Anatomic Single- and Double-Bundle Anterior Cruciate Ligament Reconstruction, Part 1

Anterior cruciate ligament reconstruction is a frequently performed orthopaedic procedure. Although short-term results are generally good, long-term outcomes are less favorable. Thus, there is renewed interest in improving surgical techniques. Recent studies of anterior cruciate ligament anatomy and function have characterized the 2-bundle structure of the native ligament. During non-weightbearing conditions, the anteromedial (AM) and posterolateral (PL) bundles display reciprocal tension patterns. However, during weightbearing, both the AM and PL bundles are maximally elongated at low flexion angles and shorten significantly with increasing knee flexion. Conventional single-bundle reconstruction techniques often result in nonanatomic tunnel placement, with a tibial PL to a femoral "high AM" tunnel position. In vitro studies have demonstrated that these nonanatomic single-bundle reconstructions cannot completely restore normal anterior-posterior or rotatory laxity. Cadaveric studies suggest that anatomic single-bundle and anatomic double-bundle reconstruction may better restore knee stability. Although many cadaver studies suggest that double-bundle reconstruction techniques result in superior stability when compared with single-bundle techniques, others failed to demonstrate a clear benefit of this more complex procedure. Cadaver studies generally do not apply physiologically relevant loads and provide only a "time-zero" assessment that ignores effects of healing and remodeling after anterior cruciate ligament reconstruction. In vivo, dynamic studies offer the most comprehensive assessment of knee function after injury or reconstruction, as they can evaluate dynamic stability during functional joint loading. Studies of knee kinematics during activities such as gait and running suggest that nonanatomic single-bundle anterior cruciate ligament reconstruction fails to restore preinjury knee function under functional loading conditions. Similar studies of more anatomic single- and double-bundle surgical approaches are in progress, and preliminary results suggest that these anatomic techniques may be more effective for restoring preinjury knee function. However, more extensive, well-designed studies of both kinematics and long-term outcomes are warranted to characterize the potential benefits of more anatomic reconstruction techniques for improving long-term outcomes after anterior cruciate ligament reconstruction.