Single-Tunnel, Double-Bundle Anterior Cruciate Ligament Reconstruction: Clinical Evaluation, Treatment Options, and Surgical Technique

To achieve the best possible result for anterior cruciate ligament reconstruction, there are several fundamental elements that need to be addressed. The first is graft placement. Although many published reports state that the graft was placed anatomically, their operative description and their accompanying radiographs clearly denote that they were not anatomic. We as well as others have now clearly documented the bony landmarks that define the anatomic insertions of the anterior cruciate ligament on the femur and the tibia. In this work we also document the technical problems and misconceptions that occur when drilling the femoral and tibial tunnels. Our technique for creating anatomic tunnels also is presented; however, we also note that there are other techniques that can also achieve the desired results. The second element to be considered is that of graft selection. A review of the basic science literature on graft regeneration or “ligamentization” notes that both patellar tendon and hamstring autografts undergo biochemical metamorphosis to the same graft tissue although clinical studies suggest that there still may be a difference. Allograft tissue also undergoes a similar pattern as autografts but lags significantly behind in graft maturity and strength. Finally, all 3 graft tissues regenerate a longitudinal collagen pattern as seen in the original anterior cruciate ligament but with different size collagen fibrils. Our very preliminary studies suggest that the patellar tendon autograft undergoes significant graft hypertrophy that was still present even 2-1/2 years after reconstruction and that tunnel widening may be compensatory for this hypertrophy.