Single-Bundle and Double-Bundle Posterior Cruciate Ligament Reconstructions: A Systematic Review and Meta-analysis of 441 Patients at a Minimum 2 Years' Follow-up


      To perform a systematic review on the techniques and a meta-analysis on the functional and objective outcomes after single-bundle (SB) versus double-bundle (DB) posterior cruciate ligament (PCL) reconstructions.


      A systematic review of the techniques, as well as functional and objective outcomes of clinical studies comparing SB versus DB PCL reconstruction with a mean follow-up of at least 24 months and minimum level of evidence of III were performed. After review of the literature, a quality analysis of the studies (Detsky score) and a meta-analysis comparing raw mean differences in data between SB and DB PCL groups were performed. Clinical outcome measures included in the meta-analysis were functional outcomes (Lysholm, Tegner, and objective International Knee Documentation Committee [IKDC] scores) and objective measurements (arthrometer and stress radiographs).


      The systematic search identified 11 studies (441 patients). Three studies were prospective randomized controlled trials and the other 8 studies were case-control studies. Two hundred thirty-two patients were treated with SB PCL reconstruction, whereas 209 were treated with DB PCL reconstruction. Only 4 studies satisfied the threshold for a satisfactory level of methodologic quality (>75%). There were no significant differences between SB and DB PCL reconstructions in postoperative Lysholm (P = .6, 95% confidence interval [CI], –0.98, 2.18) or Tegner scores (P = .37, 95% CI, −0.19, 0.92). DB PCL reconstruction provided significantly better objective posterior tibial translation stability than the SB technique using the Telos technique at 90° (P = −.58, 95% CI, −1.06, −0.10).


      Improved patient-reported outcomes and knee stability were achieved with both SB and DB PCL reconstruction surgery. DB PCL reconstruction provided significantly improved objective posterior tibial stability and objective IKDC scores when compared with SB PCL reconstruction in randomized clinical trials. No significant difference was found for the other patient-reported outcomes.

      Level of Evidence

      Level III, systematic review and meta-analysis of Level II and III studies.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Parolie J.M.
        • Bergfeld J.A.
        Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete.
        Am J Sports Med. 1986; 14: 35-38
        • Torg J.S.
        • Barton T.M.
        • Pavlov H.
        • Stine R.
        Natural history of the posterior cruciate ligament-deficient knee.
        Clin Orthop Relat Res. 1989; 246: 208-216
        • Strobel M.J.
        • Weiler A.
        • Schulz M.S.
        • Russe K.
        • Eichhorn H.J.
        Arthroscopic evaluation of articular cartilage lesions in posterior-cruciate-ligament-deficient knees.
        Arthroscopy. 2003; 19: 262-268
        • Van de Velde S.K.
        • Bingham J.T.
        • Gill T.J.
        • Li G.
        Analysis of tibiofemoral cartilage deformation in the posterior cruciate ligament-deficient knee.
        J Bone Joint Surg Am. 2009; 91: 167-175
        • McAllister D.R.
        • Petrigliano F.A.
        Diagnosis and treatment of posterior cruciate ligament injuries.
        Curr Sports Med Rep. 2007; 6: 293-299
        • Amis A.A.
        • Bull A.M.
        • Gupte C.M.
        • Hijazi I.
        • Race A.
        • Robinson J.R.
        Biomechanics of the PCL and related structures: Posterolateral, posteromedial and meniscofemoral ligaments.
        Knee Surg Sports Traumatol Arthrosc. 2003; 11: 271-281
        • Girgis F.G.
        • Marshall J.L.
        • Monajem A.
        The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis.
        Clin Orthop Relat Res. 1975; 106: 216-231
        • Makris C.A.
        • Georgoulis A.D.
        • Papageorgiou C.D.
        • Moebius U.G.
        • Soucacos P.N.
        Posterior cruciate ligament architecture: Evaluation under microsurgical dissection.
        Arthroscopy. 2000; 16: 627-632
        • Lopes Jr., O.V.
        • Ferretti M.
        • Shen W.
        • Ekdahl M.
        • Smolinski P.
        • Fu F.H.
        Topography of the femoral attachment of the posterior cruciate ligament.
        J Bone Joint Surg Am. 2008; 90: 249-255
        • Butler D.L.
        • Noyes F.R.
        • Grood E.S.
        Ligamentous restraints to anterior-posterior drawer in the human knee. A biomechanical study.
        J Bone Joint Surg Am. 1980; 62: 259-270
        • Markolf K.L.
        • Slauterbeck J.R.
        • Armstrong K.L.
        • Shapiro M.S.
        • Finerman G.A.
        A biomechanical study of replacement of the posterior cruciate ligament with a graft. Part II: Forces in the graft compared with forces in the intact ligament.
        J Bone Joint Surg Am. 1997; 79: 381-386
        • Markolf K.L.
        • Zemanovic J.R.
        • McAllister D.R.
        Cyclic loading of posterior cruciate ligament replacements fixed with tibial tunnel and tibial inlay methods.
        J Bone Joint Surg Am. 2002; 84: 518-524
        • Kennedy N.I.
        • Wijdicks C.A.
        • Goldsmith M.T.
        • et al.
        Kinematic analysis of the posterior cruciate ligament, part 1: The individual and collective function of the anterolateral and posteromedial bundles.
        Am J Sports Med. 2013; 41: 2828-2838
        • Wijdicks C.A.
        • Kennedy N.I.
        • Goldsmith M.T.
        • et al.
        Kinematic analysis of the posterior cruciate ligament, part 2: A comparison of anatomic single- versus double-bundle reconstruction.
        Am J Sports Med. 2013; 41: 2839-2848
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
        Ann Intern Med. 2009; 151 (w264): 264-269
        • Detsky A.S.
        • Naylor C.D.
        • O'Rourke K.
        • McGeer A.J.
        • L'Abbe K.A.
        Incorporating variations in the quality of individual randomized trials into meta-analysis.
        J Clin Epidemiol. 1992; 45: 255-265
        • Bhandari M.
        • Richards R.R.
        • Sprague S.
        • Schemitsch E.H.
        The quality of reporting of randomized trials in the Journal of Bone and Joint Surgery from 1988 through 2000.
        J Bone Joint Surg Am. 2002; 84: 388-396
        • Wright J.G.
        • Swiontkowski M.F.
        • Heckman J.D.
        Introducing levels of evidence to the journal.
        J Bone Joint Surg Am. 2003; 85: 1-3
        • Harris J.D.
        • Quatman C.E.
        • Manring M.M.
        • Siston R.A.
        • Flanigan D.C.
        How to write a systematic review.
        Am J Sports Med. 2014; 42: 2761-2768
        • Schumm W.R.
        • Higgins M.
        • Lockett L.
        • et al.
        Does dividing the range by four provide an accurate estimate of a standard deviation in family science research? A teaching editorial.
        Marriage Fam Rev. 2016; 53: 1-23
        • Deie M.
        • Adachi N.
        • Nakamae A.
        • Takazawa K.
        • Ochi M.
        Evaluation of single-bundle versus double-bundle PCL reconstructions with more than 10-year follow-up.
        ScientificWorldJournal. 2015; 2015: 751465
        • Yoon K.H.
        • Bae D.K.
        • Song S.J.
        • Cho H.J.
        • Lee J.H.
        A prospective randomized study comparing arthroscopic single-bundle and double-bundle posterior cruciate ligament reconstructions preserving remnant fibers.
        Am J Sports Med. 2011; 39: 474-480
        • Houe T.
        • Jørgensen U.
        Arthroscopic posterior cruciate ligament reconstruction: One- vs. two-tunnel technique.
        Scand J Med Sci Sports. 2004; 14: 107-111
        • Cumming T.B.
        • Churilov L.
        • Sena E.S.
        The missing medians: Exclusion of ordinal data from meta-analyses.
        PLoS One. 2015; 10 (e0145580)
        • Higgins J.P.
        • Thompson S.G.
        • Deeks J.J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
      1. Development Core Team. R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing. ISBN 3-900051-07-02005.

        • Viechtbauer W.
        Conducting meta-analyses in R with the metafor package.
        J Stat Softw. 2010; 36: 48
        • Jain V.
        • Goyal A.
        • Mohindra M.
        • Kumar R.
        • Joshi D.
        • Chaudhary D.
        A comparative analysis of arthroscopic double-bundle versus single-bundle posterior cruciate ligament reconstruction using hamstring tendon autograft.
        Arch Orthop Trauma Surg. 2016; 136: 1555-1561
        • Li Y.
        • Li J.
        • Wang J.
        • Gao S.
        • Zhang Y.
        Comparison of single-bundle and double-bundle isolated posterior cruciate ligament reconstruction with allograft: A prospective, randomized study.
        Arthroscopy. 2014; 30: 695-700
        • Wang C.J.
        • Weng L.H.
        • Hsu C.C.
        • Chan Y.S.
        Arthroscopic single- versus double-bundle posterior cruciate ligament reconstructions using hamstring autograft.
        Injury. 2004; 35: 1293-1299
        • Fanelli G.C.
        • Beck J.D.
        • Edson C.J.
        Single compared to double-bundle PCL reconstruction using allograft tissue.
        J Knee Surg. 2012; 25: 59-64
        • Kim S.J.
        • Jung M.
        • Moon H.K.
        • Kim S.G.
        • Chun Y.M.
        Anterolateral transtibial posterior cruciate ligament reconstruction combined with anatomical reconstruction of posterolateral corner insufficiency: Comparison of single-bundle versus double-bundle posterior cruciate ligament reconstruction over a 2- to 6-year follow-up.
        Am J Sports Med. 2011; 39: 481-489
        • Shon O.J.
        • Lee D.C.
        • Park C.H.
        • Kim W.H.
        • Jung K.A.
        A comparison of arthroscopically assisted single and double bundle tibial inlay reconstruction for isolated posterior cruciate ligament injury.
        Clin Orthop Surg. 2010; 2: 76-84
        • Kim S.J.
        • Kim T.E.
        • Jo S.B.
        • Kung Y.P.
        Comparison of the clinical results of three posterior cruciate ligament reconstruction techniques.
        J Bone Joint Surg Am. 2009; 91: 2543-2549
        • Hatayama K.
        • Higuchi H.
        • Kimura M.
        • Kobayashi Y.
        • Asagumo H.
        • Takagishi K.
        A comparison of arthroscopic single- and double-bundle posterior cruciate ligament reconstruction: Review of 20 cases.
        Am J Orthop (Belle Mead NJ). 2006; 35: 568-571
        • Maruyama Y.
        • Shitoto K.
        • Baba T.
        • Kaneko K.
        Evaluation of the clinical results of posterior cruciate ligament reconstruction—A comparison between the use of the bone tendon bone and semitendinosus and gracilis tendons.
        Sports Med Arthrosc Rehabil Ther Technol. 2012; 4: 30
        • Hoher J.
        • Scheffler S.
        • Weiler A.
        Graft choice and graft fixation in PCL reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2003; 11: 297-306
        • Kennedy N.I.
        • LaPrade R.F.
        • Goldsmith M.T.
        • et al.
        Posterior cruciate ligament graft fixation angles, part 2: Biomechanical evaluation for anatomic double-bundle reconstruction.
        Am J Sports Med. 2014; 42: 2346-2355
        • Spiridonov S.I.
        • Slinkard N.J.
        • LaPrade R.F.
        Isolated and combined grade-III posterior cruciate ligament tears treated with double-bundle reconstruction with use of endoscopically placed femoral tunnels and grafts: Operative technique and clinical outcomes.
        J Bone Joint Surg Am. 2011; 93: 1773-1780
        • Kennedy N.I.
        • LaPrade R.F.
        • Goldsmith M.T.
        • et al.
        Posterior cruciate ligament graft fixation angles, part 1: Biomechanical evaluation for anatomic single-bundle reconstruction.
        Am J Sports Med. 2014; 42: 2338-2345
        • LaPrade R.F.
        • Smith S.D.
        • Wilson K.J.
        • Wijdicks C.A.
        Quantification of functional brace forces for posterior cruciate ligament injuries on the knee joint: An in vivo investigation.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 3070-3076
        • Hewett T.E.
        • Noyes F.R.
        • Lee M.D.
        Diagnosis of complete and partial posterior cruciate ligament ruptures. Stress radiography compared with KT-1000 arthrometer and posterior drawer testing.
        Am J Sports Med. 1997; 25: 648-655
        • Jung T.M.
        • Reinhardt C.
        • Scheffler S.U.
        • Weiler A.
        Stress radiography to measure posterior cruciate ligament insufficiency: A comparison of five different techniques.
        Knee Surg Sports Traumatol Arthrosc. 2006; 14: 1116-1121