Double-bundle anterior cruciate ligament reconstruction: Surgical technique

Single-bundle anterior cruciate reconstruction does not restore the complexity of the native ligament which has 2 main components: anteromedial and posterolateral. The purpose of reconstruction has traditionally been the reduction of anterior drawer in response to anterior tibial loads. Although successful in reducing the anterior drawer, several investigators complain of the inability of modern techniques to completely restore the rotational stability and avoid the pivot shift phenomenon. Recent laboratory studies using different investigation devices demonstrated that the single bundle reconstruction is certainly effective in restoring anterior knee stability in response to an anterior tibial load, but it is not so effective in reducing the coupled anterior tibial translation resulting from a combined valgus and internal tibial torque. On the basis of these findings it has been suggested to reconstruct both the anteromedial and posterolateral bundles. The anteromedial bundle should mainly resist anterior loads while the posterolateral should mainly control rotational loads. Various techniques of double-bundle reconstruction have been developed, and promising preliminary results have been reported. However, no consensus exists on the number of bony tunnels required, on the proper tunnel positioning and on bundles tensioning. In this article, we will discuss the surgical principles and techniques of double-bundle anterior cruciate ligament reconstruction.