Initial Assessment in the Acute and Chronic Multiple-Ligament-Injured Knee
4.7 Single- or Double-Bundle Cruciate Reconstructions
The vast majority of ACL reconstructions that are performed utilize a single-bundle technique [ 68 ] . In an attempt to recreate a more anatomic reconstruction, the relative position of the tunnels, particularly on the femoral side, has gone through an evolution [ 69, 70 ] . The use of an anteromedial drilling portal was borne out of concern for the theoretical inability of a tran- stibial reconstruction to anatomically position the graft in the native femoral footprint and subsequently restore transverse
Killer turn Fig. 4.7 Killer turn
phenomenon. Courtesy of Sports Medicine Clinic, Carleton University.
Reprinted with permission
plane knee rotatory control [ 71 ] . However, there continues to be controversy with respect to ideal placement of the femoral tunnel. Moreover, the lack of reliable landmarks on which to base femoral tunnel placement has lead to variability and incon- sistency in ACL reconstructions. An analogous situation has developed with respect to PCL reconstruction. The desire to create a truly anatomic repair, and thereby provide maximum stability, has lead many surgeons to look for alternatives to single-bundle cruciate reconstructions.
The ACL and PCL have long been cited to possess two distinct bundles that independently contribute to their stability at various degrees of knee fl exion and extension [ 72, 73 ] . Over the past 10 years, the interest in double-bundle cruciate ligament repairs has increased due to a desire to create a more stable and overall more anatomic repair [ 74, 75 ] . With respect to the ACL, a double-bundle repair attempts to independently recreate the anteromedial bundle, which is tighter in fl exion, and the posterolateral bundle, which is tighter in extension [ 76 ] . Proponents of the double-bundle ACL reconstruction cite better rotational and sagittal plane stability when compared to single-bundle reconstructions [ 77, 78 ] . Despite the convincing biomechanical evidence for the superiority of double-bundle ACL reconstructions, a meta-analysis on the topic suggests no in vivo clinically signi fi cant differences with respect to stability and control between single- and double-bundle ACL recon- structions [ 79 ] . In addition, the procedure is not without its relative drawbacks. Increased surgical time, the need for addi- tional graft material, and an increased technical challenge have contributed to some surgeons’ trepidation for adopting the double-bundle technique. Continued higher-level research on the topic will likely lead to more de fi nitive evidence on which to base treatment decisions.
The same stimulus that propelled the interest in double-bundle ACL reconstructions has also lead to the concept of double- bundle PCL reconstructions (Fig. 4.8 ). The relative rarity of PCL reconstructions, compared to ACL reconstructions, has contributed to a lower total volume of literature regarding double-bundle PCL reconstructions. The theoretical advantages of a double-bundle PCL reconstruction are less posterior laxity and better rotational control, although there is currently a pau- city of research to support these claims [ 80– 82 ] . Double-bundle PCL reconstructions, like their ACL counterparts, also have the drawbacks of increased operative time, a greater need for graft material, and increased technical challenge [ 83 ] .
In the setting of a multiligament knee injury, the relative merits of double-bundle ACL and PCL reconstructions must be scrutinized. Recurrent laxity is a frequent complaint following multiligament knee reconstruction. Therefore, the potential increased stability afforded by a double-bundle approach may help obviate this problem. However, the gross instability asso- ciated with multiligament knee injuries may not allow for fi ne adjustments in the tensioning of the double-bundle constructs.
In addition, the geometric complexity associated with placement of four tunnels on both the femoral and tibial sides of the
Fig. 4.8 Double-bundle PCL reconstruction. From Chen B, Gao S. Double-bundle posterior cruciate ligament reconstruction using a non-hardware suspension fi xation technique and 8 strands of autogenous hamstring tendons.
Arthroscopy: J Arthroscopic Related Surg.
25(7);2009:777–782.
Reprinted with kind permission from Elsevier
joint may outweigh the potential bene fi ts, especially when one considers that proximal tibial and distal femoral bone stock will allow for only a fi nite number of tunnels and apertures before coalescence and intersection dif fi culties arise. Finally, increased arthroscopic operative time, in the setting of a potentially compromised knee joint capsule, may not be optimal.
Overall, the decision to utilize a double-bundle ACL or PCL reconstruction must be based on individual patient factors, institutional resource availability, and the technical abilities of the treating surgeon.
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63 G.C. Fanelli (ed.), The Multiple Ligament Injured Knee: A Practical Guide to Management,
DOI 10.1007/978-0-387-49289-6_5, © Springer Science+Business Media New York 2013