 5 ppb in 19 of the 22 patients in the MoM group and in 1 of the 12 patients in the MoP group. The chromium levels were over 5 ppb in 11 of the 22 patients in the MoM group and in none of the 12 patients in the MoP group. Pseudotumors were operated in 4 of the 22 patients in the MoM group and in none of the patients in the MoP group. Interpretation - Our results clearly show that the MoM hinge TKA carries a high risk of increased levels of systemic metal ions and also local ARMD, leading to complicated knee revisions. We therefore discourage the use of MoM hinge TKA.

Tunnel communication and increased graft signal intensity on magnetic resonance imaging of double-bundle anterior cruciate ligament reconstruction.

PURPOSE: This study aimed to evaluate the association between magnetic resonance imaging (MRI) findings of tunnel communication and increased graft signal intensity (SI) and clinical evaluation of knee stability and outcome after double-bundle (DB) anterior cruciate ligament (ACL) reconstruction. METHODS: Fifty-nine patients were evaluated with 1.5 T MRI and with clinical evaluation 2 years after DB ACL reconstruction. The MRI finding of tunnel communication was defined as the absence of a bony bridge between the anteromedial (AM) and posterolateral (PL) tunnels. The SI of the intra-articular portion of both grafts was analyzed on proton-density (PD)-weighted and T2-weighted images and graded on a scale, with I being a normal SI similar to that of the posterior cruciate ligament, II being > 50% of the graft having a normal SI, and III being < 50% of the graft having a normal SI. The clinical evaluation of knee stability and function included KT-1,000 arthrometric side-to-side difference, pivot shift test, and International Knee Documentation Committee (IKDC) and Lysholm knee evaluation scores. The association between the MRI findings and the clinical findings was calculated using the Fisher exact test and the 2-tailed t test. RESULTS: Tunnel communication was seen in the femur in 10% of patients and in the tibia in 27% of patients. Increased graft SI was seen in 15% of the AM grafts and 59% of the PL grafts. No statistically significant association (P < .05) between the MRI findings of tunnel communication or increased graft SI and knee laxity was found. CONCLUSIONS: The MRI findings of tunnel communication or increased graft SI were not associated with knee laxity 2 years after DB ACL reconstruction. Tibial tunnel communication was associated with increased range of movement with flexion, and increased AM graft SI was associated with reduced range of flexion in the knee. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Effect of tunnel placements on clinical and magnetic resonance imaging findings 2 years after anterior cruciate ligament reconstruction using the double-bundle technique.

PURPOSE: The purpose of the study reported here was to find out if the clinical and magnetic resonance imaging (MRI) findings of a reconstructed anterior cruciate ligament (ACL) have an association. Our hypothesis, which was based on the different functions of the ACL bundles, was that the visibility of the anteromedial graft would have an impact on anteroposterior stability, and the visibility of the posterolateral graft on rotational stability of the knee. METHODS: This study is a level II, prospective clinical and MRI study (NCT02000258). The study involved 75 patients. One experienced orthopedic surgeon performed all double-bundle ACL reconstructions. Two independent examiners made the clinical examinations at 2-year follow-up: clinical examination of the knee; KT-1000, International Knee Documentation Committee and Lysholm knee evaluation scores; and International Knee Documentation Committee functional score. The MRI evaluations were made by two musculoskeletal radiologists separately, and the means of these measurements were used. RESULTS: We found that the location of the graft in the tibia had an impact on the MRI visibility of the graft at 2-year follow-up. There were significantly more partially or totally invisible grafts if the insertion of the graft was more anterior in the tibia. No association was found between the clinical results and the graft locations. CONCLUSION: Anterior graft location in the tibia can cause graft invisibility in the MRI 2 years after ACL reconstruction, but this has no effect on the clinical recovery of the patient.

[Treatment of anterior cruciate ligament rupture]. / Eturistisiderepeämän hoito.

Anterior cruciate ligament rupture of the knee is a common knee injury associated with sports and exercise. The injury typically arises when the foot is tightly locked against the floor or ground, whereby a sudden change of direction combined with the slowed motion causes a rotary motion of the upper part of the tibia and a force rupturing the cruciate ligament. Approximately 30% of the injuries take place during a situation of direct contact. The instability of the knee due to the rupture may be strongly invalidizing. In such case surgical therapy is required, if appropriate conservative treatment does not lead to a good result.

Comparison of tunnel placements and clinical results of single-bundle anterior cruciate ligament reconstruction before and after starting the use of double-bundle technique.

PURPOSE: To investigate whether the locations of the grafts in single-bundle (SB) anterior cruciate ligament (ACL) reconstruction have changed to more anatomical as the double-bundle (DB) method has become more familiar. METHODS: Operation using anteromedial (not transtibial) portal and freehand technique [Group A (N = 25) in 2003, Group B (N = 25) in 2007]. The evaluation methods preoperatively and at the 2-year follow-up (two blinded examiners): clinical examination, stability measurement (KT-1000 arthrometer), the International Knee Documentation Committee (IKDC), and the Lysholm knee scores. A musculoskeletal radiologist made tunnel measurements from the magnetic resonance imaging (MRI). RESULTS: The average tunnel placement in the femoral side: from Blumensaat's line 27 % (Group A) and 26 % (Group B), from the posterior edge of the femur 32 % (Group A) and 29 % (Group B). The average tunnel placement in the tibial side: from the anterior edge 45 % (Group A) and 45 % (Group B), from the lateral side 57 % (Group A) and 54 % (Group B) (P = 0.024). Graft failures ending up to revision ACL surgery: 4 (Group A) and 0 (Group B) (P = 0.045). Operation time reduced 19 min (P = 0.001). CONCLUSION: Tunnel placement at the femoral side was already very low (anatomical) in patients operated in 2003. No significant difference was found when comparing to the patients operated in 2007. There were significantly more graft failures in the Group A, suggesting that the use of the DB method in ACL surgery in 2007 may have also improved the technique and results of the SB ACL reconstruction. LEVEL OF EVIDENCE: Prospective comparative study, Level II.

Double-bundle anterior cruciate ligament reconstruction: a review of literature.

PURPOSE: Anterior cruciate ligament (ACL) reconstruction has been under intensive discussion and debate, although the anatomy of this ligament was resolved thoroughly almost 200 years ago. The ACL consist of two bundles, anteromedial (AM) and posterolateral (PL). The conventional single-bundle method reconstructs the AM bundle only, while the modern double-bundle technique recreates both bundles for their anatomical sites. METHODS: An English language literature search was undertaken over the years 2000-2012 for ACL reconstruction, double-bundle versus single bundle technique. The search found 14 RCTs and two meta-analyses published to date. RESULTS: Two of the 14 studies (14 %) showed no difference between the two reconstruction methods while the remaining majority (12 trials, 86 %) concluded that the DB technique was better than the SB method. After the DB reconstruction, rotational stability of the knee was better in seven studies (50 %) and anteroposterior stability in six (43 %). No study spoke for the single-bundle technique. In addition, with the double-bundle technique knee scores were reported to be better in five (36 %) studies, and three trials (21 %) revealed less reoperations in the double-bundle group. CONCLUSIONS: The double-bundle ACL reconstruction technique was reported to have better or at least the same results as the conventional single-bundle method-even at a five-year follow-up. However, the majority of these studies had a rather short follow-up, and thus, longer studies are needed to confirm the true long-term results of ACL surgery. Long follow-up periods are also needed to find out whether double-bundle ACL reconstruction can eventually prevent knee osteoarthritis.

Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective randomized study with 5-year results.

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 were randomized: double-bundle ACL reconstruction with bioabsorbable screw fixation (DB group; n = 30), single-bundle ACL reconstruction with bioabsorbable screw fixation (SBB group; n = 30), and single-bundle ACL reconstruction with metallic screw fixation (SBM group; n = 30). The following evaluation methods were used: clinical examination, KT-1000 arthrometer measurement, and International Knee Documentation Committee (IKDC) and Lysholm knee scores. Additionally, radiographic evaluation was made by a musculoskeletal radiologist who was unaware of the patients' clinical and surgical data. A single orthopaedic surgeon performed all the operations, and clinical follow-up assessments were made in a blinded manner by an independent examiner. RESULTS: Preoperatively, there were no differences between the groups. Eleven patients (7 in the SBB group, 3 in the SBM group, and 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. Further, no significant group differences were found in the knee scores. CONCLUSION: 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.

Double-bundle versus single-bundle anterior cruciate ligament reconstruction: randomized clinical and magnetic resonance imaging study with 2-year follow-up.

BACKGROUND: One aspect of the debate over the reconstruction of the anterior cruciate ligament is whether it should be carried out with the single-bundle or double-bundle technique. HYPOTHESIS: The double-bundle technique results in fewer graft failures than the single-bundle technique in anterior cruciate ligament reconstruction. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 153 patients were prospectively randomized into 2 groups of anterior cruciate ligament reconstruction with hamstring autografts using aperture interference screw fixation: single-bundle technique (SB group, n = 78) and double-bundle technique (DB group, n = 75). The evaluation methods were clinical examination, KT-1000 arthrometric measurement, the International Knee Documentation Committee (IKDC) and the Lysholm knee scores, and magnetic resonance imaging (MRI) evaluation. All of the operations were performed by 1 experienced orthopaedic surgeon, and all clinical assessments were made by 2 blinded and independent examiners. A musculoskeletal radiologist blinded to the clinical data made the MRI interpretation. RESULTS: There were no differences between the study groups preoperatively. Ninety percent of patients (n = 138) were available at a minimum 2-year follow-up (range, 24-37 months). Eight patients (7 in the SB group and 1 in the DB group) had graft failure during the follow-up and had anterior cruciate ligament revision surgery (P = .04). In addition, 7 patients (5 in the SB group and 2 in the DB group) had an invisible graft on the MRI assessment at the 2-year follow-up. Also, the anteromedial bundle was partially invisible in 2 patients and the posterolateral bundle in 9 patients. Together, the total number of failures and invisible grafts were significantly higher in the SB group (12 patients, 15%) than the DB group (3 patients, 4%) (P = .024). No significant group differences were found in the knee scores or stability evaluations at the follow-up. CONCLUSION: This 2-year randomized trial showed that the revision rate of the anterior cruciate ligament reconstruction was significantly lower with the double-bundle technique than that with the single-bundle technique. However, additional years of follow-up are needed to reveal the long-term results.

ACL reconstruction with double-bundle technique: a review of clinical results.

Anatomical and biomechanical studies have shown that the anterior cruciate ligament (ACL) primarily consists of 2 distinct bundles, the anteromedial (AM) and posterolateral (PL), which act separately during the knee's range of motion. Conventional ACL reconstruction techniques have focused on restoration of the AM bundle only, while giving limited attention to the PL bundle. The outcomes of these single-bundle techniques have been relatively good in ACL reconstruction. In recent years, many authors have developed double-bundle ACL reconstruction techniques to better replicate ACL anatomy and its 2 bundles. The purpose of this article is to analyze the clinical results of the double-bundle ACL reconstruction according to the current literature. The review focuses primarily on randomized controlled trials. According to the 14 randomized controlled trials published in the literature and included in this review, 4 (29%) trials did not find any significant differences in the results between double-bundle and single-bundle ACL reconstruction. Ten (71%) trials reported significantly better results with double-bundle technique than with single-bundle technique, of which 7 (50%) reported better rotational stability, 6 (43%) reported better anterior stability, 3 (21%) reported better objective knee scores, 3 (21%) reported better subjective knee scores, 2 (14%) reported fewer graft failures, and 1 (7%) reported less degenerative changes of the knee. In addition, none of the trials found the single-bundle technique to have better results in any of these evaluations when compared with the double-bundle technique. However, 13 (93%) of the 14 trials had only a short-term follow-up (1-3 years), and only 1 (7%) trial conducted long-term follow-up (8-10 years). Therefore, only through long-term follow-up studies will we be able to determine whether the double-bundle reconstruction is really better than the single-bundle technique.