Skip to main content
SpringerLink
Log in

Single- versus Double-bundle ACL Reconstruction: Is There Any Difference in Stability and Function at 3-year Followup?

  • Symposium: Complex Knee Ligament Surgery
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Despite a number of studies comparing postoperative stability and function after anatomic double-bundle and single-bundle anterior cruciate ligament reconstruction (ACLR), it remains unclear whether double-bundle reconstruction improves stability or function.

Questions/purposes

We therefore asked whether patients having single- and double-bundle ACLR using semitendinosus (ST) alone differed with regard to (1) postoperative stability; (2) ROM; and (3) five functional scores.

Methods

We prospectively followed 60 patients with an isolated anterior cruciate ligament (ACL) injury. Thirty patients underwent single-bundle and 30 patients underwent double-bundle ACL reconstruction. Clinically we assessed stability and range of motion (ROM); anteroposterior stability was assessed by Rolimeter and rotational stability by a pivot shift test. Function was assessed by IKDC, Noyes, Lysholm, Marx, and Tegner activity scales. The minimum followup was 36 months (mean, 46.2 months; range, 36–60 months).

Results

Residual anteroposterior laxity at 3 years postoperatively was similar in both groups: 1.4 ± 0.3 mm versus 1.4 ± 0.2 mm, respectively. We observed no difference in the pivot shift test. ROM was similar in both groups, although double-bundle patients required more physical therapy sessions to gain full ROM. IKDC, Noyes, Lysholm, Marx, and Tegner scores were similar at final followup.

Conclusion

Double-bundle reconstruction of the ACL did not improve function or stability compared with single-bundle reconstruction.

Level of Evidence

Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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

Fig. 1A–B
Fig. 2A–B
Fig. 3A–B
Fig. 4A–B

Similar content being viewed by others

References

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

    PubMed  CAS  Google Scholar 

  2. Amis AA, Dawkins GP. Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg Br. 1991;73:260–267.

    PubMed  CAS  Google Scholar 

  3. Balasch H, Schiller M, Friebel H, Hoffmann F. Evaluation of anterior knee joint instability with the Rolimeter. A test in comparison with manual assessment and measuring with the KT-1000 arthrometer. Knee Surg Sports Traumatol Arthrosc. 1999;7:204–208.

    Article  PubMed  CAS  Google Scholar 

  4. Calvisi V, Lupparelli S, Rinonapoli G, Padua R. Single-bundle versus double bundle arthroscopic reconstruction of the anterior cruciate ligament: what does the available evidence suggest? J Orthop Traumatol. 2007;8:95–100.

    Article  Google Scholar 

  5. Chen CH, Chuang TY, Wang KC, Chen WJ, Shih CH. Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon autograft: clinical outcome in 4–7 years. Knee Surg Sports Traumatol Arthrosc. 2006;14:1077–1085.

    Article  PubMed  CAS  Google Scholar 

  6. Crawford C, Nyland J, Landes S, Jackson R, Chang HC, Nawab A, Caborn DN. Anatomic double bundle ACL reconstruction: a literature review. Knee Surg Sports Traumatol Arthrosc. 2007;15:946–964.

    Article  PubMed  Google Scholar 

  7. Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BR Jr. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med. 2003;31:2–11.

    PubMed  Google Scholar 

  8. Fu FH, Karlsson J. A long journey to be anatomic. Knee Surg Sports Traumatol Arthrosc. 2010;18:1151–1153.

    Article  PubMed  Google Scholar 

  9. Gadikota HR, Seon JK, Kozanek M, Oh LS, Gill TJ, Montgomery KD, Li G. Biomechanical comparison of single-tunnel-double-bundle and single-bundle anterior cruciate ligament reconstructions. Am J Sports Med. 2009;37:962–969.

    Article  PubMed  Google Scholar 

  10. Ganko A, Engebretsen L, Ozer H. The Rolimeter: a new arthrometer compared with the KT-1000. Knee Surg Sports Traumatol Arthrosc. 2000;8:36–39.

    Article  PubMed  CAS  Google Scholar 

  11. Girgis FG, Marshall JL, Monajem A. The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res. 1975;106:216–231.

    Article  PubMed  Google Scholar 

  12. Gobbi A. Single versus double hamstring tendon harvest for ACL reconstruction. Sports Med Arthrosc. 2010;18:15–19.

    Article  PubMed  Google Scholar 

  13. Gobbi A, Domzalski M, Pascual J. Comparison of anterior cruciate ligament reconstruction in male and female athletes using the patellar tendon and hamstring autografts. Knee Surg Sports Traumatol Arthrosc. 2004;12:534–539.

    Article  PubMed  Google Scholar 

  14. Gobbi A, Domzalski M, Pascual J, Zanazzo M. Hamstring anterior cruciate ligament reconstruction: is it necessary to sacrifice the gracilis? Arthroscopy. 2005;21:275–280.

    Article  PubMed  Google Scholar 

  15. Gobbi A, Francisco R. Factors affecting return to sports after anterior cruciate ligament reconstruction with patellar tendon and hamstring graft: a prospective clinical investigation. Knee Surg Sports Traumatol Arthrosc. 2006;14:1021–1028.

    Article  PubMed  Google Scholar 

  16. Gobbi A, Mahajan S, Tuy B, Panuncialman I. Hamstring graft tibial fixation: biomechanical properties of different linkage systems. Knee Surg Sports Traumatol Arthrosc. 2002;10:330–334.

    Article  PubMed  Google Scholar 

  17. Gobbi A, Mahajan S, Zanazzo M, Tuy B. Patellar tendon versus quadrupled bone-semitendinosus anterior cruciate ligament reconstruction: a prospective clinical investigation in athletes. Arthroscopy. 2003;19:592–601.

    Article  PubMed  Google Scholar 

  18. Harner CD, Poehling GG. Double bundle or double trouble? Arthroscopy. 2004;20:1013–1014.

    Article  PubMed  Google Scholar 

  19. Irrgang JJ, Anderson AF, Boland AL, et al.: Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med 2001;29:600–613.

    PubMed  CAS  Google Scholar 

  20. Kanaya A, Ochi M, Deie M, Adachi N, Nishimori M, Nakamae A. Intraoperative evaluation of anteroposterior and rotational stabilities in anterior cruciate ligament reconstruction: lower femoral tunnel placed single-bundle versus double-bundle reconstruction. Knee Surg Sports Traumatol Arthrosc. 2009;17:907–913.

    Article  PubMed  Google Scholar 

  21. Kondo E, Merican AM, Yasuda K, Amis AA. Biomechanical comparisons of knee stability after anterior cruciate ligament reconstruction between 2 clinically available transtibial procedures: anatomic double bundle versus single bundle. Am J Sports Med. 2010;38:1349–1358.

    Article  PubMed  Google Scholar 

  22. Lane C, Warren R, Pearle A. D. The pivot shift. J Am Acad Orthop Surg. 2008;16:679–688.

    PubMed  Google Scholar 

  23. Lewis PB, Parameswaran AD, Rue JP, Bach BR Jr. Systematic review of single-bundle anterior cruciate ligament reconstruction outcomes: a baseline assessment for consideration of double-bundle techniques. Am J Sports Med. 2008;36:2028–2036.

    Article  PubMed  Google Scholar 

  24. Longo UG, King JB, Denaro V, Maffulli N. Double-bundle arthroscopic reconstruction of the anterior cruciate ligament: does the evidence add up? J Bone Joint Surg Br. 2008;90:995–999.

    Article  PubMed  CAS  Google Scholar 

  25. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10:150–154.

    Article  PubMed  CAS  Google Scholar 

  26. Mae T, Shino K, Matsumoto N, Nakata K, Nakamura N, Iwahashi T. Force sharing between two grafts in the anatomical two-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006;14:505–509.

    Article  PubMed  Google Scholar 

  27. Mae T, Shino K, Miyama T, Shinjo H, Ochi T, Yoshikawa H, Fujie H. Single- versus two-femoral socket anterior cruciate ligament reconstruction technique: biomechanical analysis using a robotic simulator. Arthroscopy. 2001;17:708–716.

    Article  PubMed  CAS  Google Scholar 

  28. Markolf KL, Jackson SR, McAllister DR. A comparison of 11 o’clock versus oblique femoral tunnels in the anterior cruciate ligament-reconstructed knee: knee kinematics during a simulated pivot test. Am J Sports Med. 2010;38:912–917.

    Article  PubMed  Google Scholar 

  29. Marx RG, Stump TJ, Jones EC, Wickiewicz TL, Warren RF. Development and evaluation of an activity rating scale for disorders of the knee. Am J Sports Med. 2001;29:213–218.

    PubMed  CAS  Google Scholar 

  30. Meredick RB, Vance KJ, Appleby D, Lubowitz JH. Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a meta-analysis. Am J Sports Med. 2008;36:1414–1421.

    Article  PubMed  Google Scholar 

  31. Nakamura N, Horibe S, Sasaki S, Kitaguchi T, Tagami M, Mitsuoka T, Toritsuka Y, Hamada M, Shino K. Evaluation of active knee flexion and hamstring strength after anterior cruciate ligament reconstruction using hamstring tendons. Arthroscopy. 2002;18:598–602.

    Article  PubMed  Google Scholar 

  32. National Institutes of Health (NIH), National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), Vanderbilt University, United States. Prognosis and Predictors of ACL Reconstruction—A Multicenter Cohort Study. Available at: http://clinicaltrials.gov/ct2/show/NCT00463099. Accessed March 1, 2011.

  33. Noyes FR, Barber SD, Mooar LA. A rationale for assessing sports activity levels and limitations in knee disorders. Clin Orthop Relat Res. 1989;246:238–249.

    PubMed  Google Scholar 

  34. Park SJ, Jung YB, Jung HJ, Jung HJ, Shin HK, Kim E, Song KS, Kim GS, Cheon HY, Kim S. Outcome of arthroscopic single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a preliminary 2-year prospective study. Arthroscopy. 2010;26:630–636.

    Article  PubMed  Google Scholar 

  35. Prodromos C, Brown C, Fu FH, Georgoulis A, Gobbi A, Howell S, Johnson D, Paulos L, Shelbourne K. The Anterior Cruciate Ligament Reconstruction and Basic Science. Philadelphia: Saunders Elsevier Publications; 2008:551–614.

  36. Radford WJ, Amis AA. Biomechanics of a double prosthetic ligament in the anterior cruciate ligament. J Bone Joint Surg Br. 1990;72:1038–1043.

    PubMed  CAS  Google Scholar 

  37. Reinhardt KR, Hetsroni I, Marx RG. Graft selection for anterior cruciate ligament reconstruction: a level I systematic review comparing failure rates and functional outcomes. Orthop Clin North Am. 2010;41:249–262.

    Article  PubMed  Google Scholar 

  38. Shen W, Jordan S, Fu F. Review article: anatomic double bundle anterior cruciate ligament reconstruction. J Orthop Surg (Hong Kong). 2007;15:216–221.

    CAS  Google Scholar 

  39. Shino K, Nakata K, Nakamura N, Toritsuka Y, Horibe S, Nakagawa S, Suzuki T. Rectangular tunnel double-bundle anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft to mimic natural fiber arrangement. Arthroscopy. 2008;24:1178–1183.

    Article  PubMed  Google Scholar 

  40. Siebold R, Cafaltzis K. Differentiation between intraoperative and postoperative bone tunnel widening and communication in double-bundle anterior cruciate ligament reconstruction: a prospective study. Arthroscopy. 2010;26:1066–1073.

    Article  PubMed  Google Scholar 

  41. Siebold R, Dehler C, Ellert T. Prospective randomized comparison of double-bundle versus single-bundle anterior cruciate ligament reconstruction. Arthroscopy. 2008;24:137–145.

    Article  PubMed  Google Scholar 

  42. Siebold R, Webster KE, Feller JA, Sutherland AG, Elliott J. Anterior cruciate ligament reconstruction in females: a comparison of hamstring tendon and patellar tendon autografts. Knee Surg Sports Traumatol Arthrosc. 2006;14:1070–1076.

    Article  PubMed  Google Scholar 

  43. Song EK, Oh LS, Gill TJ, Li G, Gadikota HR, Seon JK. Prospective comparative study of anterior cruciate ligament reconstruction using the double-bundle and single-bundle techniques. Am J Sports Med. 2009;37:1705–1711.

    Article  PubMed  Google Scholar 

  44. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;198:43–49.

    PubMed  Google Scholar 

  45. Torg JS, Conrad W, Kalen V. Clinical diagnosis of anterior cruciate ligament instability in the athlete. Am J Sports Med. 1976;4:84–93.

    Article  PubMed  CAS  Google Scholar 

  46. Van Eck CF, Lesniak BP, Schreiber VM, Fu FH. Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart. Arthroscopy. 2010;26:258–268.

    Article  PubMed  Google Scholar 

  47. Van Eck CF, Schreiber VM, Mejia HA, Samuelsson K, van Dijk CN, Karlsson J, Fu FH. ‘Anatomic’ anterior cruciate ligament reconstruction: a systematic review of surgical techniques and reporting of surgical data. Arthroscopy. 2010;26(Suppl):S2–12.

    PubMed  Google Scholar 

  48. Wright RW. Knee injury outcomes measures. J Am Acad Orthop Surg. 2009;17:31–39.

    PubMed  Google Scholar 

  49. Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL. Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med. 2002;30:660–666.

    PubMed  Google Scholar 

  50. Yasuda K, Kondo E, Ichiyama H, Kitamura N, Tanabe Y, Tohyama H, Minami A. Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy. 2004;20:1015–1025.

    Article  PubMed  Google Scholar 

  51. Zelle BA, Brucker PU, Feng MT, Fu FH. Anatomical double-bundle anterior cruciate ligament reconstruction. Sports Med. 2006;36:99–108.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We thank Dr Celeste Scotti for evaluating all patients preoperatively and at 3, 6, 12, 24, and 36 months postoperatively. We also thank Dr Somanna Malchira for his help in preparing the manuscript. We also thank Andrea Primo, professional statistician, for statistical analysis of our study.

Author information

Authors and Affiliations

  1. Orthopaedic Arthroscopic Surgery International, Via Amadeo GA, 24, 20133, Milano, Italy

    Alberto Gobbi MD, Vivek Mahajan MD & Georgios Karnatzikos MD

  2. Department of Orthopaedics, Osaka Health Science University, 1-9-27 Temma, Kita-ku, 530-0043, Osaka, Japan

    Norimasa Nakamura MD, PhD

Authors
  1. Alberto Gobbi MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Vivek Mahajan MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Georgios Karnatzikos MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Norimasa Nakamura MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Alberto Gobbi MD.

Additional information

Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

About this article

Cite this article

Gobbi, A., Mahajan, V., Karnatzikos, G. et al. Single- versus Double-bundle ACL Reconstruction: Is There Any Difference in Stability and Function at 3-year Followup?. Clin Orthop Relat Res 470, 824–834 (2012). https://doi.org/10.1007/s11999-011-1940-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-011-1940-9

Keywords

Search

Navigation