Single- versus double-bundle anterior cruciate ligament reconstruction.
F or this inaugural Clinical Faceoff, I have invited two internationally known experts on anterior cruciate ligament (ACL) reconstruction to discuss two approaches: singleand double-bundle reconstruction. Russell Warren, MD, is the Surgeon-in-Chief Emeritus at Hospital for Special Surgery and a past president of the American Orthopaedic Society for Sports Medicine (AOSSM) and American Shoulder and Elbow Surgeons. Joining Dr. Warren and me is Freddie Fu, MD, the David Silver Professor and Chairman of the Department of Orthopaedic Surgery at University of Pittsburgh and past president of AOSSM and the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine. There is great controversy in this area, and the discussion between these two experts addresses the key issues. Robert Marx MD: Should doublebundle ACL reconstruction be used for all primary cases? Russell Warren MD: A definitive study is still needed to determine whether primary ACL reconstruction should be performed with a doublebundle technique instead of a singlebundle approach. To date, multiple studies have shown improvements in rotational control with a double-bundle approach, but the clinical relevance of this is unclear as many studies have failed to demonstrate significant differences on important parameters. Recently, Dr. Irrgang et al. [6] indicated that ‘‘at this time, there is no definitive evidence that double-bundle ACL reconstruction is better than singlebundle ACL reconstruction in terms of measures of knee joint structures, functions, and clinical outcomes.’’ They proposed an NIH-funded study in an attempt to answer this question. I have found single-bundle reconstruction to be of value to my patients over many years. Bone-patellar tendon-bone autograft can be used for a single-bundle reconstruction, allowing for bone-tobone healing and aperture fixation. The double-bundle technique typically uses ‘‘suspensory’’ fixation, leading to increased creep and potential tunnel widening. Anatomic reconstruction with the double-bundle technique leads to the two bundles functioning somewhat independently at different degrees of knee flexion, potentially placing the entire load on a smaller graft (bundle). If single-bundle ACL reconstruction is performed, it must be placed anatomically so the change in length with flexion is minimal, as observed in a normal ACL. Graft tunnel location is critical to both techniques. Using intraoperative computer navigation, we found that some knees have higher degrees of rotation after ACL injury [2]. These knees may be better served by a double-bundle approach. Further Clinical Faceoff The Association of Bone and Joint Surgeons1 2012