Does Double-Bundle Anterior Cruciate Ligament Reconstruction Improve Postoperative Knee Stability Compared With Single-Bundle Techniques? A Systematic Review of Overlapping Meta-analyses

• Published in: Arthroscopy Vol. 31; no. 6; pp. 1185 - 1196
• Main Authors: Mascarenhas, Randy, M.D., F.R.C.S.C, Cvetanovich, Gregory L., M.D, Sayegh, Eli T., B.S, Verma, Nikhil N., M.D, Cole, Brian J., M.D., M.B.A, Bush-Joseph, Charles, M.D, Bach, Bernard R., M.D
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.06.2015
• Subjects: Anterior Cruciate Ligament - surgery; Anterior Cruciate Ligament Injuries; Anterior Cruciate Ligament Reconstruction - methods; Humans; Joint Instability - etiology; Joint Instability - surgery; Knee Injuries - complications; Knee Injuries - surgery; Knee Joint - surgery; Orthopedics
• ISSN: 0749-8063; 1526-3231
• DOI: 10.1016/j.arthro.2014.11.014

Purpose Multiple meta-analyses of randomized controlled trials, the highest available level of evidence, have been conducted to determine whether double-bundle (DB) or single-bundle (SB) anterior cruciate ligament reconstruction (ACL-R) provides superior clinical outcomes and knee stability; however, results are discordant. The purpose of this study was to conduct a systematic review of meta-analyses comparing SB and DB ACL-R to discern the cause of the discordance and to determine which of these meta-analyses provides the current best available evidence. Methods We evaluated available scientific support for SB as compared with DB ACL-R by systematically reviewing the literature for published meta-analyses. Data on patient clinical outcomes and knee stability (as measured by KT arthrometry and pivot-shift testing) were extracted. Meta-analysis quality was judged using the Oxman-Guyatt and Quality of Reporting of Meta-analyses systems. The Jadad algorithm was then applied to determine which meta-analyses provided the highest level of evidence. Results Nine meta-analyses were included, of which 3 included Level I Evidence and 6 included both Level I and Level II Evidence. Most studies found significant differences favoring DB reconstruction on pivot-shift testing, KT arthrometry measurement of anterior tibial translation, and International Knee Documentation Committee objective grading. Most studies detected no significant differences between the 2 techniques in subjective outcome scores (Tegner, Lysholm, and International Knee Documentation Committee subjective), graft failure, or complications. Oxman-Guyatt and Quality of Reporting of Meta-analyses scores varied, with 2 studies exhibiting major flaws (Oxman-Guyatt score <3). After application of the Jadad decision algorithm, 3 concordant high-quality meta-analyses were selected, with each concluding that DB ACL-R provided significantly better knee stability (by KT arthrometry and pivot-shift testing) than SB ACL-R but no advantages in clinical outcomes or risk of graft failure. Conclusions The current best available evidence suggests that DB ACL-R provides better postoperative knee stability than SB ACL-R, whereas clinical outcomes and risk of graft failure are similar between techniques. Level of Evidence Level II, systematic review of Level I and II studies.