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Footprint Optimization in Anterior Cruciate Ligament Reconstruction: A Single Tunnel Double-bundle Approach
*Corresponding author: Dr.Mukesh Laddha, Senior Knee and Shoulder Consultant, Rathi Nursing Home, Dhantoli, Nagpur, 440022, India. drmsl1812@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Ladha M, Bhardwaj L, Lohiya AG. Footprint Optimization in Anterior Cruciate Ligament Reconstruction: A Single Tunnel Double-Bundle Approach. Int J Recent Surg Med Sci. 2025:11(e019) doi: 10.25259/IJRSMS_45_2025
Abstract
Objectives:
Anterior cruciate ligament reconstruction is a widely performed procedure aimed at restoring knee stability and function.The study aims to investigate the feasibility, efficacy, and potential benefits of utilizing the footprint optimization single tunnel double-bundle approach in anterior cruciate ligament reconstruction surgery.
Material and Methods:
A total of 35 patients undergoing anterior cruciate ligament reconstruction were prospectively enrolled. Anterior cruciate ligament tunnel made using patented rectangular tunnel dilators. This rectangular tunnel optimizes the footprint of the anterior cruciate ligament, thereby mimicking a double-bundle effect with a single tunnel. Soft tissue hamstring grafts were used in all patients. The graft squeezing method was used for graft passage, with fixation achieved by suspensory ligament attachment on the femoral side and aperture fixation on the tibial side. Patient outcomes were evaluated at a mean follow-up of 3 years using passive knee range of motion (ROM), Lysholm score, International Knee Documentation Committee (IKDC) score, Lachman test for anteroposterior stability, and pivot-shift test for rotational stability.
Results:
The study observed encouraging results in terms of rehabilitation progress and return to activities of daily living (ADL). Passive Knee ROM exhibited a significant enhancement in knee flexion following surgery, as the average pre-operative ROM of 106 degrees increased to 134 degrees at the 36-month follow-up. ROM remained stable throughout the following years. The Lysholm knee score and IKDC scores steadily improved from a pre-operative score of 52.46±8.13 to 92.79±1.00 and 34.43±4.13 preoperatively to 86.43±0.61, respectively, at a final follow-up of 36 months. Therefore, all evaluated parameters demonstrated positive outcomes. However, one complication, a cyclops lesion was identified.
Conclusion:
This single-tunnel double-bundle anterior cruciate ligament reconstruction technique with a unique tunnel dilatation system and graft squeezing technique shows promising potential for achieving good functional outcomes and restoring knee stability. Long-term follow-up studies with a larger patient population are warranted to further validate these findings.
Keywords
Anteromedial
Anterior cruciate ligament
Posterolateral
Reconstruction
Tunnel dilator
INTRODUCTION
The annual incidence of anterior cruciate ligament (ACL) tears in the general population has been estimated to range from 30 to 78 per 100,000 individuals.[1] Many of these patients undergo ACL reconstruction surgery due to persistent functional instability or the intention to return to high-demand activities such as pivoting sports.[2] Anatomic ACL reconstruction is a surgical technique that aims to restore the native anatomy of the ACL by replicating its original femoral and tibial insertion points, potentially leading to improved long-term outcomes and a reduced risk of osteoarthritis progression in the affected knee.[3,4] Anatomic ACL reconstruction necessitates an understanding of the anteromedial (AM) and posterolateral (PL) aspects of the ACL’s tibial and femoral attachments for accurate bone tunnel placement. Standardized surgical protocols are paramount to the success of this reconstructive procedure.[5] The single-bundle (SB) technique has been the prevailing approach for ACL reconstruction. However, the double-bundle technique offers a more anatomical reconstruction than the SB technique. This is achieved by replicating both the AM and PL bundles of the native ACL. This approach aims to restore both anterior stability and rotational control of the knee, potentially leading to improved biomechanical outcomes, as evidenced in several studies.[6-8] During the early postoperative period following anatomic ACL reconstruction using hamstring autograft, the fixation points of the graft within the femoral and tibial tunnels represent the most vulnerable element.[9] To optimize the effectiveness of this surgical technique, the interconnection between the dimensions of the graft and the native ACL is important.[10] The exact graft diameter is required to minimize the risk of complications(e.g., graft rupture or tunnel instability). Recent studies suggest potential benefits for patients even with the increase in graft diameter, up to 0.5 mm, particularly for grafts up to 10 mm in size. However, insufficient evidence supports using grafts exceeding 10 mm in diameter.[2] Cortical suspensory fixation using devices like the EndoButton (EB) CL (Smith and Nephew Inc., Andover, Massachusetts, USA) is the prevailing technique for femoral fixation of soft-tissue grafts in ACL reconstruction. Over-drilling of the femoral condyle is required to facilitate the flipping mechanism of the device at the lateral femoral cortex. This can lead to incomplete graft filling within the tunnel, potentially creating space for graft motion and impeding graft incorporation. Additionally, inaccurate measurement of the socket depth can result in either an inability to flip the button or insufficient graft purchase within the bone. Finally, the recent shift towards anatomic tunnel placement that results in shorter tunnels leads to concerns about achieving adequate graft bone ingrowth.[9] ACL reconstruction necessitates secure fixation of the graft using interference screws. Both titanium and stainless-steel screws offer high initial strength and promote early bony integration that leads to the formation of new bones and their connection with the grafts. These materials can lead to chronic inflammation and may require additional surgery for removal. Bioabsorbable screws, while eliminating the need for a second surgery, have lower initial strength and can fragment during resorption, break during placement, or lead to a loss of fixation and sterile inflammation with osteolysis and cyst formation.[11] Despite ACL reconstruction being a well-established procedure, technical aspects related to ACL anatomy, such as optimal tunnel placement, remain under debate.[12] To achieve anatomic ACL reconstruction, a rectangular graft and tunnel design were employed to mimic the native ligament's flat, ribbon-like shape. Several types of grafts were used in this procedure, including bone-patellar tendon-bone (BPTB) and quadriceps tendon (QT) autografts. Comparative biomechanical studies have demonstrated superior performance of rectangular tunnels compared to round tunnels in ACL reconstruction with BPTB autografts. (4) Similarly, another biomechanical study using the concept of rectangular tunnel dilators to achieve anatomic ACL reconstruction has shown that rectangular tunnels are advantageous over conventional round tunnels for ACLR with QT grafts. This study used the rectangular tunnel dilators concept of the anatomy of ACL reconstruction and its relevance to clinical practice. The main objective of this study is to explore an alternative surgical technique for ACL reconstruction, known as a single tunnel double-bundle approach for both the ACL graft and its femoral fixation.
MATERIAL AND METHODS
Study design
This is an experimental study conducted among patients undergoing ACLR. A total of 32 patients were considered for the purpose of the study. Alloy composition was used for ACLR and was patented under Intellectual Property India with the patent number 416112. The alloy specification used for making medical devices, as per the standard was stainless steel grades 304 stainless steel, 304V stainless steel. Clinical outcomes among the patients were assessed by passive knee range of motion (ROM), Lysholm knee score, and International Knee Documentation Committee (IKDC) score. The anteroposterior stability was measured by using the Lachman test, and rotational stability was measured using the Pivot shift test pre-operatively and 3-month, 6-month, 12-month, 24-month, and 36-month post-operatively.
Following ACLR, patients frequently exhibit deficits in passive knee ROM. Postoperative factors such as effusion, nociception, and peri-articular scar tissue formation were implicated in these limitations.[13] Passive ROM exercises serve a crucial role in enhancing flexibility and mitigating the development of intra-articular adhesions.[14] This encompasses gentle stretching techniques, manual therapy modalities, and the application of specialized equipment. The primary objective was to progressively augment knee ROM while minimizing discomfort and safeguarding the surgical repair.[15] The Lysholm Knee Score is a valuable tool for monitoring rehabilitation progress and objectively tracking patient improvement over time. This score compares with pre-injury functional baselines, offering valuable insights into the degree of functional recovery and achievement of rehabilitation.[16] This multi-faceted approach to knee joint function evaluation guides therapeutic decision-making and tailors rehabilitation protocols to optimize the patient's recuperative process. Similar to the Lysholm knee score, the IKDC score incorporates a comprehensive assessment of subjective parameters such as symptomatology, sporting activities, and the patient's ability to perform daily tasks.[17] The IKDC score provides a holistic understanding of the patient's functional recovery trajectory and the influence of ACLR on their overall knee function and activity tolerance.[18] The Lachman test was carried out to objectively assess anteroposterior laxity.[19,20] The pivot shift test is a crucial clinical assessment tool used to evaluate the rotational stability of the knee joint.[21]
Eligibility criteria
Several factors were considered to be eligible for ACL reconstruction surgery. First, a definitive confirmation of a torn ACL through a physical examination and imaging tests should be done. This tear must also cause significant knee instability that requires surgical repair to regain proper function. A crucial factor for successful ACL reconstruction is a strong commitment to following the post-operative rehabilitation program Additionally, the patient should be in good overall health, free from any active infections or active infections in the joint or chronic illnesses like rheumatoid arthritis or diabetes that could hinder healing. The patient should not have any other major knee injuries associated with the surgery, which might complicate the procedure or recovery, such as meniscal tears or other ligament injuries, or those who have already undergone reconstructive surgery on the same knee. Additionally, allergies to implant materials, and advanced osteoarthritis requiring alternative treatments, significant bone loss that makes anchoring the repair devices difficult, insufficient soft tissue around the knee for proper graft placement, and substantial knee malalignment requiring correction before or during surgery were also excluded from surgery. Pregnant women were excluded due to the risks associated with anesthesia and surgery itself.
Device description
BUTTONFIX® (Chetan Meditech Pvt. Ltd. - BIOTEK, Ahmedabad, Gujarat, India) fixation button with adjustable loop provides leading strength and incorporates a unique design to help protect the graft during loop reduction. The single loop size of BUTTONFIX can be universally used with any graft length. The graft support frame protects the graft from damage and any abrasion. It has the exclusive feature of maximized graft in the tunnel and was preloaded with braided sutures. It requires minimal force to reduce the loop, and it has a familiar loop reduction procedure.
Bio interference screws (Chetan Meditech Pvt. Ltd. -BIOTEK, Ahmedabad, Gujarat, India) exhibited an ideal combination of strength, stiffness, and toughness that surpasses absorbable materials. It provided interference screw fixation while eliminating the need for trans osseous tunnels in tendon repairs and ligament reconstruction.
Surgical technique
The patient received spinal anesthesia, and then a padded pneumatic cuff was placed at the top of the thigh. They were positioned lying flat on their back with their knee bent at a 90-degree angle and hanging off the end of the operating table. A side support for the thigh was secured to keep the knee stable when applying a force that pulls the leg outward. The surgical area was prepped and draped following all sterile techniques. The cuff was then inflated to 300 mm Hg.
After the standard knee examination with arthroscopy, a portal was created on the front inner side of the knee joint (AM). A tendon was taken from the hamstring muscles in the back of the thigh to fix a torn ligament. For semitendinosus and gracilis reconstruction, a four-strand piece was made using both hamstring tendons, and for more complex repair, a six-strand piece was created. This involved three strands, each from the two hamstring tendons, with one tendon for the AM part of the ligament and the other for the PL part. In all cases, both hamstring tendons were used to make the new ligament.[8]
Portal placement
The arthroscopy began with creating a high anterolateral portal near the kneecap and a low anteromedial portal to avoid the meniscus. Another portal was placed behind the medial collateral ligament (MCL) on the posteromedial aspect of the knee, made in the initial five cases, to assess the femoral tunnel made with the tunnel dilatation technique. The transpatellar (TP) portal was created by splitting the patellar tendon. Examination revealed a complete ACL tear on the femoral side. The torn ACL was debrided, and the tibial and femoral footprints were exposed. Visualizing through the portals, the surgeon confirmed a rectangular tibial footprint and a rectangular femoral footprint for ACL reconstruction.
Rectangular tunnel dilators
Tunnel dilators come in various sizes, like 8 × 8.5 mm, 8 × 9 mm, 8 × 9.5 mm, and 8 × 310 mm [Figure 1].
- (a-c) Rectangular tunnel dilators
The characteristics of the tunnel and graft have been represented in Table 1.
| Graft size(mm) | Tunnel size | Surface area Covered | Percentage increase of surface area coverage with FPE | ||
|---|---|---|---|---|---|
| C | FPE | C | FPE | ||
| 8 mm | 8 | 7 × 9 | 50.24 | 63 | 25.39 |
| 9 mm | 9 | 8 × 10 | 63.58 | 80 | 25.82 |
| 10 mm | 10 | 9 × 11 | 78.50 | 99 | 26.11 |
| 11 mm | 11 | 10 × 12 | 94.98 | 120 | 26.34 |
C - Conventional single bundle anatomical ACLR, FPE - footprint enhancing ACLR technique, all area calculations are in square mm.
Femoral tunnel preparation
Viewed from the TP portal, a guidewire was passed through the low AM portal using a 6 mm offset guide, creating a 35 mm long tunnel from medial to lateral in the lateral femoral condyle with a 4.5 mm drill. An 8 mm drill then created a 20 mm socket within the tunnel. While the TP and PM portals showed a circular tunnel in an oval footprint, specially designed rectangular dilators (7-11 mm range) were used to enlarge the footprint. This aimed to maintain the anteroposterior dimension while increasing the superoinferior coverage for better ligament attachment. Sequential dilation with 8 × 9 mm and 8 × 10 mm dilators achieved this, resulting in an oblique femoral tunnel with improved footprint coverage, as seen from the portals. The round shape of the femoral footprint was converted to a somewhat oval or rectangular footprint covering more [Figure 2a-d].
- (a-d) Femoral tunnel preparation
Tibial tunnel preparation
The tipaimer jig positioned at the center of the tibial footprint guided drilling an 8mm tunnel from the AM position at a 55°angle. Initially, the tunnel appeared circular despite the rectangular footprint. To improve coverage within the footprint, the same rectangular dilators used for the femur (sized 8×9mm and 8×10mm) were used to sequentially widen the tibial tunnel. This technique increased the tunnel's anteroposterior dimension (depth) while maintaining its mediolateral width, resulting in a shape better matching the rectangular footprint [Figure 3a-c].
- (a-c) Tibial tunnel preparation
Graft-squeezing technique
The 9 mm quadruple hamstring graft was a popular choice for ACL reconstruction. The surgical technique began with the first drill using an 8mm reamer to create a circular tunnel. Following this, the tunnel was sequentially dilated with a rectangular tunnel dilator until it reached the dimensions of 8 × 10 mm. This ensured that the 9 mm graft could be accommodated in the 8 × 10 mm tunnel as a soft tissue graft, providing stability and support to the reconstructed ACL [Figure 4].
- Graft Squeezing technique
Double-bundle-like effect
All available single-bundle reconstruction techniques created a circular tunnel that covers only a portion of the anatomic footprint. This technique covered the maximum available footprint in size and shape through a single rectangular femoral and rectangular tibial tunnel, thereby creating a double-bundle-like effect with single-bundle reconstruction[Figure 5 and 6].
- Double-bundle-like effect
- (a) Arthroscopic view from Posteromedial portal showing femoral footprint, (b) Arthroscopic view from the high anterolateral portal showing the rectangular tibial footprint, (c) Arthroscopic view from the Posteromedial portal showing a circular tunnel in the oval femoral footprint, (d) Arthroscopic view from the Posteromedial portal showing a oval tunnel covering maximum femoral footprint, (e) Arthroscopic view from the high anterolateral portal showing circular tunnel in rectangular tibial footprint, (f) Arthroscopic view from the high anterolateral portal showing rectangular tunnel in rectangular tibial footprint, (g) Arthroscopic view from the anterolateral portal (after graft fixation) showing complete rectangular tibial footprint coverage nearing to the original footprint, (h) Arthroscopic view from the posteromedial portal (after graft fixation) with the knee in extension showing differential tension in the graft.
RESULTS
In our study involving 35 patients, comprising 24 males and 11 females, with an average age of 30 years, we observed encouraging outcomes regarding rehabilitation and return to activities of daily living (ADL). Patients underwent fast-track rehabilitation protocols, facilitating an early return to their pre-injury lifestyles. Post-operative magnetic resonance imaging (MRI) [Table 2] scans conducted around 9 months post-surgery revealed complete healing in 10 cases, indicating the effectiveness of our treatment approach. Importantly, there were no instances of treatment failure observed across the cohort. However, one complication, a Cyclops lesion, was identified. Despite this, all patients were able to resume their pre-injury levels of work and recreational activities within 8 to 9 months following surgery. These findings underscore the efficacy of our intervention in promoting rapid recovery and functional restoration in patients undergoing orthopedic procedures.
| Parameter | N=35 |
|---|---|
| Sex | |
| Male, n(%) | 24 (68.57) |
| Female Male, n(%) | 11 (31.43) |
| Age, mean±SD | 30.49 ± 5.43 |
| Time to surgery after injury in weeks, mean±SD |
14.20 ± 5.20 |
| Side of Injury, n(%) | |
| Left | 12(34.29) |
| Right | 23(65.71) |
| Graft diameter (mm), n(%) | |
| 8 | 10 (28.57) |
| 9 | 20 (57.14) |
| 10 | 05 (14.29) |
| Femoral tunnel diameter, n(%) | |
| 7 × 9 | 10 (28.57) |
| 8 × 10 | 20 (57.14) |
| 9 × 11 | 5 (14.29) |
| Tibial tunnel diameter (mm), n(%) | |
| 7 × 9 | 10 (28.57) |
| 8 × 10 | 20 (57.14) |
| 9 × 11 | 5 (14.29) |
| Partial meniscectomy-yes, n(%) | 5 (14.29) |
Partial meniscectomy-yes, n(%) 5 (14.29) Passive knee range of motion (ROM) exhibited a significant enhancement in knee flexion following surgery, as the average pre-operative ROM of 106 degrees increased to 134 degrees at the 3-month follow-up. ROM remained stable throughout the following years. The Lysholm knee score, which assesses knee function and symptoms, steadily improved from a pre-operative average of 52 to a peak of 98 at 12 and 24 months. After 36 months, the score slightly declined, although it still indicated good function. The IKDC score, which measures overall knee function, demonstrated significant improvement after surgery and maintained stability thereafter for up to 36 months[Table 3].
| Outcome parameter, N=35 |
Pre-Operative | Post-Op 6 months |
Post-Op 9 months |
Post-Op 12 months |
Post-Op 36 months |
|---|---|---|---|---|---|
| Passive knee range of motion (ROM), mean±SD | 106.29±13.74 | 126.71±4.19 | 131.14±3.45 | 134.86±3.53 | 136.00±3.16 |
| Lysholm knee score, mean±SD | 52.46±8.13 | 93.00±1.75 | 95.23±1.44 | 97.97±0.95 | 92.79±1.00 |
| International knee Documentation Committee (IKDC) score, mean±SD |
34.43±4.13 | 81.83±1.36 | 83.20±1.08 | 85.20±0.83 | 86.43±0.61 |
| Anteroposterior Stability: Lachman Test, Present, n Absent, n |
35.00 _ |
_ 35.00 |
_ 35.00 |
_ 35.00 |
_ 35.00 |
| Anteroposterior Stability: Lachman Test, Present, n Absent, n |
35.00 _ |
_ 35.00 |
_ 35.00 |
_ 35.00 |
_ 35.00 |
ROM: Range of motion; SD: Standard deviation
An MRI after surgery showed a successful reconstruction of the footprints in the femur and tibia. The MR scan revealed a rectangular shape closely resembling the natural anatomy and matched the images taken during surgery. Figure 7 represents relook ACL and post oiperaiotve MRI images.
- (a-c): (a) Relook arthroacopy image of healed ACL, (b) healed ACL with no intrasubstance signal change on post op MRI, (c) post operative MRI showing maximum coverage of footprint (white arrow)
DISCUSSION
New ACL reconstruction techniques are striving to mimic the natural knee more closely.Rectangular-shaped graft tunnel better replicates normal knee biomechanics compared to a round tunnel. While techniques that focus on the prevention of forward sliding of the knee joint (anterior translation) might achieve this initially by tightening the graft more, they can also disrupt the natural position of the shinbone (tibia) relative to the femur.[22] The double-bundle technique is another approach that aims to recreate the natural ACL. This method uses a larger graft to cover more of the original ACL area, potentially improving stability and controlling both front-to-back and twisting motions in the knee.[23] The femoral insertion of the ACL presents variations in its morphology, area, and morphometric characteristics over time. It goes from a large semi-circular shape that almost contacts the posterior articular cartilage in the of younger group to a smaller, fattened, and ribbon-like shape that moves away from the edge of the articular cartilage and is kept inbound anteriorly by the lateral intercondylar ridge in the older age group.[24] Under simulated Lachman testing and pivot-shift testing, a rectangular tunnel reconstruction technique results in significantly lower ATT at 0° and 15° reconstructed with a hamstring SB graft using a round tunnel strategy.[4]
The single-tunnel double-bundle technique has been shown to provide better rotational stability compared to the single-tunnel double-bundle and double-tunnel double-bundle methods.[7,25] The single tunnel technique reduces the risk of tunnel communication, socket wall damage, and operative complications.[26] A study comparing single-tunnel double-bundle and double-tunnel double-bundle techniques found that both methods achieved similar IKDC scores, Tegner activity scales, and ROM.[7] A study conducted by Scriviens et al. evaluated femoral and tibial tunnel widening and resorption of the interference screw using BPTB autograft. It showed that it had high rates of resorption and replacement with bone, and there were no increases in the cross-sectional area of the femoral tunnel and tibial tunnel at 2 to 5 years postoperatively.[27]
An increased surface area between the graft and cancellous flexion than kneesbone may enhance revascularization, promoting improved graft-host integration and potentially leading to more successful outcomes. This approach closely mimics the native insertion site of the ACL, potentially facilitating the restoration of normal ligament morphology and function. Furthermore, the dilator technique offers the advantage of enhanced rotational stability for the graft at the bone interface, which may contribute to improved overall mechanical stability of the reconstructed ACL.[28] These findings suggest that the dilator technique is a bone-preserving strategy that presents significant advantages for ACL reconstruction by promoting optimal healing and potentially improving the long-term success of the procedure. Additionally, studies have demonstrated the ability of this technique to create larger bone tunnels compared to conventional methods, potentially leading to improved clinical outcomes.[29] A few limitations of the study included a relatively small sample size, a short follow-up period, a single center, and a lack of a control group.
CONCLUSION
These findings suggest that the single-tunnel technique aimed to achieve a footprint-enhancing effect, mimicking the double-bundle approach, and has shown promising outcomes in this prospective study. At 3-year follow-up, patients exhibited favourable progress in terms of knee function, as evidenced by improvements in passive ROM, Lysholm score, IKDC score, and Lachman test for anteroposterior stability and pivot-shift tests. The single tunnel double-bundle technique offers a compelling approach to ACL reconstruction. Promoting enhanced graft-bone interface and potentially facilitating optimal healing processes may improve long-term outcomes. Additionally, compared to conventional techniques, the rectangular tunnel has been shown to facilitate the creation of larger bone tunnels, which could potentially translate into superior clinical results.
Author contributions:
ML: Conceptualization, validation, formal analysis, investigation, data curation, writing-original draft, writing-review and editing; LB: Formal analysis, investigation, data curation, writing-review and editing; AL: Investigation, data curation, writing-review and editing. All authors: Visualization, writing-review and editing.
Ethical approval:
The research/study approved by the Institutional Review Board at Kingsway Hospitals Ethics Committee, Nagpur IEC/2021/022, dated 12th Nov, 2021.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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