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Review
, 37 (2), 213-26

Single-bundle Versus Double-Bundle Anterior Cruciate Ligament Reconstruction: An Up-To-Date Meta-Analysis

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Review

Single-bundle Versus Double-Bundle Anterior Cruciate Ligament Reconstruction: An Up-To-Date Meta-Analysis

Xue Li et al. Int Orthop.

Abstract

Purpose: The aim of this meta-analysis was to compare the results of arthroscopic single-bundle and double-bundle anterior cruciate ligament (ACL) reconstruction.

Methods: We systematically searched electronic databases to identify randomised controlled trials (RCTs) in which arthroscopic single-bundle was compared with double-bundle for ACL reconstruction. The search strategy followed the requirements of the Cochrane Library Handbook. The outcomes of these studies were analysed in terms of graft failures, Lysholm score, negative pivot-shift test, KT1000 arthrometer measurements, knee extensor and flexor peak torques, knee extension and flexion deficit, and subjective and objective International Knee Documentation Committee (IKDC) final score. Methodological quality was assessed and data were extracted independently. Standard mean difference (SMD) or odds ratio (OR) with 95 % confidence interval (CI) was calculated by a fixed effects or random effects model. Heterogeneity across the studies was assessed with the I-square and chi-square statistic. Forest plots were also generated.

Results: We identified 17 RCTs comprising 1,381 patients who were treated by arthroscopic single-bundle versus double-bundle ACL reconstruction. The results of meta-analysis of these studies showed that arthroscopic double-bundle reconstruction was associated with a lower risk of graft failures (P=0.002) and a lower rate of positive pivot-shift test (P<0.0001). Compared with single-bundle reconstruction, double-bundle reconstruction had a lower KT1000 arthrometer measurement (P<0.00001), a lower knee extension deficit (P=0.006) and a higher subjective IKDC score (P=0.03). There was no statistically significant difference between single-bundle and double-bundle reconstruction in Lysholm score (P=0.91), knee extensor peak torques (P=0.97), knee flexor peak torques (P=0.96), knee flexion deficit (P=0.30) and objective IKDC score (P=0.18).

Conclusions: Considering the more favourable outcomes of graft failures, knee joint stability and knee joint function in double-bundle reconstruction, we concluded that arthroscopic double-bundle reconstruction should be considered as the primary treatment in ACL reconstruction.

Figures

Fig. 1
Fig. 1
Flow chart of eligibility selection
Fig. 2
Fig. 2
Forest plot of Lysholm score. Individual studies are listed on the left with Lysholm score (mean and standard deviation) as well as number of patients in each study group. A visual representation of the standard mean difference for each study is plotted on the right with a diamond. The large black diamond at the bottom represents the pooled treatment effect of all studies. It lies on the midline, representing no significant difference (P = 0.91) with a fixed effects model. DB double-bundle, SB single-bundle, Järvelä 2008a the study of reference [22], Järvelä 2008b the study of reference [24]
Fig. 3
Fig. 3
Forest plot of Lysholm score in the anatomical subgroup. The pooled treatment effect, with a random effects model, demonstrates no significant difference between double-bundle (DB) and single-bundle (SB) (P = 0.31)
Fig. 4
Fig. 4
Forest plot of Lysholm score in the isometric subgroup. The pooled treatment effect, with a fixed effects model, demonstrates no significant difference between double-bundle (DB) and single-bundle (SB) (P = 0.41)
Fig. 5
Fig. 5
Forest plot of objective IKDC score. The pooled treatment effect, represented by the black diamond, demonstrates no significant difference (P = 0.18)
Fig. 6
Fig. 6
Forest plot of subjective IKDC score. The pooled treatment effect, represented by the black diamond, demonstrates a significant difference favouring double-bundle (DB) (P = 0.03)
Fig. 7
Fig. 7
Forest plot of knee extension deficit. The pooled treatment effect, represented by the black diamond, demonstrates a significant difference favouring double-bundle (DB) (P = 0.006)
Fig. 8
Fig. 8
Forest plot of knee flexion deficit. The pooled treatment effect, represented by the black diamond, demonstrates no significant difference (P = 0.30)
Fig. 9
Fig. 9
Forest plot of negative pivot-shift test. The pooled treatment effect, represented by the black diamond, demonstrates a significant difference favouring double-bundle (DB) with a higher negative rate (P < 0.0001)
Fig. 10
Fig. 10
Forest plot of KT1000 arthrometer measurements. The large black diamond at the bottom represents the pooled treatment effect of all studies. It lies exclusively to the left and does not cross the midline, representing a lower KT1000 arthrometer measurement favouring double-bundle (DB) with a significant difference (P < 0.00001)
Fig. 11
Fig. 11
Forest plot of knee extensor peak torques. The pooled treatment effect, represented by the black diamond, demonstrates no significant difference (P = 0.97)
Fig. 12
Fig. 12
Forest plot of knee flexor peak torques. The pooled treatment effect, represented by the black diamond, demonstrates no significant difference (P = 0.96)
Fig. 13
Fig. 13
Forest plot of graft failure. The pooled treatment effect, represented by the black diamond, demonstrates a significant difference favouring double-bundle (DB) with a lower rate of graft failure (P = 0.002)
Fig. 14
Fig. 14
Funnel plot showing minimal publication bias of KT1000 arthrometer measurements

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