Evidence-Based Orthopaedics   |    
Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Was Superior to Conventional Single-Bundle Reconstruction
Robert G. Marx, MD
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Hospital for Special Surgery, New York, NY

Source of funding: No external funding.
For correspondence: Dr. M. Hussein, Artros Center for Orthopaedic Surgery and Sports Medicine, Tehnoloski Park 21, 1000 Ljubljana, Slovenia. E-mail address: mhussein@artros.si
Disclosure: The author received no payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. Neither the author nor his institution has had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, the author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Feb 20;95(4):365-365. doi: 10.2106/JBJS.9504.ebo804
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    Robert G. Marx, MD, MSc, FRCSC
    Posted on April 01, 2013
    Author’s response to Dr. Fu’s comment
    Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA

    Randomized trials are needed to advance our knowledge and improve patient care. The beauty of well-designed, clearly reported research such as this is that the reader can interpret the results based on their own knowledge, judgment and common sense. While Dr. Fu’s work on anatomic ACL reconstruction has contributed to change my own surgical technique over the past decade [1], in my opinion further research in this area is required. The results of this study will not change my current practice of anatomic single bundle ACL reconstruction.

    1. Marx RG. CORR Faceoff: Single- versus double-bundle anterior cruciate ligament reconstruction. Clin Orthop Relat Res. 2013 Feb;471(2):363-7.

    Freddie H. Fu, MD, D.Sc. (Hon.), D.Ps. (Hon.)
    Posted on March 14, 2013
    Differing interpretations of the same study
    Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, PIttsburgh, PA, USA

    I read this commentary with interest. Our level I randomized controlled trial (RCT) in the March 2012 issue of American Journal of Sports Medicine, by Hussein et al., reported that anatomic double-bundle reconstruction was superior to both anatomic single-bundle reconstruction and conventional single-bundle reconstruction.1 Moreover, anatomic single-bundle reconstruction was superior to conventional single-bundle reconstruction. We wholeheartedly agree with Dr. Marx that double-bundle ACL reconstruction can be technically demanding, as well as result in increased OR time and in the complexity of potential revision cases.

    In his commentary, Dr. Marx states that "anatomic double-bundle reconstruction is not warranted on the basis of these data." However, interestingly, an OrthoEvidence report of this same study concluded that anatomic double-bundle reconstruction should be the primary method for ACL reconstruction, and, when unattainable, an anatomic single-bundle should serve as the next surgical option. OrthoEvidence is an open access, evidence-based orthopaedics resource organized by Dr. Mohit Bhandari (McMaster University Department of Orthopaedic Surgery, Ontario, Canada) that provides critical appraisal of available literature evidence. We therefore found it unusual to read these differing interpretations of our study.

    We also agree with Dr. Marx that current clinical outcome measures, including patient-reported and clinician-measured outcomes utilized today in the evaluation of patients undergoing ACL reconstruction, are less than ideal and not without limitation. Our letter to the editor of AJSM in 2009 underscores that current outcome evaluations may not be able to detect clinically relevant differences between single- and double-bundle ACL reconstruction.2 We advocated that grouping "normal" with "nearly normal", as was done in Dr. Marx’s interpretation of our study, is not appropriate when reporting results after ACL reconstruction. The analysis from OrthoEvidence examined “normal” outcomes alone, which was consistent with our recommendation and analysis in the previously mentioned letter to the editor.

    Today, we can no longer accept that there are no differences between techniques without a critical and objective evaluation of outcome measurements. The utilization of more sophisticated outcome measurement tools, such as dynamic in vivo kinematics, will be required to provide an objective evaluation of ACL reconstruction techniques to realize differences otherwise not detectable clinically. Until such studies are complete, both anatomic double-bundle and anatomic single-bundle procedures serve as viable primary treatment options for reconstructing the ACL. This is consistent with the results of our study. This choice should be individualized to the patients' native anatomic characteristics and be able to restore the native insertion sites as closely as possible to the native ligament. Adhering to principles such as these will ultimately allow us to provide the patient with the best potential for a successful outcome.

    Finally, in reality, no study is perfect or without limitation and we fully acknowledge this. Nevertheless, we are trying to do the best that we can to determine whether differences exist between anatomic single- and double-bundle ACL reconstruction techniques. This remains a topic of intense interest for our research group focusing on anatomic ACL reconstruction in the University of Pittsburgh Department of Orthopaedic Surgery.

    We hope that this clarifies our position on the topic of anatomic single- versus double-bundle ACL reconstruction.


    1. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH. Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up. Am J Sports Med. 2012 Mar;40(3):512-20.

    2. Irrgang JJ, Bost JE, Fu FH. Re: Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a meta-analysis. Am J Sports Med. 2009 Feb;37(2):421-2; author reply 422.

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