Dr. Ishwar Bohra

Dr. Ishwar Bohra
Sr. Consultant
BLK Centre for Orthopaedics,
Joint Reconstruction
& Spine Surgery
BLK Super Speciality
Hospital, New Delhi

A Boon for the Bone

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.