International Orthopaedics - 2026-08-14 - Journal Article; Review
Evolution of anatomical anterior cruciate ligament reconstruction: a narrative review of double-bundle and rectangular-tunnel techniques.
Ozeki N, Koga H
Topics
Key Takeaway
Anatomic ACL reconstruction has evolved from isometric single-bundle transtibial techniques toward individualized, dual-bundle and rectangular-tunnel morphology-based strategies that address both anterior and rotational instability, with concomitant meniscal pathology, remnant preservation, lateral extra-articular augmentation, and tibial slope correction now recognized as integral components.
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Summary
This narrative review synthesizes the surgical, biomechanical, and biological evolution of anatomic ACL reconstruction, examining tunnel positioning, graft configuration, tensioning philosophy, remnant preservation, concomitant meniscal injury, lateral extra-articular procedures, and tibial slope correction. The review traces the shift from isometric transtibial single-bundle reconstruction to double-bundle and rectangular-tunnel bone-patellar tendon-bone techniques based on the ACL's dual-bundle structure and broad insertion morphology. It concludes that ACL injury is a multi-structural pathology requiring individualized, anatomy-driven surgical planning to restore comprehensive knee stability.
Key Limitation
As a narrative review without systematic search methodology or outcome data synthesis, conclusions reflect author interpretation rather than pooled evidence, and no comparative efficacy data are provided to guide selection among the described techniques.
Original Abstract
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.