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Orthopaedic Surgery Cartilage Repair
Figure 1: Schematic Drawing Representing the Final
include tests for rotational stability. Yamamoto et al.,
15
on the other
Positioning of the Anteromedial and Posterolateral Bundles
hand, reported no significant differences between double bundle and
single bundle ACL reconstruction of the PL bundle in terms of response
CL
to rotatory loads. However, single PL bundle reconstruction was found to
endobutton (20mm)
be associated with increased anterior tibial translation with application of
anterior loads. In a biomechanical study by Yagi et al.,
14
restoration of the
knee kinematics was also demonstrated to be better with a double
CL
bundle than a single bundle reconstruction technique particularly in
endobutton (15mm)
AM bundle
terms of rotational control. Further in vivo studies by Tashman et al.
12
also
revealed that single bundle reconstruction sufficiently restores AP tibial
translation but fails to provide rotational stability during dynamic loading.
PL bundle
In general, the available studies so far have demonstrated that single
Bony bridge
bundle ACL reconstruction can only partially restore the normal knee
No. 5
kinematics as it limits anterior translation but is unable to control pivot
tycron/orthocord
Titanium 4.5 screw
shift. In addition, biomechanical analysis of an anatomically reconstructed
suture
for tibial post
knee also demonstrated that anterior tibial translation for double bundle
reconstruction is significantly closer to that of an intact knee and
Figure 2: Anteroposterior (A) and Lateral Post-operative (B)
Radiographs Are Taken to Check the Position of the Grafts
produces better rotatory stability.
4,9,16
Double bundle techniques have initially been performed as a double
AB ligament reconstruction using different grafts (doubled semitendinosus
and gracilis tendons) and independent fixations. Theoretically, this
would modify the biomechanical asset of the ACL because of the
different calibres and properties of the grafts. The double bundle
technique with semintendinosus tendon alone reproduces the
biomechanical properties of the AM and PL bundles, which the authors
believe, have to be strictly considered as parts of the same structure with
similar, if not identical, properties. Additionally, a single harvesting
allows preservation of the gracilis tendon, enhancing the results of a
reconstructed knee with less influence on internal rotation strength and
deep flexion movements.
17
Two endobuttons and a post-screw construct are visible. Graft fixation has always been an issue in ACL reconstruction and
anatomical double bundle reconstruction; therefore, the reduction of
Post-operatively, rehabilitation is commenced following the protocol fixation implants offered by this technique can diminish the number of
described by Rosenberg.
11
false steps to be faced along the procedure.
Discussion Conclusions
Early cadaveric investigations performed by Radford et al.
10
demonstrated The double bundle surgical technique is a feasible procedure to reconstruct
the superior anteroposterior knee stability achieved through various double bundle ACL with less morbidity compared with standard double
ranges of flexion with a double bundle ACL reconstruction compared bundle techniques. Further biomechanical and clinical randomised studies
with single bundle reconstruction. Their investigation, however, did not have to be completed to fully validate this technique. ■
1. Adachi N, Ochi M, Uchio Y, et al., Reconstruction of the Extension After Anterior Cruciate Ligament Injury, Am J Sports reconstruction, Am J Sports Med, 2004;32:975–83.
Anterior Cruciate Ligament: Single Vs Double Multistranded Med, 1996;24:603–7. 13. Woo S, News in Biomechanics Research on ACL, 8th
Hamstring Tendons, JBJS Br, 2004;86:515–220. 8. MunetaT, Sekiya I, Ogiuchi T et, al., Effects of Aggressive Early International Conference on Orthopaedics Biomechanics and
2. Chen L, Cooley V, Rosenberg T, ACL Reconstruction with Rehabilitation on the Outcome of Anterior Cruciate Ligament Sports Rehabilitation, November 19–21, 2004, Assisi, Italy.
Hamstring Tendon, Orthop Clin North Am, 2003;34:9–18. Reconstruction with Multi-strand Semitendinosus Tendon, Int 14. Yagi M, Wong E, Kanamori A, et al., Biomechanical Analysis of
3. Gobbi A, Mahajan S, Tuy B, et al., Hamstring graft tibial Orthop (SICOT), 1998;22:352–6. an Anatomic Anterior Cruciate Ligament Reconstruction, Am J
fixation: biomechanical properties of different linkage systems, 9. Muneta T, Sekiya I, Yagishita K, et al., Two-bundle Sports Med, 2000;28:660–66.
Knee Surg Sports Traumatol Arthrosc, 2002;10:330–34. Reconstruction of the Anterior Cruciate Ligament Using 15. Yamamoto Y, Hsu W-H, Woo SL-Y, et al., Knee Stability and
4. Hamada M, Shino K, Horibe S, et al., Single- Vs Bi-socket Semitendinosus Tendon with EndoButton: Operative Technique Graft Function After Anterior Cruciate Ligament Reconstruction,
Anterior Cruciate Ligament Reconstruction Using Autogenous and Preliminary Results, Arthroscopy, 1999;15:618–24. Am J Sports Med, 2004;32:1825–32.
Multiple-stranded Hamstring Tendons with EndoButton Femoral 10. Radford WJ, Amis AA, Biomechanics of a Double Prosthetic 16. Zaracznyj B, Reconstruction of the Anterior Cruciate Ligament
Fixation: A Prospective Study, Arthroscopy, 2001;17:801–7. Ligament in the Anterior Cruciate Ligament, JBJS Br, 1990;72: of the Knee Using a Doubled Tendon Graft, Clin Orthop,
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Structure and Its Relation to Soft Tissue Structure and 11. Rosenberg TD, Graft B, Techniques for ACL Reconstruction with 17. Gobbi A, et al., Hamstring anterior cruciate ligament
Applications to Radiography, J Anat, 1974;117:605–18. Multi-Trac Drill Guide, 1994, Mansfield, MA: Acufex reconstruction: is it necessary to sacrifice the gracilis?,
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Ligament Insufficiency, Clin Orthop, 1983;172:90–92. 12. Tashman S, Colon D, Anderson K, et al., Abnormal rotational
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86 EUROPEAN MUSCULOSKELETAL REVIEW 2007
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