Journal of Orthopaedics 16 (2019) 224–229 Contents lists available at ScienceDirect Journal of Orthopaedics journal homepage: www.elsevier.com/locate/jor Double bundle anterior cruciate ligament reconstruction: Failure rate and patients-reported outcomes at 4–11 years of follow up T ∗ Piero Volpia, , Alessandro Quagliaa, Giulia Carimatia, Marco Gallib, Rocco Papaliac, Stefano Petrilloc a Knee Surgery and Sports Traumatology Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy b Centre of Sports Traumatology and Arthroscopic Surgery, Galeazzi Orthopaedics Institution of Milan, Via Riccardo Galeazzi 4, 20161, Milan, Italy c Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro Del Portillo, 200, 00128, Trigoria, Rome, Italy ARTICLE INFO ABSTRACT Keywords: Background: Biomechanical studies have demonstrated that single bundle (SB) anterior cruciate ligament (ACL) Double bundle reconstruction (SB-ACLr), which represents the gold standard for the management of ACL lesions, is not suffi- Anterior cruciate ligament cient to completely restore the rotational stability and resistance to valgus stress of the knee. Arthroscopy Purpose: To evaluate the failure rate and patients reported outcomes at a long-term follow-up of double bundle Failure anterior cruciate ligament reconstruction (DB-ACLr). Clinical outcomes Study design: Retrospective cohort study. Materials and methods: The database of arthroscopic DB-ACLr procedures performed from 2006 to 2015 at our Institution was retrospectively reviewed. Patients were screened for eligibility according to the following in- clusion criteria: magnetic resonance imaging (MRI) evidence of anterior cruciate ligament (ACL) lesion, positive anterior drawer test and/or Lachman test; age ≤ 45 years at the time of surgery; DB-ACLr with autologous hamstrings, minimum follow up of 24 months. Patients were excluded if they presented associated lesions of the knee preoperatively or at the time of surgery, expect for meniscal lesions, or in case of inability to complete clinical questionnaires. Clinical outcomes were assessed at a mean follow up of 95.4 ± 21.9 months (range 51–129 months; median 98 months) using the Tegner-Lysholm score and the IKDC subjective score. Failures were defined as Tegner-Lysholm score ≤65 points, and were confirmed with MRI. Results: 58 (81.7%) male and 13 (18.3%) female patients (mean age 29.7 ± 7.8 years) were included in the study. 2 (2.8%, 95% CI 0.3–9.8%) patients had a failure of DB-ACLr both occurred after a sports trauma. The IKDC subjective score was statically better in patients younger than 30 years. Tegner-Lysholm and IKDC sub- jective score were statistically better in professional athletes and in patients with isolated medial or lateral meniscus lesion instead of combined medial and lateral meniscus lesion. Conclusion: DB-ACLr technique provides excellent clinical results at a long term follow-up. Low failure rate and high percentage of return to sports participation at the same pre-injury level was found in our cohort of patients. 1. Introduction active patients.25 The aim of surgery is to restore the stability of the knee, allowing the return to sports participation, and preventing the The anterior cruciate ligament (ACL) is essential for the knee joint development of associated lesions7 such as meniscal or collateral liga- biomechanics and function.2 It efforts resistance to anterior dislocation ments tears,1 chondral injuries,32 fractures and early osteoarthritis.33 of the tibia,6 providing proprioception and rotational stability of the Anatomical studies have shown that the ACL is made of two bun- knee.5 dles, the antero-medial and postero-lateral.9,19,35 The single bundle In several sports activities requiring rotational motions or jumping (SB) ACL reconstruction (SB-ACLr) technique represents the gold like soccer, rugby, basketball, volleyball or skiing, the knee sustains standard for the management of ACL lesions.14 However, several stu- high mechanical loads and the ACL is more prone to injury.3,12 Surgical dies have demonstrated that, despite its capacities to restore stability in reconstruction of ACL lesions is often necessary, especially in young and the antero-posterior plane, SB-ACLr is not sufficient to completely ∗ Corresponding author. E-mail addresses: [email protected] (P. Volpi), [email protected] (A. Quaglia), [email protected] (G. Carimati), [email protected] (M. Galli), [email protected] (R. Papalia), [email protected] (S. Petrillo). https://doi.org/10.1016/j.jor.2019.02.021 Received 30 August 2018; Accepted 17 February 2019 Available online 28 February 2019 0972-978X/ © 2019 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of Prof. PK Surendran Memorial Education Foundation. P. Volpi, et al. Journal of Orthopaedics 16 (2019) 224–229 restore the rotational stability and resistance to valgus stress11,24 of the lower scores indicating the worst function of the knee. knee. Moreover, 15–25% of unsatisfactory results were recorded, with 4 some patients reporting persistent pain or instability. 2.4. Imaging Double bundle (DB) ACL reconstruction (DB-ACLr) technique was proposed to reproduce a more anatomic and functional ligament, re- All patients underwent preoperative MRI scans to diagnose ACL constructing both the ACL bundles. Various studies have shown a su- injury and associated lesions. Furthermore, a standard pre-operative periority of DB-ACLr respect to SB technique to restore rotatory stability radiographic assessment of the knee was performed in all patients using 22,23,30 ff of the knee, while other studies found no di erences between the antero-posterior, lateral and axillary view. In all patients with poor two procedures in term of outcomes, complications and failure results according to Tegner-Lysholm score and IKDC score, a MRI 17,18 rate. evaluation of the operated knee was performed at the final follow up. The primary purpose of our study was to evaluate the failure rate of DB-ACLr technique at a long term follow-up. In our hypothesis, DB- 2.5. Surgical procedure ACLr presents a failure rate not superior to 3%. Moreover, we have assessed the clinical outcomes and return to sports participation ac- The arthroscopic DB-ACLr technique has been previously de- cording to patients age, meniscal lesions and level of pre-injury sports scribed.31 All the surgical procedures were performed by the senior full- activity at the time of surgery. trained knee surgeon (P.V.). The patient, under spinal anesthesia, is placed in supine position 2. Materials and methods with the inferior limb on a leg holder permitting knee movement from 0° to 110°. A diagnostic arthroscopy is firstly performed to evaluate the 2.1. Ethics ACL rupture and to treat any meniscal lesion. In all patients presenting a meniscal lesion (medial or lateral or combined), a partial me- The ethics review board of our institution approved the study. niscectomy was performed preserving the more healthy meniscal tissue as possible. 2.2. Patient enrolment Then, both semitendinosus (ST) and gracilis (G) tendons are har- vested using a small oblique anteromedial (AM) incision at the level of We retrospectively reviewed the database of arthroscopic DB-ACLr the pes anserinus. Both tendons were doubled, and their diameters procedures performed at our Institution from January 2006 to should be minimum 5–6 mm for the G tendon, and 6–7 mm for the ST December 2015. A total of 162 DB-ACLr procedures were performed in tendon. 161 patients. Inclusion and exclusion criteria are shown in Table 1. Two tibial tunnels were created with a calibrated tibial guide 22 patients were excluded because of short term follow up, while (DePuy Mitek, Raynham, MA) specifically designed by the senior sur- other 30 patients were not compliant with the inclusion/exclusion geon to perform this technique. Then, the correct position of the fe- criteria. The remaining 109 patients were contacted telephonically. 71 moral tunnels is identified using a Kirschner wire introduced into the of them accepted our invitation and were enrolled in the study. joint through the tibial tunnels. The PL femoral socket is created at a depth of 30 mm by passing 2.3. Clinical evaluation through the PL tibial tunnel, while the AM femoral half-tunnel is cre- ated at a depth of 35 mm by passing through the AM tibial tunnel. 2 Clinical outcomes were assessed at the final follow up using the sutures are used to pass the graft (Fig. 1). Tegner-Lysholm score and the IKDC subjective score. Two blinded The G was used for the PL, while the ST was used for the AM. After surgeons administered both questionnaires. The mathematical average placement and pretensioning of the grafts proximally, both PL and AM fi ff of the results obtained by each examiner was used for statistical pur- bundles are xed by inserting two di erent pins through a cannula, fi pose. while PL and AM bundles are distally xed separately with a bioscrew. fi The Tegner-Lysholm score29 is a knee rating scale made of 8 sec- The xation of the PL and AM bundle was performed with the knee fl fi tions, evaluating post-operative limp, pain, locking, stair-climbing ca- exed at 10° and 45° respectively. The tension of the graft was nally pacity, necessity of support, instability, swelling, and squatting capa- tested with a probe (Fig. 2). city. The final score ranges from 0 to 100, and it can be classified as excellent (> 90 points), good (84–90 points), fair (65–83 points), or 2.6. Postoperative management poor (< 65 points). We have assumed as a failure a Tegner-Lysholm score ≤65 points. Postoperative management and rehabilitation protocol was the The IKDC subjective score15 is a knee rating scale made of 10 sec- same in all patients. Full weight bearing was allowed from the day after tions, evaluating post-operative knee pain, stiffness and swallowing, surgery using two crutches.