Abstract
Purpose
This article introduces guidelines for single- (SB) and double-bundle (DB) ACL reconstruction based on the concept of complete footprint restoration. The goal is to reconstruct a maximum of anterior cruciate ligament (ACL) insertion site area to regain a maximum of ACL function. The concept is based on the hypothesis that the restored biomechanical envelope of the knee is a function of reconstructed ACL insertion site area.
Methods
Individual combinations of graft diameters and drill angles were calculated and matched for all individual insertion site lengths between 8 and 21 mm to maximize the percentage of anatomical footprint restoration. An “insertion site table” was developed to propose individual guidelines during ACL surgery for SB and DB ACL reconstruction based on the intraoperative measurement of the tibial insertion site length.
Results
Our calculations support the use of SB in “small footprints” up to 13 mm, which may restore more than 95% of the native insertion site length. “Intermediate footprints” between 14 and 15 mm may be restored by both a SB or DB ACL reconstruction. For “larger footprints” of 16 mm or more, DB has the potential to replicate 97% or more of the insertion site length which cannot be achieved by a SB ACL reconstruction.
Conclusions
The concept of complete footprint restoration aims to reconstruct a maximum of ACL insertion site area to restore a maximum of functional envelope of the knee. Depending on the individual situation, different surgical approaches (SB/DB), graft diameters and drill angles may apply. An “insertion site table” was designed to give guidelines for SB and DB reconstruction during surgery. According to the new concept, DB ACL reconstruction is only considered as a surgical tool for large footprints and is not indicated for smaller ones.
Similar content being viewed by others
References
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
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
Amis AA, Dawkins GPC (1991) Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg Br 73:260–267
Arnoczky SP (1983) Anatomy of the anterior cruciate ligament. Clin Orthop Relat Res 172:19–25
Bach JM, Hull ML (1998) Strain inhomogeneity in the anterior cruciate ligament under application of external and muscular loads. J Biomech Eng 120:497–503
Branch TP, Browne JE, Campbell JD, Siebold R, Freedberg HI, Arendt EA, Lavoie F, Neyret P, Jacobs CA (2010) Rotational laxity greater in patients with anterior cruciate ligament injury than healthy volunteers. Knee Surg Sports Traumatol Arthrosc 18:1379–1384
Brophy RH, Voos JE, Shannon FJ, Granchi CC, Wickiewicz TL, Warren RF, Pearle AD (2008) Changes in the length of virtual anterior cruciate ligament fibers during stability testing: a comparison of conventional single-bundle reconstruction and native anterior cruciate ligament. Am J Sports Med 36:2196–2203
Colombet P, Menetrey J, Panisset JC (2008) Société française d’arthroscopie. The effect of the posterolateral bundle in the anterior cruciate ligament reconstruction. Rev Chir Orthop Reparatrice Appar Mot 94:369–371
Colombet P, Robinson J, Christel P, Franceschi JP, Djian P, Bellier G, Sbihi A (2006) Morphology of anterior cruciate ligament attachment for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy 22:984–992
Dodds JA, Arnoczky SP (1994) Anatomy of the anterior cruciate ligament: a blueprint for repair and reconstruction. Arthroscopy 10:132–139
Duthon VB, Barea C, Abrassart S, Fasel JH, Fritschy D, Ménétrey J (2006) Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 14:204–213
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
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
Ferretti M, Levicoff EA, Macpherson TA, Moreland MS, Cohen M, Fu FH (2007) The fetal anterior cruciate ligament: an anatomic and histologic study. Arthroscopy 23:278–282
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 22:85–89
Girgis FG, Marshall JL, Monajem A (1975) The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res 106:216–231
Giron F, Cuomo P, Aglietti P, Bull AM, Amis AA (2006) Femoral attachment of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 14:250–256
Hamner DL, Brown CH Jr, Steiner ME, Hecker AT, Hayes WC (1999) Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am 81:549–557
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
Harner CD, Baek GH, Vogrin TM, Carlin GJ, Kashiwaguchi S, Woo SL (1999) Quantitative analysis of human cruciate ligament insertions. Arthroscopy 15:741–749
Ho JY, Gardiner A, Shah V, Steiner ME (2010) Equal kinematics between central anatomic single-bundle and double-bundle anterior cruciate ligament reconstructions. Arthroscopy 25:464–472
Hofbauer M, Valentin P, Kdolsky R, Ostermann RC, Graf A, Figl M, Aldrian S (2010) Rotational and translational laxity after computer-navigated single- and double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 18:1201–1207
Ishibashi Y, Tsuda E, Fukuda A, Tsukada H, Toh S (2008) Stability evaluation of single-bundle and double-bundle reconstruction during navigated ACL reconstruction. Sports Med Arthrosc 16:77–83
Järvelä T (2007) Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective, randomize clinical study. Knee Surg Sports Traumatol Arthrosc 15:500–507
Kato Y, Ingham SJ, Kramer S, Smolinski P, Saito A, Fu FH (2010) Effect of tunnel position for anatomic single-bundle ACL reconstruction on knee biomechanics in a porcine model. Knee Surg Sports Traumatol Arthrosc 18:2–10
Kondo E, Yasuda K, Azuma H, Tanabe Y, Yagi T (2008) Prospective clinical comparisons of anatomic double-bundle versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients. Am J Sports Med 36:1675–1687
Kopf S, Martin DE, Tashman S, Fu FH (2010) Effect of tibial drill angles on bone tunnel aperture during anterior cruciate ligament reconstruction. J Bone Joint Surg Am 92:871–881
Kopf S, Musahl V, Tashman S, Szczodry M, Shen W, Fu FH (2009) A systematic review of the femoral origin and tibial insertion a morphology of the ACL. Knee Surg Sports Traumatol Arthrosc 17:213–219
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
Mochizuki T, Muneta T, Nagase T, Shirasawa S, Akita KI, Sekiya I (2006) Cadaveric knee observation study for describing anatomic femoral tunnel placement for two-bundle anterior cruciate ligament reconstruction. Arthroscopy 22:356–361
Monaco E, Labianca L, Conteduca F, De Carli A, Ferretti A (2007) Double bundle or single bundle plus extraarticular tenodesis in ACL reconstruction? A CAOS study. Knee Surg Sports Traumatol Arthrosc 15:1168–1174
Morimoto Y, Ferretti M, Ekdahl M, Smolinski P, Fu FH (2009) Tibiofemoral joint contact area and pressure after single-bundle and double-bundle anterior cruciate ligament reconstruction. Arthroscopy 25:62–69
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
Musahl V, Voos JE, O’Loughlin PF, Choi D, Stueber V, Kendoff D, Pearle AD (2010) Comparing stability of different single- and double-bundle anterior cruciate ligament reconstruction techniques: a cadaveric study using navigation. Arthroscopy 26:S41–S48
Odensten M, Gillquist J (1985) Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg Am 67:257–262
Otsubo H, Shino K, Nakamura N, Nakata K, Nakagawa S, Koyanagi M (2007) Arthroscopic evaluation of ACL grafts reconstructed with the anatomical two-bundle technique using hamstring tendon autograft. Knee Surg Sports Traumatol Arthrosc 15:720–728
Paessler HH (1995) Anatomical reconstruction of the anterior cruciate ligament with a patellar tendon autograft using a miniarthrotomy technique. In: Szabo Z, Kerstein M, Lewis JE (eds) Surgical technology international III. Universal Medical Press, INC, San Francisco
Pernin J, Verdonk P, Si Selmi TA, Massin P, Neyret P (2010) Long-term follow-up of 24.5 years after intra-articular anterior cruciate ligament reconstruction with lateral extra-articular augmentation. Am J Sports Med 38:1094–1102
Petersen W, Zantop T (2007) Anatomy of the anterior cruciate ligament with regard to its two bundles. Clin Orthop Relat Res 454:35–47
Pombo MW, Shen W, Fu FH (2008) Anatomic double-bundle anterior cruciate ligament reconstruction: where are we today? Arthroscopy 24:1168–1177
Pujol N, Fong O, Karoubi M, Beaufils P, Boisrenoult P (2010) Anatomic double-bundle ACL reconstruction using a bone-patellar tendon-bone autograft: a technical note. Knee Surg Sports Traumatol Arthrosc 18:43–46
Robinson J, Stanford FC, Kendoff D, Stüber V, Pearle AD (2009) Replication of the range of native anterior cruciate ligament fiber length change behavior achieved by different grafts: measurement using computer-assisted navigation. Am J Sports Med 37:1406–1441
Sahasrabudhe A, Christel P, Anne F, Appleby D, Basdekis G (2010) Postoperative evaluation of tibial footprint and tunnels charecteristics characteristics after anatomic double-bundle anterior cruciate ligament reconstruction with anatomic aimers. Knee Surg Sports Traumatol Arthrosc 18:1599–1606
Shino K, Nakata K, Nakamura N, Toritsuka Y, Horibe S, Nakagawa S, Suzuki T (2008) Rectangular tunnel double-bundle anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft to mimic natural fiber arrangement. Arthroscopy 24:1178–1183
Siebold R, Dehler C, Ellert T (2008) Prospective randomized comparison of double-bundle versus single-bundle anterior cruciate ligament reconstruction. Arthroscopy 24:137–145
Siebold R, Ellert T, Metz S, Metz J (2008) Femoral insertions of the anteromedial and postero-lateral bundles of the anterior cruciate ligament: morphometry and arthroscopic orientation models for bone tunnel placement. A cadaver study. Arthroscopy 24:585–592
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
Siebold R, Zantop T (2009) Anatomic double-bundle ACL reconstruction: a call for indications. Knee Surg Sports Traumatol Arthrosc 17:211–212
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
Takeda Y, Sato R, Ogawa T, Fujii K, Naruse A (2009) In vivo magnetic resonance imaging measurement of tibiofemoral relation with different knee flexion angles after single- and double-bundle anterior cruciate ligament reconstructions. Arthroscopy 25:733–741
Tashman S, Kopf S, Fu FH (2008) The kinematic basis of ACL reconstruction. Oper Tech Sports Med 16:116–118
Tsai AG, Wijdicks CA, Walsh MP, Laprade RF (2010) Comparative kinematic evaluation of all-inside single-bundle and double-bundle anterior cruciate ligament reconstruction: a biomechanical study. Am J Sports Med 38:263–272
van Eck CF, Lesniak BP, Schreiber VM, Fu FH (2010) Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart. Arthroscopy 26:258–268
van Eck CF, Schreiber VM, Liu TT, Fu FH (2010) The anatomic approach to primary, revision and augmentation anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 18:1154–1163
Woo SL, Debski RE, Withrow JD, Janaushek MA (1999) Biomechanics of the knee ligaments. Am J Sports Med 27:533–543
Wu C, Noorani S, Vercillo F, Woo SL (2009) Tension patterns of the anteromedial and posterolateral grafts in a double-bundle anterior cruciate ligament reconstruction. J Orthop Res 27:879–884
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
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 30:660–666
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: comparisons among 3 different procedures. Arthroscopy 22:240–251
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
Zaffagnini S, Bruni D, Marcheggiani Muccioli GM, Bonanzinga T, Lopomo N, Bignozzi S, Marcacci M (2010) 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 PMID: 20668835
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
Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH (2006) ACL anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc 14:982–992
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Siebold, R. The concept of complete footprint restoration with guidelines for single- and double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 19, 699–706 (2011). https://doi.org/10.1007/s00167-010-1376-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00167-010-1376-x