Double bundle or single bundle plus extraarticular tenodesis in ACL reconstruction?

Abstract

Anatomic reconstructions of anterior cruciate ligament (ACL) with double bundle gracilis and semitendonosus tendons graft, reproducing AM and PL bundles, have been introduced to offer a better biomechanical outcome, especially during rotatory loads. On the other hand, many methods of tenodesing the lateral aspect of the tibia to the femur to reduce internal rotation (IR) of the tibia and minimize anterior translation of the tibia relative to the femur as a backup for intra-articular reconstruction, have been also suggested. The goal of this study is to evaluate the effect, on the IR of the tibia, of a lateral reconstruction in addition to a standard single bundle ACL reconstruction as compared with an anatomic double bundle ACL reconstruction. Computer assisted ACL reconstruction has been used because it could be very effective in evaluating the global kinematic performance of the reconstructed knee. We selected 20 consecutive ACL reconstruction procedures to be performed in males in our hospital. Patients were alternately assigned to one of the two groups--group A: standard single bundle ACL reconstruction with doubled gracilis and semitendinosus tendons graft with an arthroscopically assisted two incisions technique and a lateral extraarticular reconstruction; group B: double bundle ACL reconstruction with doubled gracilis and semitendinosus tendons graft with an arthroscopically assisted two incisions technique. In all ACL reconstruction procedures navigation process was performed. Both surgical techniques reduced significantly AP displacement, IR and external rotation (ER) of the tibia respect to pre-operative ACL deficient condition (p<0.05). Comparing the group A after the single bundle reconstruction and the group B after the AM bundle fixation, non differences were found in AP displacement, IR and ER of the tibia (p=0.75, p=0.07 and p=0.07 respectively; power: 0.94). Comparing the group A after the addition of the lateral tenodesis and group B after the PL bundle fixation (AM+PL) no differences in AP tibial displacement and in ER of tibia were found (p=0.9 and 0.15, respectively; power: 0.99); however a significant reduction in IR of the tibia was found in group A after the addition of the lateral tenodesis respect to the group B after the addition of the PL bundle (p=0.0001; power: 0.26). On the basis of our study, the addition of a lateral extraarticular reconstruction to a standard single bundle ACL reconstruction with hamstrings tendons graft in an "in vivo" reconstruction, is more effective in reducing the IR of the tibia at 30 degrees of knee flexion, as compared with a standard single bundle ACL reconstruction and with an anatomic double bundle reconstruction is confirmed.

Reconstructive versus non-reconstructive treatment of anterior cruciate ligament insufficiency. A retrospective matched-pair long-term follow-up

“…But as there is a variety of possible tools for measuring the rotational stability in the lab, the manual pivot shift test still remains the only validated parameter in the daily clinical routine. Even if there is an attempt of an objective quantitative measurement by several technical devices [17][18][19][20], objective quantitative assessment of the pivot shift phenomenon is currently lacking and the evaluation greatly depends on the examiner's subjective experience and impression [21,22]. Therefore, accurate assessment of the pivot shift is essential to obtain an exact clinical assessment of ACL-deficient or reconstructed knee.…”

Percutaneous Reconstruction of the Anterolateral Ligament of the Knee With a Polyester Tape

“…26,27 Recently, it was shown that performing lateral extra-articular tenodesis in association with intra-articular reconstruction of the ACL using a single bundle might be superior to intraarticular ACL reconstruction with a double bundle, from a rotational point of view, which confirms the importance of these extra-articular structures. 28 The rationale of combining intra-and extra-articular procedures in ACL reconstruction is to limit the internal rotation of the reconstructed knee, thus providing more knee stability in the rotational axis and preventing excessive stresses on the ACL graft. Many studies have already investigated the role of such extraarticular procedures.…”

Does Combined Intra- and Extraarticular ACL Reconstruction Improve Function and Stability? A Meta-analysis

“…We have recognized two reports of the same study; although we combined useful data from both reports, most relevant information was extracted from the full text report [14]. We excluded another study [29] that was not an RCT. The remaining eight studies (Appendix 2; supplemental materials are available with the online version of CORR 1 ) met the inclusion criteria for our systematic review ( Fig.…”