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, 7 (2), 143-51

Twenty-Year Experience of a Double-Bundle Anterior Cruciate Ligament Reconstruction


Twenty-Year Experience of a Double-Bundle Anterior Cruciate Ligament Reconstruction

Takeshi Muneta. Clin Orthop Surg.


Double-bundle (DB) anterior cruciate ligament (ACL) reconstruction using a four-strand semitendinosus tendon was started in our department in July 1994. The motivation for starting the procedure was that the EndoButton with an inside-out procedure instrument became available in Japan. A review article of our DB ACL reconstruction procedure was summarized for the twentieth anniversary of the surgical procedure. Initial tension setting of the two grafts was changed in the first 8 years to achieve better stability during DB ACL reconstruction. A randomized clinical trial (RCT) was started in July 2002 to clarify superiority of the DB procedure to single-bundle (SB) reconstruction under the concept of anatomic reconstruction. Several anatomic studies were performed to describe normal ACL anatomy, which is essential for realizing anatomic reconstruction. A remnant-preserving technique would be an additional option for our DB procedure to improve reconstruction outcomes. Thus, a new remnant-preserving DB procedure was started in 2012. The reproducibility of the new procedure was investigated using three-dimensional computed tomography images. More complex procedures were performed using a transtibial technique and EndoButtons. Initial tension balancing between the two grafts was important for a better outcome. Superiority of knee stability after the DB compared to that after the SB procedure was clarified by the RCT. However, no patient consensus has been reached on any subjective advantage to the DB procedure. Studies of normal ACL anatomy have left questions unresolved regarding where the two tunnels should be created for direct and indirect insertions based on normal anatomy. A new remnant-preserving DB ACL procedure has been practiced. The procedure was more reproducible with respect to creating the femoral tunnel. DB ACL reconstruction using a semitendinosus tendon is an attractive option when pursuing a better outcome for patients.

Keywords: Anatomy; Anterior cruciate ligament reconstruction; Remnant; Tunnel.

Conflict of interest statement

CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported.


Fig. 1
Fig. 1. A greater tendon-bone junction area is achieved with the double-bundle (DB) technique. DB reconstruction features: (1) greater tendon-bone junction area facilitating better stabilization of the graft, (2) greater tendon-bone junction area facilitating graft healing, (3) less anterior notch plasty, and (4) the possibility to realize ideal initial graft settings.
Fig. 2
Fig. 2. Tibial drill hole placement: anatomic landmarks and radiographic findings. Guidewires should not be placed over the D-point laterally.
Fig. 3
Fig. 3. Normal anterior cruciate ligament (ACL) anatomy. (A) Direct insertion is bundle-like and exists on the lateral wall of the intercondylar notch. (B) Indirect insertion is membranous in cadaveric knees and its ligamentous function has not been well evaluated. (C) Arthroscopic observation of normal femoral ACL femoral attachment. A normal ACL consists of direct and indirect insertions. (D) The insertions cannot be separated with continuous extension from the articular surface.
Fig. 4
Fig. 4. (A, B) The front side of an injured anterior cruciate ligament (ACL). Particularly, the anteromedial portion is rather preserved as a roof of the femoral attachment in two cases. Blue arrows indicate anterior border of the ACL. (C, D) Two cases of findings behind the remnant of an injured ACL. The posterior part of the ACL remnant is an indirect insertion, and it is ruptured and scarred with some inflammation in two cases. Pink arrows indicate scarred indirect insertion with synovial tissue.
Fig. 5
Fig. 5. (A, B) Two cases of anteromedial and posterolateral femoral tunnels created behind the remnant.

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Cited by 2 PubMed Central articles


    1. Muneta T, Sekiya I, Yagishita K, Ogiuchi T, Yamamoto H, Shinomiya K. Two-bundle reconstruction of the anterior cruciate ligament using semitendinosus tendon with endobuttons: operative technique and preliminary results. Arthroscopy. 1999;15(6):618–624. - PubMed
    1. Muneta T, Sekiya I, Ogiuchi T, Yagishita K, Yamamoto H, Shinomiya K. Effects of aggressive early rehabilitation on the outcome of anterior cruciate ligament reconstruction with multi-strand semitendinosus tendon. Int Orthop. 1998;22(6):352–356. - PMC - PubMed
    1. Yamamoto H, Ishibashi T, Muneta T, Furuya K, Mizuta T. Effusions after anterior cruciate ligament reconstruction using the ligament augmentation device. Arthroscopy. 1992;8(3):305–310. - PubMed
    1. Muneta T, Sekiya I, Ogiuchi T, Yagishita K, Yamamoto H, Shinomiya K. Objective factors affecting overall subjective evaluation of recovery after anterior cruciate ligament reconstruction. Scand J Med Sci Sports. 1998;8(5 Pt 1):283–289. - PubMed
    1. Hefzy MS, Grood ES, Noyes FR. Factors affecting the region of most isometric femoral attachments. Part II: the anterior cruciate ligament. Am J Sports Med. 1989;17(2):208–216. - PubMed

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