Zhenyue DONG, Yingzhen NIU, Jianchao QI, Yifan SONG, Fei WANG

Long term results after double and single bundle ACL reconstruction: Is there any difference? A meta - analysis of randomized controlled trials

Objective: The double-bundle (DB) techniques are considered to yield better stability of the knee compared with single-bundle (SB) for anterior cruciate ligament (ACL) reconstruction. However, most studies followed up patients in short to middle-term within 5 years, and the longer-term efficacy of SB and DB ACL reconstruction is still beyond consensus. The purpose of this meta-analysis is to compare the longer-term efficacy between double-bundle (DB) and single-bundle (SB) techniques. Methods: PubMed, EMBASE, and Cochrane Library databases were searched for relevant articles published up to November, 2017 with an English language restriction. The searches were limited to human subjects and randomized controlled trials (RCTs). In addition, the reference lists of identified articles were checked manually to avoid missing other potentially eligible studies. This process was performed iteratively until no additional articles could be included. The quality of the included studies was assessed using The Cochrane Collaboration's risk of bias tool. All statistical analyses were performed with Review Manager soft-ware. Results: A total of five RCTs involving 294 patients were included finally. No studies were excluded due to insufficient data or low quality. The pooled results showed no statistically significant difference between SB and double bundle DB reconstructions for Lysholm, IKDC, pivot shift, KT scores, and the development of osteoarthritis at a minimum of 5 years. No significant heterogeneity was found across all outcomes. Conclusion: The best available evidence demonstrated that SB and DB techniques could yield similar efficacy for ACL reconstruction. And no superiority was founded in DB ACL reconstruction with a minimal 5-year follow-up. Given that, the relatively simple and proven techniques of SB ACL reconstruction may be preferable for orthopedic surgeons.

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Amis AA, Dawkins GP. Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg Br. 1991;73:260e267.

Griffin LY, Agel J, Albohm MJ, et al. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg. 2000;8: 141e150.

Swenson DM, Collins CL, Best TM, Flanigan DC, Fields SK, Comstock RD. Epidemiology of knee injuries among U.S. High school athletes, 2005/2006- 2010/2011. Med Sci Sports Exerc. 2013;45:462e469.

Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: Osteoarthritis. Am J Sports Med. 2007;35:1756e1769.

Mott HW. Semitendinosus anatomic reconstruction for cruciate ligament insufficiency. Clin Orthop Relat Res139. 1983:90e92.

Kondo E, Merican AM, Yasuda K, Amis AA. Biomechanical comparison of anatomic double-bundle, anatomic single-bundle, and nonanatomic singlebundle anterior cruciate ligament reconstructions. Am J Sports Med. 2011;39: 279e288.

Mascarenhas R, Cvetanovich GL, Sayegh ET, et al. Does double-bundle anterior cruciate ligament reconstruction improve postoperative knee stability compared with single-bundle techniques? A systematic review of overlapping meta-analyses. Arthroscopy. 2015;31:1185e1196.

Chen G, Wang S. Comparison of single-bundle versus double-bundle anterior cruciate ligament reconstruction after a minimum of 3-year follow-up: a metaanalysis of randomized controlled trials. Int J Clin Exp Med. 2015;8: 14604e14614.

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the prisma statement. Int J Surg. 2010;8: 336e341.

Higgins JP, Altman DG, Gotzsche PC, et al. The cochrane collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.

Zaffagnini S, Bruni D, Marcheggiani Muccioli GM, et al. Single-bundle patellar tendon versus non-anatomical double-bundle hamstrings acl reconstruction: a prospective randomized study at 8-year minimum follow-up. Knee Surg Sports Traumatol Arthrosc. 2011;19:390e397.

Jarvela S, Kiekara T, Suomalainen P, Jarvela T. Double-bundle versus singlebundle anterior cruciate ligament reconstruction: a prospective randomized study with 10-year results. Am J Sports Med. 2017;45:2578e2585.

Beyaz S, Güler ÜO, Demir S € ¸ , et al. Tunnel widening after single- versus doublebundle anterior cruciate ligament reconstruction: a randomized 8-year followup study. Arch Orthop Trauma Surg. 2017 Nov;137(11):1547e1555.

Samuelsson K, Desai N, McNair E, et al. Level of evidence in anterior cruciate ligament reconstruction research: a systematic review. Am J Sports Med. 2013;41:924e934.

Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10:150e154.

Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;198:43e49.

Briggs KK, Lysholm J, Tegner Y, Rodkey WG, Kocher MS, Steadman JR. The reliability, validity, and responsiveness of the lysholm score and tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med. 2009;37:890e897.

Bengtsson J, Mollborg J, Werner S. A study for testing the sensitivity and reliability of the lysholm knee scoring scale. Knee Surg Sports Traumatol Arthrosc. 1996;4:27e31.

Meredick RB, Vance KJ, Appleby D, Lubowitz JH. Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a meta-analysis. Am J Sports Med. 2008;36:1414e1421.

Xu M, Gao S, Zeng C, et al. Outcomes of anterior cruciate ligament reconstruction using single-bundle versus double-bundle technique: meta-analysis of 19 randomized controlled trials. Arthroscopy. 2013;29:357e365.

Li YL, Ning GZ, Wu Q, et al. Single-bundle or double-bundle for anterior cruciate ligament reconstruction: a meta-analysis. Knee. 2014;21:28e37.

Li X, Xu CP, Song JQ, Jiang N, Yu B. Single-bundle versus double-bundle anterior cruciate ligament reconstruction: an up-to-date meta-analysis. Int Orthop. 2013;37:213e226.

van Eck CF, Kopf S, Irrgang JJ, et al. Single-bundle versus double-bundle reconstruction for anterior cruciate ligament rupture: a meta-analysis–does anatomy matter? Arthroscopy. 2012;28:405e424.

Kongtharvonskul J, Attia J, Thamakaison S, Kijkunasathian C, Woratanarat P, Thakkinstian A. Clinical outcomes of double- vs single-bundle anterior cruciate ligament reconstruction: a systematic review of randomized control trials. Scand J Med Sci Sports. 2013;23:1e14.

Zhu Y, Tang RK, Zhao P, Zhu SS, Li YG, Li JB. Double-bundle reconstruction results in superior clinical outcome than single-bundle reconstruction. Knee Surg Sports Traumatol Arthrosc. 2013;21:1085e1096.

Tiamklang T, Sumanont S, Foocharoen T, Laopaiboon M. Double-bundle versus single-bundle reconstruction for anterior cruciate ligament rupture in adults. Cochrane Database Syst Rev. 2012;11:Cd008413.

Lertwanich P, Praphruetkit T, Keyurapan E, Lamsam C, Kulthanan T. Validity and reliability of Thai version of the international knee documentation committee subjective knee form. J Med Assoc Thai. 2008;91:1218e1225.

Irrgang JJ, Anderson AF, Boland AL, et al. Responsiveness of the international knee documentation committee subjective knee form. Am J Sports Med. 2006;34:1567e1573.

Bjornsson H, Desai N, Musahl V, et al. Is double-bundle anterior cruciate ligament reconstruction superior to single-bundle? A comprehensive systematic review. Knee Surg Sports Traumatol Arthrosc. 2015;23:696e739.

Desai N, Bjornsson H, Musahl V, et al. Anatomic single- versus double-bundle acl reconstruction: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2014;22:1009e1023.

Mae T, Shino K, Miyama T, et al. Single- versus two-femoral socket anterior cruciate ligament reconstruction technique: biomechanical analysis using a robotic simulator. Arthroscopy. 2001;17:708e716.

Cinque ME, Dornan GJ, Chahla J, Moatshe G, LaPrade RF. High rates of osteoarthritis develop after anterior cruciate ligament surgery: an analysis of 4108 patients. Am J Sports Med. 2018;8, 2011-2019.

Ajuied A, Wong F, Smith C, et al. Anterior cruciate ligament injury and radiologic progression of knee osteoarthritis: a systematic review and meta-analysis. Am J Sports Med. 2014;42:2242e2252.

Hoffelner T, Resch H, Moroder P, et al. No increased occurrence of osteoarthritis after anterior cruciate ligament reconstruction after isolated anterior cruciate ligament injury in athletes. Arthroscopy. 2012;28:517e525.

Luc B, Gribble PA, Pietrosimone BG. Osteoarthritis prevalence following anterior cruciate ligament reconstruction: a systematic review and numbersneeded-to-treat analysis. J Athl Train. 2014;49:806e819.

Karikis I, Desai N, Sernert N, Rostgard-Christensen L, Kartus J. Comparison of anatomic double- and single-bundle techniques for anterior cruciate ligament reconstruction using hamstring tendon autografts: a prospective randomized study with 5-year clinical and radiographic follow-up. Am J Sports Med. 2016;44:1225e1236.

Adravanti P, Dini F, de Girolamo L, Cattani M, Rosa MA. Single-bundle versus double-bundle anterior cruciate ligament reconstruction: a prospective randomized controlled trial with 6-year follow-up. J Knee Surg. 2017;30:898e904.

Kohn MD, Sassoon AA, Fernando ND. Classifications in brief: Kellgren-lawrence classification of osteoarthritis. Clin Orthop Relat Res. 2016;474:1886e1893.

Barenius B, Ponzer S, Shalabi A, Bujak R, Norlen L, Eriksson K. Increased risk of osteoarthritis after anterior cruciate ligament reconstruction: a 14-year followup study of a randomized controlled trial. Am J Sports Med. 2014;42: 1049e1057.

Holm I, Oiestad BE, Risberg MA, Aune AK. No difference in knee function or prevalence of osteoarthritis after reconstruction of the anterior cruciate ligament with 4-strand hamstring autograft versus patellar tendon-bone autograft: a randomized study with 10-year follow-up. Am J Sports Med. 2010;38:448e454.

Oiestad BE, Holm I, Engebretsen L, Risberg MA. The association between radiographic knee osteoarthritis and knee symptoms, function and quality of life 10-15 years after anterior cruciate ligament reconstruction. Br J Sports Med. 2011;45:583e588.

Song EK, Seon JK, Yim JH, Woo SH, Seo HY, Lee KB. Progression of osteoarthritis after double- and single-bundle anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41:2340e2346.

Zhang Z, Gu B, Zhu W, Zhu L. Double-bundle versus single-bundle anterior cruciate ligament reconstructions: a prospective, randomized study with 2- year follow-up. Eur J orthop Surg Traumatol. 2014;24:559e565.

Louboutin H, Debarge R, Richou J, et al. Osteoarthritis in patients with anterior cruciate ligament rupture: a review of risk factors. Knee. 2009;16:239e244.

Snow M, Stanish WD. Double-bundle acl reconstruction: how big is the learning curve? Knee Surg Sports Traumatol Arthrosc. 2010;18:1195e1200.

Sernert N, Hansson E. Similar cost-utility for double- and single-bundle techniques in acl reconstruction. Knee Surg Sports Traumatol Arthrosc. 2018;26(2): 634e647.

Nunez M, Sastre S, Nunez E, Lozano L, Nicodemo C, Segur JM. Health-related quality of life and direct costs in patients with anterior cruciate ligament injury: single-bundle versus double-bundle reconstruction in a low-demand cohort–a randomized trial with 2 years of follow-up. Arthroscopy. 2012;28: 929e935.