Double-Bundle Versus Single-Bundle Anterior Cruciate Ligament Reconstruction

Timo Järvelä, MD, PhD ^a^,^b^,^*, Sally Järvelä, MD, PhD ^c

^a Sports Clinic, Hospital Mehiläinen, Itäinenkatu 3, FIN-33210 Tampere, Finland

^b Tampere University, Teiskontie 35, Tampere 33210, Finland

^c Department of Orthopaedics and Traumatology, Tampere University Hospital, Teiskontie 35, Tampere 33210, Finland

^* Corresponding author. Sports Clinic, Hospital Mehiläinen, Itäinenkatu 3, FIN-33210 Tampere, Finland.

Abstract

According to the 20 prospective, randomized studies found from the English literature and included into this review, 6 studies (30%) did not find any significant differences in the clinical results between double-bundle and single-bundle anterior cruciate ligament reconstructions. However, 14 studies (70%) reported significantly better results with the double-bundle technique than with the single-bundle technique. In addition, none of the studies found that the single-bundle technique had better results in any of these evaluations than the double-bundle technique.

Keywords

• Anterior cruciate ligament reconstruction • ACL • Reconstruction • Double-bundle • Single-bundle

Introduction

Anatomic and biomechanical studies have shown that the anterior cruciate ligament (ACL) mainly consists of 2 distinct bundles, the anteromedial (AM) bundle and the posterolateral (PL) bundle, which act separately during the knee’s range of motion.¹^–⁷ 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 reconstructive surgery. In recent years, following the desire to better replicate ACL anatomy and its 2 bundles, many orthopedic surgeons developed double-bundle ACL reconstruction techniques.

The purpose of this review was to analyze the clinical results of the double-bundle versus single-bundle ACL reconstruction according to the current literature. The main focus in reviewing these clinical studies is on the randomized controlled trials.

Randomized controlled trials

The first prospective, randomized study comparing single-bundle and double-bundle techniques in ACL reconstruction was published by Adachi and colleagues ⁸ in 2004; however, the investigators used only 1 tunnel on the tibial side and 2 tunnels on the femoral side, so the double-bundle technique used in their study was not an anatomic double-bundle ACL reconstruction. They did not find any significant differences concerning knee stability, knee scores, and subjective evaluations between their single-bundle and double-bundle groups at an average of 32-months of follow-up.

Aglietti and colleagues ⁹ randomized 75 patients into 3 groups of ACL reconstruction: a single-bundle technique, a double-bundle with transtibial technique, and a double-bundle with a double-incision technique. They found significantly better rotational and anterior stability at the 2-year follow-up using the double-bundle with double-incision technique compared with the transtibial double-bundle or single-bundle techniques.

In the other prospective, randomized study of Aglietti and colleagues ¹⁰ published in 2010, they compared single-bundle and double-bundle ACL reconstruction with a double-incision technique in both groups with 70 patients. At a minimum of 2-year follow-up, the double-bundle group had significantly better visual analog scale for pain, anterior knee stability, and knee scores than the single-bundle group.

Järvelä ¹¹ compared his anatomic double-bundle technique with hamstring grafts and bioabsorbable screw fixation with his single-bundle ACL reconstruction using similar fixation and graft material in a prospective, randomized study of 65 patients (Figs. 1 and 2). The anteromedial portal and freehand technique were used in both groups to create the femoral tunnels as anatomically as possible. At a minimum of 1-year follow-up, the rotational stability, as evaluated by the pivot shift, was significantly better in the double-bundle group than in the single-bundle group. However, the anterior stability and the International Knee Documentation Committee (IKDC) and Lysholm knee scores were equally good in both groups.

Fig. 1 Arthroscopic view of the left knee showing tunnel placements of the single-bundle ACL reconstruction on the tibial side (left) and on the femoral side (right).

Fig. 2 Schematic view of the right knee showing the tunnel and screw placements of the double-bundle ACL reconstruction.

In another prospective, randomized study of Järvelä and colleagues,¹² 77 patients were divided into 3 groups: single-bundle with metallic screw fixation, single-bundle with bioabsorbable screw fixation, and double-bundle with bioabsorbable screw fixation. At a minimum of 2-year follow-up, the rotational stability was best in the double-bundle group. In addition, the patients in the single-bundle groups had 6 graft failures leading to revision ACL surgery, whereas only 1 patient in the double-bundle group had a graft failure. These differences were significant.

In the third prospective, randomized study of Järvelä and colleagues,¹³ 60 patients were divided into either double-bundle or single-bundle ACL reconstruction using hamstring autografts and bioabsorbable screw fixation in both groups. At the minimum of 2-year follow-up, the double-bundle group had significantly less tunnel enlargement in the tibial side evaluated by magnetic resonance imaging (MRI) than the single-bundle group; however, there were no differences in the stability evaluations or the IKDC and Lysholm knee scores between the groups.

Yagi and colleagues ¹⁴ randomized 60 patients into 3 groups: an anteromedial bundle reconstruction group, a posterolateral bundle reconstruction group, and a double-bundle reconstruction group. All the patients were examined 1 year after surgery. Anterior stability and the IKDC knee scores were equal in each group; however, rotational stability, as evaluated by the pivot shift and by 3-dimensional electromagnetic sensors, was best in the double-bundle group.

Muneta and colleagues ¹⁵ randomized 68 patients into double-bundle or single-bundle ACL reconstruction groups. At the 2-year follow-up, the double-bundle group had significantly better rotational and anterior stability than the single-bundle group, although no differences were found in the subjective knee scores.

Streich and colleagues ¹⁶ randomized 50 male athletes into anatomic double-bundle or anatomic single-bundle (low femoral tunnel) ACL reconstruction. At the 2-year follow-up, no significant differences were found between the groups concerning rotational and anterior stability of the knee. Also, the objective and subjective knee scores were equal in both groups. The investigators concluded that ACL reconstruction with a single-bundle technique and more horizontal femoral tunnel placement obtained comparable clinical results than those with a double-bundle technique in high-demand athletes.

Siebold and colleagues ¹⁷ randomized 70 patients into double-bundle or single-bundle ACL reconstruction. At an average of 19 months of follow-up, the double-bundle group had significantly better rotational and anterior stability than the single-bundle group. Also, the objective IKDC score was significantly better in the double-bundle group, although no differences were found in the subjective knee scores.

Sastre and colleagues ¹⁸ randomized 40 patients into double-bundle or single-bundle ACL reconstruction with an anatomic low femoral tunnel position in both techniques. At the 2-year follow-up, no differences were found between the groups in anterior or rotational stability or in the IKDC knee scores.

Zaffagnini and colleagues ¹⁹ randomized 100 patients into double-bundle or single-bundle ACL reconstruction with extra-articular augmentation on the lateral side of the knee. Seventy-two patients were available for 3-year follow-up. The double-bundle group showed significantly better results in terms of subjective, objective, and functional evaluations of the knee. Also, anterior stability was significantly better in the double-bundle group compared with the single-bundle group.

Zaffagnini and colleagues ²⁰ have published another prospective randomized study. In that study, 79 patients were evaluated with a minimum of 8-year follow-up; however, the double-bundle technique they used was nonanatomic with only one tunnel on the femoral and tibial side combined with one “over-the-top” passage of the graft. The investigators concluded that although both the single-bundle and the nonanatomic double-bundle techniques provided satisfactory results, the nonanatomic double-bundle reconstruction showed significantly better functional results with a faster return to sports activity, a lower reoperation rate, and lower degenerative knee changes determined radiographically than the single-bundle technique.

Wang and colleagues ²¹ randomized 64 patients into double-bundle or single-bundle ACL reconstruction using hamstring grafts and cortical fixation on the femoral side. At the 10-month follow-up, no differences were found between the groups in anterior or rotational stability or in the IKDC knee scores.

Ibrahim and colleagues ²²

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