Double-bundle versus single-bundle anterior cruciate ligament reconstructions: a prospective, randomized study with 2-year follow-up

Anatomic Double-Bundle and Single-Bundle Reconstructions Yield Similar Outcomes Following Anterior Cruciate Ligament Rupture: A Systematic Review and Meta-analysis

PURPOSE

To evaluate outcomes of arthroscopic single-bundle (SB) versus anatomic double-bundle (ADB) anterior cruciate ligament reconstruction (ACLR) in adults through a synthesis of randomized controlled trials (RCTs). We hypothesized that SB and ADB methods would lead to similar outcomes after reconstruction of ACL rupture.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist guided our reporting. To identify RCTs that compared SB and ADB reconstructions, a thorough literature search was conducted of PubMed, Embase, Cochrane library, and Web of Science. The methodologic quality of each included study was independently assessed by 2 authors using the Cochrane Collaboration's risk of bias tool. The Anatomic ACL Reconstruction Scoring Checklist (AARSC) was used to screen the eligibility of each study's operative approaches. Twelve clinical outcomes were investigated through pooled analyses conducted using Review Manager 5.3.

RESULTS

This meta-analysis synthesized 13 RCTs comparing postoperative outcomes between ADB and SB reconstructions of ACLs. After a minimum follow-up of 12 months, ADB and SB technique resulted in similar subjective clinical outcomes, including the International Knee Documentation Committee subjective score, Lysholm score, Tegner activity score, and Knee injury and Osteoarthritis Outcome Score sports subscale. Similarly, no statistically significant outcomes were found for objective outcomes such as International Knee Documentation Committee objective grade, pivot-shift test, Lachman test, side-to-side difference, extension deficit, flexion deficit, and osteoarthritis change. However, patients who underwent SB reconstruction had significantly greater complication rates than those that underwent ADB reconstruction.

CONCLUSIONS

When an ACLR approach meets a minimal total AARSC score of 8, ADB and SB techniques may result in similar subjective and objective outcomes, but the ADB technique may lead to lower complication rates following surgery. We recommend that surgeons favor ADB ACLR, as guided by the AARSC.

LEVEL OF EVIDENCE

Level I, systematic review and meta-analysis of Level I randomized controlled trials.

Radiological maturation and clinical results of double-bundle and single-bundle anterior cruciate ligament reconstruction. A 5-year prospective case-controlled trial

INTRODUCTION

The aim of the study was to make a prospective comparison of the radiological and clinical outcomes of patients undergoing single-bundle and double-bundle anterior cruciate ligament (ACL) reconstruction.

METHOD

This prospective, case-controlled study included 65 patients, separated into 2 groups as 33 patients undergoing single bundle (SB), and 32 patients undergoing double bundle (DB) ACL reconstruction. The patients were evaluated clinically using the International Knee Documentation Committee (IKDC) and the Lysholm knee scores. Stability was evaluated with the KT-1000 Arthrometer Measurement, the Lachman and pivot shift tests. Magnetic resonance images (MRI) at 1 and 5 years postoperatively were evaluated by a musculoskeletal radiologist. All the operations were performed by a single surgeon and the clinical evaluations were made by an independent researcher.

RESULTS

Evaluation was made of a total of 53 patients (SB: 28, DB: 25). No statistically significant difference was determined between the groups regarding the postoperative IKDC and Lysholm scores. The pivot shift tests were negative in the DB group and positive in two patients of the SB group. The Lachman test was negative in all the patients. No significant difference was determined between the groups. No statistically significant difference was determined between the two groups in respect of the arthrometer measurements. In the SB group, revision surgery was performed in two patients due to graft failure. No graft failure findings were determined in the DB group, and no statistically significant difference was determined between the groups in respect of graft failure. On the MRIs taken at 1 year postoperatively, the ACL was seen to be hyperintense in 16 patients in the DB group and 6 patients in the SB group (p = 0.004). On the 5-year MRIs, ACL hypointensity could not be seen in three patients of the SB group and two of the DB group, with no difference determined between the groups (p > 0.05).

CONCLUSION

In the 5-year follow-up period, no difference was determined between patients undergoing SB ACL reconstruction and those undergoing DB ACL reconstruction regarding clinical scores, knee stability, and MRI findings, but graft maturation occurs later the patients undergoing DB reconstruction.

Double bundle ACL reconstruction leads to better restoration of knee laxity and subjective outcomes than single bundle ACL reconstruction

PURPOSE

The purpose of this meta-analysis is to compare arthroscopic single bundle (SB) and double bundle (DB) anterior cruciate ligament (ACL) reconstructions in the light of all available randomised controlled trials (RCTs). A meta-analysis of this well-researched topic was performed and subgroup analyses of the medial portal (MP) technique and the transtibial technique (TT) were added as a new idea. The hypothesis was that the DB technique is superior to the SB technique also in subgroup analyses of the MP and TT techniques.

METHODS

Instructions of the PRISMA checklist were followed. Systematic literature search from electronic databases, including PubMed, Cochrane library and Scopus was performed to find RCTs that compared the SB and DB techniques. Nine outcomes were used to compare these two techniques. Each study was assessed according to the Cochrane Collaboration's risk of bias tool and three subgroup analyses (minimum 2-years' follow-up, TT technique and MP technique) were performed.

RESULTS

A total of 40 studies were included in this meta-analysis. When analysing all the included studies, the DB technique was superior to the SB technique in KT-1000/2000 evaluation (p < 0.01), IKDC subjective evaluation (p < 0.05), Lysholm scores (p = 0.02), pivot shift (p < 0.01) and IKDC objective evaluation (p = 0.02). Similar results were also found in the subgroup analyses of minimum 2-years' follow-up and the TT technique. However, there were no differences between the two techniques in a subgroup analysis of the MP technique.

CONCLUSION

Generally, DB ACL reconstruction leads to better restoration of knee laxity and subjective outcomes than SB ACL reconstruction. The subgroup analysis of the MP technique revealed that surgeons can achieve equally as good results with both techniques when femoral tunnels are drilled through the medial portal.

LEVEL OF EVIDENCE

II.

Comparing post-operative pain between single bundle and double bundle anterior cruciate ligament reconstruction: a retrospective study

Background

In anterior cruciate ligament (ACL) reconstruction, the clinical outcome and level of post-operative pain are important factors. To date there have been no studies evaluating differences in post-operative pain between single bundle and double bundle ACL reconstruction with a hamstring graft.

Hypothesis/purpose

We hypothesized that post-operative pain in single bundle ACL reconstruction would be less than in double bundle ACL reconstruction. This study was to compare post-operative pain between patients undergoing single bundle versus double bundle ACL reconstruction.

Study design

Cohort study.

Methods

This was a retrospective study comparing post-operative pain scores between single bundle and double bundle ACL reconstruction. Each patient was given our standard regimen of oral diclofenac (25 mg/tab) three times per day and paracetamol (500 mg/tab) six times per day for 1 day post-operatively. If the patient complained of moderate to severe pain (pain numeric rating scale (PNRS) > 3), 3 mg of morphine was injected intravenously every 3 h for 24 h and 1 mg of morphine as a rescue medication every 1 h for 24 h. PNRS and morphine consumption were recorded at 4-h intervals for 24 h.

Results

209 patients were included in this study of whom 102 and 107 patients received single bundle and double bundle ACL reconstruction, respectively. The average post-operative pain scores of the single bundle group were lower at all time points. Linear mixed effect regression analyses showed that the single bungle group had lower post-operative pain than the double bundle group after adjusting for confounders (beta = − 0.45; 95% CI = − 0.838, − 0.062) but there was no statistically significant difference between numbers of bundle ACL reconstruction with regard to morphine consumption.

Conclusion

Single bundle ACL reconstruction had significantly lower post-operative pain scores than double bundle ACL reconstruction.

Clinical relevance

Double bundle ACL reconstruction results in higher post-operative pain, which may slow the start of rehabilitation and reduce patient satisfaction. In middle-aged adult patients with low-demand activities, we suggest performing a single bundle ACL reconstruction.

Subjective assessment reported by patients shows differences between single-bundle and double-bundle anterior cruciate ligament reconstruction, systematic review and meta-analysis

To determine the functional recovery, active reincorporation, and anteroposterior and rotational stability of patients undergoing anterior cruciate ligament (ACL) reconstruction using arthroscopy techniques with simple-bundle (SB) or double-bundle (DB). The following databases were searched: PubMed, Embase (Elsevier platform), the Cochrane Central Register of Controlled Trials (Wiley platform), Web of Science, and CINAHL. Level I and II studies involving anterior cruciate ligament arthroscopy were included in the search. Records were screened by title and abstract and assessed the risk of bias of selected studies. Meta-analyses using RevMan 5.3 software were conducted on the following outcomes: knee functionality, objective measurements of knee stability, rotational knee stability and knee anterior stability, sports reincorporation, and subjective assessments. Twenty-four studies of patients undergoing ACL reconstruction were included in the qualitative and quantitative synthesis (1707 patients) for Lysholm score, Subjective International Knee Documentation Committee (IKDC) score, Tegner score, KT-1000/2000, Lachman test, Objective IKDC score, and Pivot-Shift test. A return to pre-injury level showed a significant decrease in the Lysholm score (mean difference, - 0.99; 95% CI - 1.71 to - 0.40; P = 0.007) and Tegner score (mean difference, - 0.07; 95% CI, - 0.13 to - 0.01; P = 0.02) at DB reconstruction, similar to the knee functionality outcome of the subjective IKDC score (mean difference - 1.42; 95% CI - 2.46 to - 0.38; P = 0.007). There is no clear or significant difference in clinical stability and knee function or in sports incorporation with the true difference occurring in the subjective assessment.

Pain Following Single-bundle versus Double-bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review

BACKGROUND: Double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) has been known to result in better functional outcomes, joint stability, and lower revision rates compared to single-bundle (SB) ACLR. However, given the increased invasiveness and damage to the surrounding tissue area, it is proposed that it may be associated with increased pain. AIM: This review aims to gather all studies and literature that reported pain as an outcome when comparing SB versus DB ACLR. METHODS: Literature searching was conducted across seven search engines for studies reporting pain as an outcome and comparing SB versus DB ACLR. RESULTS: Eight studies met the eligibility criteria and were included in the study. Overall, the studies show variable findings regarding pain in DB compared to SB ACLR, with the only statistically significant results from two studies indicating that DB ACLR is associated with more pain than SB ACLR. CONCLUSION: Based on the limited evidence available, no conclusions can be made regarding the pain experienced between people receiving either procedure. This constitutes a need for additional studies with increased follow-up time periods, larger sample size, and better study design.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury - Secondary publication

BACKGROUND

This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS).

METHODS

The JOA ACL guideline committee revised the previous guideline based on "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of "the balance of benefit and harm" was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

RESULTS

We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature.

CONCLUSIONS

This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.

Long term results after double and single bundle ACL reconstruction: Is there any difference? A meta - analysis of randomized controlled trials

Objective

The double-bundle (DB) techniques are considered to yield better stability of the knee compared with single-bundle (SB) for anterior cruciate ligament (ACL) reconstruction. However, most studies followed up patients in short to middle-term within 5 years, and the longer-term efficacy of SB and DB ACL reconstruction is still beyond consensus. The purpose of this meta-analysis is to compare the longer-term efficacy between double-bundle (DB) and single-bundle (SB) techniques.

Methods

PubMed, EMBASE, and Cochrane Library databases were searched for relevant articles published up to November, 2017 with an English language restriction. The searches were limited to human subjects and randomized controlled trials (RCTs). In addition, the reference lists of identified articles were checked manually to avoid missing other potentially eligible studies. This process was performed iteratively until no additional articles could be included. The quality of the included studies was assessed using The Cochrane Collaboration's risk of bias tool. All statistical analyses were performed with Review Manager soft-ware.

Results

A total of five RCTs involving 294 patients were included finally. No studies were excluded due to insufficient data or low quality. The pooled results showed no statistically significant difference between SB and double bundle DB reconstructions for Lysholm, IKDC, pivot shift, KT scores, and the development of osteoarthritis at a minimum of 5 years. No significant heterogeneity was found across all outcomes.

Conclusion

The best available evidence demonstrated that SB and DB techniques could yield similar efficacy for ACL reconstruction. And no superiority was founded in DB ACL reconstruction with a minimal 5-year follow-up. Given that, the relatively simple and proven techniques of SB ACL reconstruction may be preferable for orthopedic surgeons.

Level of evidence: Level I, Therapeutic Study.

Single-bundle versus double-bundle autologous anterior cruciate ligament reconstruction: a meta-analysis of randomized controlled trials at 5-year minimum follow-up

BACKGROUND

Both single-bundle (SB) and double-bundle (DB) techniques were widely used in anterior cruciate ligament (ACL) reconstruction recently. Nevertheless, up to now, no consensus has been reached on whether the DB technique was superior to the SB technique. Moreover, follow-up of the included studies in the published meta-analyses is mostly short term. Our study aims to compare the mid- to long-term outcome of SB and DB ACL reconstruction concerning knee stability, clinical function, graft failure rate, and osteoarthritis (OA) changes.

METHODS

This study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The PubMed, Embase, and the Cochrane Library were searched from inception to October 2017. The study included only a randomized controlled trial (RCT) that compared SB and DB ACL reconstruction and that had a minimum of 5-year follow-up. The Cochrane Collaboration's risk of bias tool was used to assess the risk of bias for all included studies. Stata/SE 12.0 was used to perform a meta-analysis of the clinical outcome.

RESULTS

Five RCTs were included, with a total of 294 patients: 150 patients and 144 patients in the DB group and the SB group, respectively. Assessing knee stability, there was no statistical difference in side-to-side difference and negative rate of the pivot-shift test. Considering functional outcome, no significant difference was found in proportion with International Knee Documentation Committee (IKDC) grade A, IKDC score, Lysholm scores, and Tegner scores. As for graft failure rate and OA changes, no significant difference was found between the DB group and the SB group.

CONCLUSION

The DB technique was not superior to the SB technique in autologous ACL reconstruction regarding knee stability, clinical function, graft failure rate, and OA changes with a mid- to long-term follow-up.

Double-Bundle Versus Single-Bundle Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Study With 10-Year Results

BACKGROUND

A long-term follow-up comparing double-bundle and single-bundle techniques for anterior cruciate ligament (ACL) reconstruction has not been reported before.

HYPOTHESIS

Double-bundle ACL reconstruction may have fewer graft ruptures, lower rates of osteoarthritis (OA), and better stability than single-bundle reconstruction.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

Ninety patients were randomized for double-bundle ACL reconstruction with bioabsorbable screw fixation (DB group; n = 30), single-bundle ACL reconstruction with bioabsorbable screw fixation (SBB group; n = 30), and single-bundle ACL reconstruction with metallic screw fixation (SBM group; n = 30). Evaluation methods consisted of a clinical examination, KT-1000 arthrometer measurements, International Knee Documentation Committee (IKDC) and Lysholm knee scores, and a radiographic examination of both the operated and contralateral knees.

RESULTS

Eighty-one patients (90%) were available at the 10-year follow-up. Eleven patients (1 in the DB group, 7 in the SBB group, and 3 in the SBM group) had a graft failure during the follow-up and went on to undergo revision ACL surgery ( P = .043). In the remaining 70 patients at 10 years, no significant group differences were found in the pivot-shift test findings, KT-1000 arthrometer measurements, or knee scores. The most OA findings were found in the medial compartment of the knee, with 38% of the patients in the operated knee and 28% of the patients in the contralateral nonoperated knee. However, no significant group difference was found. The most severe OA changes were in the patients who had the longest delay from the primary injury to ACL reconstruction ( P = .047) and in the patients who underwent partial meniscal resection at the time of ACL reconstruction ( P = .024).

CONCLUSION

Double-bundle ACL reconstruction resulted in significantly fewer graft failures than single-bundle ACL reconstruction during the follow-up. Knee stability and OA rates were similar at 10 years. The most severe OA changes were found in the patients who had the longest delay from the primary injury to ACL reconstruction and in the patients who underwent partial meniscal resection at the time of ACL reconstruction.

The Results of Single Bundle Versus Double Bundle ACL Reconstruction Surgery, a Retrospective Study and Review of Literature

Objective:

The purpose of this study was to evaluate the results of single bundle and double bundle surgical techniques for anterior cruciate ligament (ACL) reconstruction.

Methods:

In this study, all single bundle and double bundle ACL reconstruction surgeries that were done in our university hospital from January 2008 to December 2012 were enrolled. All patients were followed at 2,6,12, 24 weeks and 1 a 2 years post operatively. On last follow up all patients were evaluated by clinical examination, KT-1000 and Lysholm questionnaire.

Results:

Seventy five patients were operated using single bundle and eighty five patients with double bundle technique. Fifty seven percent of patients in single bundle and 80% of patients in double bundle group had experienced pain during follow-up period. None of cases had knee extension or flexion loss. The average side to side differences using KT-1000 was 3.5 ± 0.38 (2.9-4.1) millimeters in single bundle group and 3.39 ± 0.39 (2.8-4) millimeters in double bundle group. These results showed no significant difference between two groups (P= 0.31). Lysholm score improved significantly in both groups, but there was no significant difference between them.

Conclusion:

According to this study the clinical results of single bundle ACL reconstruction was similar to double bundle reconstruction in short term follow up. Further studies are needed to evaluate the long term results.

A systematic review of single- versus double-bundle ACL reconstruction using the anatomic anterior cruciate ligament reconstruction scoring checklist

PURPOSE

The aim of this systematic review was to apply the anatomic ACL reconstruction scoring checklist (AARSC) and to evaluate the degree to which clinical studies comparing single-bundle (SB) and double-bundle (DB) ACL reconstructions are anatomic.

METHODS

A systematic electronic search was performed using the databases PubMed (MEDLINE), EMBASE and Cochrane Library. Studies published from January 1995 to January 2014 comparing SB and DB ACL reconstructions with clinical outcome measurements were included. The items from the AARSC were recorded for both the SB and DB groups in each study.

RESULTS

Eight-thousand nine-hundred and ninety-four studies were analysed, 77 were included. Randomized clinical trials (29; 38%) and prospective comparative studies (29; 38%) were the most frequent study type. Most studies were published in 2011 (19; 25%). The most commonly reported items for both SB and DB groups were as follows: graft type (152; 99%), femoral and tibial fixation method (149; 97% respectively), knee flexion angle during graft tensioning (124; 8%) and placement of the tibial tunnel at the ACL insertion site (101; 66%). The highest level of documentation used for ACL tunnel position for both groups was often one dimensional, e.g. drawing, operative notes or o'clock reference. The DB reconstruction was in general more thoroughly reported. The means for the AARSC were 6.9 ± 2.8 for the SB group and 8.3 ± 2.8 for the DB group. Both means were below a proposed required minimum score of 10 for anatomic ACL reconstruction.

CONCLUSIONS

There was substantial underreporting of surgical data for both the SB and DB groups in clinical studies. This underreporting creates difficulties when analysing, comparing and pooling results of scientific studies on this subject.

A Randomized Clinical Trial Comparing Patellar Tendon, Hamstring Tendon, and Double-Bundle ACL Reconstructions: Patient-Reported and Clinical Outcomes at a Minimal 2-Year Follow-up

OBJECTIVE

To compare 3 anatomically positioned autografts for anterior cruciate ligament (ACL) reconstruction, by measuring patient-reported disease-specific quality of life at 2 years postoperatively.

DESIGN

Double-blinded, randomized clinical trial with intraoperative computer-generated treatment allocation. Patients and an independent trained evaluator were blinded.

SETTING

University-based orthopedic referral practice.

PATIENTS

Three hundred thirty patients (14-50 years; 183 male patients) with isolated ACL deficiency were equally randomized to: (1) patellar tendon, PT: 28.7 years (SD = 9.7); (2) quadruple-stranded hamstring tendon, HT: 28.5 years (SD = 9.9); and (3) double bundle using HT, DB: 28.3 years (SD = 9.8); 322 patients completed 2-year follow-up.

INTERVENTION

Anterior cruciate ligament reconstruction using PT, HT, or DB autografts.

MAIN OUTCOME MEASURES

Measured at baseline, 1 and 2 years postoperatively-primary: anterior cruciate ligament quality-of-life scores; secondary: International Knee Documentation Committee (IKDC) scores, KT-1000 arthrometer, pivot shift, range of motion, Tegner activity, Cincinnati Occupational Scale, and single-leg hop. Proportions of correct graft type guesses by the patients and evaluator assessed blinding effectiveness.

RESULTS

Baseline characteristics were not different. Anterior cruciate ligament quality-of-life scores increased over time for all groups (P = 0.001) but were not different at 2 years (P = 0.591): PT = 84.6 (SD = 16.6, 95% confidence interval [CI] = 81.4-87.8), HT = 82.5 (SD = 17.7, 95% CI = 79.2-85.9), and DB = 82.4 (SD = 17.5, 95% CI = 79.1-85.7). Two-year KT-1000 side-to-side differences (PT = 1.86 mm; HT = 2.97 mm; DB = 2.65 mm) were statistically significant between PT-HT (P = 0.002) and PT-DB (P = 0.044). The remaining secondary outcomes were not statistically different. Correct graft type guesses occurred 51% of the time for patients and 46% for the evaluator.

CONCLUSIONS

Two-year disease-specific quality-of-life outcome was not different between the ACL reconstruction techniques. The PT reconstructions had significantly lower side-to-side differences on static stability measures. Patient and evaluator blinding was achieved.

LEVEL OF EVIDENCE

Level 1 (Therapeutic Studies).

CLINICAL RELEVANCE

This high-quality, large, double-blind randomized clinical trial (RCT) addresses the insufficient evidence in the literature comparing PT, single-bundle hamstring, and DB hamstring reconstructions for ACL rupture in adults. In addition to the clinical and functional results, this RCT uniquely reports on the disease-specific, patient-reported quality-of-life outcome at 2 years postoperatively.

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

PURPOSE

Multiple meta-analyses of randomized controlled trials, the highest available level of evidence, have been conducted to determine whether double-bundle (DB) or single-bundle (SB) anterior cruciate ligament reconstruction (ACL-R) provides superior clinical outcomes and knee stability; however, results are discordant. The purpose of this study was to conduct a systematic review of meta-analyses comparing SB and DB ACL-R to discern the cause of the discordance and to determine which of these meta-analyses provides the current best available evidence.

METHODS

We evaluated available scientific support for SB as compared with DB ACL-R by systematically reviewing the literature for published meta-analyses. Data on patient clinical outcomes and knee stability (as measured by KT arthrometry and pivot-shift testing) were extracted. Meta-analysis quality was judged using the Oxman-Guyatt and Quality of Reporting of Meta-analyses systems. The Jadad algorithm was then applied to determine which meta-analyses provided the highest level of evidence.

RESULTS

Nine meta-analyses were included, of which 3 included Level I Evidence and 6 included both Level I and Level II Evidence. Most studies found significant differences favoring DB reconstruction on pivot-shift testing, KT arthrometry measurement of anterior tibial translation, and International Knee Documentation Committee objective grading. Most studies detected no significant differences between the 2 techniques in subjective outcome scores (Tegner, Lysholm, and International Knee Documentation Committee subjective), graft failure, or complications. Oxman-Guyatt and Quality of Reporting of Meta-analyses scores varied, with 2 studies exhibiting major flaws (Oxman-Guyatt score <3). After application of the Jadad decision algorithm, 3 concordant high-quality meta-analyses were selected, with each concluding that DB ACL-R provided significantly better knee stability (by KT arthrometry and pivot-shift testing) than SB ACL-R but no advantages in clinical outcomes or risk of graft failure.

CONCLUSIONS

The current best available evidence suggests that DB ACL-R provides better postoperative knee stability than SB ACL-R, whereas clinical outcomes and risk of graft failure are similar between techniques.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II studies.

The Relationship between Anterior Cruciate Ligament Injury and Osteoarthritis of the Knee

Anterior cruciate ligament (ACL) tears are a common injury, particularly in the athletic and youth populations. The known association between ACL injury and subsequent osteoarthritis (OA) of the knee merits a more in-depth understanding of the relationship between the ACL-injured knee and osteoarthritis. ACL injury, especially with concomitant meniscal or other ligamentous pathology, predisposes the knee to an increased risk of osteoarthritis. ACL insufficiency results in deterioration of the normal physiologic knee bending culminating in increased anterior tibial translation and increased internal tibial rotation. This leads to increased mean contact stresses in the posterior medial and lateral compartments under anterior and rotational loading. However, surgical reconstruction of the ACL has not been shown to reduce the risk of future OA development back to baseline and has variability based on operative factors of graft choice, timing of surgery, presence of meniscal and chondral abnormalities, and surgical technique. Known strategies to prevent OA development are applicable to patients with ACL deficiency or after ACL reconstruction and include weight management, avoidance of excessive musculoskeletal loading, and strength training. Reconstruction of the ACL does not necessarily prevent osteoarthritis in many of these patients and may depend on several external variables.

Outcome of transtibial AperFix system in anterior cruciate ligament injuries

BACKGROUND

The anterior cruciate ligament (ACL) is one of the major stabilizing factor of the knee that resist anterior translation, valgus and varus forces. ACL is the most commonly ruptured ligament of the knee. The graft fixation to bone is considered to be the weakest link of the reconstruction. According to the parallel forces to the tibial drill hole and the quality of tibial metaphyseal bone is inferior to femoral bone stock, graft fixation to the tibia is more difficult to secure. AperFix system (Cayenne Medical, Inc., Scottsdale, Arizona, USA) which consists femoral and tibial component that includes bioinert polymer polyetheretherketone (PEEK) is one of the new choice for ACL reconstruction surgery. aim of this study was to assess the clinical outcomes and fixation durability of the AperFix (Cayenne Madical, Inc., Scottsdale, Arizona, USA) system and to determine the effect of patient's age in arthroscopic reconstruction of the anterior cruciate ligament.

MATERIALS AND METHODS

Patients with symptomatic anterior cruciate ligament rupture underwent arthroscopic reconstruction. Patients were evaluated in terms of range of motion (ROM) values; Lysholm, Cincinati and Tegner activity scales; laxity testing and complications. Femoral tunnel widening was assessed by computer tomography scans. Early postoperative and last followup radiographs were compared.

RESULTS

Fifty one patients were evaluated with mean followup of 29 months (range 25-34 months). Mean age at the surgery was 26.5 ± 7.2 years. Lysholm, Cincinati and Tegner activity scales were significantly higher from preoperative scores (Lysholm scores: Preoperative: 51.4 ± 17.2, postoperative: 88.6 ± 7.7 [P < 0.001]; Tegner activity scores: Preoperative 3.3 ± 1.38, postoperative: 5.3 ± 1.6 [P < 0.001]; Cincinati scores: Preoperative: 44.3 ± 17, postoperative: 81.3 ± 13.9 [P < 0.001]). The mean femoral tunnel diameter increased significantly from 9.94 ± 0.79 mm postoperatively to 10.79 ± 0.95 mm (P < 0.05). The mean ROM deficit (involved vs. contra knee) was -7.2 ± 16 (P < 0.001). There was no significant difference for knee score, ROM deficits (<30 years: -7.3 ± 15 and >30 years -7.06 ± 19) and femoral tunnel enlargement (<30 years: 0.83 ± 0.52 and >30 years 0.87 ± 0.43) of the patients with below and above 30 year. There was no significant difference for knee scores and femoral tunnel enlargement between patients with meniscal injuries and don't have meniscus lesions.

CONCLUSION

The AperFix system gives satisfactory clinical and radiological results with low complication rate. However, long term clinical and radiological results are needed to decide the ideal anterior cruciate ligament reconstruction method.