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

Background: 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. Indications: 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. Technique Description: 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. Results: 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 ( Discussion/Conclusion: 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. Patient Consent Disclosure Statement: 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.