A recent 2012 'online first' publication in the KSSTA journal (Knee surgery, sports traumatology, arthroscopy) entitled 'Patient selection of anatomical double bundle or traditional single bundle ACL reconstruction' highlights the trend within medicine of considering patient opinion and expecting patients to become more informed.
The normal ACL (anterior cruciate ligament) is anatomically composed of two bundles, named for their location - a longer antero-medial (AM) bundle and a shorter postero-lateral (PL) bundle. A 'double-bundle' procedure attempts to replace each of the bundles. It is more challenging to perform, and from the patient's perspective there are two additional bone tunnels and one additional incision (skin cut).
In this paper the surgeons felt that it was appropriate that a patient should be informed of the difference between double bundle and single bundle ACL, but I think that in doing so one needs to differentiate between traditional single bundle and the newer concept of anatomical single bundle.
The other important recent concept is of 'filling the footprint' of the native ACL on the femoral and tibial sides using hamstrings which can be made into thicker graft constructs (4-8 strands), for example a 4 strand consisting a of a quadruple semitendinosus and leaving the gracilis in situ (i.e only harvesting one tendon) or a 6 strand construct consisting a quadruple semiteninosus and a double gracilis. These thicker grafts fill more of the ACL footprint and may provide a more rotationally stable construct. There is less need for a double bundle reconstruction with its technical issues, in particular tensioning of the posterolateral bundle, especially as the clinical differences in outcome are not proven.
However I must admit the ‘double bundle’ concept has definitely improved our single bundle techniques as more consideration is given to anatomy and rotational stability.
Even recently - at a cadaveric knee meeting this month (March 2012) in Munich – there was essentially no mention of double-bundle surgery at all. It was amazing that the audience (like in this paper in the esska journal) were still comparing anatomic single bundle with traditional UK single bundle transtibial techniques, where the procedure was dictated by the instrumentation and the femoral tunnel depended completely on the tibial tunnel. In Australia and in particular Sydney where I did my fellowship training, the leading knee surgeons seem to have always perfomed a more anatomic ACL reconstruction and independent femoral tunnel drilling has always been routine.
I think most of the high volume knee ligament surgeons in the UK now will be using anatomic single bundle ACL reconstruction with independent femoral and tibial tunnel drilling, that is getting them both correct and then tensioning and fixing the ACL with a proven fixation device. We now - through education and workshops - need to convert our colleagues.