All-inside ACL reconstruction: How does it compare to standard ACL reconstruction techniques?

Connaughton, Alexander; Geeslin, Andrew G.; Uggen, Christopher

doi:10.1016/j.jor.2017.03.002

Cited by 56 publications

(70 citation statements)

References 47 publications

(148 reference statements)

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“…The all-inside technique for ACL reconstruction [5], compared to the traditional Antero-Medial (AM) or Transtibial methods, features substantial improvements including two closed-socket tunnels, double (femoral and tibial) suspensory fixation and smaller skin incisions [6]. That allows the graft insertion to be performed through an arthroscopic portal, minimizing postoperative bleeding, soft tissue damage and especially bone loss (reduction from 54 to 64%) and postoperative pain [7][8][9].…”

Section: Introductionmentioning

confidence: 99%

All-inside technique in ACL reconstruction: mid-term clinical outcomes and comparison with AM technique (Hamstrings and BpTB grafts)

Pautasso

Capella

Barberis

et al. 2020

Eur J Orthop Surg Traumatol

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Purpose The aim of this study was to define the subjective and objective clinical results of all-inside surgical technique at a medium-term follow-up and to compare these results with those obtained from antero-medial (AM) ACL reconstruction technique using hamstrings (HS) or bone-patellar tendon-bone (BpTB) grafts to detect eventual superiority of one technique to another. Methods A retrospective analysis of routinely collected data was conducted. Inclusion criteria were ACL reconstruction through all-inside technique or AM technique with HS or BpTB performed between January 2015 and May 2018; age between 15 and 30 year old; minimum 24 months’ available follow-up. Exclusion criteria were contralateral ACL reconstruction; need for any other associated procedures during surgery. Clinical outcomes were assessed with KOOS, Lysholm, Tegner scores and KT-1000 device. Results According to the selection criteria, 157 patients were enrolled and divided subsequently into 3 groups: all-inside (51 patients), AM-HS (53 patients) and AM-BpTB (53 patients). A significant postoperative improvement of each score in all groups was detected. The mean KT-1000 was 3.1 ± 1.0 mm in all-inside group, while 3.3 ± 1.4 mm and 2.5 ± 0.4 mm in AM-HS and AM-BpTB groups, respectively. Comparing the results obtained, no statistically significant difference was found between the three techniques (p = 0.27). Statistically significant differences were highlighted in surgical duration: all-inside method was the longest (117′), followed by AM-BpTB surgery (101′) and AM-HS technique (87′). Conclusions The all-inside technique showed good postoperative results at medium-term follow-up. It could be a valuable solution for ACL reconstruction, especially in young patients due to its less invasiveness, despite surgical skills and time needed. Levels of evidence Level IV.

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Section: Introductionmentioning

confidence: 99%

All-inside technique in ACL reconstruction: mid-term clinical outcomes and comparison with AM technique (Hamstrings and BpTB grafts)

Pautasso

Capella

Barberis

et al. 2020

Eur J Orthop Surg Traumatol

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“…The all-inside anterior cruciate ligament reconstruction (ACLR) technique uses adjustable-length, looped cortical button devices for fixation of the graft on both tibial and femoral ends. Typically, a quadrupled semitendinosus hamstring tendon graft is used because of its favorable biomechanical properties over other graft materials 4 , 5 , 9 , 10 , 13 and similar elasticity and force elasticity curve to the native ACL. 15 Outcome studies 5 , 14 , 19 suggest that subjective and objective outcomes are comparable with a standard quadrupled semitendinosus and gracilis hamstring ACLR using suspensory or aperture fixation.…”

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confidence: 99%

Biomechanical Comparison of Graft Preparation Techniques for All-Inside Anterior Cruciate Ligament Reconstruction

Bowes

Mohamed

Baptiste

et al. 2020

Orthopaedic Journal of Sports Medicine

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Background: All-inside anterior cruciate ligament reconstruction (ACLR) is an emerging technique used to treat ACL injuries. The all-inside technique uses a 4-stranded graft made from a single tendon that is looped on itself. The 4 strands of the graft must be secured to each other to become a closed-loop structure. Various suture configurations exist to secure the graft to adjustable loop devices, and there is a lack of data to support one technique over another. In addition to the primary sutures used to fasten the graft together, accessory sutures can be tied over the button as secondary fixation. Purpose: To evaluate biomechanical properties of 4-stranded grafts prepared in 5 different configurations. Study Design: Controlled laboratory study. Methods: Porcine flexor tendons (N = 25) were prepared in 5 different configurations (n = 5 tendons per group): simple-interrupted sutures (unsecured fixation), side-to-side fixation with and without secondary fixation, and end-to-end fixation with and without secondary fixation. The grafts were put through the same mechanical testing protocol (cyclic loading, pull to failure) to measure average load at graft failure, average displacement at failure, average stiffness, and average elongation rate. Differences between graft preparation techniques were investigated using 1-way analyses of variance (ANOVAs) with post hoc t tests ( P < .05). Results: Significant 1-way ANOVAs for each biomechanical property were found. Unsecured fixation was the weakest graft preparation with the lowest stiffness (167 ± 12 N/mm), lowest ultimate failure load (637 ± 99 N), and highest elongation rate (0.0033 ± 0.0007 mm/s). End-to-end fixation without secondary fixation showed the highest ultimate failure load (846 ± 26 N), highest stiffness (212 ± 10 N/mm), and lowest rate of elongation (0.0025 ± 0.0001 mm/s). End-to-end fixation, both with and without secondary fixation, as well as side-to-side fixation with secondary fixation showed significantly higher ultimate failure loads than grafts with unsecured fixation. End-to-end fixation performed better than side-to-side fixation; however, for most variables, the difference was not statistically significant. Secondary fixation did not provide significant improvement. Conclusion: The all-inside ACL graft with simple-interrupted sutures is biomechanically inferior to a graft that has its free ends secured to the adjustable tibial loop. Adding secondary fixation to the tibial button does not significantly change the biomechanical properties. Further clinical studies are required to determine whether these findings translate into differences in clinical outcome. Clinical Relevance: All-inside ACLR is gaining popularity in hamstring ACL reconstructive techniques. These results provide surgeons with guidance on the best graft preparation method when using a single quadrupled hamstring tendon graft.

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“…In an effort to limit morbidity and potentially obtain a larger graft diameter, the all-inside ACL reconstruction technique was developed, and it includes a quadrupled semitendinosus soft-tissue graft with suspensory femoral and tibial fixation. [1][2][3] A growing body of evidence on adjustable-loop cortical fixation includes time-zero biomechanical studies as well as clinical studies.…”

Section: See Related Article On Page 909mentioning

confidence: 99%

Editorial Commentary: All-Inside Anterior Cruciate Ligament Reconstruction: In Pursuit of Ideal Graft Fixation

Geeslin¹

2019

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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With evolution of techniques in orthopaedic surgery, incremental improvements can be anticipated. All-inside anterior cruciate ligament (ACL) reconstruction represents a revolution in treatment of ACL injuries, and further technical modifications may result in gradual improvements. This process of continual optimization of our techniques is important for providing the best possible surgical outcomes. Supplemental fixation of the inner graft limbs may lead to improved time-zero biomechanical performance when all-inside ACL reconstruction is performed. However, in ACL surgery, optimal graft selection and fixation are still debated.

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All-inside ACL reconstruction: How does it compare to standard ACL reconstruction techniques?

Cited by 56 publications

References 47 publications

All-inside technique in ACL reconstruction: mid-term clinical outcomes and comparison with AM technique (Hamstrings and BpTB grafts)

All-inside technique in ACL reconstruction: mid-term clinical outcomes and comparison with AM technique (Hamstrings and BpTB grafts)

Biomechanical Comparison of Graft Preparation Techniques for All-Inside Anterior Cruciate Ligament Reconstruction

Editorial Commentary: All-Inside Anterior Cruciate Ligament Reconstruction: In Pursuit of Ideal Graft Fixation

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