Tunnel enlargement, particularly on the tibial side, represents one of the most challenging technical issues in revision anterior cruciate ligament (ACL) reconstruction. Enlarged tunnels complicate anatomic tunnel placement, compromise primary fixation stability, and have traditionally necessitated a two-stage revision procedure. However, recent advances in biological reconstruction strategies and fixation techniques have expanded the indications for single-stage revision surgery. This review first reviews the current literature regarding the mechanical and biological mechanisms underlying tunnel enlargement following ACL reconstruction. This technique utilizes a periosteum–patellar tendon–tibial tubercle autograft to achieve implant-free biological press-fit tibial fixation. The primary objectives are to restore bone stock, reconstruct a new anatomic tibial tunnel, and provide reliable primary fixation within a single surgical procedure. In addition, the biomechanical rationale, clinical outcomes, and potential advantages of this technique for single-stage revision in the presence of severe tibial tunnel enlargement are discussed. Current evidence suggests that, with meticulous preoperative planning and appropriate patient selection, single-stage revision ACL reconstruction using this biological press-fit fixation technique can provide satisfactory mid-term clinical outcomes, even in patients who have traditionally been considered candidates for two-stage revision surgery.