KNEE

Prospective randomized comparison of knee stability and jointdegeneration for double- and single-bundle ACL reconstruction

Ran Sun • Bai-cheng Chen • Fei Wang •

Xiao-feng Wang • Jing-qing Chen

Received: 13 August 2013 / Accepted: 4 March 2014

� Springer-Verlag Berlin Heidelberg 2014

Abstract

Purpose This study aims to determine the outcome of

double-bundle anterior cruciate ligament (ACL) recon-

struction using an allograft in comparison with ACL

reconstruction using a double-bundle autograft or a single-

bundle allograft.

Methods A total of 424 patients who accepted primary

ACL reconstructions were divided randomly into three

groups: double-bundle technique with autograft (DB-AU

group, n = 154), double-bundle technique with allograft

(DB-AL group, n = 128), and single-bundle technique

with allograft (SB group, n = 142). The KT-1000

arthrometer and pivot-shift tests were performed at 3, 12,

and 36 months after surgery, and clinical outcome mea-

surements include the Lysholm score and the IKDC rating

scales. Radiological assessments evaluated arthritic chan-

ges and tunnel expansion at 36 months postoperatively.

Results The KT-1000 test scores in the DB-AU and DB-

AL groups were significantly better than those in the SB

group at 12 and 36 months postoperatively (P \ 0.05). The

pivot-shift tests scores in the DB-AU and DB-AL groups

were significantly better than those in the SB group at the

3, 12, and 36 month follow-ups (P \ 0.05). Based on the

IKDC score and Lysholm score, there were no significant

difference between the three groups during follow-up

(P [ 0.05). At 36 months postoperatively, 42.3 % of

patients in the SB group showed a progression in arthritic

changes, which was greater than in the DB-AU (29.2 %)

and DB-AL (27.3 %) groups (P \ 0.05). At 36 months, the

rates of tunnel expansion in the DB-AU group and the DB-

AL group were lower than in the SB group (P \ 0.05).

Conclusions Double-bundle ACL reconstruction can be

used to achieve better anterior and rotational stability and

has a lower rate of arthritic progression and tunnel

expansion than the single-bundle procedure.

Level of evidence I.

Keywords Anterior cruciate ligament � Double-bundle

technique � Prospective randomized study � Knee

Introduction

Anterior cruciate ligament (ACL) injury is the most com-

mon type of sports injury and has the capacity to seriously

affect quality of life. Several ongoing studies regarding

ACL reconstruction focus on comparing surgical tech-

niques, especially single-bundle versus double-bundle

procedures. Several studies suggest that anatomic double-

bundle ACL reconstruction should improve pivot-shift

resistance, increase rotational knee control, help preserve

menisci, and limit progression toward arthritis [5, 11, 33,

35, 36]. A number of studies, however, reported no dif-

ferences in terms of anteroposterior laxity, rotational sta-

bility, and any other clinical aspects at final follow-up

between the two techniques [4, 8, 13, 14]. The optimal

choice of graft material for ACL reconstruction remains

controversial. Reconstruction using autogenous tendinous

tissue has emerged as the most popular method for

reconstruction. However, a desire to avoid the sacrifice of

autogenous tissue and to minimize surgical trauma and

R. Sun (&) � B. Chen � F. Wang � X. Wang � J. Chen

Department of Joint Surgery, The Third Hospital of Hebei

Medical University, Shijiazhuang, People’s Republic of China

e-mail: 1146773358@qq.com

R. Sun � B. Chen � F. Wang � X. Wang � J. Chen

Key Laboratory of Biomechanics of Hebei Province, Orthopedic

Research Institute of Hebei Province, 139 Ziqiang Road,

Shijiazhuang, Hebei, People’s Republic of China

123

Knee Surg Sports Traumatol Arthrosc

DOI 10.1007/s00167-014-2934-4

postoperative morbidity has prompted the consideration of

allograft sources. The use of allografts has considerably

increased over the past decade [2, 16, 25, 26]. Additional

advantages include a shorter operation time and smaller

incisions. Additionally, there is no size limitation with an

allograft, and it may be more appropriate for multiple

ligamentous injury. However, allograft ACLR carries its

own problems, and surgeons are therefore faced with a

dilemma when deciding which type of graft to use.

This study compares the results of three different ACL

reconstruction techniques: the double-bundle technique

with a hamstring autograft, the double-bundle technique

with an allograft (DB-AL), and the single-bundle technique

with allograft (SB group). The purpose of this study is to

assess the outcome of double-bundle ACL reconstruction

using an allograft compared to single-bundle ACL recon-

struction. It is hypothesized that the allograft double-bun-

dle procedure may show significant superiority in terms of

the anterior laxity of the knee joint and the pivot-shift test

than the allograft single-bundle procedure, though there

may be no significant difference between allograft and

autograft double-bundle reconstructions.

Materials and methods

This study was carried out in the Third Hospital of Hebei

Medical University (Shijiazhuang, China) between 2000

and 2005. In total, 472 patients were included using the

following criteria: a primary ACL reconstruction, closed

growth plates, and the absence of ligament injury to the

contralateral knee. These patients were randomized with

closed envelopes into 3 different groups for ACL recon-

struction with different surgical methods: the double-bun-

dle technique with a hamstring autograft (DB-AU group),

the DB-AL group, and the SB group.

Surgical procedure

Graft preparation

For double-bundle ACL reconstruction with the use of a

hamstring autograft (DB-AU group), semitendinosus and

gracilis tendons were harvested with a standard tendon

stripper. The semitendinosus tendon (for the AM bundle)

and the gracilis tendon (for the PL bundle) were folded in

half over the Retro-Button loop (Arthrex, REF, AR). The

diameter of the doubled semitendinosus graft was

approximately 7–8 mm, and the diameter of the doubled

gracilis graft was approximately 6–7 mm. For double-

bundle reconstruction with the use of allograft (DB-AL

group), two deep-frozen tibialis anterior tendons were used.

For the single-bundle ACL reconstruction using an

allograft, two tibialis anterior tendons were quadrupled and

looped over the Retro-Button loop. The diameter of the

allograft was no \8 mm.

Double-bundle procedure

Femur tunnel positioning: The AM femoral tunnel guide

wire was located in the anterior and medial area of the

ACL insertion site and then drilled into the lateral femoral

condyle at approximately 1:30 o’clock in the left knee

(10:30 o’clock in the right). The tunnel was drilled with a

cannulated drill 4 mm in diameter over the guide wire and

through the anteromedial portal. The final drilling of the

tunnel was performed after measuring the diameters of the

grafts. The AM femoral tunnel was approximately 30 mm

in depth. The PL femoral guide wire was set laterally and

posterior to the AM femoral tunnel with 90� knee flexion at

approximately 3 o’clock in the left knee (9 o’clock in the

right). The PL femoral tunnel was drilled through the

anteromedial portal. A 2-mm bony bridge was preserved

between the two bone tunnels.

Tibial tunnel positioning: The tibial guide wire for the

AM bundle was positioned at the anterior portion of the

natural ACL insertion, which is located approximately

13 mm anterior to the anterior edge of the posterior cru-

ciate ligament. The tibial guide wire for the PL bundle was

placed 7 mm posterior and lateral to the AM guide wire in

the natural ACL insertion site. The AM bone tunnel was

drilled at a 50� angle and the PL bone tunnel at a 45� angle

to the tibia l plateau and approximately 1.5 (AM bundle)

and 3.5 cm (PL bundle) medial to the tibial tuberosity.

The graft for the PL bundle was first introduced through

the joint to the femoral drilled hole. The Retro Button was

flipped and fixed on the femoral cortical surface. Then, the

graft for the AM bundle was introduced and fixed in the

same manner. On the tibial side, the PL bundle was ten-

sioned by hand and fixed at full extension, followed by the

AM bundle at 30� knee flexion with tension. Bio absorb-

able interference screws (Arthrex, REF, AR) were used for

fixation on the tibial side for each graft, and these screws

were placed in the most distal part of the bone tunnel and in

contact with cortical bone.

Single-bundle procedure

The femoral tunnel guide wire was located at the centre of

the femoral ACL insertion site and then drilled into the

lateral femoral condyle at the 10 o’clock (or 2:00 right)

position in the left knee. The tibial guide wire for the SB

tunnel was positioned at the centre of the natural ACL

insertion site. Grafts were fixed by Retro Buttons and bio

absorbable screws in the femoral and the tibial side,

respectively.

Knee Surg Sports Traumatol Arthrosc

123

Follow-up and evaluation

All patients were followed up in routine clinical practice at

3, 12, and 36 months after surgery. Ligamentous laxity,

range of motion, and clinical scores were documented at

each office visit and entered into the research registry. A

standard radiographic series including a standing antero-

posterior view and a lateral view were taken for each

patient.

The routine stability measurement was performed, as

Daniel et al. described [3], with the use of a KT-1000

arthrometer under a load of 134 N (MEDmetric Corpora-

tion, San Diego, CA, USA) with the knee at 20� flexion.

Pivot shift was graded by the examiner according to IKDC

criteria as ‘‘equal’’ (grade 0), ‘‘glide’’ (grade ?1), ‘‘clunk’’

(grade ?2), or ‘‘gross’’ (grade ?3). A well-trained physical

therapist who was not a coauthor of this study and was

blinded to the procedure collected the KT-1000 arthrome-

ter results postoperatively. One well-trained orthopaedic

surgeon, who was blinded to the procedure, performed the

pivot-shift test. These measurements were performed pre-

operatively and at 3, 12, and 36 months after the operation.

The clinical outcome was assessed according to the Lys-

holm and IKDC rating scales at 3, 12, and 36 months

postoperatively. The range of motion of the knee joint was

measured with each patient in the supine position using a

goniometer and documented following the method reported

by Shelbourne et al. [22] at 3, 12, and 36 months

postoperatively.

Radiological assessment of the patient included standing

anteroposterior view and lateral view. The assessment was

performed by an independent radiologist. Based on the

IKDC guidelines, radiographic changes were graded as

normal, mild (minimal evidence of arthritis and joint space

narrowing that is just detectable), moderate (evidence of

arthritis and up to 50 % joint space narrowing), or severe

(joint space narrowing [50 %). Tunnel expansion was

determined by measuring the widest dimension in milli-

metres on the X-ray films of the femoral and tibial tunnels

for the AM, PL, and SB bundles. The femoral tunnels were

measured on the anteroposterior radiographs, and the tibial

tunnels were measured on the lateral radiographs. The

difference between the widest dimension of the tunnel and

the diameter of the drill that was used to create the tunnel

was calculated at 36 months after surgery. Expansion of

the bone tunnel was divided into three grades: mild

(\2 mm), moderate (\4 mm), and severe (C4 mm).

This study was approved by the Institutional Review

Board of the Third Hospital of Hebei Medical University

(Approval No. 2008-C026). Signed informed consent was

obtained from each patient. The clinical investigations

were conducted following the principles expressed in the

Declaration of Helsinki.

Statistics

The data were analysed with the SAS software (SAS

Institute, Cary, NC). Based on the clinical outcomes and

radiographic assessment of a preliminary study, a total

sample size of no \393 patients was calculated to be

required to perform the statistical analysis. Categorical

variables were recorded as numbers and percentiles with

frequency tables. Continuous variables were expressed as

the mean ± standard deviation. The analysis of variance

was used for continuous variables such as KT-1000 results,

Lysholm scores, subjective IKDC scores and range of

motion values. The chi-square test was used for categorical

data, including the pivot-shift test scores, objective IKDC

scores, arthritic changes, and measurements of tunnel

expansion. The significance level was set at P \ 0.05.

Results

Thirteen patients (nine in the DB-AL group, and four in the

SB group) had fewer than 3 months of follow-up postop-

eratively;25 patients (12 in DB-AU group, 5 in the DB-AL

group, and eight in the SB group) could not be followed up

in the outpatient clinic; and nine patients (three in the DB-

AU group, two in the DB-AL group, and four in the SB

group) had an injury-induced graft failure during the fol-

low-up period. One patient in the DB-AL group had ACL

reconstruction of the contralateral knee during the follow-

up period. These 48 patients were excluded from the study.

The remaining 424 patients (154 in the DB-AU group, 128

in the DB-AL group, and 142 in the SB group) met the

inclusion criteria with a minimum of 36 months follow-up

(range, 1–40 months) and were included in this study.

There were no significant differences in age, BMI, gender,

or length of follow-up between the three groups (Table 1).

The data regarding the side-to-side differences in ante-

rior tibial translation measured with the KT-1000

arthrometer are recorded in Fig. 1. There were no signifi-

cant differences between these three groups at the 3-month

follow-up visit. However, the anterior stability measured in

the DB-AU and the DB-AL groups was significantly better

than the SB group at the 12- and 36-month follow-up visits

(12 months: P \ 0.001; 36 months: P \ 0.001). The pivot-

Table 1 Age, gender, and BMI among the three groups

DB-AU DB-AL SB P value

No. of knees 154 128 142

Age (range) 27.5 (19–52) 27.1 (19–50) 28.2 (19–52) n.s.

M/F 106/48 94/34 101/41 n.s.

BMI 23.5 24.8 24.2 n.s.

Knee Surg Sports Traumatol Arthrosc

123

shift test results were significantly better at the 3, 12, and

36-month follow-up visit in patients with the double-bun-

dle technique (DB-AU and DB-AL) than in those patients

using the single-bundle technique (Table 2). There was no

significant difference between the DB-AU and the DB-AL

groups. There were no clunk and gross results in these three

groups. According to the Lysholm score, there was no

significant difference between the DB-AU, DB-AL, and SB

groups (Table 3). However, the scores from the 12- and

36-month visits are significantly better than those of

3-month visit in each group (DB-AU: P \ 0.001; DB-AL:

P = 0.002; SB: P = 0.001). According to the IKDC 2000

score, there was no significant difference between these

three groups (Table 4). However, the IKDC 2000 scores

from the 12- and 36-month visits are significantly better

than those from the 3-month visit in each group (1. Sub-

jective score: DB-AU: P \ 0.001, DB-AL: P \ 0.001, SB:

P \ 0.001 2. Objective score: DB-AU: P = 0.001, DB-

AL: P = 0.025, SB: P = 0.009). The range of motion at

the 3-, 12-, and 36-month visits postoperatively are sum-

marized in Fig. 2. However, the range of motion measured

in the DB-AU and the DB-AL groups was significantly

better than those from SB group at 3-month postoperatively

(involved extension: P = 0.010, involved flexion:

P = 0.013, side-to-side for extension: P = 0.001, side-to-

side for flexion: P \ 0.01).

Mild or moderate progression of arthritic changes were

found in 42.3 % of patients in the SB group, which was

higher than the DB-AU (29.2 %) and the DB-AL (27.3 %)

groups (Table 5). However, no significant difference

between the DB-AU and DB-AL groups was found. The

rate of the femoral tunnel expansion was 14.9 % in the DB-

AU group and 16.4 % in the DB-AL group (Fig. 3), and

both were lower than in the SB (26.8 %) group. On the

tibial side, the rates of expansion of the tunnels were

13.0 % in the DB-AU group and 13.3 % in DB-AL group,

and both were lower than in the SB (23.9 %) group

(Table 5).

Discussion

The most important finding of the present study was that

double-bundle ACL reconstruction can achieve better

anterior and rotational stability and has a lower rate of

arthritic progression and tunnel expansion at 3-year follow-

up visits than the single-bundle procedure. These findings

Fig. 1 KT-1000 arthrometer measurements at the force of 134 N at

follow-up. Pairwise comparison: *versus SB P \ 0.05

Table 2 Pivot-shift test of the knee postoperatively at follow-up

Pivot-shift

test

DB-AU

(N = 154)

DB-AL

(N = 128)

SB

(N = 142)

P value

3 Month

Equal/glide 139/15* 118/10* 115/27 0.010

12 Month

Equal/glide 133/21* 113/15* 108/34 0.013

36 Month

Equal/glide 125/29* 110/18* 100/42 0.005

Pairwise comparison: * versus SB P \ 0.05

Table 3 Lysholm score of the knee postoperatively at follow-up

DB-AU

(N = 154)

DB-AL

(N = 128)

SB

(N = 142)

P

Lysholm score

3 Months 88.9 ± 5.1 89.7 ± 4.7 88.4 ± 4.8 n.s.

12 Months 90.9 ± 4.9* 92.1 ± 4.5* 90.8 ± 5.0* n.s

36 Months 91.7 ± 4.2* 92.2 ± 4.0* 91.2 ± 4.8* n.s

Pairwise comparison of Lysholm score: * versus 3 months P \ 0.05

Table 4 IKDC score of the knee postoperatively at follow-up

DB-AU

(N = 154)

DB-AL

(N = 128)

SB

(N = 142)

P

Subjective IKDC 2000

3 Months 87.1 ± 5.6 87.0 ± 5.7 86.4 ± 5.3 n.s.

12 Months 92.4 ± 4.5* 93.3 ± 4.2* 92.2 ± 4.5* n.s.

36 Months 92.9 ± 4.3* 93.7 ± 4.0* 92.7 ± 4.3* n.s.

Objective IKDC 2000

3 Months:A/B/

C/D/

86/52/16/0 75/42/11/0 83/45/14/0 n.s.

12 Months: A/B/

C/D/

111/35/8/

0**

94/27/7/0** 104/30/8/

0**

n.s.

36 Months: A/B/

C/D/

119/30/5/

0**

98/24/6/0** 110/25/7/

0**

n.s.

Pairwise comparison of subjective IKDC 2000: * versus 3 months

P \ 0.05

Pairwise comparison of objective IKDC 2000: ** versus 3 months

P \ 0.05

Knee Surg Sports Traumatol Arthrosc

123

are consistent with the data from other vitro and clinical

studies [5, 11, 27, 31, 35]. Based on our findings and those

in the literature, we suggest that at present, surgeons should

use the more anatomic double-bundle technique for ACL

reconstruction using an allograft, especially in patients with

complex instability and greater transverse plane rotational

knee stress demands.

Allografts and autografts for double-bundle ACL

reconstruction

There are fewer relevant studies regarding double-bundle

ACL reconstruction with allografts [2, 16, 25, 26, 32]. Our

study indicated that allografts cannot directly cause

delayed healing and relaxation, and allograft for ACL

reconstruction does not accelerated the degeneration of

articular cartilage. Deep-frozen tibialis anterior tendon and

hamstring autografts were used for double-bundle recon-

struction. No graft received irradiation for secondary ster-

ilization. These two types of grafts have similar tension,

which is close to the tension of the original ligament. Al-

mqvist et al. [2] indicated that the tibialis anterior tendon

allograft for ACL reconstruction produced good clinical

results in the majority of patients at long-term follow-up.

However, some studies have reported an increase in the

rate of postoperative traumatic rupture in allograft groups.

Fig. 2 Range of motion. Pairwise comparison: *versus SB P \ 0.05 (3 month)

Table 5 Arthritic change and tunnel expansion at 36 months follow-

up

DB-AU

(N = 154)

DB-AL

(N = 128)

SB

(N = 142)

P value

Arthritic changes

Normal/mild/

moderate/severe

109/37/8/

0*

93/26/9/

0*

82/44/16/

0

0.008

Femoral tunnels tunnel expansion

\2 mm/\4 mm/

C4 mm

131/23/0* 107/21/0* 104/38/0 0.022

Tibial tunnels tunnel expansion

\2 mm/\4 mm/

C4 mm

134/20/0* 111/17/0* 108/34/0 0.019

Pairwise comparison: * versus SB P \ 0.05

Knee Surg Sports Traumatol Arthrosc

123

Mehta et al. [16] indicated that the revision rate was 0.7 %

in the autograft group versus 9.7 % in the allograft group.

Singhal et al. [25] indicated that the failure/reoperation rate

of those aged 25 years or younger was 55 %, compared

with 24 % in those older than 25 years. However, we

recognized that a lack of objective judgment standards and

a theoretical basis to determine allograft tendon failure and

deterioration. In the above experiment, the graft failure had

no direct relationship to the use of allograft tendons.

Comparing the stability of double-bundle and single-

bundle ACL reconstruction

Previous prospective studies were conducted in consecu-

tive patients with ACL injury who underwent double-

bundle ACL reconstruction [1, 4, 5, 27, 29, 31, 35]. Aglietti

et al. [1] compared the clinical results of single- and dou-

ble-bundle ACL reconstruction in a 2-year minimum fol-

low-up study, and the KT-1000 arthrometer data showed a

statistically significant decrease in the average anterior

tibial translation in the DB group. Our data from KT-1000

measurements showed that anterior stability was better in

the DB groups than in the SB groups at 12 and 36 months.

We also found that at 3-month follow-up visits, anterior

stability of the DB and the SB group showed no differ-

ences, which indicates that DB reconstruction can achieve

early tendon-bone healing and provide initial stability. In

addition, because each bundle in the double-bundle

reconstruction is thinner than in single-bundle reconstruc-

tion, the core portion of the former graft may be revascu-

larized sooner. Furthermore, double-bundle ACL

reconstruction has wider contact areas between the bone

and the grafted tendon than single-bundle reconstruction.

These theoretical advantages should be proved in future

clinical studies. Previous biomechanical studies [12–14]

reported that single-bundle ACL reconstruction frequently

leaves a residual ‘‘mini pivot’’ [4, 11, 18, 21, 23]. Jarvela

et al. [7] reported a prospective randomized clinical study

at an average follow-up of 14 months, the rotational sta-

bility, as evaluated by pivot-shift test, was significantly

better in the double-bundle group than in the single-bundle

group. We found that rotational stability after single-bundle

reconstruction was significantly worse than after the dou-

ble-bundle technique during 3- to 36-month follow-up

visits.

The tunnel position of the anteromedial bundle in dou-

ble-bundle reconstruction was more critical [6, 15, 19, 28,

34]. Muneta et al. [19] created the femoral AM tunnel at

the 12:30 o’clock position for the left knee and reported a

positive pivot-shift result in 20 % of the patients. Loh et al.

[15] confirmed that the low position of the femoral tunnel

could better resist the rotational load of the knee than the

high position. In our study, the AM tunnel positioning on

the femoral side was at 1:30 o’clock for the left knee. We

used a medial arthroscopy surgical approach to creating the

AM femoral tunnel; a transtibial technique can make it

difficult to create a low enough position of the femoral

tunnel. Leung et al. [12] showed that the centre of the PL

bundle was positioned 8.60 and 8.65 mm from the shallow

and the deep cartilage borders of the lateral wall of the

intercondylar notch. During surgery, the posterolateral

bundle is difficult to accurately locate. The AM bundle of

the main reference position and the position of PL bundle

posterolateral to the AM bundle were at approximately 3

o’clock in the left knee (9 o’clock in the right knee).

Osteoarthritis and tunnel expansion after ACL

reconstruction

Evidence suggests that single-bundle ACL reconstruction

does not reliably prevent the development of knee osteo-

arthritis [8, 10, 17, 20, 30], and our study indicated that the

slight progression of arthritis changes in the SB group was

higher than in the DB group at the 36-month follow-up

visit. Morimoto et al. [17] suggests that changes in the

contact area and pressure after SB-ACL reconstruction

may be one of the causes of osteoarthritis on long-term

follow-up. DB-ACL reconstruction may reduce the inci-

dence of osteoarthritis by closely restoring contact area and

Fig. 3 Mild progression of arthritic changes in DB reconstruction at

36 months after surgery

Knee Surg Sports Traumatol Arthrosc

123

pressure. These theoretical advantages should be proved in

future clinical studies. Kawaguchi et al. [9] indicated that

both the incidence and the degree of femoral tunnel

enlargement after anatomic double-bundle reconstruction

with hamstring tendon grafts were significantly less than

those after single-bundle reconstruction. Our study indi-

cated that the incidence of both femoral and tibial side

tunnel enlargement is lower after double-bundle recon-

struction than single-bundle reconstruction but that there is

no significant difference between the use of autografts and

allografts. Siebold et al. [24] indicated that significant bone

tunnel widening occurred in all four bone tunnels after

double-bundle ACL reconstruction. An interesting finding

was that expansion of the femoral tunnel for the AM

bundle was greater than expansion of the femoral tunnel for

the PL bundle. This result may be related to the relatively

high placement of the AM-bundle femoral tunnel causing

increased graft-tunnel motion during flexion of the knee

and contributing to increased tunnel expansion.

The current study has some limitations. First, the eval-

uation of rotational stability was performed clinically only.

The anterior stability of the knee joint can be measured

reliably with the KT-1000 arthrometer, though currently

there is no simple instrument for accurately measuring the

rotational instability of the knee. The most specific and

sensitive clinical test for evaluating rotational instability of

the knee is the pivot-shift test, which can sometimes be

difficult to perform. The second limitation is that a total of

48 patients were lost during the follow-up period. This

naturally limits the conclusions concerning the insignificant

findings in group comparisons. A positive factor was our

study had 424 patients at baseline, which was more than

many previous clinical studies of ACL reconstruction

comparing the single-bundle technique with its double-

bundle counterpart. The third limitation is that the follow-

up period was only 3 years. To establish the efficacy of this

double-bundle reconstruction, further prospective study

with a longer follow-up period is definitely needed.

Conclusions

Based on this study, it can be concluded that double-bundle

ACL reconstruction gains better anterior and rotational

stability and has a lower rate of arthritic progression and

tunnel expansion than the single-bundle procedure when

measured 3 years postoperatively. Tibialis anterior tendon

allografts for double-bundle ACL reconstruction produced

good clinical results in the majority of patients at long-term

follow-up.

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