Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective, randomize clinical study

  • Timo JärveläEmail author


Anatomical observation and biomechanical studies have shown that the anterior cruciate ligament (ACL) mainly consists of two distinct bundles, the anteromedial (AM) bundle and posterolateral (PL) bundle. Conventional single-bundle ACL reconstruction techniques have focused on the restoration of the AM bundle while giving limited attention to the PL bundle. The purpose of this prospective, randomized clinical study is to compare the outcomes of ACL reconstruction when using either double-bundle or single-bundle technique and bioabsorbable interference screw fixation, and similar rehabilitation with both techniques. Sixty-five patients were randomized into either double-bundle (n = 35) or single-bundle (n = 30) ACL reconstruction with hamstring tendons and bioabsorbable screw (Hexalon, Inion Company, Tampere, Finland) fixation in both groups. The evaluation methods were clinical examination, KT-1000 arthrometer measurements, radiographic evaluation, as well as International Knee Documentation Committee and Lysholm knee scores. There were no differences between the study groups preoperatively. For an average of 14 months of follow-up (range 12–20 months), 30 patients of the double-bundle group and 29 patients of the single-bundle group were available (91%). At the follow-up, the rotational stability, as evaluated by pivot shift test, was significantly better in the double-bundle group than in the single-bundle group. However, in anterior stability of the knee, there was no significant difference between the groups. None of the patients in the double-bundle group had graft failure, while four patients in the single-bundle group had. In addition, knee scores were equal at the follow-up, and all the results were significantly better at the follow-up than preoperatively, in both groups.


Anterior cruciate ligament Double bundle technique Prospective randomize study 



The help of Sanna Kivimäki, physiotherapist, in collecting the data of this study is gratefully acknowledged. The study was financially supported by the Medical Research Fund of Tampere University Hospital and the Finnish Medical Foundation.


  1. 1.
    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 86:515–520PubMedGoogle Scholar
  2. 2.
    Amis AA, Dawkins GP (1991) Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg Br 73:260–267PubMedGoogle Scholar
  3. 3.
    Cha PS, Brucker PU, West RV, Zelle BA, Yagi M, Kurosaka M, Fu FH (2005) Arthroscopic double-bundle anterior cruciate ligament reconstruction: an anatomic approach. Arthroscopy 21:1275PubMedCrossRefGoogle Scholar
  4. 4.
    Daniel DM, Malcom LL, Losse G, Stone ML, Sachs R, Burks R (1985) Instrumented measurement of anterior laxity of the knee. J Bone Joint Surg Am 67:720–726PubMedGoogle Scholar
  5. 5.
    Fu FH, Bennett CH, Ma CB, Menetrey J, Lattermann C (2000) Current trends in anterior cruciate ligament reconstruction. Part II. Operative procedures and clinical correlations. Am J Sports Med 28:124–130PubMedGoogle Scholar
  6. 6.
    Gabriel MT, Wong EK, Woo SL, Yagi M, Debski RE (2004) Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. J Orthop Res 22:85–89PubMedCrossRefGoogle Scholar
  7. 7.
    Girgis FG, Marshall JL, Monajem A (1975) The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop 106:216–231PubMedCrossRefGoogle Scholar
  8. 8.
    Hamada M, Shino K, Horibe S, Mitsuoka T, Miyama T, Shiozaki Y, Mae T (2001) Single- versus bi-socket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstring tendons with endobutton femoral fixation. A prospective study. Arthroscopy 17:801–807PubMedCrossRefGoogle Scholar
  9. 9.
    Hara K, Kubo T, Suginoshita T, Shimizu C, Hirasawa Y (2000) Reconstruction of the anterior cruciate ligament using a double-bundle. Arthroscopy 16:860–864PubMedCrossRefGoogle Scholar
  10. 10.
    Harner CD, Baek GH, Vogrin TM, Carlin GJ, Kashiwaguchi S, Woo SL (1999) Quantitative analysis of human cruciate ligament insertions. Arthroscopy 15:741–749PubMedCrossRefGoogle Scholar
  11. 11.
    Hefti F, Drobny T, Hackenbusch W, Kipfer WC, Holzach P, Jakob RP, Muller We, Staubli H-U (1990) Evaluation of knee ligament injuries: the OAK and IKDC forms. In: Jakob RP, Staubli H-U (eds) The knee and the cruciate ligament. Springer, Berlin, Heidelberg, New York, pp 134–139Google Scholar
  12. 12.
    Kim SJ, Kim HK (1995) Reliability of the anterior drawer test, the pivot shift test, and the Lachman test. Clin Orthop 317:237–242PubMedGoogle Scholar
  13. 13.
    Kousa P, Järvinen TLN, Vihavainen M, Kannus P, Järvinen M (2003) The fixation strength of six hamstring tendon graft fixation devices in anterior cruciate ligament reconstruction. Part I: femoral site. Am J Sports Med 31:174–181PubMedGoogle Scholar
  14. 14.
    Kousa P, Järvinen TLN, Vihavainen M, Kannus P, Järvinen M (2003) The fixation strength of six hamstring tendon graft fixation devices in anterior cruciate ligament reconstruction. Part II: tibial site. Am J Sports Med 31:182–188PubMedGoogle Scholar
  15. 15.
    Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL (2003) Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o’clock and 10 o’clock femoral tunnel placement. Arthroscopy 19:297–304PubMedCrossRefGoogle Scholar
  16. 16.
    Lysholm J, Gillquist J (1982) Evaluation of knee ligament surgery results with special emphasis on use of scoring scale. Am J Sports Med 10:150–154PubMedGoogle Scholar
  17. 17.
    Ma CB, Francis K, Towers J, Irrgang J, Fu FH, Harner CH (2004) Hamstring anterior cruciate ligament reconstruction: a comparison of bioabsorbable interference screw and endobutton-post fixation. Arthroscopy 20:122–128PubMedCrossRefGoogle Scholar
  18. 18.
    Marcacci M, Molgota AP, Zaffagnini S, Vascellari A, Iacono F, Presti ML (2003) Anatomic double-bundle anterior cruciate ligament reconstruction with hamstrings. Arthroscopy 19:536–540CrossRefGoogle Scholar
  19. 19.
    Mott HW (1983) Semitendinosus anatomic reconstruction for cruciate ligament insufficiency. Clin Orthop 172:90–92PubMedGoogle Scholar
  20. 20.
    Muneta T, Sekiya I, Yagishita K, Ogiuchi T, Yamamoto H, Shinomiya K (1999) Two-bundle reconstruction of the anterior cruciate ligament using semitendinosus tendon with Endobuttons: operative technique and preliminary results. Arthroscopy 15:618–624PubMedCrossRefGoogle Scholar
  21. 21.
    Pinczewski LA, Deehan DJ, Salmon LJ, Russell VJ, Clingeleffer A (2002) A five-year comparison of patellar tendon versus four-strand hamstring tendon autograft for arthroscopic reconstruction of the anterior cruciate ligament. Am J Sports Med 30:523–536PubMedGoogle Scholar
  22. 22.
    Takeuchi R, Saito T, Mituhashi S, Suzuki E, Yamada I, Koshino T (2002) Double-bundle anatomic anterior cruciate ligament reconstruction using bone-hamstring-bone composite graft. Arthroscopy 18:550–555PubMedCrossRefGoogle Scholar
  23. 23.
    Woo SL, Kanamori A, Zeminski J, Yagi M, Papageorgiou C, Fu FH (2002) The effectiveness of reconstruction of the anterior cruciate ligament with hamstring and patellar tendon. A cadaveric study comparing anterior tibial and rotational loads. J Bone Joint Surg Am 84:907–914PubMedGoogle Scholar
  24. 24.
    Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL (2002) Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med 30:660–666PubMedGoogle Scholar
  25. 25.
    Yasuda K, Kondo E, Ichiyama H, Kitamura N, Tanabe Y, Tohyama H, Minami A (2004) Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy 20:1015–1025PubMedCrossRefGoogle Scholar
  26. 26.
    Yasuda K, Kondo E, Ichiyama H, Tanabe Y, Tohyama H (2006) Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: Comparison among 3 different procedures. Arthroscopy 22:240–251PubMedCrossRefGoogle Scholar
  27. 27.
    Zaricznyj B (1987) Reconstruction of the anterior cruciate ligament of the knee using a doubled tendon graft. Clin Orthop 220:162–175PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  1. 1.Department of Orthopaedics and TraumatologyHatanpää HospitalTampereFinland
  2. 2.Sports Clinic and Hospital MehiläinenTampereFinland

Personalised recommendations