A Comparison of the Effect of Central Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction and Double-Bundle Anterior Cruciate Ligament Reconstruction on Pivot-Shift Kinematics

Hospital for Special Surgery, Sports Medicine and Shoulder Surgery Service, New York, New York, USA.
The American Journal of Sports Medicine (Impact Factor: 4.36). 09/2010; 38(9):1788-94. DOI: 10.1177/0363546510369303
Source: PubMed


Biomechanical differences between anatomical double-bundle and central single-bundle anterior cruciate ligament reconstruction using the same graft tissue have not been defined.
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.
Controlled laboratory study.
Using a computer-assisted navigation system, 10 paired knees were subjected to biomechanical testing with a standardized Lachman and mechanized pivot-shift examination. The navigation system recorded the 3D motion path of a tracked point at the center of the tibia, center of the medial tibial plateau, and center of the lateral tibial plateau with each maneuver. The testing protocol consisted of evaluation in the intact state, after complete anterior cruciate ligament transection, after medial and lateral meniscectomy, and after anterior cruciate ligament reconstruction with (1) a single-bundle center-center or (2) anatomical double-bundle technique. Repeated-measures analysis of variance with a post hoc Tukey test was used to compare the measured translations with each test condition.
A significant difference in anterior translation was seen with Lachman examination between the anterior cruciate ligament- and medial and lateral meniscus-deficient condition compared with both the double-bundle and single-bundle center-center anterior cruciate ligament reconstruction (P < .001); no significant difference was observed between reconstructions. The double-bundle construct was significantly better in limiting anterior translation of the lateral compartment compared with the single-bundle reconstruction during a pivot-shift maneuver (2.0 +/- 5.7 mm vs 7.8 +/- 1.8 mm, P < .001) and was not significantly different than the intact anterior cruciate ligament condition (2.7 mm +/- 4.7 mm, P > .05). Discussion: Although double-bundle and single-bundle, center-center anterior cruciate ligament reconstructions appear equally effective in controlling anterior translation during a Lachman examination, analysis of pivot-shift kinematics reveals significant differences between these surgical reconstructions. An altered rotational axis resulted in significantly greater translation of the lateral compartment in the single-bundle compared with double-bundle reconstruction.
A double-bundle anterior cruciate ligament reconstruction 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.

Download full-text


Available from: Travis G. Maak,
  • Source
    • "The reliability of current devices used to quantify rotational laxity is relatively low and such devices are not routinely used in clinical practice, with the vast majority still in pre-clinical development.50 The pivot shift phenomenon has been mapped and characterised using invasive navigation-based technology, allowing comparison of ACL reconstruction techniques.51-55 However, a non-invasive adaptation of this has not yet tested in the clinical setting. "
    [Show abstract] [Hide abstract]
    ABSTRACT: We performed in vitro validation of a non-invasive skin-mounted system that could allow quantification of anteroposterior (AP) laxity in the outpatient setting. A total of 12 cadaveric lower limbs were tested with a commercial image-free navigation system using trackers secured by bone screws. We then tested a non-invasive fabric-strap system. The lower limb was secured at 10° intervals from 0° to 60° of knee flexion and 100 N of force was applied perpendicular to the tibia. Acceptable coefficient of repeatability (CR) and limits of agreement (LOA) of 3 mm were set based on diagnostic criteria for anterior cruciate ligament (ACL) insufficiency. Reliability and precision within the individual invasive and non-invasive systems was acceptable throughout the range of flexion tested (intra-class correlation coefficient 0.88, CR 1.6 mm). Agreement between the two systems was acceptable measuring AP laxity between full extension and 40° knee flexion (LOA 2.9 mm). Beyond 40° of flexion, agreement between the systems was unacceptable (LOA > 3 mm). These results indicate that from full knee extension to 40° flexion, non-invasive navigation-based quantification of AP tibial translation is as accurate as the standard validated commercial system, particularly in the clinically and functionally important range of 20° to 30° knee flexion. This could be useful in diagnosis and post-operative evaluation of ACL pathology. Cite this article: Bone Joint Res 2013;2:233-7.
    11/2013; 2(11):233-7. DOI:10.1302/2046-3758.211.2000199
  • Source
    • "These studies mainly focused on matching and filling ACL footprints. The benefits of these modern techniques are still subject to debate [6] [7], and the results, despite being generally good, are not always excellent. "
    [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: The aim of modern techniques for anatomic reconstruction of the ACL is to reproduce ACL footprints, in order to restore anatomy and therefore normal biomechanics. Is there an oversizing of the hamstring grafts related to ACL dimensions? METHODS: Twenty-two paired cadaver knees were dissected. ACL dimensions at mid-portion and ACL footprints were measured after removing the synovial membrane. Hamstrings were harvested and prepared in a quadruple strand graft in order to measure the mean circumference. RESULTS: The average ACL tibial and femoral insertion site areas of the ACL were 117.9mm(2) (range, 90 to 130mm) and 96.8mm(2) (range, 80 to 121mm), respectively. The average diameter and cross sectional area of the ACL tendon at mid-portion were 6.1mm (range, 5 to 7mm) and 29.2mm(2) (range, 20 to 38.9), respectively. The average diameter and cross-sectional area of the 4-stranded hamstring tendons were 6.7 (range, 5 to 8) and 35.3mm(2) (range, 20 to 50), respectively. There was a correlation between the 4-stranded hamstring grafts and ACL dimensions (footprints, ligament at mid substance, p<0.01). The cross sectional area of hamstring tendon was significantly larger than the ACL area at mid-portion (mean 20.9%, p<0.05). CONCLUSION: With current ACL reconstruction techniques, the graft is oversized at a mean of 21%, despite a good correlation between the ACL and the hamstring tendon, especially among small subjects and women. The question arises whether the anatomic reconstruction of the ACL should fill ACL footprints or mimic the ligament itself. CLINICAL RELEVANCE: Hamstrings grafts are significantly larger than native ACL.
    The Knee 11/2012; 20(6). DOI:10.1016/j.knee.2012.10.006 · 1.94 Impact Factor
  • Source
    • "Recent years have seen ACL reconstruction performed in a broad range of patients, regardless of age, sex or occupation, thanks to great advances in surgical techniques, instrumentation and the basic research. Favorable results have been reported for many [4-8]. We have been unable to identify any reports describing ACL reconstruction in patients with athetoid cerebral palsy in the literature. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Recent years have seen ACL reconstruction performed in a broad range of patients, regardless of age, sex or occupation, thanks to great advances in surgical techniques, instrumentation and the basic research. Favorable results have been reported; however, we have not been able to locate any reports describing ACL reconstruction in patients with athetoid cerebral palsy. We present herein a previously unreported anterior cruciate ligament (ACL) reconstruction performed in a patient with athetoid cerebral palsy. The patient was a 25-year-old woman with level II athetoid cerebral palsy according to the Gross Motor Function Classification System. She initially injured her right knee after falling off a bicycle. Two years later, she again experienced right-knee pain and a feeling of instability. A right-knee ACL tear and avulsion fracture was diagnosed upon physical examination and confirmed with magnetic resonance imaging (MRI) and X-ray examination at that time. An ACL reconstruction using an autologous hamstring double-bundle graft was performed for recurrent instability nine years after the initial injury. Cast immobilization was provided for 3 weeks following surgery and knee extension was restricted for 3 months with the functional ACL brace to prevent hyperextension due to involuntary movement. Partial weight-bearing was started 1 week postoperatively, with full weight-bearing after 4 weeks. The anterior drawer stress radiography showed a 63% anterior displacement of the involved tibia on the femur six months following the surgery, while the contralateral knee demonstrated a 60% anterior displacement of the tibia. The functional ACL functional brace was then removed. A second-look arthroscopy was performed 13 months after the ACL reconstruction, and both the anteromedial and posterolateral bundles were in excellent position as per Kondo’s criteria. The Lachman and pivot shift test performed under anesthesia were also negative. An anterior drawer stress radiography of the involved knee at 36 months following surgery showed a 61% anterior translation of the tibia. The preoperative symptoms of instability resolved and the patient expressed a high degree of satisfaction with the result of her surgery.
    Sports Medicine Arthroscopy Rehabilitation Therapy & Technology 10/2012; 4(1):36. DOI:10.1186/1758-2555-4-36
Show more