Current Controversies in ACL Reconstruction – Charles Willis-Owen 3/8/2004

Author Muneta T , Koga H , Morito T , Yagishita K , Sekiya I .

Title A retrospective study of the midterm outcome of two-bundle anterior cruciate ligament reconstruction using quadrupled semitendinosus tendon in comparison with one-bundle reconstruction.

Reference Arthroscopy. 2006 Mar;22(3):252-8.

Summary Retrospective Case-control study, comparison of outcome of 2-bundle anterior cruciate ligament reconstruction technique using quadrupled semitendinosus tendon with that of a 1-bundle reconstruction technique from 1992 through 1996. The 1-bundle group consisted of 56 patients with a follow-up period of 24 months or more (average, 46.5 months). The 2-bundle group consisted of 79 patients with a follow-up period of 24 months or more (average, 40.8 months). Manual knee laxity tests, anterior stability with KT-1000 (manual maximum), and knee extension and flexion strength by Cybex were evaluated using an average and standard deviation, and data were categorized according to the International Knee Documentation Committee (IKDC) classification. RESULTS: A statistically greater number of patients in the 1-bundle group were positive (+ or ++) based on the Lachman test (34% in the 1-bundle group and 13% in the 2-bundle group). The average KT-1000 anterior laxity of 2.7 +/- 2.3 mm in the 1-bundle group was statistically greater than the 1.9 +/- 1.9 mm in the 2-bundle group, with a statistical power between 70% and 80%. The total Lysholm knee scale score was 93 points in both groups, and the subjective recovery score was equivalent, 82% in the 1-bundle group and 86% in the 2-bundle group, respectively.

Conclusion There was no statistical difference on subjective outcome analysis. However, there was a statistical difference in the laxity. Level III evidence.

Critique Earilest of the double bundles. ST graft only – most now us ST/G, does laxity matter – appears not!

Author Yasuda K , Kondo E , Ichiyama H , Tanabe Y , Tohyama H .

Title Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: comparisons among 3 different procedures.

Reference Arthroscopy. 2006 Mar;22(3):240-51

Summary Prospective comparative cohort study. Compared the clinical outcome of anatomic double-bundle anterior cruciate ligament (ACL) reconstruction with that of nonanatomic single- and double-bundle reconstructions. Seventy-two patients with unilateral ACL-deficient knees were randomly divided into 3 groups. Concerning all background factors, there were no statistical differences among the 3 groups. In group S (n = 24), single-bundle ACL reconstruction was performed. In group N-AD (n = 24), nonanatomic double-bundle reconstruction was carried out. In group AD (n = 24), anatomic double-bundle reconstruction was performed. One surgeon performed all operations using hamstring tendon autografts. Each patient underwent clinical examinations, before surgery and at 2 years. No intraoperative and postoperative complications were experienced in each group. There were no significant differences concerning the time for operation among the 3 groups. The statistical analysis showed a significant difference in the postoperative side-to-side anterior laxity among the 3 groups (P = .006). The laxity was significantly less (P = .002) in group AD (1.1 mm) than in group S (2.8 mm), while there was no significant difference (P = .072) between groups AD and N-AD. Concerning the pivot-shift test, group AD was significantly superior to group S (P = .025). There were no significant differences in the range of knee motion, the muscle torque, and the International Knee Documentation Committee evaluation.

Conclusion Laxity of anatomic double-bundle ACL reconstruction was significantly better. There were no significant differences in the other clinical measures among any of the 3 procedures. LEVEL OF EVIDENCE: Level II.

Critique Specialist using his own technique. Does anterior laxity matter. Can it really take the same amount of time?

Author Adachi N , Ochi M , Uchio Y , Iwasa J , Kuriwaka M , Ito Y .

Title Reconstruction of the anterior cruciate ligament. Single- versus double-bundle multistranded hamstring tendons.

Reference J Bone Joint Surg Br. 2004 May;86(4):515-20

Summary 108 patients with rupture of the anterior cruciate ligament, was prospectively randomised for arthroscopic single- or double-bundle reconstruction of the ligament using hamstring tendons. The same post-operative rehabilitation protocol was used for all. The patients were followed up for a mean of 32 months (24 to 36). We measured the anterior laxity and joint position sense at different angles of flexion of the knee to determine whether both bundles in the double-bundle reconstruction contributed to the stability of the joint and proprioception. No significant difference was found between the two groups with regard to anterior laxity measured by the KT-2000 arthrometer with the knee at 20 degrees or 70 degrees flexion nor with regard to proprioception. A notchplasty was required less often in the double- compared with the single-bundle reconstruction.

Conclusion No advantage in a double-bundle as opposed to a single-bundle reconstruction in terms of stability or proprioception.

Critique Outcome measure

Author Laxdal G , Kartus J , Hansson L , Heidvall M , Ejerhed L , Karlsson J

Title A prospective randomized comparison of bone-patellar tendon-bone and hamstring grafts for anterior cruciate ligament reconstruction.

Reference Arthroscopy. 2005 Jan;21(1):34-42.

Summary Compared the results after arthroscopic anterior cruciate ligament (ACL) reconstruction using central-third, bone-patellar tendon-bone (BPTB group), 3-strand semitendinosus (ST group), or 4-strand semitendinosus/gracilis (ST/G group) autografts. Prospective randomized trial. A randomized series of 134 patients, all with unilateral ACL rupture was included in the study. In all 3 groups, interference screw fixation of the graft was used at both ends and 125 of 134 (93%) of the patients returned for the follow-up examination after 26 months (range, 20 to 43 months). The preoperative assessments in all 3 groups were similar in terms of gender, Tegner activity level, Lysholm score, KT-1000 measurements, 1-leg hop test, and the knee-walking test. At follow-up, the knee-walking test was significantly worse in the BPTB group than in the ST group (P = .0004) and ST/G group (P < .0001). Furthermore, the knee-walking test was significantly worse at follow-up than preoperatively in the BPTB group (P < .0001). The corresponding findings were not made in the other 2 groups. A significant reduction in knee laxity and an increase in activity level compared with the preoperative assessments were found in all 3 groups, without any significant differences between the groups.

Conclusion Less discomfort during the knee-walking test for Hamstrings, than BPTB. However, in terms of functional outcome and knee laxity, the groups displayed no significant differences. LEVEL OF EVIDENCE: Level I.

Critique No mention of Patellar fracture, follow up should be sufficient to identify fixation failure. Not long enough to identify late graft failure where BPTB may be worse. No assessment of HG donor site morbidity!

Author David J Biau, Caroline Tournoux, Sandrine Katsahian, Peter J Schranz, Rémy S Nizard

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