Anatomy of the anterior cruciate ligament double bundle structure: a macroscopic evaluation

Traditional anterior cruciate ligament (ACL) surgery has demonstrated good results, but there is still a subset of unsatisfactory outcomes. Trends in reconstruction technique have changed from bone-patella-tendon-bone to hamstring refixation, and the next step appears to be the double bundle concept.

We examined six fresh-frozen cadaver knees to evaluate the double bundle structure, dynamic motion characteristics and the relationship of knee flexion and relative position of the femoral insertion sites of the ACL.

In all knees, we identified an anteromedial (AM) and posterolateral (PL) bundle. The motion pattern demonstrated that the AM and PL bundles are oriented near parallel with the knee extended, and twist around each other as the knee is flexed. The visualization of the femoral footprint anatomy differs with knee flexion.

The double bundle model facilitates restoration of the original footprint anatomy and biomechanics more easily than the concept of the ACL as a one-bundle structure and the use of the o'clock position. It is essential to be aware of the degree of knee flexion when drilling the femoral tunnels.

Anatomic ACL reconstruction is a concept, not a technique, and allows a more refined surgical approach to ACL reconstruction including revision cases and partial ACL tears.