By John W. Xerogeanes, M.D.
Chief of the Emory Sports Medicine Center

1. Question: What is a double-bundle ACL reconstruction?
   Answer: A double-bundle ACL reconstruction utilizes two grafts (with two tunnels in the femur and two in the tibia) to replace the injured ACL, as opposed to the standard ACL reconstruction that uses a single graft (with one tunnel in the femur and one tunnel in the tibia) to reconstruct the injured ACL.  It is like doing two ACL operations in the same setting.
   
2. Question: What are the benefits of the double-bundle ACL reconstruction?
   Answer: The double-bundle ACL reconstruction re-creates the native kinematics (movement) of the knee better than the single bundle reconstruction.  The native ACL controls both rotation (twisting) and translation (forward/backward) movement of the knee.  The double-bundle reconstruction has been shown in biomechanical studies to be superior in controlling these motions throughout knee motion.  Theoretically, this increase control should lead to a decrease in further injury and degeneration of the patient's knee.
   
3. Question: Which patients do you recommend get this type of operation? 
    Answer: I primarily recommend this procedure in people who have failed a previous ACL reconstruction (re torn their graft). I also consider it in patients that I feel are "ACL opathic." In other words, patients that for mechanical reasons are at risk for further ACL injuries (i.e., knock-kneed patients, female athletes, etc).  Finally, in younger patients electing allograft reconstruction of their ACLs.
   
4. Question: Why not do the procedure on everyone?
   Answer: While the normal ACL reconstruction works well for a large percentage of people, I don't recommend that we change this operation unless we have definitive proof (through long-term studies) that the double-bundle operation is superior in every case.
   
5. Question: What do you use to make the bundles? 
   Answer: I use either two allograft tendons, or an allograft tendon along with the patient's own hamstring tendons.  The decision of which grafts to use depends on the patient's history, examination and discussion with the surgeon.
   
6. Question: What is the downside of this operation?
   Answer: Technically this is a very difficult operation.  Unlike normal ACL reconstruction, where you drill two tunnels, here we drill four tunnels in the same area.  You could see how the tunnels could run together or be placed in the wrong location. Remember, the main reason for failed ACL reconstruction is because the surgeon placed the tunnels in the wrong position. This operation could be disastrous in the wrong hands.
   
7. Question: Why get this operation done at the Emory Sport Medicine Center? 
   Answer: Experience. We have been studying knee biomechanics for 15 years and considering this type of operation during that time.  We have gone to Japan* and learned their surgical techniques, then modified them to produce what we feel is the state-of-the-art surgical technique.  We have been carefully selecting patients and performing this operation over the last two years.
   
8. Question: Is your technique different than the technique used at other clinics? 
   Answer: Yes. I have modified several aspects of the technique to make the reconstruction more anatomic and more reproducible.  In fact, I have designed special 
   drill guides to help surgeons place the tunnels in the correct place.
   
9. Question: Is rehabilitation different than rehabilitation after a normal ACL?
   Answer: No. 
   
10. Question: Have you performed a double-bundle reconstruction on high level athletes?   
    Answer: Yes, I have performed this operation on many athletes including collegiate athletes from Division 1, 2 and 3 programs.
    
11. Question: How do I know if I am a candidate for this surgery?
    Answer: Any failed ACL reconstruction patient is an automatic candidate.  For a first-time ACL injury, you would need to come in and let me evaluate you.
    
12. Question: Have your results/outcomes for this operation been successful? 
    Answer: I have been performing this operation over the last year on selected patients and have been very happy with the results. The patients are better on clinical  examination of translation and rotation control.  However, we need long-term follow-up to ensure that this improvement in physical examination leads to a more positivelong-term outcome.
    
    *In an attempt to improve on surgical outcomes and prevent reinjury, surgeons in Japan started anatomically reconstructing the ACL by using two grafts placed in the exact locations of the native ACL (which has two distinct bundles).  Their results have been very encouraging. I studied with the Japanese surgeons performing this operation.  It made inherent sense to me that we would get better function by reconstructing the ACL anatomically. In fact, the biomechanical data (from the lab where I used to work at the University of Pittsburgh) showed that the double-bundle reconstructions were superior to the single bundle reconstruction. This is because it controlled motion better (and more like the native ACL) through flexing and straightening the knee.

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