Anterior Cruciate Ligament Tear: Rationale and Indications for Anatomic ACL Reconstruction

  • Bart Muller
  • Shugo Maeda
  • Yoshimasa Fujimaki
  • Paulo H. Araujo
  • Freddie H. FuEmail author


Reconstruction of the anterior cruciate ligament (ACL) is one of the most frequently performed operations in orthopaedic sports medicine [17]. Traditionally, treatment for complete ACL tears has long been a conventional single-bundle (SB) reconstruction [13, 19]. Short-term results for SB reconstructions have been relatively good, with improvement in subjective knee instability and the ability to return to sports [25]. However, in a subset of patients, subjective knee instability persists, and they remain unable to return to prior activity. With SB reconstruction, good to excellent results are only achieved in 60 % of patients and less than 50 % returns to playing sport at their preinjury level [5, 7]. Moreover, long-term results suggest that the rate in which osteoarthritic (OA) changes occur is not reduced by SB reconstruction as compared to nonoperated knees [10, 15, 26]. Multiple studies have shown that the native biomechanical properties of the knee cannot be fully restored by nonanatomic SB reconstruction [8, 40] and that this may be a cause of cartilage thinning [3, 37].


Anterior Cruciate Ligament Anterior Cruciate Ligament Reconstruction Femoral Tunnel Native Anterior Cruciate Ligament Double Bundle 
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Supplementary material

Video 3

Anatomic ACL reconstruction: (3-1) Anatomic single bundle ACL reconstruction, (3-2) Anatomic double bundle ACL reconstruction (WMV 790522 kb)


  1. 1.
    Aglietti P, Giron F, Cuomo P, et al. Single-and double-incision double-bundle ACL reconstruction. Clin Orthop Relat Res. 2007;454:108–13.PubMedCrossRefGoogle Scholar
  2. 2.
    Amis AA, Dawkins GP. Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg. 1991;73-B:260–7.Google Scholar
  3. 3.
    Andriacchi TP, Briant PL, Bevill SL, et al. Rotational changes at the knee after ACL injury cause cartilage thinning. Clin Orthop Relat Res. 2006;442:39–44.PubMedCrossRefGoogle Scholar
  4. 4.
    Araujo PH, van Eck CF, Macalena JA, et al. Advances in the three-portal technique for anatomical single- or double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2011;19:1239–42.PubMedCrossRefGoogle Scholar
  5. 5.
    Ardern CL, Taylor NF, Feller JA, et al. Return-to-sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2012;40:41–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Arnoczky SP. Anatomy of the anterior cruciate ligament. Clin Orthop Relat Res. 1983;172:19–25.PubMedGoogle Scholar
  7. 7.
    Biau DJ, Tournoux C, Katsahian S, et al. ACL reconstruction: a meta-analysis of functional scores. Clin Orthop Relat Res. 2007;458:180–7.PubMedGoogle Scholar
  8. 8.
    Brophy RH, Selby RM, Altchek DW. Anterior cruciate ligament revision: double-bundle augmentation of primary vertical graft. Arthroscopy. 2006;22:681–5.Google Scholar
  9. 9.
    Chhabra A, Starman JS, Ferretti M, et al. Anatomic, radiographic, biomechanical, and kinematic evaluation of the anterior cruciate ligament and its two functional bundles. J Bone Joint Surg. 2006;88-A Suppl 4:2–10.CrossRefGoogle Scholar
  10. 10.
    Daniel DM, Stone ML, Dobson BE, et al. Fate of the ACL-injured patient: a prospective outcome study. Am J Sports Med. 1994;22:632–44.PubMedCrossRefGoogle Scholar
  11. 11.
    Ferretti M, Levicoff EA, Macpherson TA, et al. The fetal anterior cruciate ligament: an anatomic and histologic study. Arthroscopy. 2007;23:278–83.PubMedCrossRefGoogle Scholar
  12. 12.
    Ferretti M, Ekdahl M, Shen W, et al. Osseous landmarks of the femoral attachment of the anterior cruciate ligament: an anatomic study. Arthroscopy. 2007;23:1218–25.PubMedCrossRefGoogle Scholar
  13. 13.
    Freedman KB, D’Amato MJ, Nedeff DD, et al. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med. 2003;31:2–11.PubMedGoogle Scholar
  14. 14.
    Gabriel MT, Wong EK, Woo SL, et al. Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. J Orthop Res. 2004;22:85–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Gillquist J, Messner K. Anterior cruciate ligament reconstruction and the long-term incidence of gonarthrosis. Sports Med. 1999;27:143–56.PubMedCrossRefGoogle Scholar
  16. 16.
    Girgis FG, Marshall JL, Monajem A. The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res. 1975;106:216–31.PubMedCrossRefGoogle Scholar
  17. 17.
    Granan LP, Forssblad M, Lind M, et al. The Scandinavian ACL registries 2004–2007: baseline epidemiology. Acta Orthop. 2009;80:563–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Harner CD, Baek GH, Vogrin TM, et al. Quantitative analysis of human cruciate ligament insertions. Arthroscopy. 1999;15:741–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Hospodar SJ, Miller MD. Controversies in ACL reconstruction: bone-patellar tendon-bone anterior cruciate ligament reconstruction remains the gold standard. Sports Med Arthrosc. 2009;17:242–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Järvelä T. Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective, randomize clinical study. Knee Surg Sports Traumatol Arthrosc. 2007;15:500–7.PubMedCrossRefGoogle Scholar
  21. 21.
    Kato Y, Ingham SJ, Kramer S, et al. Effect of tunnel position for anatomic single-bundle ACL reconstruction on knee biomechanics in a porcine model. Knee Surg Sports Traumatol Arthrosc. 2010;18:2–10.PubMedCrossRefGoogle Scholar
  22. 22.
    Kondo E, Yasuda K, Azuma H, et al. Prospective clinical comparisons of anatomic double-bundle versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients. Am J Sports Med. 2008;36:1675–87.PubMedCrossRefGoogle Scholar
  23. 23.
    Kopf S, Pombo MW, Szczodry M, et al. Size variability of the human anterior cruciate ligament insertion sites. Am J Sports Med. 2011;39:108–13.PubMedCrossRefGoogle Scholar
  24. 24.
    Kopf S, Pombo MW, Shen W, et al. The ability of 3 different approaches to restore the anatomic anteromedial bundle femoral insertion site during anatomic anterior cruciate ligament reconstruction. Arthroscopy. 2011;27:200–6.PubMedCrossRefGoogle Scholar
  25. 25.
    Lewis PB, Parameswaran AD, Rue JP, et al. Systematic review of single-bundle anterior cruciate ligament reconstruction outcomes: a baseline assessment for consideration of double-bundle techniques. Am J Sports Med. 2008;36:2028–36.PubMedCrossRefGoogle Scholar
  26. 26.
    Lohmander LS, Ostenberg A, Englund M, et al. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis Rheum. 2004;50:3145–52.PubMedCrossRefGoogle Scholar
  27. 27.
    Mauro CS, Irrgang JJ, Williams BA, et al. Loss of extension following anterior cruciate ligament reconstruction: analysis of incidence and etiology using IKDC criteria. Arthroscopy. 2008;24:146–53.PubMedCrossRefGoogle Scholar
  28. 28.
    McConkey MO, Bonasia DE, Amendola A. Pediatric anterior cruciate ligament reconstruction. Curr Rev Musculoskelet Med. 2011;4:37–44.PubMedCrossRefGoogle Scholar
  29. 29.
    Mochizuki T, Muneta T, Nagase T, et al. Cadaveric knee observation study for describing anatomic femoral tunnel placement for two-bundle anterior cruciate ligament reconstruction. Arthroscopy. 2006;22:356–61.PubMedCrossRefGoogle Scholar
  30. 30.
    Muneta T, Koga H, Mochizuki T, et al. A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques. Arthroscopy. 2007;23:618–28.PubMedCrossRefGoogle Scholar
  31. 31.
    Odensten M, Gillquist J. Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg. 1985;67-A:257–62.Google Scholar
  32. 32.
    Palmer I. On the injuries to the ligaments of the knee joint: a clinical study. 1938. Clin Orthop Relat Res. 2007;454:17–22; discussion 14.PubMedCrossRefGoogle Scholar
  33. 33.
    Pombo MW, Shen W, Fu FH. Anatomic double-bundle anterior cruciate ligament reconstruction: where are we today? Arthroscopy. 2008;24:1168–77.PubMedCrossRefGoogle Scholar
  34. 34.
    Purnell ML, Larson AI, Clancy W. Anterior cruciate ligament insertions on the tibia and femur and their relationships to critical bony landmarks using high-resolution volume-rendering computed tomography. Am J Sports Med. 2008;36:2083–90.PubMedCrossRefGoogle Scholar
  35. 35.
    Shen W, Forsythe B, Ingham SM, et al. Application of the anatomic double-bundle reconstruction concept to revision and augmentation anterior cruciate ligament surgeries. J Bone Joint Surg. 2008;90 Suppl 4:20–34.PubMedCrossRefGoogle Scholar
  36. 36.
    Siebold R, Dehler C, Ellert T. Prospective randomized comparison of double-bundle versus single-bundle anterior cruciate ligament reconstruction. Arthroscopy. 2008;24:137–45.PubMedCrossRefGoogle Scholar
  37. 37.
    Tashman S, Kolowich P, Collon D, et al. Dynamic function of the ACL-reconstructed knee during running. Clin Orthop Relat Res. 2007;454:66–73.PubMedCrossRefGoogle Scholar
  38. 38.
    van Eck CF, Schreiber VM, Liu TT, et al. The anatomic approach to primary, revision and augmentation anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2010;18:1154–63.PubMedCrossRefGoogle Scholar
  39. 39.
    van Eck CF, Lesniak BP, Schreiber VM, et al. Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart. Arthroscopy. 2010;26:258–68.PubMedCrossRefGoogle Scholar
  40. 40.
    Woo SL, Kanamori A, Zeminski J, et al. The effectiveness of reconstruction of the anterior cruciate ligament with hamstrings and patellar tendon: a cadaveric study comparing anterior tibial and rotational loads. J Bone Joint Surg. 2002;84-A:907–14.PubMedGoogle Scholar
  41. 41.
    Yagi M, Wong EK, Kanamori A, et al. Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med. 2002;30:660–6.PubMedGoogle Scholar
  42. 42.
    Yagi M, Kuroda R, Nagamune K, et al. Double-bundle ACL reconstruction can improve rotational stability. Clin Orthop Relat Res. 2007;454:100–7.PubMedCrossRefGoogle Scholar
  43. 43.
    Yamamoto Y, Hsu WH, Woo SL, et al. Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. Am J Sports Med. 2004;32:1825–32.PubMedCrossRefGoogle Scholar
  44. 44.
    Yasuda K, Kondo E, Ichiyama H, et al. Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: comparisons among 3 different procedures. Arthroscopy. 2006;22:240–51.PubMedCrossRefGoogle Scholar
  45. 45.
    Zantop T, Petersen W, Fu FH. Anatomy of the anterior cruciate ligament. Oper Tech Orthop. 2005;15:20–8.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2013

Authors and Affiliations

  • Bart Muller
    • 1
    • 2
  • Shugo Maeda
    • 1
    • 3
  • Yoshimasa Fujimaki
    • 1
    • 4
  • Paulo H. Araujo
    • 1
  • Freddie H. Fu
    • 5
    Email author
  1. 1.Department of Orthopaedic SurgeryUniversity of PittsburghPittsburghUSA
  2. 2.Department of Orthopaedic SurgeryUniversity of AmsterdamAmsterdamThe Netherlands
  3. 3.Department of Orthopaedic SurgeryHirosaki University Graduate School of MedicineHirosaki, AomoriJapan
  4. 4.Department of Orthopaedic SurgeryShowa University School of MedicineShinagawa-kuJapan
  5. 5.Department of Orthopaedic SurgeryUniversity of Pittsburgh Medical CenterPittsburghUSA

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