Double Bundle ACL Reconstruction Surgery

The anterior cruciate ligament, or ACL, is one of four major ligaments in the knee that provide stability to the joint. When a patient sustains a tear to the ACL, a sensation of instability, or giving out, may develop in the injured knee. This symptom of instability tends to be particularly problematic for athletes who want to remain active in sports. Some sports are particularly difficult to continue participation in athletes who have injured their ACL. These high-risk sports, such as soccer, basketball, and lacrosse, involve sudden cutting and pivoting movements that require an intact ACL.

When an athlete tears their ACL, the knee will tend to buckle when pivoting or suddenly changing direction. In order to restore stability to the knee, your healthcare provider may recommend an ACL reconstruction to insert a new ligament in the place of the damaged ACL. A newer technique, called a double-bundle ACL reconstruction, has been developed to better replicate the function of the normal ACL.

Surgeon looking at screen during arthroscopic surgery
Edward Olive / Getty Images

ACL Bundles

The ACL is made of a tough, fibrous tissue that spans the knee joint, attaching to the femur (thigh bone) on top, and the tibia (shin bone) below. The ligament itself is made of thousands of individual fibers, that together form the ACL. Some of these fibers are organized into distinct bundles. The normal ACL has two primary bundles of fibers.

These bundles are positioned closely together, in some patients with normal ACLs it can be difficult to discern distinct bundles. But we know there are two primary bundles, and each bundle is named for its location. The longer anteromedial bundle is positioned in front of the shorter posterolateral bundle.

Single Bundle ACL Surgery

Most ACL reconstruction surgeries are done using a single-bundle reconstruction. A single-bundle ACL reconstruction uses a tendon graft to replace the torn ACL. Unfortunately, ACL tears cannot be repaired, or sewn together, and a graft must be used to reconstruct the ligament. When the ACL is reconstructed, the graft is placed in the position of the anteromedial bundle.

Grafts are held in place by making a hole in the bone called a tunnel. One tunnel is made in the femur and one in the tibia. The graft is held in the bone with a fixation device, often a screw.

Double Bundle ACL Surgery

Instead of placing just one larger graft, the double-bundle ACL reconstruction procedure uses two smaller grafts. Therefore, there are essentially two ligament reconstructions, one for each bundle. The double-bundle procedure requires two additional bone tunnels to accommodate a second graft and one additional incision. The surgical procedure may take slightly longer, although surgeons performing this procedure routinely can perform it in a similar manner to a single bundle ACL reconstruction.

Is a Double Bundle Better?

Studies have demonstrated some advantages of the double-bundle ACL reconstruction. These studies show more 'normal' function of the reconstructed ligament after this double-bundle ACL reconstruction surgery. What is not known is if this means the patients will have better success with the double-bundle ACL reconstructions. Specifically, the ability to return to sports at the same level as before the injury has not been shown to be better with either technique of reconstructing the ACL.

Double-bundle ACL reconstruction is a new procedure, and as is the case with any new procedure, the long-term results are not well understood. It is possible that this procedure will be an improvement on the standard single-bundle ACL reconstructions, but it is also possible that these patients may have the same, or even worse, long-term results. No one really knows just yet.

The double-bundle is technically more demanding of a procedure, and there are fewer surgeons with experience in this surgical technique.

A Word From Verywell

It is not clear that the double-bundle ACL reconstruction is a better procedure, but some patients are willing to try a new procedure in an effort to possibly improve their long-term result. Standard single-bundle ACL reconstructions have excellent results, with a large number of patients able to return to activities at their pre-injury level. However, the results are not 100%, and some patients have persistent instability after ACL reconstructions and may develop problems later in life.

The double-bundle ACL reconstruction is an effort to improve the results of an already excellent procedure. If you are interested, talk to your healthcare provider about this procedure. As mentioned, few surgeons perform the double-bundle ACL reconstruction. But you can certainly discuss this procedure with your healthcare provider and get his or her thoughts on the double-bundle ACL reconstruction.

3 Sources
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  1. Suomalainen P, Kannus P, Järvelä T. Double-bundle Anterior Cruciate Ligament reconstruction: a review of literature. International Orthopaedics (SICOT). 2013;37(2):227-232. doi. 10.1007/s00264-012-1680-9. Published February, 2013.

  2. Chen H, Chen B, Tie K, Fu Z, Chen L. Single-bundle versus double-bundle autologous anterior cruciate ligament reconstruction: a meta-analysis of randomized controlled trials at 5-year minimum follow-up. Journal of Orthopaedic Surgery and Research. 2018;13(1):50. doi. 10.1186/s13018-018-0753-x. Published March, 2018.

  3. Järvelä S, Kiekara T, Suomalainen P, Järvelä T. Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective randomized study with 10-year results. American Journal of Sports Medicine. 2017;45(11):2578-2585. doi. 10.1177/0363546517712231. Published September, 2017.

Additional Reading
  • Ahn JH, Kang HW, Choi KJ. "Outcomes After Double-Bundle Anterior Cruciate Ligament Reconstruction" Arthroscopy. pii: S0749-8063(17)30799-5.

  • Dhawan A, Gallo RA, Lynch SA. "Anatomic Tunnel Placement in Anterior Cruciate Ligament Reconstruction" J Am Acad Orthop Surg 24(7):443-54.

  • Li YL, Ning GZ, Wu Q, Wu QL, Li Y, Hao Y, Feng SQ. "Single-bundle or double-bundle for anterior cruciate ligament reconstruction: a meta-analysis" Knee. 21(1):28-37.

By Jonathan Cluett, MD
Jonathan Cluett, MD, is board-certified in orthopedic surgery. He served as assistant team physician to Chivas USA (Major League Soccer) and the United States men's and women's national soccer teams.