Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique

Abstract

PurposeTo compare the “all‐inside technique” for anterior cruciate ligament (ACL) reconstruction using a short, quadrupled semitendinosus tendon (ST4) autograft and suspensory cortical fixation on both the femoral and tibial side vs the “conventional technique” using a semitendinosus/gracilis (ST/G) autograft fixed with a suspensory device on the femoral side and with an interference screw on the tibial side, in terms of clinical and functional outcomes. MethodsA total of 90 patients were enrolled, randomised into two groups, and prospectively followed. Group A comprised 45 patients treated with the all‐inside technique and Group B included 45 patients treated with the conventional ACL technique (55 males, 35 females; mean age 28.7 ± 11.3 years). Patients completed the Lysholm knee score, the International Knee Documentation Committee (IKDC) score, the Knee Injury and Osteoarthritis Score (KOOS), and the Knee Society Score (KSS) preoperatively and at 2 years postoperatively. Anterior tibial translation measurement (KT‐1000 arthrometer) and isokinetic testing of the operative vs non‐operative limb were also conducted and the limb symmetry index (LSI) was determined. ResultsAt 24 months, the Lysholm, IKDC, KOOS, and KSS scores between the two groups were similar (n.s.). Anterior tibial translation between the operative and non‐operative knee was also similar among the two groups (n.s.). Patients of Group A had significantly higher mean LSIs in terms of flexor peak torque (1.0 ± 0.1 vs 0.9 ± 0.1; p < 0.001), time‐to‐peak (0.9 ± 0.1 vs 0.8 ± 0.1; p < 0.001) and total work (0.9 ± 0.1 vs 0.8 ± 0.1; p < 0.001) at 180°/s, and significantly better mean LSI for isometric flexor/extensor ratio at 90° (1.1 ± 0.3 vs 0.8 ± 0.2; p < 0.001). ConclusionThe all‐inside ACL reconstruction with an ST4 autograft and cortical button fixation on both ends is a viable alternative to the conventional technique. It affords preservation of knee flexor strength, which is of advantage, especially when treating athletes with ACL injury. Level of evidenceI.

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

“…Since both the semitendinosus and gracilis tendon function both as knee exors and tibial internal rotators, harvest causes weakness of internal tibial rotation. Both Kouloumentus et al and Monaco et al had stated that the improved exion strength in the group of patients who underwent all-inside ACLR could be attributed to the gracilis-sparing technique (3,4), and it is bene cial to functional activity or sports with high demands on hamstring muscle strength (25).…”

“…The methodological quality of the RCTs was evaluated with the Jadad score. One study (3), clearly mentioning the method for randomization, appropriate blinding, and the withdrawal of patients from follow-up, scored ve points. Two studies (12,14) scored 3 points with all randomization, blinding, and withdrawals documented; however, the detailed method of randomization and blinding was not mentioned.…”

“…In autologous graft selection, six studies (3,14,(16)(17)(18)(19) used quadrupled semitendinosus tendon (ST4) in the all-inside group and double gracilis and semitendinosus tendon (DGST) in the full tibial tunnel group; one study did not clearly mention the autologous tendon graft donor site (15). All the studies mentioned the suspensory cortical button graft xation device was used on both the femoral and tibial side in the allinside group of patients.…”

“…All the studies mentioned the suspensory cortical button graft xation device was used on both the femoral and tibial side in the allinside group of patients. However, for the full tibial tunnel ACLR groups, three studies (3,16,18) used femoral side cortical button xation with tibial side interference screw xation, and the other four studies mentioned interference screw graft xation on both sides. The details of xation device choice are shown in Table 1.…”

“…Flexion strength was investigated by Kouloumentas et al and Monaco et al Both these studies stated that better exion strength was noted in the group of patients treated with all-inside ACLR (3,4). Although the data from the two studies could not be pooled due to different evaluation methods of exion strength, the studies stated that preservation of the gracilis tendon might be associated with minor donor site morbidity and better exion strength recovery.…”