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62the most common procedures performed by orthopedicgeons in the United States, with approximately 100,000

rformed per year.1 ACL surgery has seen considerable ad-cement in the past 3 decades, with current arthroscopic

hniques providing success rates ranging from 69% to%.2,3 Despite these clinical success rates, a recent studymonstrated that 95% of patients who underwent single-ndle ACL reconstruction developed medial compartmenthrosis on radiographs in 7 years and less than half of thetients were able to return to their preinjury level ofivity.4,5 Because arthrosis was observed medially, it cannotattributed to the initial subluxation event, which usuallyults in a bone contusion or a concomitant meniscal tearolving the lateral compartment.4

Although single-bundle ACL reconstructions continue tothe gold standard in the treatment of the ACL-deficientee, several studies have documented persistent knee laxityd instability after surgery.6,7 Because of these studies, there

tion that recreates both the anteromedial (AM) and the pos-terolateral (PL) bundles. The double-bundle anatomy of theACL was first described in 1938 by Palmer, with terminologyof the AM and PL bundles being chosen according to thetibial insertion sites of the 2 bundles.8 The tibial and femoralinsertion sites of both the AM and PL bundles have been welldescribed.9,10 The femoral origin has an oval shape withthe center of the AM bundle lying in close proximity to theover-the-top position and the center of the PL bundle lyingclose to the anterior and inferior articular margin. The visu-alization of the femoral origin site changes as the knee istaken through an arc of motion. The 2 bundles are parallelwith a vertical orientation when the knee is in extension (ie,the AM footprint is situated directly superior to the PL foot-print). The orientation changes to a more horizontal position,with the PL footprint becoming anterior to the AM footprintwhen the knee is flexed beyond 90. The changing orienta-tion of the 2 bundles footprints as the knee is taken throughan arc of motion leads to the observed crossing pattern of theindependent components of the ACL. Although the 2 bun-dles are intertwined, their functional tensioning pattern isindependent throughout knee range of motion.11 Near ter-

epartment of Orthopaedic Surgery, University of Pittsburgh MedicalCenter, Pittsburgh, PA.

niversity of Pittsburgh Medical School, Pittsburgh, PA.ress reprint requests to Freddie H. Fu, MD, DSc (Hon), DPs (Hon), Depart-natomic Double-Bundle Anruciate Ligament Reconstrsing Tibialis Anterior Alltios Paul Tjoumakaris, MD,* Anthony Buonceddie H. Fu, MD, DSc (Hon), DPs (Hon)*

Single-bundle anterior cruciate ligament (ACfor the treatment of ACL deficiency. Despitgood-to-excellent results, a significant subsymptoms of instability. Anatomical studies h2 bundles of the ACL (anteromedial and pohave supported the theory that an anatomic rpredictable restoration of normal knee kinemACL reconstruction as well as a postoperatiarticle. The senior authors 2-year results aroutcomes in nearly all patients.Oper Tech Sports Med 15:62-67 2007 Els

KEYWORDS knee, reconstruction, ACL, doublemitig

ment of Orthopaedic Surgery, University of Pittsburgh Medical Center,3200 S. Water Street, Pittsburgh, PA 15203. E-mail: Freddie.fu@upmc.edu

1060-1872/07/$-see front matter 2007 Elsevier Inc. All rights reserved.doi:10.1053/j.otsm.2006.07.003riortionraftni, MD,* James S. Starman, BS,

onstruction is the current gold standardcess rates that approach 80% to 90%f patients continue to report residualnsistently documented the presence of

ateral), and recent biomechanical datatruction of the ACL may provide a moreA surgical technique for double-bundleabilitation protocol are outlined in thisgiven, demonstrating excellent clinical

Inc. All rights reserved.nal extension, the AM is moderately loose, and the PL isht. As the knee is flexed, the femoral attachment of the ACL

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Double-bundle ACL reconstruction using tibialis anterior allograft 63umes a more horizontal orientation, causing the AM bun-to tighten and the PL bundle to loosen.

The idea of reconstructing both bundles of the ACL wasscribed by Mott and Zaricznyj in the 1980s.12,13 Mottlled 2 separate tunnels whereas Zaricznyj used a singleoral and 2 tibial tunnels. Despite publishing their results,technique did not gain widespread appeal, as results of

gle-bundle reconstructions were encouraging. There hasen recent biomechanical evidence to support the conceptt an anatomic double-bundle ACL reconstruction moreurately recreates the native anatomy of the knee joint.14,15

th translational and coupled rotational translation werenificantly less in the specimens with double-bundle ACLonstructions. These recent biomechanical data has led theior author (F.H.F.) to develop a double-bundle techniquet is now used routinely in the management of the ACL

ficient knee at our center. This article will outline the tech-ue and preliminary results of anatomic double bundleL reconstruction with 2 femoral and tibial tunnels using

o tibialis anterior allografts.

urgical Techniqueesthesia and Patient Positioning

tients undergoing this procedure receive a femoral nerveck within the preoperative holding area. Once within theerating suite, the patient is given conscious sedation andced supine on the operating room table. A thorough ex-ination under anesthesia (EUA) is undertaken to confirmfindings from the office examination. A tourniquet is

plied to the proximal thigh of the operative limb and thetralateral extremity is placed in a padded well leg holder

xed and abducted at the knee and hip so that the operativeld is cleared of any obstruction. Care is undertaken to pad

peroneal nerve and heel of the uninvolved leg. The oper-ve limb is then placed in an arthroscopic leg holder thatows for greater than 100 of knee flexion and the foot of thele is lowered. The leg is then elevated for five minutes andtourniquet inflated to 100 mmHg greater than the systolic

re 1 Knee is positioned to allow forge of motion between 0 and 120. In-operative assessment of the knee flex-

angle is essential for proper tunnelcement. (Color version of figure isilable online.)ssure. The leg is then prepped with betadine solution andped free in the usual fashion (Fig. 1).

abprorgical Landmarksd Diagnostic Arthroscopye knee is slightly flexed to 45, and the anatomical land-rks are identified. The inferior pole of the patella is drawnwell as the tibial tubercle. The borders of the patellardon are identified as well as the anterior crest and postero-dial border of the tibia. The lateral porthole is located justthe lateral border of the patellar tendon with its most

erior border flush with the inferior border of the patella.e medial porthole is marked beginning at the inferior polethe patella and extending distally just on the medial borderthe patellar tendon. An accessory medial porthole that willer be used for the PL tunnel is marked approximately 2 cmdial to the anteromedial porthole just at the level of thent line. The tibial incision is marked on the anteromedialect of the tibia midway between the anterior and posterior

rders of the tibia. This incision is approximately 4 cm ingth beginning 2 cm distal to the medial joint line (Fig. 2).Diagnostic arthroscopy is undertaken after establishmentthe lateral and medial portholes. Placement of the lateralrthole slightly superior obviates the need for excessive fatd debridement as the arthroscope is introduced proximalthis vital structure through this viewing porthole. All 3rtholes are used for viewing during the procedure, and thegeon is encouraged to obtain different vantage points fromh porthole to assure proper anatomical position of theoral tunnel. This obviates the need for any notchplasty forACL reconstruction. We begin our arthroscopy in the

tellofemoral joint debriding only the synovium that ob-ucts our view with a 4.5-mm full radius resector. Thehroscope is then swung down into the notch for a clearw of the ACL and posterior cruciate ligament (PCL). Varusess is then applied to the knee in the figure of four posi-n, and the lateral hemi-joint is inspected. Any articular orniscal pathology is addressed at the time of inspection.e knee is then placed in slight flexion and valgus and thedial hemi-joint is inspected. The scope is then brought

ck to the notch with the leg at 90 of flexion (the neutralsition). At this point, a spinal needle is used to localize theessory medial porthole. The needle should be visualizedstrartviestrtiomeThmebapoaccove the anterior horn of the medial meniscus and shouldvide direct access to the origin of the PL bundle on the

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64 F.P. Tjoumakaris et aleral femoral condyle. Placing the arthroscope in the medialrthole may help to delineate this more clearly. The acces-y medial porthole is then incised with an upturned 11de being careful not to transect the anterior horn of thedial meniscus.The notch is inspected for disruption of the fibers of theL. A probe is used to apply stress to the damaged ligament.cing the knee in the figure of four position can aid inwing the root of the lateral meniscus as it enters the tibia.t anterior to this structure, and often confluent with theeral meniscus is the insertion of the PL bundle of the ACL.ese fibers are followed proximally to the lateral femoraldyle and assessed for competence. The knee is thenught back to the neutral position and the AM bundle isessed. A thermal device and small radius resector are usedcarefully dissect out the fibers of the ACL removing onlyue that has no origin or insertion. The femoral and tibialertion sites of the AM and PL bundles are marked with thectrocautery device for later placement of the tunnels.

aft Preparation

re 2 Arthroscopic portal placement. Three portals are used to allowroved visualization of the lateral femoral notch. LP lateral portal; medial portal; AMP accessory anteromedial portal. (Color

sion of figure is available online.)o tibialis anterior allografts are individually fashioned as auble loop. The folded length of each graft should be ap-

dia(Coximately 12 cm for sufficient graft tissue. The grafts aremed to a folded diameter of 7 mm for the PL bundle andm for the AM bundle. A #2 braided suture is whip-stitchedand down both ends of the graft for 3 cm. The graft is thensed through the closed-looped EndoButton (Smith &phew, Andover, MA). Two Fiberwire sutures (Arthrex, Na-s, FL; one striped and one nonstriped for later identifica-n) are placed within the button holes. A 2-0 absorbableure is tied through both strands of the folded graft toure them once the graft is passed within the closed-loopeddoButton. Each graft is marked to alert the surgeon when toage or flip the EndoButton (Fig. 3).

ocedure in Detail/32-mm Steinman pin is first passed via the low antero-dial portal onto the medial face of the lateral femoral con-le. The pin is placed approximately 8 mm posterior to theterior articular margin and approximately 5 mm superiorthe inferior articular margin of the lateral femoral condyle.ce correct placement of the pin is obtained, the knee isught into approximately 120 of hyperflexion and tapped

o place with a mallet. The 7-mm acorn reamer is thenlled over the pin to a depth of 25 mm. The drill for thedoButton is then used to breach the far lateral cortex. Thenscondylar length is then measured with a depth gauged the appropriately sized EndoButton is placed on theograft. If the length is greater than 35 mm, the 7-mm acornmer is replaced within the PL tunnel and the tunnel isreased to a depth of 30 mm by hand. There should be atst fifteen millimeters of graft tissue within the tunnel.A 4-cm incision is made over the anteromedial surface of

tibia for creation of the tibial tunnels and passage of thefts. The tibial PL footprint, which is located just medial toposterior horn of the lateral meniscus and anterior to the

L, is then identified (Fig. 4). The footprint should haveen previously marked with the electrocautery device. Aect-tip ACL guide set to 55 is placed in the notch with thecentered within the PL tibial footprint. A pin is then

ced through the guide for later reaming. The AM tibialtprint is then identified and a pin is placed at this location

th a direct tip ACL guide set to 45 (Fig. 5). The AM pin

re 3 Doubled-over tibialis anterior allografts, with whip stitchEndobutton CL attached, PL graft (top) is sized to a 7 mmmeter and AM graft (bottom) is sized to an 8 mm diameter.lor version of figure is available online.)

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Double-bundle ACL reconstruction using tibialis anterior allograft 65uld be located in a more lateral position on the proximalia than the PL pin. Note that the PL tibial guide pin is quitetical in comparison to the AM tibial guide pin which ishtly horizontal. The PL and AM tunnels are then reamed

a diameter of 7 and 8 mm, respectively. This should allow-cm bone bridge between the tunnels within the notch.Attention is then directed to the AM femoral footprint. The2 Steinman pin is placed 3 mm posterior and slightlyerior to the previously drilled femoral PL tunnel. Theinman pin can be placed transtibially via the previouslylled AM tunnel or via the accessory medial porthole,ichever one will allow the proper trajectory low enough

thin the notch. The knee is hyperflexed as the Steinmanis then tapped into place. An eight millimeter acorn

mer is then placed over the pin and passed within the jointrest against the notch wall. The AM femoral tunnel is thenmed to a depth of 40 mm. The far cortex is then breached

re 4 (A) PL tibial tunnerl landmarks,ACUFEX tibial drill guide set to 55.External view of drill guide in posi-

n for PL tibial pin placement. Latn lateral meniscus; PCL posteriorciate ligament. (Color version of fig-is available online.)bleha

re 5 AM tibial pin placement. Director guide is set at 45. (Colorsion of figure is available online.)similar fashion to the PL tunnel and the appropriately sizeddoButton loop is placed on the allograft. Ideally, thereuld be at least 15 to 20 mm of graft tissue within the AMnel (Fig. 6).

aft Fixatione grafts are then passed using a beath pin and suture shut-g techniques. The PL bundle is passed first so as to opti-

ze visualization (Fig. 7). The femoral attachments are se-red first with the EndoButton device and bio-absorbableerference screws with a small soft tissue staple are used forial fixation. Before tibial fixation, the knee is cycled through al range of motion from 0 to 120 twenty to thirty timesile maintaining tension on both graft ends to remove anyck and check isometry. The PL bundle is tensioned firsttween 0 to 10 of flexion. The AM bundle is then ten-ned with the knee in approximately 60 of flexion. Notet the reconstructed state recreates the crossing pattern ofPL and AM bundles (Fig. 8).

ehabilitatione patient is placed in a hinged knee brace that is locked inension for 1 week. Crutches are used for 4 to 6 weeks untiladriceps function returns. The brace is unlocked only fortinuous passive motion and range of motion during the

t week. The patient practices weight bearing as tolerated bar-g any concomitant meniscal repair. The accelerated rehabili-ion protocol as described by Irrgang is then followed.16 Re-n to sports is typically allowed after six months providedquate strength gains have been achieved. All patients areised to use a functional knee brace when returning to sports

ring the first 1 to 2 years after reconstruction.

esults1987, Zaricznyj published the first clinical results for dou-RThextquconfirsrintatturadeadvdu

RIn-bundle ACL reconstruction.13 Twelve of the 14 patientsd excellent results. Muneta and coworkers in 1999 pub-

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66 F.P. Tjoumakaris et aled preliminary results suggesting that the double-bundlecedure showed a better trend with respect to anterior

bility.17 Hamada and coworkers in 2001 published aear follow-up on 160 consecutive patients who under-nt single or bisocket ACL reconstructions demonstratingstatistical significant difference between the two techniquesIKDC, KT measurements, or thigh muscle strength.18 Fur-rmore, Adachi and coworkers in 2004 performed a ran-mized prospective study of 108 patients (55 single bundle;double bundle) with an average of 32 months follow-up.statistically significant difference was noted with regards

knee joint stability (KT-2000) or with regards to proprio-

re 6 Femoral drill holes for the AM and PL bundle. PL is refer-ed off the anterior articular cartilage border and, AM is refer-ed off the PL tunnel. It is essential to assess the knee flexion angleen determining tunnel location.reswire 7 PL graft in position. PL is fixed with the knee in full extension.tion. There was a statistically significant difference withards to a decreased incidence of notchplasty for the dou-bundle group compared with the single bundle group.19

The senior author (F.H.F.) has performed a total of 177mary double-bundle ACL reconstructions using the iden-al surgical technique as outlined. The average preoperativechman and Pivot Shift Examination was 1.8 and 1.5,pectively. The average preoperative KT-2000 measure-nt was 3.72 mm (side-to-side difference). The averageoperative range of motion (total arc) was 125. The aver-preoperative IKDC score was grade C (abnormal). Post-

erative parameters at latest follow-up were: Lachmande (160 patients grade 0, 11 patients 1, 6 patients 2),ot shift grade (1 patient 2 shift, 7 patients with 1 shift,

d 169 with grade 0 shift), KT-2000 (average side to sideference: 1.2 mm), and range of motion (total arc 138).e final IKDC score at latest follow-up demonstrated 8 pa-nts with grade C outcome (abnormal), 7 patients withde B outcome (near normal), and the remaining 162 pa-

nts with grade A outcome (normal). There were 8 failuresour series that required double-bundle revision surgery. Atear radiographic follow-up, there was no evidence of tun-

l expansion on standard knee radiogaphs.

onclusionL reconstruction is one of the most common orthopaediccedures performed in the United States. Single-bundleL reconstruction, which focuses mainly on the AM bun-, remains the gold standard that has enjoyed great suc-s and returned many athletes to their sport. Despite this

parent success, several authors have demonstrated that ro-ional instability persists. The goal of anatomic double-ndle ACL reconstruction is to address this issue and better

re 8 AM and PL grafts in position. AM obscures the PL graft. AMxed with the knee in 60 in flexion.tore kinematics to normal. The hope is that this techniquell decrease the rate of degenerative changes at long term

follow-up, but long term clinical outcome studies are imper-ative. Regardless of which technique the orthopaedic sportssurgeon chooses to use, knowledge of the bundle anatomyand clinical applications of these concepts to routine ACLsurgery will undoubtedly make a better surgeon.

References1. Griffin LY, Agel J, Albohm MJ, et al: Non-contact anterior cruciate

ligament injuries: risk factors and prevention strategies. J Am AcadOrthop Surg 8:141-150, 2000

2. Freedman KB, DAmato MJ, Nedeff DD, et al: Arthroscopic anteriorcruciate ligament reconstruction: a metaanalysis comparing patellartendon and hamstring tendon autografts. Am J Sports Med 31:2-11,2003

3. Yunes M, Richmond JC, Engels EA, et al: Patellar versus hamstringtendons in anterior cruciate ligament reconstruction: a meta-analysis.Arthroscopy 17:248-257, 2001

4. Fithian DC, Paxton LW, Stone ML, et. al: Prospective trial of a treatmentalgorithm for the management of the anterior cruciate ligament-injuredknee. Am J Sports Med 33:335-346, 2005

5. Fithian DC, Paxton LW, Goltz DH: Fate of the anterior cruciate injuredknee. Orthop Clin North Am 33:621-636, 2002

6. Ristanis S, Stergiou N, Patras K, et al: Excessive tibial rotation duringhigh-demand activities is not restored by anterior cruciate ligamentreconstruction. Arthroscopy 21:1323-1329, 2005

7. Tashman S, Collon D, Anderson K, et al: Abnormal rotational kneemotion during running after anterior cruciate ligament reconstruction.Am J Sports Med 32:975-983, 2004

8. Palmer I: On the injuries to the ligaments of the knee joint. Acta ChirScand 91:282, 1938

9. Harner CD, Baek GH, Vogrin, et al: Quantitative analysis of humancruciate ligament insertions. Arthroscopy 15:741-749, 1999

10. Odensten M, Gillquist J: Functional anatomy of the anterior cruciateligament and a rationale for reconstruction. J Bone Joint Surg Am 67-A:257-262, 1985

11. Gabriel MT, Wong EK, Woo SL, et al: Distribution of in situ forces inthe anterior cruciate ligament in response to rotatory loads. J OrthopRes 22:85-89, 2004

12. Mott HW: Semitendinosus anatomic reconstruction for cruciate liga-ment insufficiency. Clin Orthop Relat Res 172:90-92, 1983

13. Zaricznyj B: Reconstruction of the anterior cruciate ligament of theknee using a doubled tendon graft. Clin Orthop Relat Res 220:162-175, 1987

14. Mae T, Shino K, Miyama T, et al: Single- versus two femoral socketanterior cruciate ligament reconstruction technique: biomechanicalanalysis using a robotic simulator. Arthroscopy 17:708-716, 2001

15. Yagi M, Wong EK, Kanamori A, et al: Biomechanical analysis of ananatomic anterior cruciate ligament reconstruction. Am J Sports Med30:660-666, 2002

16. Irrgang JJ: Modern trends in anterior cruciate ligament rehabilitation:nonoperative and postoperative management, Clin Sports Med 12:797-813, 1993

17. Muneta T, Sekiya I, Yagishita K, et al: Two-bundle reconstruction of theanterior cruciate ligament using semitendinosus tendon with endobut-tons: operative technique and preliminary results. Arthroscopy 15:618-624, 1999

18. Hamada M, Shino K, Horibe S, et al: Single- versus bi-socket anteriorcruciate ligament reconstruction using autogenous multiple-strandedhamstring tendons with endobutton femoral fixation: a prospectivestudy. Arthroscopy 17:801-807, 2001

19. Adachi N, Ochi M, Uchio Y, et al: Reconstruction of the anterior cru-ciate ligament single versus double-bundle multistranded hamstringtendons. J Bone Joint Surg [Br] 86-B:515-520, 2004

Double-bundle ACL reconstruction using tibialis anterior allograft 67

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Using Tibialis Anterior AllograftSurgical TechniqueAnesthesia and Patient PositioningSurgical Landmarks and Diagnostic ArthroscopyGraft PreparationProcedure in DetailGraft Fixation

RehabilitationResultsConclusionReferences