Clinical outcomes of double‐ vs single‐bundle anterior cruciate ligament reconstruction: A systematic review of randomized control trials

Abstract

Clinical outcomes of anterior cruciate ligament (ACL) reconstruction with double-bundle and single-bundle techniques are still controversial. We therefore performed a systematic review to compare postoperative outcomes between the two techniques. Randomized control trials comparing the outcomes between the two techniques were identified from Medline and EMBASE since inception to April 27, 2011. Data were independently extracted by two reviewers. Thirteen of 318 studies were eligible; 9, 11, 7, and 8 studies were pooled for rotation, translation, function, and complication outcomes, respectively. The double-bundle technique was approximately four times (95% CI: 2.65, 11.99) and two times (95% CI: 1.16, 5.21) more likely to show a normal pivot shift and normal International Knee Documentation Committee (IKDC) grading compared with the single-bundle technique. However, there were nonsignificant differences in KT grading (OR = 1.66, 95% CI: 0.77, 3.82), IKDC score (0.29, 95% CI: -1.17, 1.75), Lysholm knee score (-0.87, 95% CI: -2.66, 0.93), Tegner activity score (0.37, 95% CI: -0.05, 0.79), and complications (OR = 1.11, 95% CI: 0.48, 2.57). Heterogeneity was present in some outcomes but there was no evidence of publication bias for any outcome. The double-bundle may be better than the single-bundle ACL reconstruction technique in rotational stability but not for function, translation, and complications.

Does Double-Bundle Anterior Cruciate Ligament Reconstruction Improve Postoperative Knee Stability Compared With Single-Bundle Techniques? A Systematic Review of Overlapping Meta-analyses

“…4,6-9,14-17 Only 2 studies reported a potential conflict of interest. 14,16 Three of the studies included Level I Evidence only, 16,18,19 and 6 included Level I and Level II Evidence. [12][13][14][15]17,20 The studies included from 754 patients 16 to 1,686 patients, 17 with mean follow-up of studies included in the metaanalyses ranging from 5 months 25 to 103 months.…”

“…[12][13][14][15][16][17][18][19][20] These studies were published between 2008 and 2014, with all 9 performing a meta-analysis. 4,6-9,14-17 Only 2 studies reported a potential conflict of interest.…”

“…Although all of the included studies searched Medline and Embase, some studies did not include searches of Scopus, the Cochrane Database of Systematic Reviews, the Cumulative Index to Nursing and Allied Health (2014) Meredick et al, 16 Kongtharvonskul et al 19 "Furthermore, there were two meta-analyses published in 2008 and 2012 respectively, 'and no accordant conclusion was reported' in the two studies. Moreover, more RCTs have been published recently."…”

“…Finally, the prior meta-analysis did not take the length of follow-up into consideration." Kongtharvonskul et al 19 Meredick et al 16 ".this meta-analysis did not consider other clinically relevant outcomes (e.g., function outcomes and complications) and sources of heterogeneity (e.g., grade of injury, age, sex, and use of instrument assessments) were not assessed. Moreover, other RCTs.…”

“…3,4 The native ACL is composed of the functionally distinct anteromedial (AM) and posterolateral (PL) bundles. 5,6 Cadaveric studies have suggested that double-bundle (DB) anterior cruciate ligament reconstruction (ACL-R) may provide improved anterior and rotational stability compared with singlebundle (SB) ACL-R. 7,8 Improvements in femoral tunnel positioning for SB ACL-R to a more lateral position may negate the biomechanical stability benefits of DB ACL-R. 9 DB ACL-R has gained popularity because of an improved ability to replicate the normal anatomy of the AM and PL bundles of the ACL and the potential benefit of restoring more normal knee kinematics and stability than with SB ACL-R. 7,8,10,11 Numerous clinical studies, including many prospective, randomized controlled trials, have been published to compare SB ACL-R and DB ACL-R. [12][13][14][15][16][17][18][19][20] On the basis of the proliferation of clinical studies comparing SB and DB ACL-R, multiple authors have conducted systematic reviews and meta-analyses comparing SB ACL-R and DB ACL-R. [12][13][14][15][16][17][18][19][20] Meredick et al 16 conducted the first such meta-analysis in 2008, finding a small (0.52 mm) but statistically significant improvement in knee stability as determined by KT arthrometry (MEDmetric, San Diego, CA) in favor of DB ACL-R with no other differences between techniques. Although numerous overlapping meta-analyses have been performed to compare SB and DB ACL-R, the results of the meta-analyses have been discordant in their findings regarding the clinical outcomes and knee stability provided by these 2 techniques.…”