Graft Suturing Method Affects on Graft Diameter in Hamstring-Based Anterior Cruciate Ligament Reconstruction.

INTRODUCTION:  Various benefits of needleless suture loop techniques in anterior cruciate ligament reconstruction graft preparation have been discussed, yet their impact on graft diameter remains unexplored. We hypothesized that the suture loop technique would reduce the graft diameter compared to the conventional locking suture technique. METHODS:  Fifty-seven patients whose grafts were made with the Krackow stitch (group K) and 54 patients with the suture loop (group SL) were analyzed retrospectively. (1) The distal (sutured side) diameter of each anteromedial bundle and posterolateral bundle was compared to the proximal (non-sutured side) diameter, and (2) the average of the proximal and distal graft diameters in each group was calculated. RESULTS:  In group K, 78.9% of anteromedial bundles and 40.3% of posterolateral bundles exhibited a larger distal diameter than the proximal, while in group SL, 42.6% of anteromedial bundles and 3.7% of posterolateral bundles showed a larger distal diameter. In both bundles, there were significantly fewer grafts with larger distal diameters in group SL (p < 0.001). The mean distal diameter of anteromedial bundles was smaller in group SL (6.33 ± 0.43 mm vs. 6.07 ± 0.43 mm, p < 0.005). Consequently, the distal cross-sectional area of anteromedial bundles in group SL was 8% smaller than that in group K. CONCLUSION:  The use of the suture loop technique resulted in a significantly smaller distal diameter of the anteromedial bundle. This reduces the size of the tibial tunnel and may contribute to a reduction in potential damage to adjacent structures.

Outcomes of an All-Soft Tissue Fixation Technique for Reconstruction of the Medial Patellofemoral Complex Using Double-Bundle Quadriceps Tendon Autograft for Recurrent Patellar Dislocation in Skeletally Immature Patients.

Background: Patellar fracture, femoral physis injury, and recurrent instability are concerning complications in medial patellofemoral ligament (MPFL) reconstruction (MPFLR) techniques for recurrent patellar dislocation in children and adolescents. Purpose: To evaluate the outcomes of an anatomic all-soft tissue fixation technique for reconstruction of the medial patellofemoral complex (MPFC) using a double-bundle quadriceps tendon (QT) autograft for recurrent patellar dislocation in skeletally immature patients. Study Design: Case series; Level of evidence, 4. Methods: This retrospective study involved 24 skeletally immature patients (24 knees; 16 women and 8 men; age range, 9.5-15 years) with recurrent patellar dislocation who underwent MPFC reconstruction using a double-bundle QT autograft between September 2018 and January 2021. Only soft tissue suture fixation was used on the femoral and patellar sides of the 2 bundles of the QT. Radiographs, computed tomography, and magnetic resonance imaging were used to evaluate physeal status, lower limb alignment, patellar height and tilt, trochlear morphology, tibial tubercle-trochlear groove distance, and any associated knee pathology. Functional outcomes were assessed with the Kujala score, the visual analog scale (VAS) for pain, and the grading system of Insall et al.22. Results: The mean follow-up time was 40 ± 9.6 months (range, 28-56 months). At the final follow-up, the Kujala and VAS pain scores showed a significant improvement versus preoperative scores (P < .001), and the passive lateral patellar glide showed a significant reduction (P < .001). All patients had negative apprehension and J signs. Of the 24 patients, 23 regained full range of motion, while 1 patient had a knee flexion deficit. The patellar tilt angle improved significantly at the final follow-up (P < .001). There was no patellar fracture, femoral physis injury, or recurrence of patellar dislocation. According to the grading system of Insall et al, the results were excellent in 15 knees (62.5%), good in 8 knees (33.3%), fair in 1 knee (4.2%), and no knees showed poor results. Conclusion: Reconstruction of the MPFC using a double-bundle QT autograft with an all-soft tissue fixation technique was an effective method for treating patellar instability in skeletally immature patients.

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.

Anatomic versus Low Tibial Tunnel in Double-Bundle Posterior Cruciate Ligament Reconstruction: Clinical and Radiologic Outcomes with a Minimum 2-Year Follow-Up.

There is currently no consensus on the optimal placement of the tibial tunnel for double-bundle posterior cruciate ligament (PCL) reconstruction. The purpose of this study was to compare the clinical and radiologic outcomes of double-bundle PCL reconstruction utilizing anatomic versus low tibial tunnels. We conducted a retrospective cohort study involving patients who underwent double-bundle PCL reconstruction between Jan 2019 and Jan 2022, with a minimum follow-up of 2 years (n = 36). Based on the tibial tunnel position on postoperative computed tomography, patients were categorized into two groups: anatomic placement (group A; n = 18) and low tunnel placement (group L; n = 18). We compared the range of motion, stability test, complications, and side-to-side differences in tibial posterior translation using kneeling stress radiography between the two groups. There were no significant differences between the groups regarding clinical outcomes or complication rates. No significant differences in the posterior drawer test and side-to-side difference on kneeling stress radiography (2.5 ± 1.2 mm in group A vs. 3.7 ± 2.0 mm in group L; p = 0.346). In conclusion, the main findings of this study indicate that both anatomic tunnel and low tibial tunnel placements in double-bundle PCL reconstruction demonstrated comparable and satisfactory clinical and radiologic outcomes, with similar overall complication rates at the 2-year follow-up.

Factors affecting the post-operative over-constraint after anatomic double-bundle anterior cruciate ligament reconstruction.

Objective: Initial tension at graft fixation is one of key factors for good outcomes in anterior cruciate ligament (ACL) reconstruction. Identifying the pre-operative factors that influence postoperative knee laxity under the anterior tibial load is useful in determining the initial tension at graft fixation. Thus, the purpose of this study was to clarify the pre-operative factors affecting the side-to-side difference in anterior laxity immediately after the anatomic double-bundle ACL reconstruction with a constant initial tension. Methods: Fifty-five patients underwent the anatomic double-bundle ACL reconstruction with hamstring tendon grafts. Anterior tibial displacement (ATD) was measured on both knees using KT-2000 Knee Arthrometer under anterior drawer load of 67 N, 89 N, 134 N and manual maximum load at 30° of flexion before ACL reconstruction under anesthesia, and was also measured on the operated knees under 89 N immediately after ACL reconstruction under anesthesia. Then, side-to-side difference (SSD) before and immediately after ACL reconstruction was calculated. Correlative relation between the SSD immediately after ACL reconstruction and the ATD/the SSD in each condition was analyzed. Results: The side-to-side difference of ATD immediately after surgery was -3.8 ± 1.7 mm (0 to -8mm) in response of 89 N of anterior load. There was correlation between the SSD immediately after ACL reconstruction and all ATD on both knees except for the ATD under manual maximum load on the injured knee, while little correlation between the SSD immediately after ACL reconstruction and that before ACL reconstruction was found. Especially, ATD under 89 N on the opposite knees and ATD under 134 N on the injured knees showed selective correlation with the SSD immediately after surgery in the step-wise multiple regression analysis. Conclusion: As the anterior tibial displacements under 89 N on the contra-lateral knee and under 134 N on the injured knee had a significant correlation with the SSD immediately after ACL reconstruction, those values may be helpful in determining the increase or decrease in initial tension at graft fixation.

Double and Single Bundle in Athletes: A Comparison in Medium and Long-Term Rates to Return to Sport and Re-Injury.

Objectives: Compare, retrospectively, the medium- and long-term of return to sport rates and re-injury of the anterior cruciate ligament (ACL) in patients submitted to single-bundle (SB) compared to double-bundle (DB) technique reconstruction. Methods: Athletes operated by SB or DB ACL reconstruction, with at least five years of follow-up at a single center, were included. The following data were collected: demographic data; competitive sports practice before the injury; previous surgery; injury/surgery to the contralateral knee; return to sports and level of the return; re-injury (time of the re-injury after the first surgery; mechanism of trauma for the re-injury; necessity of operative treatment); signs and complaints related to the knee the last clinical consultation. Results: Seventy-six athletes (27 SB and 49 DB) were included. The return to sport rate (98%) was the same for both groups, and the return to the previous level rate showed an improvement in the DB group but without statistical significance (63% vs. 79%; P = 0.173). However, other outcomes showed higher results for the DB group: lower re-injury rate throughout the follow-up period (41% vs. 18%; P = 0.034) and during the first year of follow-up (22% vs. 4%; P = 0.021), and less stiffness (0% vs. 22%, P = 0.001). While in primary reconstruction cases, there was not a higher re-injury rate using SB (P = 0.744), in the revision cases, SB was correlated with more re-injuries than DB (P = 0.002). Conclusion: The overall re-injury in the medium- and long-term and the return to practice sports at the same level as before surgery in athletes submitted to DB reconstruction were slightly better than those submitted to SB reconstruction, especially in the cases that were asecond time lesion ( revisioned knees).

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.

Double-bundle anterior cruciate ligament reconstruction in patients aged 60 years and older.

Background: This study aimed to examine the clinical outcomes of double-bundle (DB) anterior cruciate ligament (ACL) reconstruction in patients aged ≥60 years. Methods: Anatomical DB-ACL reconstruction using hamstring tendon autografts was performed in 13 patients aged ≥60 years at our institution between June 2012 and May 2018. The patients included seven men and six women, and the mean age at surgery was 65.0 years (range, 60-73 years). The mean time from injury to surgery was 80.5 months (range, 1-480 months), and the mean follow-up time was 26.2 months (range, 24-42 months). All patients were assessed based on physical examination findings, clinical scores, Kellgren-Lawrence grades preoperatively and at the final postoperative follow-up, intraoperative meniscal or chondral lesions, and perioperative complications. Status of returning to sports for all patients was assessed at the final follow-up. Results: The mean side-to-side differences by arthrometer improved from 4.3 mm (range, 2-8 mm) to 0.9 mm (range, 0-2 mm), and the positive pivot-shift test decreased from 100% to 8%. The mean extensor muscle strength was 93.3% (range, 74-116%) postoperatively. The mean Lysholm score improved from 71.1 (range, 27-85) to 95.2 (range, 89-100). Ten of the 13 patients (77%) returned to their pre-injury level of sports performance, and one patient (8%) returned to sports with less intensity. Intraoperatively, meniscal tears were observed in 10 patients (77%), and chondral lesions >grade 2 were observed in 11 (85%). One patient developed perioperative complications. At the final follow-up, the Kellgren-Lawrence grade worsened in only one patient. No re-injury or infection was observed, and revision surgery was not required for any patients. Conclusions: Anatomical DB-ACL reconstruction could provide satisfactory clinical outcomes and knee function restoration in patients aged ≥60 years. Level of evidence: A retrospective study, case series (IV).

The increased lateral tibial slope may result in inferior long-term clinical outcome after DB-ACL reconstruction.

PURPOSE: To determine if there is a correlation between lateral tibial slope and long-term clinical results in patients who underwent double-bundle ACL reconstruction. METHODS: We retrospectively reviewed patients that received double-bundle ACL reconstruction at a single institution by a single surgeon from January 2011 to December 2014. All the magnetic resonance imaging were reviewed and lateral tibial slopes (LTS) were recorded by an experienced surgeon and rechecked by the other two authors of this study that specialized in orthopedic knee surgery. The relationship between PROMs measurement and lateral tibial slope were analyzed. The patients were then separated into two groups (LTS > 7.4° and < 7.4°) according to the previous study. RESULTS: A total of 119 patients were enrolled in this study. All enrolled patients were followed for at least 8 years. The PROMS result were negatively correlated with the lateral tibial slope (p values all < 0.001). The patients with high lateral tibial slope had significantly lower PROMS values (Lysholm 94.26 ± 5.61 vs 80.15 ± 8.28, p = 0.013; IKDC 82.99 ± 4.55 vs 70.09 ± 7.15, p = 0.003; Tegner 9.32 ± 0.95 vs 6.85 ± 1.99, p < 0.001). Finally, the LTS cutoff value between patients with "Good" and "Fair" Lysholm score in our study was 7.55 degrees. CONCLUSIONS: Patients with high lateral tibial slope may result in inferior long-term subjective outcomes. The using of double-bundle ACL reconstruction along cannot overcome the negative impact caused by steep lateral tibial slope. A lateral tibial slope of 7.55° may be used as a cut-off for a good clinical outcome. LEVEL OF EVIDENCE: III retrospective comparative prognostic trial.

One-stage anterior cruciate ligament revision surgery after primary failed double-bundle reconstruction: a systematic review.

INTRODUCTION: Anterior cruciate ligament (ACL) revision surgery after failed double-bundle (DB) reconstruction is a challenging procedure. This study aimed to systematically review the research on ACL revision surgery following failed DB reconstruction, providing an overview on indications, surgical techniques, clinical outcomes and potential pitfalls occurring while performing this therapeutic approach. MATERIALS AND METHODS: Literature published from exception to February 2023 was searched in the Pubmed/MEDLINE, Embase and CINAHL databases. Studies in English reporting on patients who underwent ACL revision surgery after prior failed DB reconstruction were considered. Review articles and expert opinion or editorial pieces were excluded. Outcomes of interest included indications and pre-operative planning, surgical technique and associated procedures, type of revision surgery (either one- or two-stage), graft choice, clinical and functional outcomes, rate of complications, failure rate. RESULTS: Overall, 4 studies met all the inclusion criteria for this review. All were published between 2007 and 2020. The search resulted in two retrospective comparative studies, one case series, and one case report. Average follow-up periods ranged from 24 to 45 months. From these studies, 66 patients (66 knees) were identified. One-stage revision surgery was performed in 64 on 66 patients (97%) with pathologic laxity following DB ACL reconstruction. Most frequently reported outcome was Lysholm score in five studies: average postoperative Lysholm score ranged from 90.5 to 91.0 while Tegner activity level ranged from 5.6 to 7.0. In 4 patients (6%) re-revision surgery was performed due to graft re-rupture. CONCLUSIONS: One-stage ACL revision surgery following DB ACL reconstruction appears feasible providing satisfying outcomes and limited complications. The literature on this subject is limited and further comparative studies reporting long-term outcomes are needed, as high-level studies on this topic are still lacking.

Double-Versus Single-Bundle Anterior Cruciate Ligament Reconstructive Surgery: A Prospective Study With >1 Year Follow-Up.

Background The increased prevalence of knee trauma predominantly adds to the anterior cruciate ligament (ACL) tear frequencies that require single- or double-bundle reconstructive surgeries. Few studies have demonstrated the superior results of double-bundle reconstruction compared to single-bundle approaches. This study investigated the knee function improvement capacity of both reconstruction techniques in patients with ACL tears. Methods Thirty cases with ACL tears have been enrolled and segregated equally in distinct (single-bundle versus double-bundle) batches. The diagnostic assessments were undertaken through comprehensive clinical history, knee radiographs, Lysholm scoring, the International Knee Documentation Committee (IKDC) scale, the Lachman analysis, the International Knee Documentation Committee (IKDC) scale, and the pivot shift method. Results After one year, there was a significant enhancement in the postoperative versus preoperative Lysholm scores in the single-bundle (58.5 ± 21.2 vs. 82.4 ± 26.2, p<0.001) and double-bundle (86.4 ± 22.8 vs 60.3 ± 19.2, p<0.001) groups. There was a significant improvement in the IKDC scores after a follow-up period of one year (p-value: 0.012 and p-value: 0.002, respectively) in both of the study batches. After a year of follow-up, Lysholm scores (p=0.352) and IKDC scores (p=0.574) between the study groups (82.4 ± 26.2 vs. 86.4 ± 22.8) were comparable. Conclusion The clinical outcomes remained comparable between subjects with single-bundle reconstruction versus double-bundle reconstruction subjects with ACL injuries. Findings were similar between the groups after one year and two years of surgical interventions.

Trends of Publications on Single- and Double-Bundle ACL Reconstructions over the Last 20 Years: A Bibliometric Analysis of the PubMed Literature.

Purpose: To improve the clinical outcomes of anterior cruciate ligament reconstruction (ACLR), there have been attempts to reproduce anatomic reconstruction by modifying the single-bundle (SB) and double-bundle (DB) techniques. Although DB ACLR restores better rotational control compared to SB ACLR, it is still debatable whether there are higher clinical outcomes in favor of DB ACLR. We aimed to study the trends of publications on SB and DB ACLR techniques over the last 20 years. Methods: For this bibliometric study, we performed a PubMed search on 31/05/2022 with a well-defined search strategy. The articles were downloaded into Excel software, and citations were determined from the iCite website for PubMed. The analysis was performed using SPSS software version 28.0.1. Data mining was performed using Orange software, Mac version 3.32.0, from the titles of all articles and each group of SB and DB ACLR. The output is presented as word clouds. Results: A total of 10,530 publications were identified, of which 9699 publications (92.1%) pertained to SB-ACLR and 831 publications (7.9%) to DB-ACLR. There was a steady increase in the publications on SB-ACLR until 2012, followed by a steep increase that peaked in 2021. The highest number of publications on DB-ACLR was in 2012 (n = 76; 9.1%). The mean citations per year for SB-ACLR and DB-ACLR were 2.87 ± 4.31 and 2.74 ± 3.17, respectively. The most prolific journals publishing on this topic were Knee Surgery Sports Traumatology Arthroscopy, American Journal of Sports Medicine, and Arthroscopy. The top three articles that received the maximum number of citations were from Japanese authors. Conclusion: The number of publications related to SB-ACLR was significantly higher than that related to DB-ACLR in the last 20 years. The publications related to DB-ACLR have decreased in the recent past, after reaching a peak in 2012. The citations per year of SB-ACLR and DB-ACLR were similar.

Innovative knee surgery: arthroscopic double bundle U-DOS reverse Technique for PCL tears.

The Double Bundle U-DOS Reverse Technique for posterior cruciate ligament (PCL) tears is a novel arthroscopic technique that combines two well-known procedures: the mono-tunnel approach and the medial-portal approach, provides better posterior stability, improved functional outcomes, and a reduced risk of posterior tibial subluxation. This technique allows for the simultaneous treatment of anterolateral and posteromedial bundles and has been successfully performed on 16 patients, with follow-up showing sufficient support and resistance to posterior tibial subluxation or excessive displacement, resulting in a stable knee joint.

Comparison of Outcomes Between All-Inside Single-Bundle and Double-Bundle Anterior Cruciate Ligament Reconstruction: A Retrospective Study.

Introduction: ACL rupture is the most common type of knee injury. The All-inside ACL reconstruction procedure features some distinguished components including closed-socket tunnels with less bone expulsion, double suspensory fixation, and smaller incisions. We aimed to compare the outcomes between the All-inside Single-bundle and the Double-bundle ACL reconstruction techniques. Materials and methods: This study was a retrospective study which analysed the patient-reported and the clinical outcomes on patients who underwent ACL reconstruction between January and December 2020 at Dr Kariadi General Hospital Semarang, Indonesia. We compared the patient-reported and the clinical outcomes at 6- and 12-month follow-ups between the All-inside Single-bundle and the Double-bundle groups. The patient-reported outcomes were determined using the IKDC and Tegner-Lysholm scores while the clinical outcomes included the measurement of Thigh Circumference, Single Hop test, Anterior Drawer test, Lachman test, Range of motion, and the patient's level of return to sport. Results: A total of 24 subjects were divided into two groups, namely the All-inside Single-bundle and the Double-bundle groups, consisting of 12 subjects in each group. Most of the subjects were male in both groups, including 9 (75%) subjects in the All-inside Single-bundle group, and 11 (91.67%) subjects in the Double-bundle group. The mean age of the subjects were 25.75±7.57 years old in the All-inside Single-bundle group, and 24.5±6.87 years old in the Double-bundle group. In terms of the side of the knee that suffered the most injuries in both groups were the right knees. The result of the patient-reported outcomes using IKDC and Tegner-Lysholm scores showed no statistically significant differences in both groups at 6- and 12-month follow-ups (p=0.864; p=0.293 and p=0.589; p=0.233, respectively). The results of clinical assessments at 6- and 12-month follow-ups also showed no statistically significant differences in both groups. Conclusion: Our study showed no significant differences in the patient-reported and the clinical outcomes between the All-inside Single-bundle and the Double-bundle ACL reconstruction techniques at 6- and 12-month follow-ups.

Surgical treatment of patellar dislocation: A network meta-analysis of randomized control trials and cohort studies.

Background: Currently, there are many surgical options for patellar dislocation. The purpose of this study is to perform a network meta-analysis of the randomized controlled trials (RCTs) and cohort studies to determine the better treatment. Method: We searched the Pubmed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, clinicaltrials.gov and who.int/trialsearch. Clinical outcomes included Kujala score, Lysholm score, International Knee Documentation Committee (IKDC) score, redislocation or recurrent instability. We conducted pairwise meta-analysis and network meta-analysis respectively using the frequentist model to compare the clinical outcomes. Results: There were 10 RCTs and 2 cohort studies with a total of 774 patients included in our study. In network meta-analysis, double-bundle medial patellofemoral ligament reconstruction (DB-MPFLR) achieved good results on functional scores. According to the surface under the cumulative ranking (SUCRA), DB-MPFLR had the highest probabilities of their protective effects on outcomes of Kujala score (SUCRA 96.5 %), IKDC score (SUCRA 100.0%) and redislocation (SUCRA 67.8%). However, DB-MPFLR (SUCRA 84.6%) comes second to SB-MPFLR (SUCRA 90.4%) in Lyshlom score. It is (SUCRA 70%) also inferior to vastus medialis plasty (VM-plasty) (SUCRA 81.9%) in preventing Recurrent instability. The results of subgroup analysis were similar. Conclusion: Our study demonstrated that MPFLR showed better functional scores than other surgical options.

Double-bundle reconstruction of the anterior talofibular ligament by partial peroneal brevis tendon.

BACKGROUND: Anatomic anterior talofibular ligament (ATFL) reconstruction with autologous single-bundle tendon has been widely used in the treatment of ATFL injury. However, there are few clinical reports of using the peroneus brevis tendon (PBT) for double-bundle ATFL reconstruction. The aim of this study was to investigate the clinical effect of double-bundle ATFL reconstruction with PBT. METHODS: This was a retrospective review of all patients diagnosed with ATFL injury presenting from August 2019 to December 2021. Fifty-three patients were selected after screening based on the inclusion and exclusion criteria. The following data were compared before and after surgery: Visual Analogue Scale (VAS) score, American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), the pain interference (PI) and physical function (PF) scores of the Patient-Reported Outcomes Measurement Information System (PROMIS), the diameter and width of PBT in ultrasound and muscle strength. RESULTS: All functional scores (VAS, PI/PF, AO-FAS, KAFS) and muscle strength were significantly improved at the last follow-up (P < 0.05). The diameter and width of the PBT on ultrasound postoperation were smaller than those preoperatively. CONCLUSION: Double-bundle ATFL reconstruction with the partial PBT technique is a feasible, anatomic reconstruction technique for chronic lateral instability of the ankle, which meets the anatomical characteristics of the double bundle of the ligament, and the absence of partial PBT does not affect the peroneal muscle strength. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Single bundle vs double bundle for anterior cruciate ligament reconstruction evaluated with T2 mapping: A case series.

INTRODUCTION: ACL reconstruction is needed to restore the stability and biomechanics properties of the injured knee joints in order to reproduce the function of the native ACL. The single-bundle (SB) and double-bundle (DB) techniques are most commonly used to reconstruct the injured ACL. However, its superiority upon each other is still controversial. PRESENTATION OF CASE: This study presented a case series of six patients underwent ACL reconstruction, consisted of three patients with SB ACL reconstruction and three patients with DB ACL reconstruction with further T2 mapping for joint instability evaluation. Only two DB patients showed consistent decreased value in every follow-up. DISCUSSION: ACL tear can generate joint instability. Joint instability is resulted from two mechanisms of relative cartilage overloading. First, there is an abnormal load distribution due to shifting of the center of pressure of the tibiofemoral force, resulting in increased stresses on the articular cartilage of the knee joint. There is also an increase of translation between articular surfaces, resulting in increased shear stresses on the articular cartilage. A trauma of knee joint causes cartilage damage and increased oxidative and metabolic stress of chondrocytes, resulting in chondrocyte senescence acceleration. CONCLUSION: This case series showed inconsistent results to determine either SB or DB has a better outcome in joint instability, thus further larger studies are needed.

Risk factors of residual pivot-shift after anatomic double-bundle anterior cruciate ligament reconstruction.

INTRODUCTION: Although anterior cruciate ligament reconstruction (ACLR) is considered a successful procedure, residual pivot-shift after surgery remains to be solved. The purpose of this study was to comprehensively evaluate the risk factors of residual pivot-shift after anatomic double-bundle (DB) ACLR. MATERIALS AND METHODS: A total of 164 patients who underwent primary anatomic DB-ACLR between January 2014 and December 2019 and screw removal after the index ACLR in our hospital were included in this retrospective case-control study. The manual pivot-shift test was performed under general anesthesia during screw removal surgery, and patients with grade 1 or higher pivot-shift were classified as the positive pivot-shift group, and those with grade 0 were defined as the negative pivot-shift group. Univariate and logistic regression analyses were performed to identify the factors associated with postoperative residual pivot-shift. Assessment included sex, age, time to surgery, preoperative Tegner activity scale, preoperative pivot-shift grade, preoperative anterior tibial translation by the KT-2000 arthrometer measurement, meniscus injury and its surgical procedure, knee hyperextension, cartilage damage, Segond fracture, medial and lateral posterior tibial slope, lateral-medial slope asymmetry, participation in pivoting sport/activity at the time of injury, and return to sports at postoperative one year line. RESULTS: Postoperative positive pivot-shift was observed in 14 (8.5%) of 164 patients. The KT-2000 measurement at 1-year postoperatively was significantly higher in the residual pivot-shift-positive group than in the negative group (P < 0.05). Logistic regression analysis revealed that age of patients < 20 years [P < 0.05, odds ratio (OR): 6.1)], preoperative pivot-shift grade (P < 0.05, OR: 4.4), and hyperextended knee (P < 0.05, OR: 11.8) were risk factors of postoperative pivot-shift. There were no statistically significant differences between other variables. CONCLUSIONS: Patients < 20 years of age, with high-grade preoperative pivot-shift, or hyperextended knees had a higher risk of residual postoperative pivot-shift.

Anatomical double-bundle anterior cruciate ligament reconstruction moderately improved tegner scores over the long-term: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: To assess the effects of anatomical double-bundle (DB) versus single-bundle (SB) for anterior cruciate ligament (ACL) reconstruction in skeletally mature patients with ACL injuries. METHODS: MEDLINE, EMBASE, and CENTRAL were searched from inception to February 7, 2022 were screened for randomized controlled trials. The Anatomic Anterior Cruciate Ligament Reconstruction Checklist was used to categorize studies as anatomic. A random-effects meta-analysis was conducted, with pooled results being summarized using mean difference (MD). Risk of Bias (RoB) was assessed using the RoB 2.0 tool. Certainty of evidence was rated using GRADE. RESULTS: A search of 1371 unique articles yielded eight eligible trials, representing 735 patients (360 DB, 375 SB) with mean (SD) age of 28.5 (2.86) years and follow-up of 52.1 (36.2) months. Most trials had moderate to low RoB. Overall, DB was not significantly better than SB on Lysholm scores (MD = 0.52, 95% CI, - 1.80-2.85, p = 0.66; moderate certainty) or subjective International Knee Documentation Committee (IKDC) scores (MD = - 0.40, 95% CI, - 4.35-3.55, p = 0.84; moderate certainty). Tegner scores were significantly higher in SB than DB in the intermediate term (MD = - 0.72, 95% CI, - 1.10 to - 0.34, p = 0.0002; high certainty), while significantly higher in DB relative to SB in the long-term (MD = 0.52, 95% CI, 0.02-1.03, p = 0.04; high certainty). CONCLUSION: DB ACL reconstruction significantly improves Tegner scores relative to SB ACL reconstruction over the long-term (t ≥ 5 years). Intermediate term Tegner scores favour SB reconstruction. In both durations, there was no clinically significant difference based on the pre-specified minimal clinically important difference of 1.0 point. There were also no significant differences in IKDC or Lysholm scores. Surgeons should consider anatomical DB ACL reconstruction as a result of long-term improvement in patient-reported outcomes. LEVEL OF EVIDENCE: I.

A Comprehensive Meta-analysis of Clinical and Biomechanical Outcomes Comparing Double-Bundle and Single-Bundle Posterior Cruciate Ligament Reconstruction Techniques.

BACKGROUND: Posterior cruciate ligament (PCL) reconstruction techniques have historically focused on single-bundle (SB) reconstruction of the larger anterolateral bundle without addressing the codominant posteromedial bundle. The SB technique has been associated with residual laxity and instability, leading to the development of double-bundle (DB) reconstruction techniques. PURPOSE: To perform a meta-analysis of comparative clinical and biomechanical studies to differentiate the pooled outcomes of SB and DB PCL reconstruction cohorts. STUDY DESIGN: Meta-analysis and systematic review: Level of evidence, 3. METHODS: Six databases were queried in February 2022 for literature directly comparing clinical and biomechanical outcomes for patients or cadaveric specimens undergoing DB PCL reconstruction against SB PCL reconstruction. Biomechanical outcomes included posterior tibial translational laxity, external rotational laxity, and varus laxity at 30° and 90° of knee flexion. Clinical outcomes included the side-to-side difference in posterior tibial translation during postoperative stress radiographs, risk of a major complication, and the following postoperative patient-reported outcome measures: Lysholm, Tegner, and International Knee Documentation Committee (IKDC) subjective and objective scores. A random-effects model was used to compare pooled clinical and biomechanical outcomes between the cohorts. RESULTS: Fifteen biomechanical studies and 13 clinical studies were included in this meta-analysis. The DB group demonstrated significantly less posterior tibial translation at 30° and 90° of knee flexion (P < .00001). Additionally, the DB group demonstrated significantly less external rotation laxity at 90° of knee flexion (P = .0002) but not at 30° of knee flexion (P = .33). There was no difference in varus laxity between the groups at 30° (P = .56) or 90° (P = .24) of knee flexion. There was significantly less translation on stress radiographs in the DB group (P = .02). Clinically, there was no significant difference between the groups for the Lysholm score (P = .95), Tegner score (P = .14), or risk of a major complication (P = .93). DB PCL reconstruction led to significantly higher odds of achieving "normal" or "near normal" objective IKDC outcomes for the included prospective studies (P = .04) and higher subjective IKDC scores (P = .01). CONCLUSION: DB PCL reconstruction leads to superior biomechanical outcomes and clinical outcomes relative to SB PCL reconstruction. Re-creating native anatomy during PCL reconstruction maximizes biomechanical stability and clinical outcomes.