IORG Evidence Based Series: Single Bundle vs Double Bundle ACL reconstruction

The question of which technique is better exists between double and single bundle ACL Reconstruction.

Recent metanaalysis by Eck et al from University of Pittsburgh Medical Center tries to answer this question

Single-bundle versus double-bundle reconstruction for anterior cruciate ligament rupture: a meta-analysis--does anatomy matter?

Purpose : To determine whether double-bundle anterior cruciate ligament reconstruction leads to better restoration of anterior and rotational laxity and range of motion than single-bundle reconstruction.


A search was performed in the Medline, Embase, CINAHL, and Cochrane databases. All randomized, quasi-randomized, and observational clinical trials that reported the outcome of double- versus single-bundle anterior cruciate ligament reconstruction were included in our meta-analysis. The primary outcomes were anterior laxity (KT arthrometer; MEDmetric, San Diego, CA), pivot shift, and range of motion. Subgroup analyses were performed for more than 2 years' follow-up, anatomic reconstruction, and nonanatomic reconstruction. The quality of the included studies was scored by use of the GRADE Checklist.


Included 12 studies in this meta-analysis, 5 of which were randomized. There was a statistically significant difference in favor of double-bundle reconstruction for anterior laxity (KT arthrometer difference, -0.6 mm), Lachman test (64% risk reduction of positive Lachman), and pivot-shift test (69% risk reduction of positive shift). Similar results were found for the subgroup with more than 2 years' follow-up and anatomic reconstructions. There were no significant differences for the subgroup with nonanatomic reconstructions, except a 2.6 times risk increase of extension deficit with nonanatomic double-bundle reconstruction compared with nonanatomic single-bundle reconstruction. Most of the included studies were found to have at least one serious limitation in study design.


In comparison with single-bundle reconstruction, double-bundle reconstruction showed less anterior laxity, as measured by the KT arthrometer and Lachman test, and better rotational laxity, as measured by the pivot-shift test. The majority of the included studies had at least one major limitation in study design that decreased the quality of the study.

LEVEL OF EVIDENCE: Level I, meta-analysis.

Link to Pubmed: click here

IORG Comment: Although the metanalysis talks about better anatomical and objective stability in double bundle, functional outcome is same in both groups. Additioanlly thehe long term followup in term of prevention of osteoarthrosis, failure rate, revision rates are not studied by most reported research. With gears shifting from a more anatomical approach a difference in comparative outcome between an anatomic and non anatomic single and double bundle will be interesting to observe.

Conclusion: The Statement made by Longo et al (2011) holds most accurate 'With the current evidence available, a simple SB ACL reconstruction is a suitable

technique, and it should be not abandoned until stronger scientific evidence in favour of DB ACL reconstruction will be produced.

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