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The first publication describing a technique
using both the semitendinosus and gracilis was
that of Libscomb B. [36] in 1982. The principle,
with a number of variations relating to the graft
being free or attached at its distal end, be it
single (2 strands) or double (4 strands) bundled,
along with a multitude of proposed graft
fixation techniques [37], wound be adopted by
all surgeons utilizing this graft. Subsequently
techniques developed using the semitendinosus
in triplicate. Marcacci [38] meanwhile
proposed using one of the strands of the graft to
perform an antero lateral tenodesis.
The two choices, patellar tendon or hamstring
graft, are popular today with no real
modifications except for different fixation
techniques for the hamstrings. Meta-analysis
[39, 40, 41, 42] comparing both graft choices
showed better control of laxity using the
patellar tendon yet no difference in functional
outcome. There were less patellar, loss of
extension and pain with kneeling problems in
the hamstring grafts and in one study, more
recurrent ruptures with hamstrings.
YEARS 2000-2010
Double Bundle
Even though the results of conventional
reconstructions (PT or Hamstring) were
satisfactory and reliable over time, a positive
“Pivot Shift” test of varying grades and
proportions up to 25% persisted during clinical
examination [43]. This lack of rotational
control possibly responsible for secondary
meniscal or cartilaginous problems, led
surgeons to reconsider the anatomy and
biomechanics of the ACL. The importance of
the postero lateral bundle, whose action is
effective for control of recurvatum, of the
anterior drawer between 0° and 20° and of
internal rotation was until now, ignored. An
awareness of the importance for an anatomical
reconstruction of the ACL with two bundles
became elementary. Many techniques had been
proposed in the 70’s, 80’s and 90’s, but all had
the inconvenience of only having one tunnel in
the tibia or the femur to mirror the anatomy.
Munetta [44] in 1999 was the first to publish a
preliminary series of patients operated on using
these techniques, but it was Yasuda’s article
[45] in 2004 that allowed for a perfect definition
of what anatomical zones needed to be chosen
for an anatomical positioning. The realization
of this double bundle theory and procedure
raised certain technical problems. We remain
committed to drilling the femoral tunnel from
“outside-in” and have developed a specific
guide for the postero lateral bundle [46].
Ameta-analysis [47] published by R. Meredick
and based on 4 randomized studies, noted an
improvement in arthrometer differentials of
0.52 mm without a statistical difference in
normal or subjectively normal (pivot glide)
rotary subluxation. Yasuda’s 2010 publication
[48], reviewed 10 randomized trials comparing
the single and double bundle reconstruction
and showed a 7 fold significantly better result
in anterior laxity for the double bundle
technique. Statistically, it was 8 times better for
dynamic tests that were positive (variability of
5 to 20%). One study noted a better IKDC
objective outcome. Two authors reported a
higher percentage of reruptures in the single
bundle reconstructions.
This interesting technique has a long and
difficult learning curve. It doubles the
possibility of committing an error in
positioning. Medium and long term compli
cations, especially those regarding lytic lesions
of bone, are not well arrested and a longer
follow-up is necessary to judge its superiority
over conventional techniques.
PARTIAL
RECONSTRUCTIONS
Arthroscopic double bundle reconstruction has
allowed us to progress on anatomy and also
reflect on partial tears of the ACL. Called to
mind on MRI and suspected on clinical
examination, this diagnosis should be
confirmed peri-operatively. The greater the
time between the trauma and the surgery, the
more the evaluation becomes difficult because
of the evolution of healing of theseACL lesions