Comment on “The 10-Year Outcomes of Single- versus Double-Bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review”

We commend the authors for their comprehensive systematic review and meta-analysis comparing the long-term outcomes of single- and double-bundle anterior cruciate ligament (ACL) reconstruction.[1] This study tackles a pivotal question in orthopedic surgery, given the high incidence of ACL injuries and the persistent debate surrounding optimal reconstruction techniques. The significance of this work lies in its focus on long-term outcomes, which are critical for understanding the durability and effectiveness of these surgical approaches in improving patient quality of life and knee health.

The authors' rigorous methodology is a standout feature of this study. We are particularly impressed by their inclusion of a thorough risk of bias assessment, which strengthens the credibility of their conclusions. Additionally, the sensitivity analysis based on study quality reflects a thoughtful approach to addressing variability among the included randomized controlled trials. The use of the GRADE assessment to evaluate the certainty of evidence further enhances the study's value, providing clinicians with a robust framework to interpret the findings.[2] These methodological choices underscore the authors' commitment to producing high-quality evidence, making this meta-analysis a reliable resource for orthopedic practitioners.

Among the notable findings, the authors report that double-bundle reconstruction may offer superior rotational stability and potentially reduce the risk of posttraumatic osteoarthritis. We find this observation clinically compelling, as it aligns with biomechanical evidence suggesting that double-bundle techniques more closely mimic the native ACL anatomy. Such insights are invaluable for guiding surgical decision-making, particularly in younger or more active patients where long-term knee stability is paramount. The clarity with which these results are presented further amplifies their impact, offering a meaningful contribution to the ongoing discourse in ACL reconstruction literature.

While the study excels in many respects, we respectfully note that the limited number of included trials and the presence of heterogeneity in some outcomes suggest opportunities for refinement. These aspects, inherent to many meta-analyses, do not detract from the work's merit but rather highlight the complexity of synthesizing evidence in this field. To build on this foundation, we suggest that future research incorporate larger sample sizes and standardized outcome measures. Additionally, given the potential for publication bias a common consideration in meta-analyses we propose that a funnel plot or Doi plot with an LFK index could enrich subsequent analyses, offering further assurance of the findings' robustness.[3]

Overall, this systematic review and meta-analysis represents a significant advancement in the ACL reconstruction literature. We applaud the authors for their diligent methodology and insightful analysis, which provide a solid evidence base for clinicians navigating the choice between single- and double-bundle techniques. This work not only informs current practice but also sets the stage for future investigations, promising to enhance patient outcomes in orthopedic surgery. We believe this study warrants strong consideration for publication, as it will undoubtedly stimulate further scholarly discussion and clinical progress.

Authors' Contributions

R.M. and R.S. critically and provided comments on methodological aspects. R.M. and S.K. wrote the edited the draft.

Publikationsverlauf

Eingereicht: 07. April 2025

Angenommen: 11. April 2025

Accepted Manuscript online:
15. April 2025

Artikel online veröffentlicht:
08. Mai 2025

• References

• 1 Ge Y, Fan N, Si F, Zang L. The 10-year outcomes of single- versus double-bundle anterior cruciate ligament reconstruction: a systematic review. J Knee Surg 2025; 38 (05) 245-255
• 2 Dewidar O, Lotfi T, Langendam MW. et al; eCOVID-19 recommendations map collaborators. Good or best practice statements: proposal for the operationalisation and implementation of GRADE guidance. BMJ Evid Based Med 2023; 28 (03) 189-196
• 3 Furuya-Kanamori L, Barendregt JJ, Doi SAR. A new improved graphical and quantitative method for detecting bias in meta-analysis. Int J Evid-Based Healthc 2018; 16 (04) 195-203