title: Does Double-Bundle Anterior Cruciate Ligament Reconstruction Improve Postoperative Knee Stability Compared With Single-Bundle Techniques? A Systematic Review of Overlapping Meta-analyses.
abstract: OBJECTIVE
  Multiple meta-analyses of randomized controlled trials, the highest available level of evidence, have been conducted to determine whether double-bundle (DB) or single-bundle (SB) anterior cruciate ligament reconstruction (ACL-R) provides superior clinical outcomes and knee stability; however, results are discordant. The purpose of this study was to conduct a systematic review of meta-analyses comparing SB and DB ACL-R to discern the cause of the discordance and to determine which of these meta-analyses provides the current best available evidence.
  
  
  METHODS
  We evaluated available scientific support for SB as compared with DB ACL-R by systematically reviewing the literature for published meta-analyses. Data on patient clinical outcomes and knee stability (as measured by KT arthrometry and pivot-shift testing) were extracted. Meta-analysis quality was judged using the Oxman-Guyatt and Quality of Reporting of Meta-analyses systems. The Jadad algorithm was then applied to determine which meta-analyses provided the highest level of evidence.
  
  
  RESULTS
  Nine meta-analyses were included, of which 3 included Level I Evidence and 6 included both Level I and Level II Evidence. Most studies found significant differences favoring DB reconstruction on pivot-shift testing, KT arthrometry measurement of anterior tibial translation, and International Knee Documentation Committee objective grading. Most studies detected no significant differences between the 2 techniques in subjective outcome scores (Tegner, Lysholm, and International Knee Documentation Committee subjective), graft failure, or complications. Oxman-Guyatt and Quality of Reporting of Meta-analyses scores varied, with 2 studies exhibiting major flaws (Oxman-Guyatt score <3). After application of the Jadad decision algorithm, 3 concordant high-quality meta-analyses were selected, with each concluding that DB ACL-R provided significantly better knee stability (by KT arthrometry and pivot-shift testing) than SB ACL-R but no advantages in clinical outcomes or risk of graft failure.
  
  
  CONCLUSIONS
  The current best available evidence suggests that DB ACL-R provides better postoperative knee stability than SB ACL-R, whereas clinical outcomes and risk of graft failure are similar between techniques.
  
  
  METHODS
  Level II, systematic review of Level I and II studies.
authors.affiliation: Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.. Electronic address: mascarer@hotmail.com.
authors.forename: Randy
authors.initials: R
authors.lastname: Mascarenhas
authors.affiliation: Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.
authors.forename: Gregory L
authors.initials: GL
authors.lastname: Cvetanovich
authors.affiliation: College of Physicians and Surgeons, Columbia University, New York, New York, U.S.A.
authors.forename: Eli T
authors.initials: ET
authors.lastname: Sayegh
authors.affiliation: Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.
authors.forename: Nikhil N
authors.initials: NN
authors.lastname: Verma
authors.affiliation: Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Cole
authors.affiliation: Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.
authors.forename: Charles
authors.initials: C
authors.lastname: Bush-Joseph
authors.affiliation: Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.
authors.forename: Bernard R
authors.initials: BR
authors.lastname: Bach
mesh_terms: D016118:Anterior Cruciate Ligament / Q000601:surgery*; D000070598:Anterior Cruciate Ligament Injuries; D059549:Anterior Cruciate Ligament Reconstruction / Q000379:methods*; D006801:Humans; D007593:Joint Instability / Q000209:etiology / Q000601:surgery*; D007718:Knee Injuries / Q000150:complications / Q000601:surgery*; D007719:Knee Joint / Q000601:surgery*