Re-Revision ACL Reconstruction: A Double-Bundle Technique Video

Anterior cruciate ligament (ACL) tears are a prevalent knee injury, often requiring surgery. While single-bundle reconstruction is the most employed technique for revision procedures, the native ACL consists of 2 anatomic bundles, and the double-bundle reconstruction technique aims to more accurately replicate this native anatomy. This video demonstrates a reproducible method for performing ACL reconstruction (ACLR) utilizing the double-bundle technique.

Relative indications for revision double-bundle ACLR include revision or re-revision ACLR, previous lateral extra-articular tenodesis (LET), 2 to 3+ pivot shift, normal posterior tibia slope, and large lateral femoral condyles.

Arthroscopic delineation of the ACL footprint is performed. With a curved, flexible reamer, the anteromedial socket is drilled. The posterolateral socket is reamed secondarily, providing a 2-mm bone bridge separating the 2 femoral tunnels. Two tibial tunnels are drilled under direct arthroscopic visualization. On the back table, a tibialis anterior allograft and bone-patellar tendon-bone allograft are prepared. The posterior bundle graft is initially passed. A cortical button is passed across the femoral cortex, and its position is confirmed. The anteromedial bundle graft is passed secondarily. Femoral fixation is established with a polyether ether ketone (PEEK) interference screw, and both grafts are fixed on the tibial side with a PEEK anchor. Standard closure follows, and the patient is placed in a hinged knee brace locked in extension.

A clinical trial including 81 patients with a mean 10.7-year follow-up indicated an 85% survival rate from needing a second revision ACLR when using an allograft. A meta-analysis by Seppänen et al indicated that the double-bundle technique was superior to the single-bundle technique in International Knee Documentation Committee subjective evaluations (P < .05). Another meta-analysis by Dong et al found no statistical difference in clinical outcomes between the single-bundle versus the double-bundle ACLR techniques.

Double-bundle ACLR offers significant anatomic and biomechanical benefits. In the context of re-revision ACLR, the double-bundle method provides additional collagen graft material and enhanced stability, especially in cases where concurrent LET has been performed and the posterior tibial slope remains normal.

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.