A Modified Anatomical All-Inside Double-Bundle Anterior Cruciate Ligament Reconstruction Technique

Arthroscopic anterior cruciate ligament (ACL) reconstruction (ACLR) is the standard surgical treatment for ACL injuries and is most commonly performed using anatomical single-bundle (SB) or double-bundle (DB) techniques. With the development of the all-inside technique, the all-inside SB technique using socket-based tunnels and cortical suspensory fixation has gained popularity because it helps preserve bone stock, reduces postoperative pain, and provides reliable knee stability. Compared with the SB technique, the DB technique achieves comparable clinical outcomes, more closely replicates native ACL anatomy, and may provide superior anterior and rotational stability, lower revision rates, and higher return-to-sport rates in athletes and other high-demand patients. However, the conventional DB technique requires substantial bone removal, is prone to tunnel widening or coalescence, and uses graft tissue less efficiently. To address these limitations, we describe a modified anatomical all-inside DB technique that combines the advantages of the all-inside technique and DB technique. This technique employs 4 bone sockets with suspensory fixation and bundle-specific tensioning to preserve bone stock, optimize graft utilization, and facilitate anatomic DB reconstruction.