All-Inside Anterior Cruciate Ligament Reconstruction—A Systematic Review of Techniques, Outcomes, and Complications

Abstract

The all-inside technique (AIT) for anterior cruciate ligament reconstruction (ACLR) is gaining popularity as a more anatomic, less invasive, technique with the potential for more rapid recovery. This systematic review aims to critically assess components of the technique, its safety profile, outcomes, and complications. PUBMED, EMBASE, and MEDLINE were searched for studies discussing primary ACLR using the AIT. Article screening, quality assessment, and data abstraction were completed in duplicate, and a minimal clinically important difference (MCID) was used to frame the descriptive results in a clinically significant context. A total of 13 studies satisfied the inclusion criteria. Five-hundred twenty six patients (mean age 31.9 ± 5.9 years) underwent ACLR using the AIT. The mean follow-up was 18.2 ± 7.7 months. Graft choice included autograft (73.8%) and allograft (26.2%). Drilling techniques for femoral sockets were outside-in (53.4%) and through the anteromedial portal (35.4%), whereas tibial sockets were drilled outside-in (35.0%) and through the superomedial portal (3.8%). The rehabilitation protocol had an immediate focus on obtaining full knee extension, jogging permitted 2 to 4 months postoperatively in 61.5% of studies, and return to cutting and pivoting sports 6 to 9 months postoperatively in 69.2% of studies. A MCID was reached for subjective International Knee Documentation Committee scores at 6, 12, and 24 months follow-up and Lysholm knee score at 24 months follow-up. An improvement in outcomes was most notably between 6 and 12 months postoperatively. There was a total of 31 complications (5.89%) and included graft rerupture (2.47%), loss of extension of 1° to 10° (1.14%), and cartilage or meniscus injuries on the operated knee (0.760%). Complications related to the surgical technique were not reported. The AIT for ACLR shows potential as a minimally invasive approach given the low graft failure rates and short-term improvements in knee function and stability, pain and patient important outcomes from this approach. Comparative studies with large sample sizes and a long-term follow-up are required to assess the proposed advantages of this technique. This is a Level IV study.

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

“…The KT-1000 allows objective evaluation of the anterior cruciate ligament laxity. Measurements we obtained after surgical reconstruction of the ACL (mean 3.1 ± 1.0 mm) were consistent with major studies in the literature [27,30,31]. However, it is difficult to compare our data with the ones reported in the literature: very few works describe the procedure and N force applied during the test.…”

Is all-inside with suspensory cortical button fixation a superior technique for anterior cruciate ligament reconstruction surgery? A systematic review and meta-analysis

“…A previous systematic review by de Sa et al in 2018 had reported a low graft failure rate and ideal clinical improvement using the all-inside ACLR technique. However, the review focused on compiling the reported outcomes from individual studies rather than the comparison between different surgical methods [5].…”

Is all-inside with suspensory cortical button fixation a superior technique for anterior cruciate ligament reconstruction surgery? A systematic review and meta-analysis

“…However, whether the all-inside technique is superior to conventional full tibial tunnel ACLR remains controversial. A previous systematic review reported the satisfactory clinical outcome of allinside ACLR, but few have described its comparison with the full tibial tunnel method (5). The present systematic review and meta-analysis aimed to compare surgical outcomes between all-inside ACLR using suspensory cortical button fixation with full tibial tunnel ACLR with regard to function, knee stability, graft failure, and further bone tunnel widening.…”