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Anatomical and Nonanatomical Double-Bundle Anterior Cruciate Ligament Reconstruction

Importance of Femoral Tunnel Location on Knee Kinematics

Thore Zantop, MD^,*, Nadine Diermann, MS, Tobias Schumacher, MS, Steffen Schanz, MSc, Freddie H. Fu, MD, DSc(Hon) and Wolf Petersen, MD, PhD

From the Department of Trauma, Hand, and Reconstructive Surgery, Westfalian Wilhelms University Münster, Münster, Germany, and Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania

^* Address correspondence to Thore Zantop, MD, Department of Trauma, Hand, and Reconstructive Surgery, Wilhelms University Muenster, Waldeyer Strasse 1, 48149 Muenster, Germany (e-mail: thore.zantop{at}ukmuenster.de).

Background: Studies have suggested that double-bundle anterior cruciate ligament reconstruction may restore intact knee kinematics better than single-bundle anterior cruciate ligament reconstruction. Although the tunnel position of the femoral anteromedial bundle is well established, the effects of different posterolateral bundle positions on knee kinematics are unknown.

Hypothesis: Double-bundle anterior cruciate ligament reconstruction with an anatomical (shallow) femoral posterolateral bundle tunnel placement will restore knee kinematics more closely than will a nonanatomical (deep) femoral posterolateral bundle tunnel position.

Study Design: Controlled laboratory study.

Methods: In 12 human cadaveric knees, the kinematics of the intact knee, anterior cruciate ligament–deficient knee, and double-bundle anterior cruciate ligament–reconstructed knees with nonanatomical femoral posterolateral tunnel placement and anatomical posterolateral bundle placement were determined in response to a 134-N anterior tibial load and a combined rotatory load of 10 N·m valgus and 4 N·m internal tibial rotation using a robotic/universal force moment sensor testing system. Statistical analyses were performed using a 2-way analysis of variance test.

Results: Double-bundle anterior cruciate ligament reconstruction with nonanatomical posterolateral bundle placement showed significantly higher anterior tibial translation under anterior tibial and combined rotatory load than did the intact knee at 0° and 30° of knee flexion (P < .05). Reconstruction with an anatomical posterolateral tunnel placement restored the intact knee kinematics and showed significantly lower anterior tibial translation under anterior tibial and combined rotatory load when compared with reconstruction with nonanatomical posterolateral placement (P < .05).

Conclusion: Double-bundle anterior cruciate ligament reconstruction using the anatomical posterolateral bundle tunnel position restores the intact knee kinematics. A nonanatomical posterolateral bundle position results in rotatory instability.

Clinical Relevance: Double-bundle anterior cruciate ligament reconstruction should be performed using anatomical tunnel placement of the anteromedial and posterolateral bundles. Nonanatomical double-bundle reconstruction may fail to show any clinical superiority to single-bundle reconstruction and should be avoided.

Key Words: double-bundle • anterior cruciate ligament (ACL) • reconstruction • revision • rotational instability • robot • universal force moment sensor (UFS) • tunnel

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