The article by Rue and associates, Outcomes of Single-Bundle Anterior Cruciate Ligament Reconstruction, is especially apropos right now. There is increasing pressure from podium presentations to change to some other type of ACL reconstruction, such as the double-bundle technique. (An article on Double-Bundle ACL Reconstruction is also posted in OKO.)

The article on the single-bundle technique reviews 11 studies with rigorous criteria. It reports that 85% to 90% of patients did well in general, with less than grade 2 Lachman or pivot shift test results and an instrumented laxity of less than 5 mm in 85% to 100% of patients. In addition, 85% to 90% of patients were reported to have a good to excellent functional result. Fewer than 6% of patients had complications; less than 4% had graft failure.

These results seem to provide a high degree of satisfaction with the single-bundle technique at 2 or more years follow-up. This compares with what has been discussed recently at podium presentations on the double-bundle technique, which have reported higher graft failure rates and more technical problems. In the August 2008 issue of OKO, a second article by Rue and associates lists these problems and acknowledges them as a reason to avoid dramatic changes in surgical technique for ACL reconstruction.1,2,3,4 This can lead to more difficult revision surgery and a much steeper learning curve for the orthopaedist doing fewer than 20 cases per year. The latter is true of more than 75% of orthopaedic surgeons doing ACL reconstruction.

Perhaps it is best to wait for outcomes that document a better functional result in controlled comparisons of the single-bundle technique and several approaches for the double-bundle technique to determine which technique is preferable. Just as surgeons thought bone-patellar tendon-bone was a better graft until head-to-head studies were done with hamstring tendons, the comparison with multiple tunnels has not yet been done.

My favorite faculty person in residency used to say, "The enemy of good is better." Let's look at the documentation before we change a very "good" established technique for a "better" one.

References:

1. Adachi N, Ochi M, Uchio Y, Iwasa J, Kuriwaka M, Ito Y: Reconstruction of the anterior cruciate ligament: Single-versus double-bundle multistranded hamstring tendons. J Bone Joint Surg Br 2004;86:515-520.
2. Asagumo H, Kimura M, Kobayashi Y, Taki M, Takagishi K: Anatomic reconstruction of the anterior cruciate ligament using double-bundle hamstring tendons: Surgical techniques, clinical outcomes, and complications. Arthroscopy 2007;23:602-609.
3. Hamada M, Shino K, Horibe S, et al: Single- versus bi-socket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstr ing tendons with endobutton femoral fixation: A prospective study. Arthroscopy 2001;17:801-807.
4. Giron F, Cuomo P, Edwards A, Bull A, Amis A, Aglietti P: Double-bundle "anatomic" anterior cruciate ligament reconstruction: A cadaveric study of tunnel positioning with a transtibial technique. Arthroscopy 2007;23:7-13.