Anterior Cruciate Ligament Reconstruction – Does the Surgeon Risk Worsening of the Clinical Outcome During the Learning Curve if He Switches from Single Bundle Technique to Double Bundle Technique?

Abstract

Background: Anatomical reconstruction of the anterior cruciate ligament (ACL) using the double-bundle (DB) technique is becoming increasingly popular. Despite its proved biomechanical and anatomical superiority, clinical studies have found little advantage for the DB technique. The aim of this study was therefore to evaluate whether an experienced surgeon is able to obtain his usual good results with ACL reconstruction with the single-bundle (SB) technique directly after changing to the DB technique.

Patients/Material and Methods: In a prospective, non-randomised and controlled interventional study, we compared the first 19 patients in our clinic who had an anterior cruciate ligament reconstruction using the DB technique with 31 patients who underwent a SB ACL reconstruction performed by the same surgeon during the same period of investigation. The visual analog scale (VAS) for pain and function, the Tegner activity score, the International Knee Documentation Committee (IKDC), the Lysholm and the Marshall scores were used as evaluation methods, the anterior stability (KT-1000-arthrometer measurement) and the deficits in muscle strength in extension and flexion of both knees were measured in a standard manner one year after operation.

Results: The Lysholm scores in the SB group (93.6 [± 3.8] points) and in the DB group (93.1 [± 4.2] points) were not significantly different (p > 0.05). Neither the VAS for pain (1 [± 2] points for both techniques), nor the VAS for function (8 [± 2] versus 7 [± 2] points) were significantly different (p > 0.05). For the anterior stability under Maximum Measurement Displacement (MMD), the SB group achieved a difference of 1.75 (± 1.94) mm, in comparison with 1.32 (± 1.89) mm for the DB group (p > 0.05). There was a trend to less deficit in muscle strength after DB ACL reconstruction. No complications were recorded in either group.

Conclusion: Experienced surgeons in ACL reconstruction can change from the popular SB ACL reconstruction to the DB ACL reconstruction without causing clinical problems or additional complications. The well-known good results of the DB technique were attained in the first operations performed by an experienced surgeon and are compareable to the results of the SB technique.

Zusammenfassung

Hintergrund: Die anatomische Rekonstruktion des vorderen Kreuzbands (VKB) in Double-Bundle-Technik (DB-Technik) gewinnt zunehmend an Popularität. Trotz erwiesener biomechanischer und anatomischer Überlegenheit konnten klinische Studien bisher nur geringe Vorteile der DB-Technik nachweisen. Bei an sich bereits gutem klinischen Outcome unter Single-Bundle-Technik (SB-Technik) wären zum signifikanten Nachweis einer Überlegenheit der DB-Technik hohe Patientenzahlen notwendig. Folglich muss unter dem Aspekt des Konzepts einer Lernkurve kritisch hinterfragt werden, ob der Wechsel der Operationstechnik für einen erfahrenen Operateur ethisch vertretbar ist, ohne schlechtere Ergebnisse in den Erstkarriereoperationen zu riskieren. Das Ziel der vorliegenden Arbeit war deshalb zu evaluieren, ob die gewohnt guten Ergebnisse der VKB-Rekonstruktion mit der SB-Technik eines erfahrenen Operateurs auch direkt nach dem Wechsel auf die DB-Technik mindestens gleichwertig erzielt werden können.

Patienten/Material und Methoden: Wir verglichen in einer prospektiven, nicht randomisierten, kontrollierten Interventionsstudie die ersten 19 Patienten, die in unserer Klinik eine VKB-Plastik in DB-Technik erhielten, mit 31 Patienten, welche im selben Untersuchungszeitraum durch denselben Operateur eine VKB-Plastik in traditioneller SB-Technik erhielten. Ein Jahr postoperativ wurden die visuelle Analogskala (VAS) für Schmerz und Funktion, der Tegner-, der International Knee Documentation Committee Score (IKDC-Score), der Lysholm- und Marshall-Score erhoben und die vordere Stabilität sowie die Kraftdefizite zwischen beiden Kniegelenken bei der Extension und Flexion standardisiert gemessen.

Ergebnisse: Die klinischen Ergebnisse hinsichtlich Lysholm-Score in der SB-Gruppe mit 93,6 (± 3,8) Punkten und der DB-Gruppe mit 93,1 (± 4,2) Punkten unterschieden sich nicht (p > 0,05). Weder die VAS Schmerz mit jeweils 1 (± 2) Punkten, noch die VAS Funktion mit 8 (± 2) vs. 7 (± 2) Punkten zeigten einen signifikanten Unterschied (p > 0,05). Für die vordere Stabilität zeigte die SB-Gruppe (unter Manual Maximum Displacement [MMD]) eine Seitendifferenz von 1,75 (± 1,94) mm zur gesunden Seite, die DB-Gruppe von 1,32 (± 1,89) mm (mittels KT-1000-Arthrometer; p > 0,05). Tendenziell zeigte sich weniger Kraftverlust nach DB- als nach SB-Ersatz. Komplikationen traten in beiden Gruppen nicht auf.

Schlussfolgerung: Erfahrene Kreuzbandchirurgen können von der bekannten Einbündeltechnik problemlos zur anatomischen Zweibündeltechnik wechseln. Die bekannt guten klinischen Ergebnisse der DB-Technik wurden auch für die Erstkarriereoperationen des erfahrenen Chirurgen reproduziert. Die Lernkurve der DB-Technik beschränkt sich demnach im Wesentlichen auf die operativen Abläufe, nicht auf das klinische Outcome.

Key words

learning curve - anterior cruciate ligament reconstruction - double-bundle - single-bundle - clinical outcome

Schlüsselwörter

Lernkurve - vordere Kreuzbandrekonstruktion - Doppelbündel - Einbündel - klinisches Ergebnis

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