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Purpose Compare clinical outcomes of anatomic single-bundle (SB) to anatomic double-bundle (DB) anterior cruciate ligament reconstruction (ACLR). It was hypothesized that anatomic DB ACLR would result in better International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) scores and reduced anterior and rotatory laxity compared to SB ACLR. Methods Active individuals between 14 and 50 years of age that presented within 12 months of injury were eligible to participate. Individuals with prior injury or surgery of either knee, greater than a grade 1 concomitant knee ligament injury, or ACL insertion sites less than 14 mm or greater than 18 mm were excluded. Subjects were randomized to undergo SB or DB ACLR with a 10 mm-wide quadriceps tendon autograft harvested with a patellar bone block and were followed for 24 months. The primary outcome measures included the IKDC-SKF and KT-1000 (side to side difference) and pivot shift tests. Other secondary outcomes included measures of sports activity and participation, range of motion (ROM) and re-injury. Results Enrollment in the study was suspended due to patellar fractures related to harvest of the patellar bone plug. At that time, 57 subjects had been randomized (29 DB) and two-year follow-up was attained from 51 (89.5%). At 24-month follow-up there were no between-group differences detected for the primary outcomes. Twenty-one (77.8%) DB’s and 20 (83.3%) SB’s reported returning to pre-injury sports 2 years after surgery (n.s) Three subjects (2 DB’s, 5.3% of total) sustained a graft rupture and 5 individuals (4 SB’s, 8.8% of total) had a subsequent meniscus injury. Conclusions Due to the early termination of the study, there were no detectable differences in clinical outcome between anatomic SB and DB ACLR when performed with a quadriceps tendon autograft with a bone block in individuals with ACL insertion sites that range from 14 to 18 mm. Level of Evidence Level 2

Purpose Compare side-to-side differences for knee kinematics between anatomic single-bundle (SB) and anatomic double-bundle (DB) ACLR during downhill running at 6 and 24 months post ACLR using high-accuracy dynamic stereo X-ray imaging. It was hypothesized that anatomic DB ACLR would better restore tibio-femoral kinematics compared to SB ACLR, based on comparison to the contralateral, uninjured knee. Methods Active individuals between 14 and 50 years of age that presented within 12 months of injury were eligible to participate. Individuals with prior injury or surgery of either knee, greater than a grade 1 concomitant knee ligament injury, or ACL insertion sites less than 14 mm or greater than 18 mm were excluded. Subjects were randomized to undergo SB or DB ACLR with a 10 mm-wide quadriceps tendon autograft harvested with a patellar bone block and were followed for 24 months. Dynamic knee function was assessed during treadmill downhill running using a dynamic stereo X-ray tracking system at 6 and 24 months after surgery. Three-dimensional tibio-femoral kinematics were calculated and compared between limbs (ACLR and uninjured contralateral) at each time point. Results Fifty-seven subjects were randomized (29 DB) and 2-year follow-up was attained from 51 (89.5%). No significant differences were found between SB and DB anatomic ACLR for any of the primary kinematic variables. Conclusions Contrary to the study hypothesis, double-bundle reconstruction did not show superior kinematic outcomes compared to the single-bundle ACLR. While neither procedure fully restored normal knee kinematics, both anatomic reconstructions were similarly effective for restoring near-normal dynamic knee function. The findings of this study indicate both SB and DB techniques can be used for patients with average size ACL insertion sites. Level of evidence Level I

Purpose To assess the effects of anatomical double-bundle (DB) versus single-bundle (SB) for anterior cruciate ligament (ACL) reconstruction in skeletally mature patients with ACL injuries. Methods MEDLINE, EMBASE, and CENTRAL were searched from inception to February 7, 2022 were screened for randomized controlled trials. The Anatomic Anterior Cruciate Ligament Reconstruction Checklist was used to categorize studies as anatomic. A random-effects meta-analysis was conducted, with pooled results being summarized using mean difference (MD). Risk of Bias (RoB) was assessed using the RoB 2.0 tool. Certainty of evidence was rated using GRADE. Results A search of 1371 unique articles yielded eight eligible trials, representing 735 patients (360 DB, 375 SB) with mean (SD) age of 28.5 (2.86) years and follow-up of 52.1 (36.2) months. Most trials had moderate to low RoB. Overall, DB was not significantly better than SB on Lysholm scores (MD = 0.52, 95% CI, − 1.80–2.85, p  = 0.66; moderate certainty) or subjective International Knee Documentation Committee (IKDC) scores (MD = − 0.40, 95% CI, − 4.35–3.55, p  = 0.84; moderate certainty). Tegner scores were significantly higher in SB than DB in the intermediate term (MD = − 0.72, 95% CI, − 1.10 to − 0.34, p  = 0.0002; high certainty), while significantly higher in DB relative to SB in the long-term (MD = 0.52, 95% CI, 0.02–1.03, p  = 0.04; high certainty). Conclusion DB ACL reconstruction significantly improves Tegner scores relative to SB ACL reconstruction over the long-term ( t  ≥ 5 years). Intermediate term Tegner scores favour SB reconstruction. In both durations, there was no clinically significant difference based on the pre-specified minimal clinically important difference of 1.0 point. There were also no significant differences in IKDC or Lysholm scores. Surgeons should consider anatomical DB ACL reconstruction as a result of long-term improvement in patient-reported outcomes. Level of evidence I.

Abstract Background: The achievement of an optimal return to sport (RTS) has remained a key goal after sports-related injuries, with the ongoing debate on the effectiveness of different surgical approaches for anterior cruciate ligament (ACL) rupture. This study aims to assess clinical outcomes and RTS across various surgical methods, such as anatomical single-bundle reconstruction (ASBR), central-axial single-bundle reconstruction (CASBR), and double-bundle reconstruction (DBR). Methods: A randomized clinical trial was conducted, comprising 191 patients who underwent ACL rupture. These patients were divided into three groups based on the ACL reconstruction techniques they received (ASBR, CASBR, DBR). Over the 2-year follow-up period, the study assessed RTS through four single-hop tests, isokinetic extension tests, and limb asymmetry indices. Postoperative graft status was determined using the signal-to-noise quotient (SNQ), while knee function was evaluated using the International Knee Documentation Committee 2000 (IKDC-2000) score, Lysholm score, Tegner score, and degree of knee laxity. A binary logistic regression model was developed to forecast the factors influencing ideal RTS. Results: DBR (67.63%) and CASBR (58.00%) exhibited higher RTS passing rates compared to ASBR (30.39%; χ2 = 19.57, P <0.05). Quadriceps strength symmetry in the lower limbs was identified as the key determinant of RTS (χ2 = 17.08, P <0.05). The RTS rate was influenced by SNQs of the graft’s tibial site (odds ratio: 0.544) and quadriceps strength of the reconstructed knee joint at 60°/s (odds ratio: 6.346). Notably, the DBR group showed enhanced knee stability, evidenced by superior results in the Lachman test (χ2 = 13.49, P <0.01), objective IKDC-2000 (χ2 = 27.02, P = 0.002), and anterior instability test (χ2 = 9.46, P <0.01). Furthermore, DBR demonstrated superior clinical outcomes based on the Lysholm score (DBR: 89.57 ± 7.72, CASBR: 83.00 ± 12.71, ASBR: 83.21 ± 11.95; F = 10.452, P <0.01) and IKDC-2000 score (DBR: 90.95 ± 7.00, CASBR: 84.64 ± 12.68, ASBR: 83.63 ± 11.41; F = 11.78, P <0.01). Conclusion: For patients with ACL rupture, more ideal RTS rate and clinical outcomes were shown in the DBR group than in the ASBR and CASBR groups. Autograft status and quadriceps strength are postively related to RTS. Trial Registration: ClinicalTrials.gov (NCT05400460)

Purpose Anterior cruciate ligament (ACL) graft failure is a complication that may require revision ACL reconstruction (ACL-R). Non-anatomic placement of the femoral tunnel is thought to be a frequent cause of graft failure; however, there is a lack of evidence to support this belief. The purpose of this study was to determine if non-anatomic femoral tunnel placement is associated with increased risk of revision ACL-R. Methods After screening all 315 consecutive patients who underwent primary single-bundle ACL-R by a single senior orthopedic surgeon between January 2012 and January 2017, 58 patients were found to have both strict lateral radiographs and a minimum of 24 months follow-up without revision. From a group of 456 consecutive revision ACL-R, patients were screened for strictly lateral radiographs and 59 patients were included in the revision group. Femoral tunnel placement for each patient was determined using a strict lateral radiograph taken after the primary ACL-R using the quadrant method. The center of the femoral tunnel was measured in both the posterior–anterior (PA) and proximal–distal (PD) dimensions and represented as a percentage of the total distance (normal center of anatomic footprint: PA 25% and PD 29%). Results In the PA dimension, the revision group had significantly more anterior femoral tunnel placement compared with the primary group (38% ± 11% vs. 28% ± 6%, p  < 0.01). Among patients who underwent revision; those with non-traumatic chronic failure had statistically significant more anterior femoral tunnel placement than those who experienced traumatic failure (41% ± 13% vs. 35% ± 8%, p  < 0.03). In the PD dimension, the revision group had significantly more proximal femoral tunnel placement compared with the primary group (30% ± 9% vs 38% ± 9%, p  < 0.01). Conclusion In this retrospective study of 58 patients with successful primary ACL-R compared with 59 patients with failed ACL-R, anterior and proximal (high) femoral tunnels for ACL-R were shown to be independent risk factors for ACL revision surgery. As revision ACL-R is associated with patient- and economic burden, particular attention should be given to achieving an individualized, anatomic primary ACL-R. Surgeons may reduce the risk of revision ACL-R by placing the center of the femoral tunnel within the anatomic ACL footprint. Level of evidence Level III.

Objective The femoral tunnel position is crucial to anatomic single‐bundle anterior cruciate ligament (ACL) reconstruction, but the ideal femoral footprint position are mostly based on small‐sized cadaveric studies and elderly patients with a single ethnic background. This study aimed to identify potential race‐ or gender‐specific differences in the ACL femoral footprint location and ACL orientation, determine the correlation between the ACL orientation and the femoral footprint location. Methods Magnetic resonance images (MRIs) of 90 Caucasian participants and 90 matched Chinese subjects were used for reconstruction of three‐dimensional (3D) femur and tibial models. ACL footprints were sketched by several experienced orthopedic surgeons on the MRI photographs. The anatomical coordinate system was applied to reflect the ACL footprint location and orientation of scanned samples. The femoral ACL footprint locations were represented by their distance from the origin in the anteroposterior (A/P) and distal‐proximal (D/P) directions. The orientation of the ACL was described with the sagittal, coronal and transverse deviation angles. The ACL orientation and femoral footprint position were compared by the two‐sided t‐test. Multiple regression analysis was used to study the correlation between the orientation and femoral footprint position. Results The average femur footprint A/P position was −6.6 ± 1.6 mm in the Chinese group and −5.1 ± 2.3 mm in the Caucasian group, (p < 0.001). The average femur footprint D/P position was −2.8 ± 2.4 mm in Chinese and − 3.9 ± 2.0 mm in Caucasians, (p = 0.001). The Chinese group had a mean difference of a 1.5 mm (6.1%) more posterior and 1.1 mm (5.3%) more proximal in the position from the flexion‐extension axis (FEA). And the males have a sagittal plane elevation about 4–5° higher than females in both racial groups. Furthermore, for every 1% (0.40 mm) increase in A/P and D/P values, the sagittal angle decreased by about 0.12° and 0.24°, respectively; the coronal angle decreased by about 0.10° and 0.30°, respectively. For every 1% (0.40 mm) increase in D/P value, the transverse angle increased by about 0.14°. Conclusion The significant race‐ and gender‐specific differences in the femoral footprint and orientation of the ACL should be taken in consideration during anatomic single‐bundle ACL reconstruction. Furthermore, the quantitative relationship between the ACL orientation and the footprint location might provide some reference for surgeons to develop a surgical strategy in ACL single‐bundle reconstruction and revision. There were significant racial and gender differences in anterior cruciate ligament (ACL) femoral footprint and orientation. It was hoped that the quantitative relationship between the ACL femoral footprint location and orientation could provide some reference for surgeons during anatomic single‐bundle ACL reconstruction.

Purpose To perform a systematic review and compare the functional and objective outcomes after single-bundle (SB) vs. double-bundle (DB) posterior cruciate ligament reconstruction (PCLR). Where possible to pool outcomes and arrive at summary estimates of treatment effect for DB PCLR vs. SB PCLR via an embedded meta-analysis. Methods A comprehensive PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) literature search identified 13 eligible studies evaluating clinical outcomes of both techniques for PCLR. Clinical outcome measures included in the meta-analysis were functional outcomes (Lysholm Score, Tegner Activity Scale) and objective measurements of posterior laxity of the operated knee (arthrometer and stress radiographs). Results The meta-analysis included 603 patients. Three hundred and fifteen patients were treated with SB and two hundred and eighty-eight patients with DB PCLR. There were no significant differences between SB and DB PCLR in postoperative functional Lysholm Scores (CI [− 0.18, 0.17]), Tegner Activity Scales (CI [− 0.32, 0.12]) and IKDC objective grades (CI [− 0.13, 1.17]). Regarding posterior stability using KT-1000 and Kneelax III arthrometer measurements, there were no differences between the SB and DB group. However, double-bundle reconstruction provided better objective outcome of measurement of posterior laxity (CI [0.02, 0.46]) when measured with Telos stress radiography. Conclusion A systematic review was conducted to identify current best evidence pertaining to DB and SB PCLR. An embedded meta-analysis arrived at similar summary estimates of treatment effect for motion, stability and overall function for both techniques. There is no demonstrable clinically relevant difference between techniques based on the currently available evidence. Level of evidence III.

Purpose To compare the long-term clinical outcomes of single-bundle anterior cruciate ligament reconstruction (SBR) and double-bundle anterior cruciate ligament reconstruction (DBR) in patients with isolated anterior cruciate ligament (ACL) rupture, presenting no meniscus injury and no obvious preoperative cartilage degeneration. Methods One hundred and three patients (38.6 ± 9.5 years) with a median follow-up of 151.6 months (range, 144–189 months) completed the retrospective study (SBR group: n  = 51; DBR group: n  = 52). Clinical outcomes were evaluated with physical examinations, KT-2000 anterior and posterior stability measurement with the knee in 30º of flexion, International Knee Documentation Committee (IKDC) subjective score, Tegner score, Lysholm score; magnetic resonance imaging (MRI) (3.0 T) was performed, and International Cartilage Repair Society (ICRS) cartilage degeneration grades were determined. Multivariate analysis was performed to identify factors associated with cartilage degeneration. Results There were significant differences in the pre- and postoperative IKDC, Lysholm and Tegner scores between the SBR and DBR groups. The SBR group had over double the rate of positive pressure/rub patellar test results (SBR vs DBR, 43.1% vs. 19.2%, p  < 0.011). The KT-2000, pivot-shift and Lachman test results were stratified and analyzed, and significant differences between the SBR and DBR groups were found ( p  < 0.05, respectively). The distribution of ICRS grades differed significantly between the groups at the last follow-up ( p  = 0.013). A multivariate analysis found that age and operation procedures were significant predictors of 0 and non-0 ICRS grades (odds ratio, 6.077 [95% CI 2.117–17.447] and 0.210 [95% CI 0.068–0.654], respectively) ( p  < 0.05). Conclusion Both SBR and DBR achieved overall good long-term results. DBR had advantages in objective outcome measures and was superior in preventing the occurrence of cartilage degeneration. Age was identified as a preoperative risk factor for significant postoperative cartilage degeneration. Level of evidence III. ClinicalTrials.gov: NCT03984474

Isolated and combined posterior cruciate ligament (PCL) injuries are associated with severe limitations in daily, professional, and sports activities as well as with devastating long-term effects for the knee joint. As the number of primary and recurrent PCL injuries increases, so does the body of literature, with high-quality evidence evolving in recent years. However, the debate about the ideal treatment approach such as; operative vs. non-operative; single-bundle vs. double-bundle reconstruction; transtibial vs. tibial inlay technique, continues. Ultimately, the goal in the treatment of PCL injuries is restoring native knee kinematics and preventing residual posterior and combined rotatory knee laxity through an individualized approach. Certain demographic, anatomical, and surgical risk factors for failures in operative treatment have been identified. Failures after PCL reconstruction are increasing, confronting the treating surgeon with challenges including the need for revision PCL reconstruction. Part 2 of the evidence-based update on the management of primary and recurrent PCL injuries will summarize the outcomes of operative and non-operative treatment including indications, surgical techniques, complications, and risk factors for recurrent PCL deficiency. This paper aims to support surgeons in decision-making for the treatment of PCL injuries by systematically evaluating underlying risk factors, thus preventing postoperative complications and recurrent knee laxity. Level of evidence V.

Background Single-bundle (SB) anterior cruciate ligament reconstruction (ACLR), double-bundle (DB) ACLR, and DB ACLR combined with anterolateral ligament reconstruction (DB ACLR and ALLR) have been developed to address ACL tears. We hypothesized that these three techniques provide satisfactory results for patients with ACL tears, with the DB ACL and ALLR group having more lateral knee discomfort. Methods 167 patients were retrospectively divided into three groups: SB ACLR, DB ACLR, and DB ACLR and ALLR. Postoperative evaluations were conducted via telephone interviews and in-person consultations using the Tegner and Lysholm scores. Results The mean follow-up time was 27.7 ± 4.4 months in the SB ACLR group, 25.5 ± 3.2 months in the DB ACLR group, and 28.1 ± 3.6 months in the DB ACLR and ALLR group ( P  = 0.044). For Lysholm score, the DB ACLR and ALLR group ( n  = 55) was 92.3 ± 7.0, the DB ACLR group ( n  = 21) was 92.4 ± 6.6, and the SB ACLR group ( n  = 91) was 92.5 ± 10.2 ( P  = 0.995). For the Tegner score, the DB ACLR and ALLR group was 4.5 ± 2.2, the DB ACLR group was 5.0 ± 1.6, and the SB ACLR group was 4.4 ± 1.7 ( P  = 0.378). In the DB ACLR and ALLR group, 10 of the 55 (18.2%) patients exhibited symptoms in the lateral knee. Conclusions SB ACLR, DB ACLR, and DB ACLR and ALLR with suture tape augmentation procedures yielded comparable clinical functional scores. While lateral knee symptoms were observed in patients receiving DB ACLR and ALLR with suture tape augmentation, these symptoms did not significantly influence the functional outcome.