Skip to main content

Advertisement

SpringerLink
Log in

Double-bundle Anterior Cruciate Ligament reconstruction: a review of literature

  • Review Article
  • Published:
International Orthopaedics Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Schindler OS (2012) Surgery for anterior cruciate ligament deficiency: a historical perspective. Knee Surg Sports Traumatol Arthrosc 20:5–47. doi:10.1007/s00167-011-1756-x

    Article  PubMed  Google Scholar 

  2. Takahashi M, Doi M, Abe M, Suzuki D, Nagano A (2006) Anatomical study of the femoral and tibial insertions of the anteromedial and posterolateral bundles of human anterior cruciate ligament. Am J Sports Med 34:787–792. doi:10.1177/0363546505282625

    Article  PubMed  Google Scholar 

  3. Ferretti M, Ekdahl M, Shen W, Fu FH (2007) Osseous landmarks of the femoral attachment of the anterior cruciate ligament: an anatomic study. Arthroscopy 23:1218–1225. doi:10.1016/j.arthro.2007.09.008

    Article  PubMed  Google Scholar 

  4. Edwards A, Bull AM, Amis AA (2007) The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament: Part 1: tibial attachment. Knee Surg Sports Traumatol Arthrosc 15:1414–1421. doi:10.1007/s00167-007-0417-6

    Article  PubMed  Google Scholar 

  5. Edwards A, Bull AM, Amis AA (2008) The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament. Part 2: femoral attachment. Knee Surg Sports Traumatol Arthrosc 16:29–36. doi:10.1007/s00167-007-0410-0

    Article  PubMed  Google Scholar 

  6. Ferretti M, Doca D, Ingham SM, Cohen M, Fu FH (2012) Bony and soft tissue landmarks of the ACL tibial insertion site: an anatomical study. Knee Surg Sports Traumatol Arthrosc 20:62–68. doi:10.1007/s00167-011-1592-z

    Article  PubMed  Google Scholar 

  7. Luites JW, Wymenga AB, Blankevoort L, Kooloos JG (2007) Description of the attachment geometry of the anteromedial and posterolateral bundles of the ACL from arthroscopic perspective for anatomical tunnel placement. Knee Surg Sports Traumatol Arthrosc 15:1422–1431. doi:10.1007/s00167-007-0402-0

    Article  PubMed  Google Scholar 

  8. Steckel H, Starman JS, Baums MH, Klinger HM, Schultz W, Fu FH (2007) Anatomy of the anterior cruciate ligament double bundle structure: a macroscopic evaluation. Scand J Med Sci Sports 17:387–392. doi:10.1111/j.1600-0838.2006.00579.x

    PubMed  CAS  Google Scholar 

  9. Purnell ML, Larson AI, Clancy W (2008) Anterior cruciate ligament insertions on the tibia and femur and their relationships to critical bony landmarks using high-resolution volume-rendering computed tomography. Am J Sports Med 36:2083–2090. doi:10.1177/0363546508319896

    Article  PubMed  Google Scholar 

  10. Siebold R, Ellert T, Metz S, Metz J (2008) Tibial insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: morphometry, arthroscopic landmarks, and orientation model for bone tunnel placement. Arthroscopy 24:154–161. doi:10.1016/j.arthro.2007.08.006

    Article  PubMed  Google Scholar 

  11. Siebold R, Ellert T, Metz S, Metz J (2008) Femoral insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: morphometry and arthroscopic orientation models for double-bundle bone tunnel placement—a cadaver study. Arthroscopy 24:585–592. doi:10.1016/j.arthro.2007.12.008

    Article  PubMed  Google Scholar 

  12. Zantop T, Wellmann M, Fu FH, Petersen W (2008) Tunnel positioning of anteromedial and posterolateral bundles in anatomic anterior cruciate ligament reconstruction: anatomic and radiographic findings. Am J Sports Med 36:65–72. doi:10.1177/0363546507308361

    Article  PubMed  Google Scholar 

  13. Katouda M, Soejima T, Kanazawa T, Tabuchi K, Yamaki K, Nagata K (2011) Relationship between thickness of the anteromedial bundle and thickness of the posterolateral bundle in the normal ACL. Knee Surg Sports Traumatol Arthrosc 19:1293–1298. doi:10.1007/s00167-011-1417-0

    Article  PubMed  Google Scholar 

  14. Kopf S, Pombo MW, Szczodry M, Irrgang JJ, Fu FH (2011) Size variability of the human anterior cruciate ligament insertion sites. Am J Sports Med 39:108–113. doi:10.1177/0363546510377399

    Article  PubMed  Google Scholar 

  15. Ziegler CG, Pietrini SD, Westerhaus BD, Anderson CJ, Wijdicks CA, Johansen S, Engebretsen L, LaPrade RF (2011) Arthroscopically pertinent landmarks for tunnel positioning in single-bundle and double-bundle anterior cruciate ligament reconstructions. Am J Sports Med 39:743–752. doi:10.1177/0363546510387511

    Article  PubMed  Google Scholar 

  16. Pietrini SD, Ziegler CG, Anderson CJ, Wijdicks CA, Westerhaus BD, Johansen S, Engebretsen L, LaPrade RF (2011) Radiographic landmarks for tunnel positioning in double-bundle ACL reconstructions. Knee Surg Sports Traumatol Arthrosc 19:792–800. doi:10.1007/s00167-010-1372-1

    Article  PubMed  Google Scholar 

  17. Otsubo H, Shino K, Suzuki D, Kamiya T, Suzuki T, Watanabe K, Fujimiya M, Iwahashi T, Yamashita T (2012) The arrangement and the attachment areas of three ACL bundles. Knee Surg Sports Traumatol Arthrosc 20:127–134. doi:10.1007/s00167-011-1576-z

    Article  PubMed  Google Scholar 

  18. Hara K, Mochizuki T, Sekiya I, Yamaguchi K, Akita K, Muneta T (2009) Anatomy of normal human anterior cruciate ligament attachments evaluated by divided small bundles. Am J Sports Med 37:2386–2391. doi:10.1177/0363546509340404

    Article  PubMed  Google Scholar 

  19. Colombet P, Robinson J, Christel P, Franceschi JP, Djian P, Bellier G, Sbihi A (2006) Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy 22:984–992. doi:10.1016/j.arthro.2006.04.102

    Article  PubMed  Google Scholar 

  20. Zantop T, Herbort M, Raschke MJ, Fu FH, Petersen W (2007) The role of the anteromedial and posterolateral bundles of the anterior cruciate ligament in anterior tibial translation and internal rotation. Am J Sports Med 35:223–227. doi:10.1177/0363546506294571

    Article  PubMed  Google Scholar 

  21. Lorbach O, Pape D, Maas S, Zerbe T, Busch L, Kohn D, Seil R (2010) Influence of the anteromedial and posterolateral bundles of the anterior cruciate ligament on external and internal tibiofemoral rotation. Am J Sports Med 38:721–727. doi:10.1177/0363546509353133

    Article  PubMed  Google Scholar 

  22. Markolf KL, Park S, Jackson SR, McAllister DR (2008) Contributions of the posterolateral bundle of the anterior cruciate ligament to anterior-posterior knee laxity and ligament forces. Arthroscopy 24:805–809. doi:10.1016/j.arthro.2008.02.012

    Article  PubMed  Google Scholar 

  23. Wu JL, Seon JK, Gadikota HR, Hosseini A, Sutton KM, Gill TJ, Li G (2010) In situ forces in the anteromedial and posterolateral bundles of the anterior cruciate ligament under simulated functional loading conditions. Am J Sports Med 38:558–563. doi:10.1177/0363546509350110

    Article  PubMed  Google Scholar 

  24. Fujie H, Otsubo H, Fukano S, Suzuki T, Suzuki D, Mae T, Shino K (2011) Mechanical functions of the three bundles consisting of the human anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 19(Suppl 1):S47–S53. doi:10.1007/s00167-011-1513-1

    Article  PubMed  Google Scholar 

  25. Amis AA (2012) The functions of the fibre bundles of the anterior cruciate ligament in anterior drawer, rotational laxity and the pivot shift. Knee Surg Sports Traumatol Arthrosc 20:613–620. doi:10.1007/s00167-011-1864-7

    Article  PubMed  Google Scholar 

  26. Kato Y, Ingham SJ, Maeyama A, Lertwanich P, Wang JH, Mifune Y, Kramer S, Smolinski P, Fu FH (2012) Biomechanics of the human triple-bundle anterior cruciate ligament. Arthroscopy 28:247–254. doi:10.1016/j.arthro.2011.07.019

    Article  PubMed  Google Scholar 

  27. Wunschel M, Muller O, Lo J, Obloh C, Wulker N (2010) The anterior cruciate ligament provides resistance to externally applied anterior tibial force but not to internal rotational torque during simulated weight-bearing flexion. Arthroscopy 26:1520–1527. doi:10.1016/j.arthro.2010.04.069

    Article  PubMed  Google Scholar 

  28. Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS (2010) A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med 363:331–342. doi:10.1056/NEJMoa0907797

    Article  PubMed  CAS  Google Scholar 

  29. Smith TO, Davies L, Hing CB (2010) Early versus delayed surgery for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 18:304–311. doi:10.1007/s00167-009-0965-z

    Article  PubMed  Google Scholar 

  30. Delince P, Ghafil D (2012) Anterior cruciate ligament tears: conservative or surgical treatment? A critical review of the literature. Knee Surg Sports Traumatol Arthrosc 20:48–61. doi:10.1007/s00167-011-1614-x

    Article  PubMed  Google Scholar 

  31. Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE (2005) Treatment of anterior cruciate ligament injuries, part I. Am J Sports Med 33:1579–1602. doi:10.1177/0363546505279913

    Article  PubMed  Google Scholar 

  32. Samuelsson K, Andersson D, Karlsson J (2009) Treatment of anterior cruciate ligament injuries with special reference to graft type and surgical technique: an assessment of randomized controlled trials. Arthroscopy 25:1139–1174. doi:10.1016/j.arthro.2009.07.021

    Article  PubMed  Google Scholar 

  33. Pombo MW, Shen W, Fu FH (2008) Anatomic double-bundle anterior cruciate ligament reconstruction: where are we today? Arthroscopy 24:1168–1177. doi:10.1016/j.arthro.2008.05.021

    Article  PubMed  Google Scholar 

  34. Adachi N, Ochi M, Uchio Y, Iwasa J, Kuriwaka M, Ito Y (2004) Reconstruction of the anterior cruciate ligament. Single- versus double-bundle multistranded hamstring tendons. J Bone Joint Surg Br 86:515–520

    PubMed  CAS  Google Scholar 

  35. Muneta T, Koga H, Mochizuki T, Ju YJ, Hara K, Nimura A, Yagishita K, Sekiya I (2007) A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques. Arthroscopy 23:618–628. doi:10.1016/j.arthro.2007.04.010

    Article  PubMed  Google Scholar 

  36. Jarvela T (2007) Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective, randomize clinical study. Knee Surg Sports Traumatol Arthrosc 15:500–507. doi:10.1007/s00167-006-0254-z

    Article  PubMed  Google Scholar 

  37. Jarvela T, Moisala AS, Sihvonen R, Jarvela S, Kannus P, Jarvinen M (2008) Double-bundle anterior cruciate ligament reconstruction using hamstring autografts and bioabsorbable interference screw fixation: prospective, randomized, clinical study with 2-year results. Am J Sports Med 36:290–297. doi:10.1177/0363546507308360

    Article  PubMed  Google Scholar 

  38. Siebold R, Dehler C, Ellert T (2008) Prospective randomized comparison of double-bundle versus single-bundle anterior cruciate ligament reconstruction. Arthroscopy 24:137–145. doi:10.1016/j.arthro.2007.11.013

    Article  PubMed  Google Scholar 

  39. Zaffagnini S, Bruni D, Russo A, Takazawa Y, Lo Presti M, Giordano G, Marcacci M (2008) ST/G ACL reconstruction: double strand plus extra-articular sling vs double bundle, randomized study at 3-year follow-up. Scand J Med Sci Sports 18:573–581. doi:10.1111/j.1600-0838.2007.00697.x

    Article  PubMed  CAS  Google Scholar 

  40. Zaffagnini S, Bruni D, Marcheggiani Muccioli GM, Bonanzinga T, Lopomo N, Bignozzi S, Marcacci M (2011) Single-bundle patellar tendon versus non-anatomical double-bundle hamstrings ACL reconstruction: a prospective randomized study at 8-year minimum follow-up. Knee Surg Sports Traumatol Arthrosc 19:390–397. doi:10.1007/s00167-010-1225-y

    Article  PubMed  Google Scholar 

  41. Ibrahim SA, Hamido F, Al Misfer AK, Mahgoob A, Ghafar SA, Alhran H (2009) Anterior cruciate ligament reconstruction using autologous hamstring double bundle graft compared with single bundle procedures. J Bone Joint Surg Br 91:1310–1315. doi:10.1302/0301-620X.91B10.21886

    Article  PubMed  CAS  Google Scholar 

  42. Streich NA, Friedrich K, Gotterbarm T, Schmitt H (2008) Reconstruction of the ACL with a semitendinosus tendon graft: a prospective randomized single blinded comparison of double-bundle versus single-bundle technique in male athletes. Knee Surg Sports Traumatol Arthrosc 16:232–238. doi:10.1007/s00167-007-0480-z

    Article  PubMed  Google Scholar 

  43. Sastre S, Popescu D, Nunez M, Pomes J, Tomas X, Peidro L (2010) Double-bundle versus single-bundle ACL reconstruction using the horizontal femoral position: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc 18:32–36. doi:10.1007/s00167-009-0844-7

    Article  PubMed  Google Scholar 

  44. Aglietti P, Giron F, Losco M, Cuomo P, Ciardullo A, Mondanelli N (2010) Comparison between single-and double-bundle anterior cruciate ligament reconstruction: a prospective, randomized, single-blinded clinical trial. Am J Sports Med 38:25–34. doi:10.1177/0363546509347096

    Article  PubMed  Google Scholar 

  45. Suomalainen P, Moisala AS, Paakkala A, Kannus P, Jarvela T (2011) Double-bundle versus single-bundle anterior cruciate ligament reconstruction: randomized clinical and magnetic resonance imaging study with 2-year follow-up. Am J Sports Med 39:1615–1622. doi:10.1177/0363546511405024

    Article  PubMed  Google Scholar 

  46. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH (2012) Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up. Am J Sports Med 40:512–520. doi:10.1177/0363546511426416

    Article  PubMed  Google Scholar 

  47. Suomalainen P, Jarvela T, Paakkala A, Kannus P, Jarvinen M (2012) Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective randomized study with 5-year results. Am J Sports Med 40:1511–1518. doi:10.1177/0363546512448177

    Article  PubMed  Google Scholar 

  48. Meredick RB, Vance KJ, Appleby D, Lubowitz JH (2008) Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a meta-analysis. Am J Sports Med 36:1414–1421. doi:10.1177/0363546508317964

    Article  PubMed  Google Scholar 

  49. Zhu Y, Tang RK, Zhao P, Zhu SS, Li YG, Li JB (2012) Double-bundle reconstruction results in superior clinical outcome than single-bundle reconstruction. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-012-2073-8

  50. Endele D, Jung C, Becker U, Bauer G, Mauch F (2009) Anterior cruciate ligament reconstruction with and without computer navigation: a clinical and magnetic resonance imaging evaluation 2 years after surgery. Arthroscopy 25:1067–1074. doi:10.1016/j.arthro.2009.05.016

    Article  PubMed  Google Scholar 

  51. Papalia R, Franceschi F, Vasta S, Di Martino A, Maffulli N, Denaro V (2012) Sparing the anterior cruciate ligament remnant: is it worth the hassle? Br Med Bull. doi:10.1093/bmb/ldr053

Download references

Author information

Authors and Affiliations

  1. Tampere University Hospital (TAYS), Teiskontie 35, 33520, Tampere, Finland

    Piia Suomalainen

  2. Injury and Osteoporosis Research Center, UKK-Institute, Tampere, Finland

    Pekka Kannus

  3. Sports Clinic and Hospital Mehiläinen, Tampere, Finland

    Timo Järvelä

Authors
  1. Piia Suomalainen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Pekka Kannus
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Timo Järvelä
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Piia Suomalainen.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Suomalainen, P., Kannus, P. & Järvelä, T. Double-bundle Anterior Cruciate Ligament reconstruction: a review of literature. International Orthopaedics (SICOT) 37, 227–232 (2013). https://doi.org/10.1007/s00264-012-1680-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00264-012-1680-9

Keywords

Search

Navigation