Single and Double Anterior Cruciate Ligament Reconstruction With Use of a Navigation System: The French Experience

Soft-tissue navigation and anatomic double-bundle anterior cruciate ligament reconstruction (AACLR) have developed in tandem. Navigation is now recognized as a reference in 3-dimensional measurement of laxity, but AACLR has not been proven to be superior to single-bundle reconstruction. It is now recognized that the anterior cruciate ligament (ACL) does not behave as a simple bundle of fibers with constant tension, as anteromedial bundle and posterolateral bundle fibers have been described and widely accepted. Anatomic reconstruction is becoming more popular among surgeons but, despite their expertise, surgeons have difficulty in accurately placing the tunnels and, as a result, many different techniques have been reported. These techniques can be classified in 4 groups depending on the number of bone tunnels. Navigation for ACL reconstruction was developed in France in 1994 for isometry and laxity measurement. It also can be used to predict graft impingement. A new software version was perfected in 2007 and adapted to the concept of AACLR. Virtual grafts were created to better analyze behavior within the intercondylar notch. This system is based on modular software that can be adapted to all different techniques. The French concept of AACLR was developed in 2001 and based on 2 bundles and 4 tunnels. We undertook cadaver and clinical studies and reported rotational laxity control improvement after the addition of the posterolateral bundle to standard anteromedial bundle reconstruction. However, there are limitations to our studies: the tests were performed under manual, uncontrolled forces, and we currently lack the tool to perform an instrumental pivot-shift. Randomized controlled studies have been reported and collected in a meta-analysis. Most of these studies assessed only the tibial anterior translation for laxity measurement and did not consider the coupled rotation. The rotational laxity is essential to be considered first for the selection of patients to compare a homogenous group of patients and also the final result. None of these randomized controlled studies have demonstrated the superiority of the AACLR on traditional single-bundle reconstruction. We conclude that navigation is the appropriated tool for this clinical assessment.