Placement of Double Tunnels in ACL Reconstruction Using Bony Landmarks Versus Existing Footprint Remnant: A Prospective Clinical Study With 2-Year Follow-up

Am J Sports Med. 2015 May;43(5):1206-14. doi: 10.1177/0363546515570850. Epub 2015 Mar 6.


Background: The outcomes of double-bundle anterior cruciate ligament reconstruction (DB-ACLR) are becoming controversial. One of the main reasons for the controversy is the techniques for bone tunnel placement. The common technique to place the bone tunnels is to use bony landmarks, while a new approach uses footprint remnants.

Purpose: To investigate if placement of double tunnels using bony landmarks produces the same clinical results as that of using existing footprint remnants.

Study design: Randomized controlled trial; Level of evidence, 2.

Methods: A total of 72 male patients were randomly divided into 2 groups of 36 patients each: (A) DB-ACLR tunnel placement using the footprint remnant procedure (EF group) and (B) DB-ACLR tunnel placement using the bony landmark procedure (BL group). All patients were evaluated before and after surgery. Outcomes were measured by KT-2000 arthrometer side-to-side difference, pivot-shift test, and Tegner, Lysholm, and International Knee Documentation Committee (IKDC) scores. Second-look arthroscopic evaluations were performed in 59 cases (28 and 31 cases in the EF and BL groups, respectively).

Results: The mean follow-up time was 36.9±4.8 months. Postoperative 3-dimensional computed tomography scans showed that bone sockets were variable on both femoral and tibial sides in the EF group and almost consistent in the BL group. All of the evaluation indexes were significantly improved postoperatively in both groups. There were no revision cases in the EF group and 2 in the BL group. The EF group showed a faster range of motion (ROM) recovery (at 0° to 120°) than did the BL group. At final follow-up, there was no significant difference between the EF and BL groups in Tegner score (5.88±1.39 vs 5.16±1.76; P=.058) or pivot-shift test (34 vs 32; P=.067). The EF group had a larger proportion of patients with IKDC grade A (normal) (33 vs 24; P<.020), smaller side-to-side difference (0.68±0.38 mm vs 1.23±0.61 mm; P<.001), higher Lysholm score (91.29±4.90 vs 88.71±5.09; P=.032), and better second-look arthroscopic evaluations for graft quality in the anteromedial (P=.034), posterolateral (P=.015), and combined bundles (P=.029) compared with the BL group.

Conclusion: Although both techniques provided satisfactory clinical results, DB-ACLR using the existing footprint remnant for tunnel placement showed better functional results with respect to faster ROM recovery, higher subjective outcome scores, and better arthroscopic second-look with no revision cases.

Keywords: anterior cruciate ligament (ACL); arthroscopy; bony landmark; double bundle (DB); footprint-remnant; reconstruction.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Anterior Cruciate Ligament Reconstruction / methods*
  • Arthroscopy / methods*
  • Femur / surgery
  • Follow-Up Studies
  • Humans
  • Knee Joint / surgery*
  • Male
  • Postoperative Period
  • Prospective Studies
  • Range of Motion, Articular
  • Second-Look Surgery / methods
  • Tibia / surgery
  • Tomography, X-Ray Computed
  • Young Adult