Dr. Ishwar Bohra
Sr. Consultant
BLK Centre for Orthopaedics,
Joint Reconstruction
& Spine Surgery
BLK Super Speciality
Hospital, New Delhi
Arthroscopic ACL Reconstruction:
All - Inside Technique
Arthroscopic ACL (Anterior Cruciate Ligament) Reconstruction has
witnessed tremendous innovation in the recent years. With the advent
of cutting edge technology and newer surgical techniques, patients
can now expect better functional results with shorter rehabilitation
periods.
One such promising development in ACL surgery is the ‘all-inside ACL
Reconstruction’ technique. It was originally described over twenty
years ago by Lubowitz et al. This technique features several unique
components including closed-socket tunnels with less bone removal,
dual (femoral & tibial) suspensory fixation and smaller skin incisions.
Since closed femoral and tibial sockets are drilled rather than full
tunnels, a decreased graft length is required for the all-inside ACL
technique. Hence, a single hamstring tendon harvest provides sufficient
length to serve as the autograft, tripled or quadrupled with similar
clinical outcomes when compared to standard ACL techniques using
BPTB ( Bone Patellar Tendon Bone) and S-G hamstring grafts.
One of the most unique aspects of all-inside ACL technique is perhaps
the dual suspensory fixation of the semitendinosus graft on both the
femur and tibia. However, there is a lack of biomechanical studies
comparing the functional outcome of the same to that of a single
suspensory fixation. Some of the main concerns with suspensory
fixation in ACL reconstruction are tunnel expansion and the graft
healing process. The two processes may be influenced by the motion of
the grafts within the tunnels, and two potential mechanisms causing
this have been termed the “Windshield-Wiper” and “Bungee Cord”
phenomenon.
The closed sockets of the all-inside ACL technique may offer a protective
effect in this regard. Studies using X-ray and CT imaging have reported
less socket expansion and preserved bone stock compared to full tunnels
seen in standard ACL reconstruction techniques. Closed-sockets are
also associated with reduced incidence of tibial micro-fractures while
drilling and have lesser graft length available for the WindshieldWiper
and Bungee Cord phenomenon compared to full tunnels.
Also, in skeletally immature patients an all-epiphyseal all-inside ACL
technique has been described which greatly decreases the likelihood
of physeal injury. Based on the review of the available literature, the
all-inside ACL technique has superior overall results in subjective
and objective outcome studies and is associated with decreased postoperative
pain. Continued long-term outcome studies and measures to
ease the learning curve for surgeons are vital to helping patients seek
the maximum benefit of this novel surgical technique.