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Published on: April 30, 2014
Evolution of anatomical anterior cruciate ligament reconstruction: a narrative review of double-bundle and
Nobutake Ozeki1, Hideyuki Koga2
1Institute of Science Tokyo, Center for Stem Cell and Regenerative Medicine, Tokyo, Japan.
Purpose:
Anatomic anterior cruciate ligament (ACL) reconstruction has evolved substantially from procedures aimed primarily at restoring anterior stability toward strategies designed to restore both anterior and rotational stability by reproducing native ACL anatomy, biomechanics, and physiologic knee kinematics. This narrative review summarizes the surgical, biomechanical, and biological concepts underlying this evolution.
Methods:
A narrative review of the literature on the development of anatomic ACL reconstruction was performed, focusing on tunnel positioning, graft configuration, tensioning, remnant preservation, concomitant meniscal injury, extra-articular augmentation, and posterior tibial slope correction.
Results:
The transition from isometric, transtibial single-bundle reconstruction toward anatomic techniques was driven by recognition of the ACL's dual-bundle structure and broad insertion morphology, leading to double-bundle reconstruction and later morphology-based rectangular tunnel bone-patellar tendon-bone reconstruction. Concurrently, graft tensioning philosophy shifted toward lower, more physiologic tension guided by reciprocal anteromedial-posterolateral bundle behavior, and remnant-preserving techniques emerged to enhance proprioception, vascularity, and graft integration. Concomitant meniscal injury, including ramp lesions and lateral meniscal posterior root tears, is now recognized as an integral determinant of knee kinematics and long-term joint health rather than an incidental finding, reinforcing the concept of ACL injury as a multi-structural pathology. Lateral extra-articular procedures and tibial slope-reducing osteotomy have further addressed graft failure and residual rotational instability in high-risk patients.
Conclusion:
Anatomic ACL reconstruction has progressively shifted from isolated ligament substitution toward individualized, anatomy- and biomechanics-based restoration of comprehensive knee stability, aiming to achieve durable, physiologic knee function through tailored surgical planning.