ACL Double Bundle

Reconstruction
 ACL Reconstruction:
Single vs Double Bundle Reconstruction

• What: Principle
• Why : Rationale
• How : Surgical technique
• Pitfalls
• Result
 ACL Reconstruction:
Single vs Double Bundle Reconstruction

• What: Principle
• Why : Rationale
• How : Surgical technique
• Pitfalls
• Result
Anatomy
 Principles
Reproducing the two bundle anatomy
of ACL
• Cadaveric studies have
demonstrated that the AM
bundle is approximately
twice as long as the PL
bundle, and that the two
bundles have a similar
cross-sectional diameter.
Chhabra A, Starman JS, Ferretti M, Vidal AF,
Zantop T, Fu FH. Anatomic, radiographic,
biomechanical, and kinematic evaluation of the
anterior cruciate ligament and its two functional
bundles. J Bone Joint Surg Am 2006;88 Suppl
4:2-10
 Principles
Reproducing the insertion sites of ACL
• The femoral in sertion sites of
the AM and PL bundle are
oriented vertically with the
knee in extension and
become horizontal in 90º of
knee flexion (surgical position
for ACL reconstruction
surgery).
• In extension the two bundles
are parallel and in flexion
Chhabra A, Starman JS, Ferretti M, Vidal AF, Zantop T,
they become crossed.
Fu FH. Anatomic, radiographic, biomechanical, and
kinematic evaluation of the anterior cruciate ligament
and its two functional bundles. J Bone Joint Surg Am
2006;88 Suppl 4:2-10
 Principles
Reproducing the tension pattern of ACL
• The AM bundle has its
highest tension at 45
degrees of knee flexion, and
was taut throughout the
range of motion. flexion
(surgical position for ACL
reconstruction surgery).
• The PL bundle ha s its
highest tension at full
extension, and becomes lax
as the knee flexes.
Gabriel MT, Wong EK, Woo SL, Yagi M, Debski RE. Distribution of in situ forces in the
anterior cruciate ligament in response to rotatory loads. J Orthop Res 2004;22-1:85-9.
 Principles
Individualized surgery
• The decision of whether to
perform a single or double
bundle ACL reconstruction
should be dictated by the
unique anatomy of the
patient.

van Eck CF, Schreiber VM, Liu TT, Fu FH. The

anatomic approach to primary, revision and
augmentation anterior cruciate ligament
reconstruction. Knee Surg Sports Traumatol
Arthrosc 2010;DOI 10.1007/s00167-010-1191-4.
 ACL Reconstruction:
Single vs Double Bundle Reconstruction

• What: Principle
• Why : Rationale
• How : Surgical technique
• Pitfalls
• Result
 ACL Reconstruction:
Single vs Double Bundle Reconstruction

• What: Principle
• Why : Rationale
• How : Surgical technique
• Pitfalls
• Result
 Rationale
• Radiographic evidence of degenerative changes has
been observed in up to 90% of patients at mid-term
follow-up study after traditional single-bundle ACL
reconstruction. 1,2
• Critical review of the literature from the last ten
years reveals that between 10% and 30% of patients
complain of pain and residual instability following
traditional single-bundle ACL reconstruction. 3
1. Fithian DC, Paxton EW, Stone ML, Luetzow WF, Csintalan RP, Phelan D, Daniel DM. Prospective trial
of a treatment algorithm for the management of the anterior cruciate ligament-injured knee. Am J
Sports Med 2005;33-3:335-46.
2. Keays SL, Newcombe PA, Bullock-Saxton JE, Bullock MI, Keays AC. Factors involved in the
development of osteoarthritis after anterior cruciate ligament surgery. Am J Sports Med 2010;38-
3:455-63.
3. Yunes M, Richmond JC, Engels EA, Pinczewski LA. Patellar versus hamstring tendons in anterior
cruciate ligament reconstruction: A meta-analysis. Arthroscopy 2001;17-3:248-57.
 Rationale
• The PL bundle, which is not traditionally
reconstructed, plays a significant role in rotatory
stability in the knee.
• Numerous clinical and basic science studies have
demonstrated that:
– 1) traditional single-bundle ACL reconstruction does not
adequately restore normal knee kinematics, particularly
tibial rotation. 1
– and 2) anatomic double-bundle reconstruction more
closely restores normal knee kinematics when compared
1. Tashman S, Collon D, Anderson K, Kolowich P, Anderst W. Abnormal rotational knee motion during
to anterior
running after single-bundle reconstruction.
cruciate ligament reconstruction. Am 2J Sports Med 2004;32-4:975-83.
2. Yagi M, Kuroda R, Nagamune K, Yoshiya S, Kurosaka M. Double-bundle ACL reconstruction can
improve rotational stability. Clinical Orthopaedics and Related Research 2007-454:100-7.
 ACL Reconstruction:
Single vs Double Bundle Reconstruction

• What: Principle
• Why : Rationale
• How : Surgical technique
• Pitfalls
• Result
 ACL Reconstruction:
Single vs Double Bundle Reconstruction

• What: Principle
• Why : Rationale
• How : Surgical technique
• Pitfalls
• Result
 Fundamental principles
• Large variations in tibial insertion site and femoral
intercondylar notch size need to be measured to
determine whether single-bundle or double-bundle
ACL reconstruction best suits the needs of the
individual patient
• To restore native anatomy by placing the graft in
the center of the foot-print.
• To restore the physiological function of the graft by
applying appropriate tension to mimic the native
ACL as closely as possible.
DANIEL HENSLER, CAROLA F. VAN ECK, FREDDIE H. FU, JAMES J. IRRGANG. Anatomic Anterior
Cruciate Ligament Reconstruction Utilizing the Double-Bundle Technique. J Orthop Sports Phys
Ther 2012;42(3):184-195. doi:10.2519/jospt.2012.3783
 ACL double bundle ACL single bundle
• the graft for the PL bundle is • The graft is tensioned with
tensioned with the knee at the knee in 10° to 20° of
0° of fexion and the graft for fexion
the AM bundle is tensioned
with the knee fexed to 45°
to 60°

DANIEL HENSLER, CAROLA F. VAN ECK, FREDDIE H. FU, JAMES J. IRRGANG. Anatomic Anterior
Cruciate Ligament Reconstruction Utilizing the Double-Bundle Technique. J Orthop Sports Phys
Ther 2012;42(3):184-195. doi:10.2519/jospt.2012.3783
 • for anatomic single-
bundle and double-bundle
ACL reconstruction, 3
arthroscopic portals
(central, anterolateral,
and accessory medial)
should be created
• The creation of a third
portal allows for better
visualization of the
femoral ACL insertion site
location, making a notch-
plasty unnecessary.
DANIEL HENSLER, CAROLA F. VAN ECK, FREDDIE H.
FU, JAMES J. IRRGANG. Anatomic Anterior Cruciate
Ligament Reconstruction Utilizing the Double-
Bundle Technique. J Orthop Sports Phys Ther
2012;42(3):184-195. doi:10.2519/jospt.2012.3783
 • Focus is turned toward the
intercondylar notch to
determine the rupture
pattern of the ACL.
• The measurements are used
to determine whether single-
bundle or double-bundle
reconstruction is preferred for
the patient
• After the origins of the 2
bundles on the tibia and
femur are marked, 2 tunnels
in the tibia and femur are
drilledCAROLA F. VAN ECK, FREDDIE H. FU, JAMES J.
DANIEL HENSLER,
IRRGANG. Anatomic Anterior Cruciate Ligament Reconstruction
Utilizing the Double-Bundle Technique. J Orthop Sports Phys
Ther 2012;42(3):184-195. doi:10.2519/jospt.2012.3783
 Double-bundle reconstruction
• The PL graft is passed first, followed by the AM
graft.
• To preserve insertion site integrity, suspensory
fixation is used on the femoral side and screw
fixation is used on the tibial side, where the
screw is placed 1 to 2 cm beyond the joint line.
• The PL bundle is fixed at 0° to 10° of knee flxion
and the AM bundle is fixed at 45°of flexion
DANIEL HENSLER, CAROLA F. VAN ECK, FREDDIE H. FU, JAMES J. IRRGANG. Anatomic Anterior
Cruciate Ligament Reconstruction Utilizing the Double-Bundle Technique. J Orthop Sports Phys
Ther 2012;42(3):184-195. doi:10.2519/jospt.2012.3783
 Single-bundle reconstruction
• When the intercondylar notch is small, drilling the
femoral tunnel is obscured by the medial wall of
the notch.
• Rather than performing a notchplasty to create the
additional room necessary for double-bundle
reconstruction, we believe that single-bundle ACL
reconstruction should be performed when there is
a narrow notch.
• Further indications for single-bundle reconstruction
are described in the literature.
 Single-bundle reconstruction
• The femoral and tibial tunnels are placed in the
center of the femoral and tibial ACL insertion sites.
• The size of the drilled tunnel is based on
measurements of the width and length of the
footprint.
• The tunnel may be smaller than the insertion site
area, although it must be pointed out that
perpendicular drilling is not possible; consequently,
drilling will result in an oval-shaped tunnel aperture
that may actually restore the length of the footprint.
(A) The bony ridges delineate the
native ACL insertion site. With the
knee in 90° of flexion, the lateral
intercondylar ridge forms the
superior border of the ACL insertion
site and the lateral bifurcate ridge
separates the anteromedial and
posterolateral bundle.

(B,C) Anatomic single-bundle ACL

tunnel placement. The femoral
tunnel is placed in the center of the
ACL insertion site, below the lateral
intercondylar ridge.

(D) Anterolateral portal view after

the ACL graft was passed. The
triangle between the ACL and
posterior cruciate ligament (PCL)
was restored.
Prefer to perform single bundle surgery
• Patient has a very small native ACL insertion site. This
typically can only be determined at the time of surgery
• Patient is still growing and his or her growth plate is not
closed
• Patient has severe arthritis
• Patient with multiple knee ligament injuries or knee
dislocation
• Severe bone bruising and narrow intercondylar notch
• Patients who cannot wait 9-12 months to return to sports
– Professional or highly competitive athletes
 The Principle of anatomic double bundle
ACL reconstruction surgery
• Our objective is to reproduce the anatomy of the ACL by
reconstructing both the AM and PL bundles.
• ƒWe reproduce the insertion sites of the ACL by
identifying and measuring them via careful dissection.
Bone tunnels for the new ligaments are thus placed
precisely where they belong.
• ƒThe AM and PL bundles of the ACL are differentially
tightened to reproduce the normal tensioning pattern of
the ACL.
• A La Carte surgery (i.e. individualizing each surgery for
each patient.
 details of the surgery
• For ACL reconstruction, we
typically use four small
incisions:
– Three arthroscopic incisions:
AL—Anterolateral Portal, AM—
Anteromedial Portal, AMP—
Accessory Medial Portal
– One tibial incision for the bone
tunnels
– Occasionally, an additional
incision is made on the lateral
(outer) aspect of the knee joint
over the femur to help secure
the grafts.
• ACL reconstruction usually takes 60 to 90 minutes.
• ƒFirst, the insertion sites of both bundles (AM and
PL) of the old ACL are marked on the femur and tibia.

• The injured ACL is then removed with arthroscopic

equipment.
• The insertion sites of the AM and PL bundle are measured to
decide what graft size to use for each patient.

• Care is taken to place the new tissue grafts in the exact

position of the original bundles of the ACL, creating an
“Anatomic” reconstruction.
• ƒFor each bundle of graft tissue (AM and PL) one tunnel is
created in the femur and one in the tibia (total = 4).
• ƒEach tunnel measures anywhere from 5 to 9mm in diameter,
and this dictates final graft size
• Tunnels are created by drilling over guide wires, and sutures are passed.

• The grafts are then passed through the tunnels and fixed to the femur and
tibia with a combination of special fasteners, screws and sometimes
staples:
MRI, CT scan, & X-rays demonstrating the
Double-Bundle ACL reconstruction
After Double-Bundle reconstruction, most patients
achieve excellent range-of-motion, typically equal to
the other knee. These results are typically realized as
early as 1 to 3 months after surgery
 ACL Reconstruction:
Single vs Double Bundle Reconstruction

• What: Principle
• Why : Rationale
• How : Surgical technique
• Pitfalls
• Result
 ACL Reconstruction:
Single vs Double Bundle Reconstruction

• What: Principle
• Why : Rationale
• How : Surgical technique
• Pitfalls
• Result
 Pitfalls
Femoral insertion sites orientation changes
with knee flexion
 Pitfalls
The clock concept is
easy to use. However, it
is inaccurate in
describing the location
of femoral tunnel
placement and lead to
non-anatomic tunnel
position.
 Pitfalls
Inability to observe the femoral insertion site
well by using the anteromedial portal.
 Pitfalls
Graft impingement
 Pitfalls
Missmatch tunnels

Kopf S, Forsythe B, Wong AK, Tashman S, Anderst W, Irrgang JJ, Fu FH. Nonanatomic tunnel position in
traditional transtibial single-bundle anterior cruciate ligament reconstruction evaluated by three-
dimensional computed tomography. J Bone Joint Surg Am 2010;92-6:1427-31.
Forsythe B, Kopf S, Wong AK, Martins CA, Anderst W, Tashman S, Fu FH. The location of femoral and tibial
tunnels in anatomic double-bundle anterior cruciate ligament reconstruction analyzed by three-dimensional
computed tomography models. J Bone Joint Surg Am 2010;92-6:1418-26.
 ACL Reconstruction:
Single vs Double Bundle Reconstruction

• What: Principle
• Why : Rationale
• How : Surgical technique
• Pitfalls
• Result
 ACL Reconstruction:
Single vs Double Bundle Reconstruction

• What: Principle
• Why : Rationale
• How : Surgical technique
• Pitfalls
• Result
Thank You