Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction: Kinematics and Knee Flexion Angle–Graft Tension Relation

Purpose The purpose of this study was to compare the bundle tension curves and resultant knee kinematics between 2 tensioning protocols in anatomic double-bundle anterior cruciate ligament (ACL) reconstruction. Methods Anatomic double-bundle ACL reconstruction was performed in 7 male cadaveric knees. Each graft was tensioned to 22 N under 2 conditions: (1) both bundles tensioned at 20° of knee flexion (20/20 protocol) or (2) posterolateral (PL) bundle tensioned at 15° and anteromedial (AM) bundle at 45° (45/15 protocol). Knee kinematics were recorded in response to anterior and combined rotatory loads in the intact, ACL-deficient, and reconstructed states. Bundle tension was recorded dynamically with knee motion and during each loading test. Results Tensioning both bundles at 20° of knee flexion resulted in a reciprocal bundle tension pattern that was not statistically different; the PL bundle tension was greater than the AM bundle tension in full extension, and the AM bundle tension was greater than the PL bundle tension from 25° to 120°. In the second tensioning protocol, the AM bundle tension was significantly greater than the PL bundle tension at all flexion angles. Both tensioning protocols restored normal knee kinematics. Conclusions Bundle-tensioning protocol is a variable that has a significant effect on the bundle-loading patterns in double-bundle ACL reconstruction. The 20/20 protocol resulted in AM and PL bundle–loading patterns that were equivalent during dynamic testing, whereas the 45/15 protocol led to excessive tension in the AM bundle in full extension. We recommend equal tensioning of both bundles with the knee at 20° of flexion to restore relatively normal tension curves in each bundle and to avoid excessive stress on the AM bundle. Clinical Relevance In double-bundle ACL reconstruction, there is no consensus regarding bundle-tensioning protocols. This study provides data on the individual bundle tension curves that result from 2 commonly used tensioning protocols. These data will assist clinicians as the technique and application of double-bundle ACL reconstruction move forward.