[ clinical commentary ]

DANIEL HENSLER, MD1 • CAROLA F. VAN ECK, MD, PhD2 • FREDDIE H. FU, MD, DSc, DPs3 • JAMES J. IRRGANG, PT, PhD, ATC, FAPTA4

Anatomic Anterior Cruciate

Ligament Reconstruction Utilizing
the Double-Bundle Technique

R
upture of the anterior cruciate ligament (ACL) is one of both methods need to be anatom-
the most common knee ligament injuries, with an annual ically performed.23,38,55 Anatomic
ACL reconstruction techniques
incidence of 35 per 100 000 people.26,82 This event occurs SUPPLEMENTAL
VIDEO ONLINE
aim to better restore the normal
primarily in active individuals, and female athletes are 2 anatomy and biomechanics of the
to 3 times more likely to have an ACL injury than male athletes.26,82 knee, and are hypothesized to potentially
decrease the incidence of osteoarthritis
Consequently, ACL reconstruction is of patients who undergo ACL reconstruc- after ACL reconstruction.
one of the most commonly performed or- tion have radiographic knee osteoarthri- In this paper, the different aspects of
thopaedic surgeries in the United States. tis 7 to 12 years after surgery.52,60 In the anatomic ACL reconstruction will be dis-
Traditional ACL reconstruction, in which last decade, anatomic double-bundle cussed. We will focus on the anatomy, bio-
a single graft is used to reconstruct the reconstruction of the ACL has gained mechanics, and kinematics of the ACL,
ACL, has been shown to result in normal popularity and become a widely accepted methods for anatomic single-bundle and
International Knee Documentation Com- and used method to reconstruct the ACL. double-bundle reconstruction, and impli-
mittee Subjective Knee Form scores in Though differences in the outcomes of cations for postoperative rehabilitation.
only 61% to 67% of patients after surgery single-bundle and double-bundle ACL
and rehabilitation.12 Of more concern, reconstruction comprise a topic of ongo- Anatomy of the ACL
however, is the finding that 40% to 90% ing discussion, it is generally agreed that Surgeons in all specialties need to have
an in-depth knowledge of anatomy to
TTSYNOPSIS: The goal of every orthopaedic patient. After reconstruction, the graft undergoes a
maximize outcomes for their patients.
surgeon should be to restore anatomy as close complex, lengthy process of remodeling; therefore, Based on recent research, knowledge of
as possible to normal. Intense research on recon- inappropriate (early), aggressive rehabilitation can the anatomy of the ACL is advancing,
struction of the anterior cruciate ligament (ACL) lead to graft failure and compromise the patient’s and this has led to new and different ap-
and an advancing knowledge of the anatomy and outcome. The purpose of this article is to provide proaches to restore the anatomical struc-
function of the 2 primary bundles of the ACL have an overview of the anatomy and function of the ture and physiological function of the
led to techniques of ACL reconstruction that more ACL, the methods for anatomic single-bundle
ACL.
closely restore normal anatomy. Restoring the ACL and double-bundle ACL reconstruction, and our
recommendations for postoperative rehabilitation.
The ACL consists of 2 functional bun-
footprint is one of the most important goals of the
J Orthop Sports Phys Ther 2012;42(3):184-195. dles—the anteromedial (AM) and pos-
surgery, and the choice between anatomic single-
doi:10.2519/jospt.2012.3783 terolateral (PL) bundles4,7,28,59—named
bundle and double-bundle ACL reconstruction is
determined by the anatomical features of each TTKEY WORDS: ACL, knee, surgery for their position on the tibia (FIGURE 1).
Recent research has indicated that 2 dis-

1
Post-Doctoral Research Associate, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA. 2Post-Doctoral Research Associate, Department of Orthopaedic
Surgery, University of Pittsburgh, Pittsburgh, PA. 3Distinguished Service Professor, David Silver Professor and Chairman, Department of Orthopaedic Surgery, University of
Pittsburgh, Pittsburgh, PA. 4Director of Clinical Research, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA. The authors received funding from Smith
& Nephew, Inc to support research related to reconstruction of the anterior cruciate ligament. Additionally, the authors are supported by research funding from the National
Institute of Arthritis and Musculoskeletal and Skin Diseases (grant number AR056630-01A2), and the first author was Research Fellow of the German Speaking Association of
Arthroscopy (AGA) at the Department of Orthopaedic Surgery, University of Pittsburgh. Address correspondence to Dr Freddie H. Fu, Kaufman Medical Building, Suite 1011, 3471
Fifth Avenue, University of Pittsburgh, Pittsburgh, PA 15213. E-mail: [email protected]

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 tinct bundles, separated by a septum of
vascularized connective tissue,19 are al-
ready in existence in a fetus after approxi-
mately 20 weeks of development, which
leads one to assume that the 2-bundle
anatomy of the ACL is hereditary.
In addition to the ability to identify
the remnants of the ACL, detailed knowl-
edge of the specific bony landmarks of
the femoral and tibial insertion sites is
essential for an anatomic approach to
ACL reconstruction. For the femoral in-
sertion site, the prominent landmark is
the resident’s ridge (lateral intercondylar FIGURE 1. Right-knee cadaveric specimen showing the 2-bundle anatomy of the anterior cruciate ligament. (A)
The knee is in full extension and the AM and PL bundles are parallel to each other. (B) The knee is in flexion, the
ridge), which serves as the anterior limit
AM bundle is taut, the PL bundle is looser, and the bundles cross each other. Abbreviations: AM, anteromedial; PL,
of the ACL in the anatomical position. It posterolateral.
is located on the medial wall of the lateral
femoral condyle and, in the arthroscopic AM and PL bundles of the ACL are under
view of the orthopaedic surgeon with the tension. When the knee is flexed to 60°
knee at 90° of flexion, marks the upper to 90°, the PL bundle is lax and allows
border of the ACL (FIGURE 2).18,64 In 80% rotation of the tibia on the femur.24 The
of all individuals, a second ridge, the bi- PL bundle also limits anterior translation
furcate ridge, can be identified. This ridge of the tibia at lower angles of knee flex-
separates the origins of the AM and PL ion (0°-30°). The AM bundle primarily
bundles and runs perpendicular to the resists anterior translation of the tibia
resident’s ridge (FIGURE 2).18,64 The foot- and undergoes less change in length than
prints of both bundles are larger than the the PL bundle throughout the range of
cross-sectional area of the midsubstance knee motion. The PL bundle is maximally
FIGURE 2. Arthroscopic medial portal view of the
of the ACL.29 In the literature, there is a lengthened when the knee is in full exten- right knee in 90° of flexion, showing the marked
high degree of intrastudy and interstudy sion, and the AM bundle is under maxi- native femoral insertion site of the anterior cruciate
variation in the sizes of the femoral and mum tension when the knee is flexed ligament. Both the lateral intercondylar ridge
tibial ACL insertions.49 In general, the between 45° and 60°.15,33,43 This has im- (triangles) and the lateral bifurcate ridge (arrows)
can be seen. Abbreviations: AM, anteromedial; PL,
size of the femoral insertion is slightly plications for the angle of knee flexion
posterolateral.
smaller and of a different shape than the utilized when tensioning the grafts dur-
tibial insertion, which needs to be con- ing ACL reconstruction. The AM and single-bundle ACL reconstruction re-
sidered when performing anatomic ACL PL bundles do not work individually but stored normal anterior/posterior transla-
reconstruction. rather synergistically to control and limit tion, but the knee was externally rotated
anterior/posterior translation and axial by an average of 4° and adducted by an
Biomechanics and Kinematics of the ACL rotation of the knee.43,78 average of 3° compared to the contralat-
and Knee Generally, traditional single-bundle eral normal knee. Although the magni-
The femoral footprints of the AM and PL ACL reconstruction places the ACL in a tude of the abnormal rotations may seem
bundles are vertically aligned when the nonanatomic position. It successfully re- small, the difference in external rotation
knee is in full extension, and the femo- stores normal anterior/posterior transla- is sufficient to move the contact point of
ral origin of the AM bundle is located tion but fails to restore normal rotational the lateral tibial plateau 3.5 mm poste-
superior to the PL insertion. 93 In this stability.84,86 These observations were riorly, and the difference in adduction
configuration, the 2 bundles are paral- confirmed by Tashman et al75 in an in would decrease the medial joint space by
lel to each other, whereas with the knee vivo study that used dynamic dual-video 1.3 mm in an average-sized knee. Thus,
in 90° of flexion (ie, the position of the fluoroscopy to evaluate the kinematics of conventional, nonanatomic single-bun-
knee during surgery), the 2 bundles cross the knee during walking and running on dle ACL reconstruction does not appear
each other and the femoral insertions are a treadmill in patients who underwent to restore the normal kinematics of the
nearly horizontally aligned (FIGURE 1).15,93 traditional, nonanatomic single-bundle knee, and it is hypothesized that this
When the knee is in full extension, the reconstruction. Specifically, traditional inability is one of the factors that may

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 [ clinical commentary ]
contribute to posttraumatic knee osteo-
arthritis after ACL injury and surgery.
In contrast, anatomic double-bundle
ACL reconstruction appears to better
restore rotational stability compared to
single-bundle reconstruction.86,87 In a ca-
daveric model, Yagi et al86 demonstrated
that reconstructing both bundles of the
ACL resulted in more normal restoration
of knee kinematics, particularly internal
and external rotation of the tibia. Howev-
er, these better results may be due to the
anatomic placement of the ACL and not
necessarily the double-bundle technique.
Single-bundle ACL reconstruction can
also be performed in an anatomic fash-
ion. Yamamoto et al87 showed that ana-
tomic single-bundle reconstruction with
a laterally placed femoral tunnel can re-
store knee kinematics to a level similar to
that achieved by anatomic double-bundle
reconstruction when the knee is near full
extension; however, double-bundle re-
construction resulted in more normal
kinematics when the knee was at higher
angles of flexion. The true benefits of
anatomic double-bundle reconstruction FIGURE 3. Arthroscopic view of a right knee in 90° of flexion. (A) Lateral portal view of a 14-mm insertion site. (B)
compared to anatomic single-bundle re- Lateral portal view of a 22-mm insertion site. (C) Central portal view of a 12-mm notch. (D) Central portal view of
construction should be the focus of future a 20-mm notch. This figure shows the large variations in tibial insertion site and femoral intercondylar notch size.
studies. Online video available at www.jospt.org.
The clinical evidence for double-
bundle ACL reconstruction is mounting ACL reconstruction had a normal pivot sults in better patient-reported outcomes.
but is still inconclusive. There have been shift test after surgery, compared to 62% Most importantly, long-term trials to
16 prospective clinical outcome studies of those who underwent single-bundle compare the development and progres-
that have compared double-bundle ACL reconstruction. This result indicates that sion of posttraumatic knee osteoarthritis
reconstruction to single-bundle ACL re- a normal pivot shift was more common after single-bundle and double-bundle
construction,1,3,8,35,40,41,47,57,58,70,74,77,83,85,88,90 following double-bundle ACL recon- ACL reconstruction are needed to dem-
of which 10 were randomized clinical struction (pooled odds ratio, 3.8; 95% onstrate the true benefits of anatomic
trials.1,3,35,40,41,57,70,74,83,90 A meta-analysis of confidence interval: 1.8, 7.8).38 double-bundle ACL reconstruction.
4 randomized clinical trials by Meredick Since the meta-analysis by Meredick
et al55 revealed that double-bundle ACL et al,55 there have been 6 additional ANATOMIC ACL
reconstruction resulted in a signifi- randomized clinical trials comparing RECONSTRUCTION
cantly smaller side-to-side difference in double-bundle ACL reconstruction to sin-

I
tibial translation, as measured with the gle-bundle ACL reconstruction.3,35,70,74,83,90 n the opinion of the authors,
KT1000 Knee Ligament Arthrometer Three of the trials3,35,70 demonstrated that there are 4 fundamental principles of
(MEDmetric Corporation, San Diego, double-bundle ACL reconstruction re- anatomic ACL reconstruction. The
CA); there was no difference in the pro- sulted in significantly better side-to-side first 2 principles are to appreciate the
portion of individuals who had a normal differences in anterior translation and a native anatomy of the ACL and to indi-
or nearly normal pivot shift test. Howev- significantly higher proportion of normal vidualize surgery to the patient’s specific
er, a closer analysis of the data reported pivot shift tests. To date, however, none anatomy and functional needs. Because
by Meredick et al55 revealed that 88% of of the studies have demonstrated that of the high degree of variation in the
patients who underwent double-bundle double-bundle ACL reconstruction re- sizes of the tibial and femoral insertion

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 the central portal and is created under
arthroscopic visualization, with sufficient
space from the medial condyle to avoid
damaging the condyle. Placement of the
arthroscope in the central portal helps to
visualize the lateral wall of the femoral
notch and the ACL footprint; therefore,
with the accessory portal as a working
portal, this technique eliminates the need
for notchplasty.

Anatomic Double-Bundle Reconstruction

FIGURE 5. Arthroscopic lateral portal view of the
After the portals are established and di-
right knee in 90° of flexion, showing the marked
native tibial anterior cruciate ligament insertion site. agnostic arthroscopy of the medial and
Abbreviations: AM, anteromedial; PL, posterolateral. lateral tibiofemoral and patellofemoral
compartments is performed to inspect
bundle is tensioned with the knee flexed the menisci and chondral surfaces, focus
to 45° to 60°. This is consistent with bio- is turned toward the intercondylar notch
mechanical evidence that the PL bundle to determine the rupture pattern of the
is under maximal tension with the knee ACL. The ACL is most likely to be torn
in full extension and that the AM bundle at the femoral site, but there can also be
is under maximal tension with the knee midsubstance tears as well as ruptures at
in 45° to 60° of flexion.89 For anatomic the tibial site. By visualizing and probing
single-bundle ACL reconstruction, the the remnants of the ACL, possible single-
graft is tensioned with the knee in 10° to bundle tears can be diagnosed where 1
20° of flexion. However, in clinical prac- bundle remains intact.91 In addition to
tice, there is currently no consensus on the aforementioned bony landmarks, the
FIGURE 4. Three-portal technique marked on a right
the optimal knee flexion angles during remnants of the torn ACL can help the
knee in an operating position of 90° of flexion. The
lateral portal (LP), central portal (CP), and accessory
graft tensioning in both single-bundle surgeon to locate the native tibial and
medial portal (AMP) are shown. and double-bundle approaches.44,66 femoral insertion sites. The anterior/
It is our belief that for anatomic posterior and medial/lateral dimensions
sites, as well as the sizes of the femo- single-bundle and double-bundle ACL on the tibia, as well as the proximal/dis-
ral intercondylar notch, the insertion reconstruction, 3 arthroscopic portals tal and anterior/posterior dimensions
sites and notch need to be measured (central, anterolateral, and accessory me- on the femur, are measured. Along with
to determine whether single-bundle or dial) should be created (FIGURE 4).16 Cre- measurement of the intercondylar notch
double-bundle ACL reconstruction best ation of 3 portals has several advantages width, the measurements are used to de-
suits the needs of the individual patient compared to the traditional 2-incision termine whether single-bundle or dou-
(FIGURE 3 and ONLINE VIDEO).78 A tibial inser- technique described in the literature.6 ble-bundle reconstruction is preferred
tion site shorter than 14 mm in length and The creation of a third portal allows for for the patient.
a notch narrower than 12 mm in width better visualization of the femoral ACL After the origins of the 2 bundles on
are too small to accommodate double- insertion site location, making a notch- the tibia and femur are marked, 2 tun-
bundle ACL reconstruction.79 The third plasty unnecessary.6 The anterolateral nels in the tibia and femur are drilled
principle is to restore native anatomy by portal is placed laterally, adjacent to the (FIGURES 2 and 5). The size of the tun-
placing the graft in the center of the foot- patellar tendon and the inferior border nels is determined by the size of the ACL
print. The fourth principle is to restore of the patella. The central portal is lo- footprints. To restore the normal size
the physiological function of the graft by cated slightly above the medial menis- relationship between the AM and PL
applying appropriate tension to mimic cus and directly adjacent to the medial bundles, the sizes of the graft and tunnel
the native ACL as closely as possible.5 As border of the patellar tendon. With the for the AM bundle should be larger than
such, when anatomic double-bundle ACL arthroscope in the central portal, a view the graft and tunnel for the PL bundle.
reconstruction is performed, the graft for along the ACL directly to the femoral When drilling the femoral and tibial tun-
the PL bundle is tensioned with the knee ACL footprint is possible. The accessory nels, a bony bridge of approximately 2
at 0° of flexion and the graft for the AM medial portal is located 2 cm medial to mm needs to be preserved to prevent co-

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 [ clinical commentary ]
alescence of the tunnels.81 In the end, the
sum of the diameters of the 2 tunnels and
the bony bridge between them should be
approximately equal to the size of the na-
tive footprint.
Either allograft or autograft tissue can
be used to reconstruct the ACL, depend-
ing on the wishes of the patient and the
preferences of the surgeon. Good results
are reported for different types of auto-
grafts, such as hamstring, bone-patellar
tendon-bone, or quadriceps tendon,66
and allografts.9 However, recent evidence
suggests that graft failure may occur
more frequently when an allograft is used
to reconstruct the ACL in young, active
patients. This may be due to a delayed in-
corporation of the graft into the tunnel,
which leads to inferior biomechanical
properties.14,39,51,53,63,67 As a consequence,
the authors believe that the autograft is
the best type of graft for young, active
athletes, whereas allografts can be used
FIGURE 6. Arthroscopic view of the anatomic double-bundle reconstruction technique in a right knee. (A) Marking
for less active patients because of the
of the tibial insertion site. (B) Marking of the femoral insertion site. (C) The tibial and femoral tunnels are drilled in
lesser amount of postoperative pain sec- the location of the tibial and femoral footprints. (D) The anteromedial (AM) and posterolateral (PL) bundle grafts
ondary to not harvesting a tendon graft are passed. Online video available at www.jospt.org.
during surgery.
The PL graft is passed first, followed ACL injuries.34,36 As such, we do not re- bruise of the lateral femoral condyle could
by the AM graft. To preserve insertion fer to a narrow notch as notch stenosis, potentially affect graft incorporation.61,69
site integrity, suspensory fixation is used which implies that the narrow notch is For anatomic single-bundle recon-
on the femoral side and screw fixation is pathologic. Therefore, we recommend struction, we apply the same principles
used on the tibial side, where the screw that the notch should be measured in all that are used for anatomic double-bundle
is placed 1 to 2 cm beyond the joint line. patients undergoing ACL reconstruction reconstruction. The femoral and tibial
The PL bundle is fixed at 0° to 10° of knee to determine whether double-bundle or tunnels are placed in the center of the
flexion and the AM bundle is fixed at 45° single-bundle ACL reconstruction should femoral and tibial ACL insertion sites.
of flexion (FIGURE 6 and ONLINE VIDEO).5 be performed. Rather than performing a The size of the drilled tunnel is based on
notchplasty to create the additional room measurements of the width and length of
Anatomic Single-Bundle Reconstruction necessary for double-bundle reconstruc- the footprint. For example, if the inser-
In cases when the insertion site is smaller tion, we believe that single-bundle ACL tion site is 12 mm long and 9 mm wide, a
than 14 mm and the width of the inter- reconstruction should be performed drill bit of 9 mm should be used to ensure
condylar notch is narrower than 12 mm, when there is a narrow notch. that the tunnel remains within the bor-
double-bundle reconstruction can be a Further indications for single-bundle ders of the footprint and to avoid damag-
challenge. When the intercondylar notch reconstruction are described in the litera- ing adjacent structures, especially on the
is small, drilling the femoral tunnel is ob- ture. These include open physes, severe tibial side. In these cases, we accept that
scured by the medial wall of the notch. arthritic changes (grade III or greater), single-bundle ACL reconstruction does
Additionally, a notch width narrower multiligamentous injuries, and severe not completely restore the size of the na-
than 12 mm increases the risk of damag- bone bruises, particularly of the lateral tive ACL footprint. In our example, the
ing the medial condyle, especially when femoral condyle (partial indication). In tunnel may be smaller than the insertion
drilling the AM tunnel.80 In our opinion, patients with severe arthritic changes, site area, although it must be pointed out
a small notch is an anatomical variation, a double-bundle ACL reconstruction that perpendicular drilling is not pos-
but there are studies showing that a nar- could overconstrain the knee and lead to sible; consequently, drilling will result
row notch is a risk factor for noncontact increased pain and degeneration. A bone in an oval-shaped tunnel aperture that

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 may actually restore the length of the tomically positioned.45 For this reason, the ability to perform a SLR with the
footprint. functional activities that place a high load knee at the end range of full extension.
on the graft, such as jumping, cutting, High-intensity electrical stimulation that
Failure After ACL Reconstruction pivoting, and return to sport, are more is sufficient to produce a full, sustained
Graft failure is an ongoing topic of dis- gradually initiated and progressed after contraction of the quadriceps is used to
cussion in the literature, as well as at anatomic ACL reconstruction. improve quadriceps strength. Several
meetings and conferences. Rates of func- Below is a description of the reha- randomized clinical trials have dem-
tional graft failure are reported to be be- bilitation program followed at our in- onstrated the benefits of high-intensity
tween 0% and 27.3%.65 The main cause stitution. The rehabilitation programs electrical stimulation to improve quad-
of graft failure is related to malposition of after anatomic single-bundle and dou- riceps strength,21,71 gait,71 and patient-
the tunnel, for example, placing the tibial ble-bundle ACL reconstruction are the reported outcomes21,46 following ACL
tunnel too anteriorly or placing the graft same. Immediately after surgery, the fo- reconstruction. As range of motion im-
too vertically.17,42 Poor biological incorpo- cus is to minimize pain and swelling, re- proves, quadriceps strengthening can be
ration of the graft,54 recurrent trauma, or store full passive extension symmetrical progressed to include limited-arc (from
early return to sport27 may also lead to to the noninvolved knee, achieve 90° to 90° to 60°) non–weight-bearing (open-
graft failure. Most studies that reported 100° of knee flexion, restore the ability to chain) knee extension exercises and
graft failure after ACL reconstruction perform a straight leg raise (SLR) with- low-level weight-bearing (closed-chain)
included patients who underwent non- out a quadriceps lag, and progress to full exercises, with weight equally distributed
anatomic ACL reconstruction. However, weight bearing so the individual can walk on both extremities (eg, minisquats, wall
after anatomic ACL reconstruction, a without assistive devices or a gait devia- slides). Standing weight shifts progress-
higher graft failure rate may be expected tion. The day after surgery, patients be- ing to unilateral balance exercises can be
because, as demonstrated by Kato et al,45 gin to perform ankle pumps, quadriceps used to improve the ability to tolerate full
the forces in an anatomically placed graft sets, SLRs, gastrocnemius and hamstring weight bearing and to begin to improve
will be greater (comparable to the native stretches, and heel slides. The patient is balance and postural control. Gait train-
ACL) than those in a nonanatomically encouraged to make frequent use of cold ing is performed as necessary to ensure
placed graft (less force than the native to control postoperative pain and swell- that the individual uses a normal heel-toe
ACL due to the nonanatomic position of ing. The patient ambulates with axillary gait and does not walk with a flexed knee
the graft). Therefore, rehabilitation and crutches, using weight bearing as toler- during the midstance of gait. Progressive
return to sport after anatomic ACL re- ated, with the knee brace locked in full resisted exercises are also initiated for the
construction may need to be progressed extension. Unless the patient had a con- hamstrings and hip muscles; however, to
slower than after a traditional, nonana- comitant meniscus repair, the brace can allow for healing of the harvest site, we
tomic ACL reconstruction. be unlocked for ambulation at the end of delay resisted hamstring exercises for
the first week after surgery. If the patient 4 to 6 weeks following harvest of the
REHABILITATION had a concomitant meniscus repair, use hamstring. If available, pool exercises
of the brace locked in full extension is can be used to improve range of motion,

E
xcept for a slower return to continued for 4 to 6 weeks to minimize strength, and gait.
functional activities, rehabilitation shear stresses on the healing meniscus If the patient fails to progress with
after anatomic ACL reconstruction during ambulation.72 range of motion and/or has difficulty ini-
follows rehabilitation guidelines simi- During the first 4 to 6 weeks after tiating a quadriceps contraction for more
lar to those of traditional, nonanatomic surgery, the rehabilitation program is than 1 to 2 weeks after surgery, the post-
single-bundle ACL reconstruction. Ini- gradually progressed. Active and active- operative rehabilitation program may
tially, we were concerned that anatomic assisted range-of-motion exercises are need to be altered and the surgeon should
double-bundle ACL reconstruction might used to restore range of motion as toler- be alerted. Joint mobilization and cyclic
interfere with the restoration of range of ated. If the patient had a concomitant or static stretching of the joint may be
motion; however, our clinical experience meniscus repair, knee flexion is limited needed to restore extension or flexion of
indicates that this has not been the case. to 90° for 4 weeks after surgery. Patel- the knee. If extension and flexion are both
In fact, we have observed an earlier and lar mobilization is used to maintain or limited, we believe that emphasis should
better return of the full range of knee ex- increase patellar mobility, especially su- first be placed on restoring extension. If
tension and flexion after anatomic ACL perior glide. Emphasis is placed on being stretching contributes to increased pain
reconstruction. Another concern is that, able to perform a full, sustained isometric and inflammation, it may be necessary to
based on biomechanical studies, graft contraction of the quadriceps that results temporarily limit or discontinue stretch-
forces are greater when the graft is ana- in superior migration of the patella and ing exercises until irritability of the joint

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 [ clinical commentary ]
have been debated, a review of the avail-
able evidence suggests that both forms of
exercise are beneficial when appropriate
precautions are taken to protect the heal-
ing graft and avoid excessive stress on the
patellofemoral joint.11,20,56 As such, when
performing non–weight-bearing quadri-
ceps exercises, we limit the arc of motion
from 90° to 60° of knee flexion for the
first 3 months after surgery to minimize
strain on the healing graft. Additionally,
the range of motion for non–weight-bear-
ing and weight-bearing quadriceps exer-
cises may need to be adjusted depending
on patellofemoral symptoms.
In addition to strengthening the
quadriceps and hamstrings, emphasis is
placed on strengthening the hip and core
trunk muscles, particularly the hip ab-
ductors and external rotators, to reduce
valgus collapse of the knee,62 which has
been associated with noncontact ACL
injuries.31,32
FIGURE 7. Patient 3 months after anatomic anterior cruciate ligament reconstruction of the right knee. Full range of Within the first 3 months after sur-
motion in extension (A), flexion (B), and kneeling (C and D) is achieved when compared to the uninjured side. gery, low-impact aerobic training exer-
cises, including pedaling a stationary
is reduced. Biofeedback may be consid- quadriceps, hamstrings, and hip and bicycle ergometer or walking on an el-
ered if the patient has difficulty recruiting trunk musculature is increased, as toler- liptical trainer or treadmill, can be initi-
the quadriceps muscle. Active-assisted, ated, about 4 weeks after surgery. Non– ated. Balance and perturbation exercises
terminal, non–weight-bearing knee ex- weight-bearing and weight-bearing can be used to enhance development of
tension in the range of 20° of flexion to quadriceps exercises both produce simi- neuromuscular control.
full end-range extension can be used to lar strain levels in the graft; however, as Three to 4 months after surgery, the
re-educate and strengthen the quadriceps the resistance for non–weight-bearing patient can be progressed to running at a
if a quadriceps lag is present. quadriceps exercises is increased, the slow pace on a treadmill or over ground
When the patient has no pain or swell- amount of ACL strain increases in com- for 5 to 10 minutes every other day, pro-
ing, full passive knee extension (90° to parison to weight-bearing exercises.22 vided the patient has quadriceps strength
100° of knee flexion), and can perform a It is unknown whether graft strain dur- that is 75% to 80% of the noninvolved
SLR without a lag and walk without as- ing non–weight-bearing and weight- limb, as determined by isokinetic testing
sistive devices or gait deviations, use of bearing quadriceps exercises improves or a single-repetition maximum quad-
assistive devices can be discontinued and healing or negatively affects it.10 There is riceps strength test.37 The running pro-
the intensity of the rehabilitation pro- evidence that weight-bearing quadriceps gram is gradually increased as long as the
gram can be increased. At this time, the exercises yield better patient-reported patient does not develop pain, swelling,
brace can also be discontinued. This typi- outcomes, less patellofemoral pain, and or gait asymmetries. During this time,
cally occurs 3 to 4 weeks after surgery. At less laxity than non–weight-bearing ex- the patient can also be progressed to low-
this time, range-of-motion and stretching ercises.13,68 On the other hand, it appears level submaximal (less than 50% effort)
exercises can be used to restore full mo- that non–weight-bearing quadriceps agility drills, including side-to-side shuf-
tion (FIGURE 7). We strive for full passive exercises increase quadriceps femoris fling, forward and backward running,
knee extension symmetrical to the non- muscle strength without affecting knee and jumping and landing on both limbs
involved knee and knee flexion to within stability in patients with an ACL-defi- simultaneously from distances less than
5° of the noninvolved knee. cient knee.50,66 While the advantages and 50% of the individual’s height. The brace
Resistance for non–weight-bearing disadvantages of non–weight-bearing is no longer needed during exercise.
and weight-bearing exercises for the and weight-bearing quadriceps exercises As the time from surgery increases,

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 the progression of the patient to higher- height or distance of the jump, increas- Despite this posterior placement of the
level functional activities becomes more ing the duration of the drills, incorporat- tibial tunnel, use of a transtibial method
variable and difficult to predict. This is ing changes in direction, and combining to drill the femoral tunnel still results in
due to variations in the surgical proce- multiple tasks. a femoral tunnel that is too high in the in-
dure, surgeon preferences, and individ- Once the patient is able to tolerate tercondylar notch (the high-AM position
ual factors. Therefore, the initiation of full-effort running, jumping, and agility of the femoral tunnel). To avoid this, we
higher-level functional activities, such as drills, return to sport can be considered recommend using a 3-portal technique
running, jumping and landing, cutting and a functional brace can be readjusted that allows for use of the medial portal to
and pivoting, and return to sport, may for at least 6 months. The time frame for create the AM femoral tunnel indepen-
deviate from the time periods listed in the return to sport following anatomic ACL dent of the tibial tunnel, allowing one to
postoperative rehabilitation guidelines. reconstruction is variable, but generally achieve a more anatomic reconstruction.
Because of variations between patients, occurs 9 to 12 months after surgery and is Misplaced grafts are one of the most
we progress the functional training and dependent on concomitant surgical pro- important causes of graft failure.25,73 Fur-
return-to-sport phases based on the pa- cedures, individual patient tolerance for thermore, a misplaced graft can result
tient’s ability to perform the activities the activities, surgeon preferences, and in worse clinical outcomes, with limited
without deviations or symptoms (pain, the physical demands of the sport. Ini- range of motion and nonphysiological
swelling, sense of instability). tially, training for return to sport should knee kinematics,75,92 especially when roof
During the functional training and begin with unopposed components of impingement occurs. If the graft is mis-
return-to-sport phases of rehabilitation the individual’s athletic activity. As the placed, revision ACL reconstruction to
after ACL reconstruction, emphasis is patient becomes proficient and can per- place the graft more anatomically may
placed on strengthening through the full form these activities safely, the speed need to be considered. A misplaced graft
range of motion, improving neuromus- and complexity of the activities can be may also adversely affect biological heal-
cular control, and ensuring a gradual increased. Training with opposition from ing of the graft within the tunnel and
increase in function that culminates in other players should be gradually intro- compromise healing of the bone-tendon
return to sport. duced. To return to full participation in interface.61 It is our opinion that a delay
Once the patient is able to tolerate sports, the patient should be progressed or failure to regain full range of motion
running 2.4 to 3.2 km without pain or from partial return to practice to full re- during rehabilitation is often an indicator
swelling, the patient can be progressed to turn to practice, followed by return to of nonanatomic placement of the graft.
a higher order of agility and plyometric competition. The concerns related to nonanatom-
drills. Typically, these activities begin ap- ic graft placement have prompted us
proximately 6 months after surgery. Ini- DISCUSSION to use more anatomic and individual-
tial agility drills can include side-to-side ized ACL reconstruction. Single-bundle

I
shuffling, forward and backward run- n recent years, traditional ap- and double-bundle ACL reconstruction
ning, and ladder drills. More challeng- proaches and methods to reconstruct can be performed in an anatomic man-
ing agility drills include carioca and cone the ACL have been critically evaluated, ner.69 Data from recent studies that have
drills that involve changing directions and it has been shown that the femoral compared the clinical outcomes after
at various angles. Initially, these activi- and tibial tunnels are often placed in a single-bundle and double-bundle ACL
ties should be performed at 50% effort, nonanatomic position.30 Nonanatomic reconstruction must be carefully inter-
progressing to 75% and eventually 100% placement of tunnels is most likely due preted. For example, one study com-
effort, as tolerated. to the surgeon’s efforts to avoid roof im- pared single-bundle ACL reconstruction,
During this time, the patient can also pingement and abrasion of the graft, which was performed using a transtibial
be progressed to plyometric jumping and which occurs when the tibial tunnel is method to create the femoral tunnel, to
landing drills. Initially, these activities placed too anteriorly. As a result, the sur- anatomic double-bundle reconstruction.2
should focus on landing and appropriate geon may place the tibial tunnels more When comparing the clinical outcomes
attenuation of force through the lower posteriorly. Use of a transtibial method to of single-bundle and double-bundle ACL
extremity. Such activities include dou- create the femoral tunnel also contributes reconstruction, both procedures should
ble-limb jumping, single-limb jumping, to nonanatomic placement of the graft.48 have been performed anatomically. Dif-
and dropping and landing from a plyo- For example, to place the femoral tunnel ficulty in conducting a randomized clini-
metric box. As the patient becomes pro- close to the native location of the femoral cal trial to compare single-bundle ACL
ficient with correct jumping and landing ACL insertion site, it is often necessary reconstruction to double-bundle ACL
mechanics, plyometric exercises can be to position the tibial tunnel within the reconstruction may arise if the individ-
made more challenging by increasing the tibial insertion site for the PL bundle. ual’s anatomy precludes double-bundle

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 [ clinical commentary ]
ACL reconstruction. This can occur if the reliably quantify rotational laxity of the accomplished by performing either sin-
insertion sites are too small or the inter- knee needs to be developed. gle-bundle or double-bundle ACL recon-
condylar notch is too narrow to permit To date, evaluating the clinical out- struction. The choice of technique should
double-bundle ACL reconstruction. For comes of anatomic double-bundle ACL be based on individual measurements of
this reason, a prospective randomized reconstruction has focused on the abil- the ACL insertion site and femoral in-
controlled trial that compares single- ity of the procedure to restore normal tercondylar notch size. To decrease the
bundle ACL reconstruction to double- anteroposterior and rotational laxity failure rate, it is necessary to carefully
bundle ACL reconstruction may need to of the knee. In the future, researchers plan and carry out the postoperative re-
exclude patients who have insertion sites should also consider the effects of ana- habilitation program. The patient needs
that are too small or a notch that is too tomic double-bundle ACL reconstruc- to be aware that, although anatomic ACL
narrow. Furthermore, a study that com- tion on the sense of instability and the reconstruction provides better kinemat-
pares single-bundle ACL reconstruction ability to participate in strenuous sports. ics of the knee and ultimately may lead to
to double-bundle ACL reconstruction Long-term follow-up studies are needed improved long-term health of the knee,
should exclude individuals with associ- to determine the effects of double-bundle the graft needs time to remodel and heal,
ated injuries, such as meniscal tears, ACL reconstruction on preventing or re- and one should therefore resist the temp-
chondral injuries, or multiple ligament ducing the risk of knee osteoarthritis and tation of a more aggressive rehabilitation
injuries, to achieve homogeneous groups. its associated pain and disability. In the program. t
The limitations of currently available interim, high-field magnetic resonance
clinical outcome measures must be con- imaging could be used to detect early
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@ MORE INFORMATION
reconstruction of the anterior cruciate liga- bundle anterior cruciate ligament recon-
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A cadaveric study comparing anterior tibial Med. 2011;39:1789-1799. http://dx.doi. WWW.JOSPT.ORG

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