ARTHROSCOPIC ANTERIOR CRUCIATE LIGAMENT REPAIR

SINGLE BUNDLE VS DOUBLE BUNDLE Presenter : Dr Abhishek Chaudhary (DNB ortho

resident at SGITO) Moderator: Dr Madan Ballal (professor and

head of dept of sports medicine)

JOURNAL CLUB

Applied Anatomy Biomechanics ACL tear Available treatment options Surgical procedures-single and double

bundle Journals discussion-single bundle vs double

bundle Final conclusion

In this presentation

- length of 38 mm (range 25 -41 mm)- width of 10 mm (range 7 -12 mm)

- made up of multiple collagen fascicles;- surrounded by an endotendineum - microspocially: interlacing fibrils (150 to 250 nm in diameter- grouped into fibers (1 to 20 um in diameter) - synovial membrane envelvope

- innervation:             - receives its innervation from tibal nerve;             - infiltrates the capsule posteriorly;             - golgi tendon receptors;            

- blood supply:             - major blood supply: from middle genicular artery             - bony attachments do not provide a significant source of blood to distal or proximal ligaments;            

Anatomy of ACL

Femoral attachment: ACL arises from the posteromedial corner of medial

aspect of lateral femoral condyle in the intercondylar notch;

attachment is actually an interdigitation  of collagen fibers & rigid bone thru transitional zone of fibrocartilage and mineralized fibrocartilage;

femoral attachment of ACL is on posterior part of medial surface of lateral condyle well posterior to longitudinal axis of the femoral shaft;

Tibial attachment: tibial attachment is in a fossa in front of & lateral to anterior

spine, a rather wide area from 11 mm in width to 17 mm in AP direction;

anterior fibers go forward to level of transverse meniscal ligament;

inserts into the interspinous area of the tibia;

Femoral and Tibial Attachments

Femoral and Tibial Attachments of acl

Anterior & Posterior Bundles:

ACL is composed of two principal parts: small anteromedial band and a larger bulky posterolateral portion;

anteromedial bundle is tight in flexion and the posterolateral bundle is tight in extension;

extension: both bundles are parallel; flexion: femoral insertion site of the posterolateral bundle moves anteriorly

            - both bundles are crossed             - anteromedial bundle tightens and posterolateral bundle loosens

The two bundles of acl

- represents posterior directly directed fibers w/ its attachment just lateral to midline of the intercondylar eminence and slightly lateral to most lateral                     attachement of the intermediate bundle;

 - unlike the antermedial portion, the bulkier posterolateral bundle is not isometric.

           - interruption of posterolateral bundle of ACL increases external rotation recurvatum test of posterolateral after anteromedial and intermediate                   bundles are divided;            

- - w/ knee extended, resistance to the anterior drawer test is by posterolateral bulky portion;         - it limits anterior translation, hyperextension, and rotation;           - oblique position of the posterolateral bundle provides more rotational control than is provided by the anteromedial bundle, which is in a more axial position;           - hyperextension and internal rotation place the posterolateral bundle at greater risk for injury;           - rupture cause increases in hyperextension, anterior translation (extended knee), increase in external and internal rotation (knee extended),                          and increases in external rotation with the knee in mid flexion;

posterolateral bundle:

anteromedial bundle:            -  femoral insertion of the anteromedial bundle is the center of rotation of ACL           - anteromedial bundle has isometric behavior;           - is more prone to injury with the knee in flexion           - anteromedial bundle inserts on the medial aspect of the intercondylar eminence of the tibia and forms the medial corner of the triangle;            - anteromedial band is primary check against anterior translation of tibia on femur when anterior drawer test is performed in usual manner w/ knee flexed;            - cutting this ligament may produce anterolateral instability;            - limits anterior translation of the tibia on the femur with the knee in flexion (which requires isometric behavior);           - rupture may cause in an increase in anterior translation in flexion, minimal increase in hyperextension, and minimal rotational instability; 

     - intermediate bundle:            - cutting this ligament produces straight anterior instability;            - when anteromedial band of the ligament is torn, posterolateral bulk of ligament may remain intact & anterior drawer sign will be present but surgeon will                  have impression that ligament is not torn;    

accounting for approximately 85% of the resistance to the anterior drawer test when the knee is at 90 degrees of flexion and neutral rotation.

Tension in the anterior cruciate ligament is least at 30 to 40 degrees of knee flexion. The anterior cruciate ligament also functions as a secondary restraint on tibial rotation and varus valgus angulation at full extension.

proprioceptive function

biomechanics

- ultimate tensile load: 2160 ± 157 N

Or simply we can suspend (2160/9.81=220kg) on the strongest acl before it breaks.    - stiffness:(force to deform it permanenty)- 242 ± 28 N/mm;     - passive knee extension produces forces along ACL only during last 10 degrees of knee extension;     - hyper-extension:             - the posterolateral bundle of the ACL is tight in extension;             - at 5 degrees of hyperextension, anterior cruciate ligament forces range between 50 and 240 newtons;             - hyperextension of the knee develops much higher forces in ACL than in the PCL;     - flexion:;             - during isometric quadriceps contraction, ACL strain at 30 deg of knee flexion are significantly higher than at 90 deg where ligament remain unstrained                     with isometric quadriceps activity;             - active extension of knee between the limits of 50 and 110 degrees does not strain the anterior cruciate;             - at 90 deg of knee flexion:             - ACL accounts for approx 85% of resistance to anteior drawer test

Sectioning of ACL:     - in unsectioned ACLs in neutral rotation, application of 100 newtons of anterior force produces:             - 2-5 mm of anterior translation at full extension;             - 5-8 mm of translation at 30 deg of flexion;             - as flexion angle increases further, anterior translation decreases;     - sectioning of ACL results in increased laxity at all flexion angles;             - 20-30 deg of flexion:             - maximum anterior translation occurs w/ 100-newton anterior force, 7-9 mm of increased translation is seen;     - clinically, combined ACL and MCL tears result in large increases in anterior translation;     - following sectioning of the ACL: anterior restraint derives from:             - iliotibial band: 24%             - mid medial capsule: 22%             - mid lateral capsule: 20%             - MCL:16%             - LCL: 12%

Functional Role:     - ACL is the predominant restraint to anterior tibial displacement;     - ligament accepts 75 % of anterior force at full extension & approx 85 % at 30 and 90 degrees of flexion;             - deep MCL is a major secondary restraint to anterior translation;

role in gait: (gait menu and role of knee in locomotion)            - ACL is taut in full knee extension, and tends to externally rotate tibia;             - tension in ACL is least at 40 to 50 deg of knee flexion;             - as knee moves from flexion to extension, shorter, more highly curved lateral condyle exhausts its articular surface & is checked by ACL;             - larger and less curved medial condyle continues its forward roll and skids backward, assisted by tightening of PCL;             - towards full extension there is lateral rotation of tibia & joint is "screwed home;" 

consequences of ACL deficient knee                    - absence of the normal internal rotation of the femur during the terminal swing phase

Isometry:     - anterior cruciate ligament does not remain an isometric, or constant length, structure as the knee is flexed and extended;     - ligament increases in strain magnitude as the lower leg is passively extended, with the femur in a horizontal plane;     - reconstruction of the ACL should not strive to achieve an isometric placement of the graft, but rather reproduce strain behavior of the normal ACL

Incidence –unknown but estimates It is estimated that the annual incidence of ACL injury is about 1 in 3,000 amongst the general population in the USA.

Mechanism of injury: non contact inj such as noncontact deceleration, jumping, or cutting action accounts for 70 % of ACL tears.

Contact injury (external forces)-30 % of ACL tears Immidiate Symptoms:-pain swelling,inabilty to walk normaly

or at all ,a pop sound on hyperextention .

Late symptoms: feeling of instability, joint giving up or leg falling out of knee joint these symptoms increases on walking down the stairs and when patient is trying to run

Acl tear

Signs..knee effusion (haemarthrosis)

The Lachman test is the most sensitive test for anterior tibial displacement (95% sensitivity)

Increased excursion relative to the opposite knee and absence of a firm end point suggest an injury to the anterior cruciate ligament.

The pivot shift test requires a relaxed patient and an intact medial collateral ligament. When the result is positive, this test reproduces the pathological motion in an anterior cruciate ligament–deficient knee and is easier to elicit in a chronic anterior cruciate ligament disruption or in an anaesthetized patient with an acute anterior cruciate ligament injury

Knee ligament arthrometers such as the KT-1000/2000

can assist in the diagnosis but are more effective in evaluating patients with chronic anterior cruciate ligament disruption

when pain and associated muscle guarding are absent. These devices also are useful for documentation of surgical results.

both intraoperatively and postoperatively. With a manual maximal anterior displacement, the right-left difference is less than 3 mm in 95% of normal knees. The right-left difference is 3 mm or more in 90% of knees with an acute anterior cruciate ligament injury

incidence of meniscal tears with acute anterior cruciate ligament injuries to range from 50% to 70%. The lateral meniscus is more commonly injured with the initial incident.

As a result of abnormal loading and shear stresses in the anterior cruciate ligament–deficient knee, the risk of late meniscal injury is high and appears to increase with time from the initial injury.

Most late meniscal tears occur in the medial meniscus because of its firm attachment to the capsule.

Osteochondral damage also influences prognosis. The reported incidence ranges from 21% to 31% in patients examined after the initial injury.

Associated injuries

MRI is the gold standard diagnostic investigation for ACL injury.

Also gives details of osteochondral damage and other soft tissue

Management of acl tear

History :-

The first recorded description of rupture of the ACL, was by Stark in 1850 .

Autologous Fascia Lata and Meniscal Grafts In 1912

The Hamstring Graft In 1934 the Italian orthopaedic surgeon Riccardo Galeazzidescribeda technique forACL reconstructionusing the semi-tendinosus tendon.

Patellar Tendon Grafts In 1935, Campbell. Marshall et al. in 1979 also used the central third of the patellar tendon By the1990s the technique of using a free bone-patellar tendon-bone graft harvested from the central one-third

of the patella became the “Gold Standard” of treatment.

Arthroscopic reconstruction

Synthetic Grafts Benson suggested the potential biological and biomechanical

Significanceofpurecarbonin1971 carbon fibre graft.

Allograft During the 1980s a remarkable interest developed in the use of

allograft tissue for ACL reconstruction . freeze dried grafts used after upto 18 months of preservation. inferior results compared to autografts

During the 1980s, techniques for arthroscopic ACL reconstruction were becoming increasingly popular.

The Double-Bundle graft-In 2003 Marcacci et al. described a double-bundle gracilis and semitendinosus graft that they claimed guaranteed a more anatomic ACL reconstruction and avoided the use of hardware for graft fixation

Double bundle procedure -portals

DB

Tibial tunnel

BACKGROUND: Surgical technique is essential in anterior

cruciate ligament (ACL) reconstruction.

PURPOSE: This randomized 5-year study tested the

hypothesis that double bundle ACL reconstruction with hamstring autografts and aperture screw fixation has fewer graft ruptures and rates of osteoarthritis (OA) and better stability than single bundle reconstruction.

ABSTRACT

STUDY DESIGN: Randomized controlled trial; Level of evidence, 1.

METHODS: Ninety patients bioabsorbable screw fixation (DB group; n = 30), bioabsorbable screw fixation (SBB group; n = 30),\ metallic screw fixation (SBM group; n = 30).

Evaluation: clinical examination, KT-1000 arthrometer measurement, and International Knee

Documentation Committee (IKDC) and Lysholm knee scores.

radiographic evaluation was made by a musculoskeletal radiologist who was unaware of the patients' clinical and surgical data.

A single surgeon.

Preoperatively, there were no differences.

Eleven patients (7 in the SBB group, 3 in the SBM group, and only 1 in the DB group) had a graft failure during the follow-up and went on to ACL revision surgery (P < .043).

Of the remaining 79 patients, a 5-year follow-up was performed for 65 patients (20 in the DB group, 21 in the SBB group, and 24 in the SBM group) who had their grafts intact.

At 5 years, there was no statistically significant difference in the pivot-shift or KT-1000 arthrometer tests.

In the DB group, 20% of the patients had OA in the medial femorotibial compartment and 10% in the lateral compartment, while the corresponding figures were 33% and 18% in the single-bundle groups, again an insignificant finding.

no significant group differences were found in the knee scores.

RESULTS

The double-bundle surgery resulted in significantly fewer graft failures and subsequent revision ACL surgery than the single-bundle surgeries during the 5-year follow-up. Knee stability and OA rates were similar at 5 years.

In view of the size of the groups, some caution should be exercised when interpreting the lack of difference in the secondary outcomes.

CONCLUSION:

BACKGROUND: Arthroscopic reconstruction for anterior cruciate

ligament rupture is a common orthopaedic procedure. One area of controversy is whether the method of double-bundle reconstruction, which represents the 'more anatomical' approach, gives improved outcomes compared with the more traditional single-bundle reconstruction.

OBJECTIVES: To assess the effects of double-bundle versus single-

bundle for anterior cruciate ligament reconstruction in adults with anterior cruciate ligament deficiency.

Abstract

DATA COLLECTION AND ANALYSIS: independently selected articles,.

MAIN RESULTS: Seventeen trials . 1433 cases, outcomes were available for a maximum of nine trials and 54% of

participants.

There were no statistically or clinically significant differences between double-bundle and single-bundle reconstruction in the subjective functional knee score) at short term..

At long term followup, there were statistically significant differences in favour of doublebundle reconstruction for IKDC knee examination.

There were no significant differences between the two groups in adverse effects and complications .

There were also statistically significant differences in favour of double-bundle reconstruction for newly occurring meniscal injury.

There were no statistically significant differences found between the two groups in range of motion (flexion and extension) deficits.

There is insufficient evidence to determine the relative effectiveness of double-bundle and single-bundle reconstruction for anterior cruciate ligament rupture in adults, although there is limited evidence that double-bundle ACL reconstruction has some superior results in objective measurements of knee stability and protection against repeat ACL rupture or a new meniscal injury.

High quality, large and appropriately reported randomised controlled trials of double-bundle versus single-bundle reconstruction for anterior cruciate ligament rupture in adults appear justified.

CONCLUSIONS:

BACKGROUND: Double-bundle ACL reconstruction popularity is increasing

with the aim to reproduce native ACL anatomy and improve ACL reconstruction outcome. However, to date, only a few randomized clinical studies have been published.

PURPOSE: The aim of this study was to prospectively compare the

clinical results of single- and double-bundle ACL reconstruction.

STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1.

Abstract

METHODS: Seventy patients Outcome assessment visual analog scale (VAS) score, (IKDC)

form, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and KT-1000 arthrometer evaluation.

RESULTS: minimum follow-up of 2 years. No differences between the 2 groups were observed in IKDC

subjective score. A statistically significant difference in favor of the DB group was

found with the VAS (P < .03). The objective IKDC final scores showed statistically significantly more "normal knees" in the DB group than in the SB group (P = .03).

There was 1 stability failure in the DB group and 3 in the SB group.

The KT-1000 arthrometer data showed a statistically significant decrease in the average anterior tibial translation in the DB group (1.2 mm DB vs 2.1 mm SB; P < .03). The incidence of a residual pivot-shift glide was 14% in DB and 26% in SB (P = .08).

CONCLUSION: In the 2-year minimum follow-up, DB ACL

reconstructions showed better VAS, anterior knee laxity, and final objective IKDC scores than SB. However, longer follow-up and accurate instrumented in vivo rotational stability assessment are needed

BACKGROUND: No consensus has been reached on the advantages of

double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) over the single-bundle (SB) technique, particularly with respect to the prevention of osteoarthritis (OA) after ACLR.

PURPOSE: To evaluate whether DB ACLR has any advantages in the

prevention of OA or provides better stability and function after ACLR compared with the SB technique.

STUDY DESIGN: Randomized controlled trial; Level of evidence, 2.

Abstract

METHODS: A total of 130 DB group (n = 65) SB group (n = 65). degree of OA based on the Kellgren-Lawrence pre and post

operation. stability results using the Lachman and pivot-shift tests and stress

radiography. functional outcomes based on the Lysholm knee score, Tegner

activity score, and International Knee Documentation Committee (IKDC) subjective scale.

RESULTS: 112 patients were observed for a minimum of 4 years (DB group, n =

52; SB group, n = 60). Five patients (9.6%) in the DB group and 6 patients (10%) in the SB

group had more advanced OA at the final follow-up (P = .75) Six patients (4 in the DB group and 2 in the SB group) suffered graft

failure during the follow-up and had ACL revision surgery (P = .06). Other comparisons no difference.

CONCLUSION: The DB technique, compared with SB, was not

more effective in preventing OA and did not have a more favorable failure rate.

Although the DB ACLR technique produced a better IKDC subjective scale result than did the SB ACLR technique, the 2 modalities were similar in terms of clinical outcomes and stability after a minimum 4 years of follow-up.

BACKGROUND: Double-bundle (DB) anterior cruciate ligament

reconstruction (ACLR) has been reported to yield better joint stability than single-bundle (SB) reconstruction. Few studies have compared the 2 techniques with regard to postoperative articular cartilage changes.

HYPOTHESIS: Less cartilage damage should occur in the short term

after DB ACLR than after SB ACLR.

STUDY DESIGN: Cohort study; Level of evidence, 2.

Abstract

METHODS: 52 patients (27 in the DB group and 25 in the SB group) no chondral or meniscus injury at primary ACLR, Cartilage status at 6 identified regions was evaluated by second-look

arthroscopy . Other assessments at final follow-up included International Knee

Documentation Committee (IKDC) score, Tegner and Lysholm scores, side-to-side difference on KT-2000 arthrometer, and range of motion.

RESULTS: The followup mean time18 months.(short term) Both groups had cartilage lesions at the patellofemoral joint

(patella, 9 vs 13; trochlea, 5 vs 12) and the medial compartment (1 vs 2). Significantly less severe lesions were found in the DB group than in the SB group (mean grade, 0.33 vs 0.96; P < .05).

No significant differences were found between the 2 groups in terms of cartilage status at other regions, IKDC score, Lysholm score, Tegner score, KT-2000 arthrometer anterior laxity, or range of motion.

CONCLUSION: Chondral lesions were found postoperatively

in both DB and SB ACLR groups with hamstring autograft. The DB ALCR led to less cartilage damage at the femoral trochlea at short term followup.

PURPOSE: To prospectively assess the anterior tibial translation and

rotational kinematics of the knee joint as well as the clinical outcome after singlebundle (SB) and doublebundle (DB) anterior cruciate ligament (ACL) reconstruction.

METHODS: Forty two patients randomly underwent singlebundle (Group

SB, n = 21) or double-bundle (Group DB, n = 21) ACL reconstruction using hamstring tendon autografts.

Anterior tibial translation and rotatory laxity were measured prior to and after fixation of the graft during reconstruction under the guidance of a navigation system.

Clinical outcome measurements included the evaluation of the joint stability and functional status.

Abstract

RESULTS: Stablity increases significantly in both group compared to

preoperative . The postoperative total rotation (sum of internal and external rotation)

at 30° and 60° (26.6° vs. 24.0°; 28.7° vs. 25.1°) as well as postoperative change in external rotation at 60° (-1.4° vs. -4.6°), and a change in total rotation at 30° and 60° (-7.0° vs. -11.5°; -6.1° vs. -8.9°) differed between the two groups, with better stability in the DB group.

At 2 years follow-up, IKDC subjective satisfaction score was significantly different between two groups (70.9 vs. 79.6),

while manual and instrumented laxity, pivot shift tests, modified Lysholm score, Tegner activity score, thigh muscle strengths were not different.

Correlation analysis showed little correlations between anterior laxity tests at follow-up, and the kinematic variables measured by navigation during surgery while pivot shift test, IKDC subjective satisfaction score, modified Lysholm score, and Tegner activity score were mainly correlated with navigation-measured rotations in both groups.

CONCLUSIONS: The kinematic tests in this study found

evidence suggesting that the DB ACL reconstruction improved rotatory laxity better than the SB ACL reconstruction at 30° and 60° of flexion, but there was no difference in functional outcome at 2 years follow-up between SB and DB groups.

LEVEL OF EVIDENCE: Prospective comparative study, Level II.

7

BACKGROUND: Biomechanical differences between anatomical double-bundle

and central single-bundle anterior cruciate ligament reconstruction using the same graft tissue have not been defined.

PURPOSE: The purpose of this study was to compare these

reconstructions in their ability to restore native knee kinematics during a reproducible Lachman and pivot-shift examination.

STUDY DESIGN: Controlled laboratory study.

Abstract

METHODS: Using a computer-assisted navigation system, 10 paired knees Lachman and mechanized pivot-shift examination 3D motion path tracking.

RESULTS: A significant difference in anterior translation was

seen with Lachman examination

The DB construct was significantly better in limiting anterior translation of the lateral compartment compared with the SB reconstruction during a pivot shift maneuver and was not significantly different than the intact anterior cruciate ligament condition

DISCUSSION: Although DB and SB clinically may be same

functional outcome but An altered rotational axis resulted in

significantly greater translation of the lateral compartment in the SB compared with DB reconstruction.

CLINICAL RELEVANCE: A DB-ACLR may be a favorable construct for

restoration of knee kinematics in the at risk knee with associated meniscal injuries and/or significant pivot shift on preoperative examination.

8

PURPOSE: to compare the clinical outcomes of arthroscopic anatomical

double bundle (DB) anterior cruciate ligament (ACL) reconstruction with either selective anteromedial (AM) or posterolateral (PL) bundle reconstruction while preserving a relatively healthy ACL bundle.

MATERIALS AND METHODS: 98 patients mean follow-up of 2.7 years 34 DB ACL reconstruction (group A), 34 underwent selective AM bundle reconstruction (group B), and

30 underwent selective PL bundle reconstructions (group C). Pre and post op Lysholm and International Knee Documentation

Committee (IKDC) score, side-to-side differences of anterior laxity measured by KT-2000

arthrometer at 14 kg, and stress radiography and Lachman and pivot shift test results.

RESULTS: There were no significant differences

between the three groups in anterior instability measured by KT-2000 arthrometer, pivot shift, or functional scores.

CONCLUSION: Selective bundle reconstruction in partial

ACL tears offers comparable clinical results to DB reconstruction in complete ACL tears

Double bundle repair should be reserved for high demand patients such as contact sports persons,athletes considering it provides better stability,less failures and revisions. however for general population single bundle repair is sufficient to get good to excellent functional outcome in majority of cases.

My conclusion

Thank you

Acta Orthop. Belgium., 2014, 80, 336-347 The Open Sports Medicine Journal,2010, 4, 51-57

Damien P. Byrne, Kevin J. Mulhall and Joseph F. Baker Orthopaedic Research and Innovation Foundation, Sports Surgery Clinic, Santry, Dublin, Ireland.

Atlas of Human Anatomy, Sixth Edition- Frank H. Netter, M.D

Apley’s System of Orthopaedics and Fractures 9th Ed

Campbell's Operative Orthopaedics 12th

Pubmed central.