Double‐Bundle Anterior Cruciate Ligament Reconstruction Provides Superior Short‐to‐Midterm Rotational Stability But Not Clinically Important Functional Gains Over Single‐Bundle: A Systematic Review and Meta‐analysis

Purpose To compare the biomechanical and functional outcomes between single‐bundle and double‐bundle (DB) anterior cruciate ligament reconstruction techniques using the most current evidence, stratified by follow‐up duration. Methods PubMed, Embase, and Cochrane databases were searched from 2013 to September 2025 for randomized controlled trials comparing single‐bundle versus DB anterior cruciate ligament reconstruction with a minimum follow‐up of 24 months. Primary outcomes included anterior tibial translation, rotational stability (pivot shift), and patient‐reported outcomes (subjective International Knee Documentation Committee, Lysholm score). Secondary outcomes included return‐to‐sport and graft failure rate. Continuous outcomes were pooled using inverse‐variance random‐effects models (DerSimonian‐Laird) and dichotomous outcomes using Mantel‐Haenszel fixed‐effect models, with stratification by follow‐up duration (24‐48 months vs >48 months). Heterogeneity was assessed using the I 2 statistic. Results Thirteen randomized controlled trials (1041 patients; 536 single‐bundle, 505 DB; mean age 30.2 years; 68% men; follow‐up 24‐122 months) were included. At 24 to 48 months, DB reconstruction significantly reduced the risk of a positive pivot shift (risk ratio 0.60, 95% confidence interval [CI] 0.43‐0.84, P = .003; number needed to treat = 10) and showed statistically higher subjective International Knee Documentation Committee (mean difference 5.88 points, 95% CI 0.44‐11.33) and Lysholm (mean difference 7.47 points, 95% CI 0.06‐14.88) scores; however, neither reached established minimal clinically important difference thresholds (11.5 and 8.9 points, respectively). Anterior tibial translation did not differ significantly between techniques (mean difference −0.34 mm, 95% CI −1.04 to 0.35, P = .327). No study reported sex‐disaggregated outcomes or individual‐level minimal clinically important difference attainment. Beyond 48 months, no significant differences were observed for any outcome. Conclusions DB reconstruction shows statistically significant improvements in rotational stability and patient‐reported functional scores at 24 to 48 months, but functional differences do not reach established minimal clinically important difference thresholds. No significant differences were observed beyond 48 months, a finding likely influenced by substantial study heterogeneity and graft selection. The current evidence does not support a universal clinical advantage for the DB technique; shared decision‐making based on patient activity demands and surgeon experience remains essential. Level of Evidence Level I, systematic review and meta‐analysis of randomized controlled trials.