No difference at two years between all inside transtibial technique and traditional transtibial technique in anterior cruciate ligament reconstruction

Editorial Commentary: All-Inside Anterior Cruciate Ligament Reconstruction Produces Excellent Results: Adjustable Cortical Suspensory Fixation Provides Rigid Tibial Fixation for All Ages

All-inside anterior cruciate ligament (ACL) reconstruction is the most minimally invasive ACL reconstruction technique available. Systematic review and meta-analysis show equally excellent outcomes for all-inside ACL reconstruction as compared with full tibial tunnel ACL reconstruction. Advantages of the all-inside technique may include improved tibial side fixation, improved stability, less tunnel widening, improved cosmesis, and less postoperative pain. Interference screw fixation using a full tibial tunnel technique can be complicated by inferior proximal tibial bone density. All-inside ACL reconstruction preserves the integrity of the tibial cortex and lends itself to cortical suspension fixation. Given modern adjustable suspensory cortical fixation and excellent clinical outcomes, surgeons should consider all-inside ACL reconstruction as a primary ACL reconstruction technique.

All-Inside Anterior Cruciate Ligament Reconstruction Had Clinical Outcome Similar to the Transtibial Technique Except for Improved Side-to-Side Difference and Tegner Activity Scale: A Systematic Review and Meta-Analysis

PURPOSE

To compare clinical outcomes of the all-inside technique with the transtibial technique in anterior cruciate ligament reconstruction based on available literature on this topic.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist, we conducted a systematic search for randomized controlled trials and cohort studies. Our comprehensive search encompassed PubMed, Embase, Cochrane Library, and Web of Science. We included randomized controlled trials (RCTs) and cohort studies that compared the 2 techniques with a minimal 1-year follow-up. Two independent authors assessed RCTs using the risk of bias tool developed by the Cochrane Collaboration and evaluated the quality of cohort studies using the Newcastle-Ottawa Scale for Assessing the Quality of Nonrandomized Comparative Trials. The subjective and objective outcomes, complications, and graft failure were obtained. R software was used to perform the analysis.

RESULTS

The present analysis enrolled 9 RCTs (n = 687) and 11 cohort studies (n = 910). After a minimal 1-year follow-up in RCTs, functional outcomes such as International Knee Documentation Committee (IKDC) subjective score, Lysholm score, Tegner activity scale, Knee Society Score, and hop test were found to be similar between 2 techniques. The laxity outcomes, including the IKDC objective grade and pivot-shift test, were suggested to be comparable. There was a significant difference favoring the transtibial technique in terms of side-to-side difference (P = .04; 95% confidence interval [CI], 0.08-0.90). The pooled data from cohort studies indicated equivalent results in terms of IKDC subjective score, Lysholm score, side-to-side difference, IKDC objective grade, complications, and graft failure, with the exception of statistical difference in the Tegner activity scale (P = .03; 95% CI, -0.50 to -0.04).

CONCLUSIONS

Our findings suggest that there is no difference in most outcome scores between the all-inside and transtibial techniques for anterior cruciate ligament reconstruction. There are statistically significant differences in side-to-side difference and Tegner activity scale favoring the all-inside technique.

LEVEL OF EVIDENCE

Level IV, meta-analysis of Level I to IV studies.

Comparative study of functional outcomes of arthroscopic anterior cruciate ligament reconstruction using anteromedial portal and translateral all-inside technique

Background

Anterior Cruciate Ligament (ACL) injuries are common in the active population of the Armed Forces. Symptomatic instability prompts individuals to seek a cure or a sheltered appointment. Despite the increasing numbers of ACL reconstructions performed, the outcomes have not been so spectacular with only a meager percentage of our patients returning to preinjury levels of activity. With the premise that an all-inside ACL reconstruction is likely to result in better functional outcomes, the aim of this study was to compare the short-term functional outcomes of a large consecutive series of patients undergoing ACL reconstruction using the translateral all-inside ACL reconstruction technique (AI) and standard anteromedial portal technique (AM) with a minimum follow-up of one year.

Methods

A total of 240 patients with isolated ACL tear underwent ACL reconstruction via the AI or AM technique. Their preoperative and postoperative scores were compared to look for any significant differences in functional outcomes.

Results

The two groups were matched for age, BMI, mechanism of injury, and interval from injury to surgery. There was no difference in their preoperative scores. Postoperatively, although there were significant improvements across both groups, there was no significant difference between the groups at any point of time.

Conclusion

The AI technique has garnered interest in recent literature in addressing ACL injuries. This study found no discernible benefit of the AI technique when compared to the AM technique in terms of functionality following an ACL reconstruction at any point of time up to 1 year following surgery.

All-inside versus complete tibial tunnel techniques in anterior cruciate ligament reconstruction: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

All-inside anterior cruciate ligament reconstruction (ACLR) is a novel technique that has gained attention due to its minimally invasive. However, evidence surrounding the efficacy and safety between all-inside and complete tibial tunnel ACLR are lacking. Present work was aimed to compare clinical outcome for ACLR performed with an all-inside versus a complete tibial tunnel technique.

METHODS

Systematic searches were conducted of published literature on PubMed, Embase, and Cochrane for studies according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines up to May 10, 2022. The outcomes included KT-1000 arthrometer ligament laxity test, International Knee Documentation Committee (IKDC) subjective score, Lysholm score, Tegner activity scale, and Knee Society Score (KSS) Scale, and tibial tunnel widening. Complications of interest extracted were graft re-ruptures and evaluated the graft re-rupture rate. Data from published RCTs meeting inclusion criteria were extracted and analyzed, and all the extracted data are pooled and analyzed by RevMan 5.3.

RESULTS

A total of 8 randomized controlled trials involving 544 patients (consisting of 272 all-inside and 272 complete tibial tunnel patients) were included in the meta-analysis. We found clinical outcomes (International Knee Documentation Committee [IKDC] subjective score: mean difference [MD], 2.22; 95% CI, 0.23-4.22; p = 0.03; Lysholm score: MD, 1.09; 95% CI, 0.25-1.93; p = 0.01; Tegner activity scale: MD, 0.41; 95% CI, 0.11-0.71; p < 0.01; Tibial Tunnel Widening: MD = - 1.92; 95% CI, - 3.58 to - 0.25; p = 0.02; knee laxity: MD = 0.66; 95% CI, 0.12-1.20; p = 0.02; and graft re-rupture rate: RR, 1.97;95% CI, 0.50-7.74; P = 0.33) in the all-inside and complete tibial tunnel group. The findings also indicated that all-inside may be more advantageous in tibial tunnel healing.

CONCLUSION

Our meta-analysis indicated that the all-inside ACLR was superior to complete tibial tunnel ACLR in functional outcomes and tibial tunnel widening. However, the all-inside ACLR was not entirely superior to complete tibial tunnel ACLR in knee laxity measured, and graft re-rupture rate.

Short graft anterior cruciate ligament reconstruction: Current concepts

Short graft anterior cruciate igament reconstruction is increasing in popularity for performing a primary ACLR. The short graft coupled with the all-inside technique using closed sockets and suspensory fixation at both femoral and tibial ends are its defining features. The outcomes of this technique have been comparable to well established transportal ACLR techniques. It has the benefits of preserved hamstring strength and less pain attributed to transtibial drilling. However, there is a learning curve involved and will require time before mastery of the technique. Furthermore, in combined osteotomy or multiligament surgery, the use of short graft anterior cruciate ligament reconstruction with sockets preserve bone stock and the single tendon harvest spares the other tendons for use in other ligament reconstruction.

TOTAL ARTHROSCOPIC RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT

ABSTRACT Introduction: Total internal arthroscopic anterior cruciate ligament reconstruction is one of the new technologies in recent years. The main advantage is the need for only one tendon for the surgical procedure. Objective: Compare the clinical effects of total internal and traditional anterior cruciate ligament reconstruction techniques. Methods: From January 2019 to January 2022, the clinical data of 45 patients with anterior cruciate ligament reconstruction were retrospectively analyzed, including 32 males and 13 females aged 18-33 years, mean of 24.2 ± 3.3 years. Total internal reconstruction was performed in 22 cases (total internal group) and traditional reconstruction in 23 cases (traditional group). The two groups recorded and compared the time of injury, duration of surgical procedure, postoperative VAS score, and recovery of knee function. The International Knee Literature Committee (IKDC) and the Lysholm scoring system were used to evaluate clinical efficacy. Results: 45 patients were followed for 14 to 18 months, mean (15.4 ± 1.3) months. There were no significant differences between the two groups in time between operation and injury, duration of operation, IKDC, and Lysholm score of the affected knee at the last follow-up. However, there were significant differences in the VAS score on day one, day three, day seven, two weeks, and one month after the operation (P < 0.05), with no significant difference at three months, six months, and one year after the operation. Conclusion: The effect of total internal reconstruction of the anterior cruciate ligament is equivalent to that of traditional methods, with less postoperative pain, making it the ideal choice for this treatment. Level of evidence II; Therapeutic studies - investigation of treatment outcomes.

Simultaneous Arthroscopic Anterior Cruciate Ligament Reconstruction Using Double Suspensory Technique and Medial Open-Wedge, High Tibial Osteotomy

Anterior cruciate ligament reconstruction (ACLR) is generally performed regardless of knee malalignments. However, there are some indications for either staged or simultaneous ACL reconstruction and realignment procedures, such as high tibial osteotomy (HTO). Simultaneous HTO-ACL reconstruction has the apparent benefit of a single surgical procedure with a faster recovery than a staged procedure, and it produces good clinical outcomes. Several techniques have been described for simultaneous ACLR and medial open wedge HTO. The tibial tunnel preparation and graft fixation are the most challenging part of the procedure. Recent studies on comparison of fixation of tibial tunnel graft using suspensory fixation versus bioabsorbable screws have shown superior results of more bone preservation and less graft rupture. We assumed suspensory fixation on the tibial side with bone preservation might be more reliable in patients who received ACLR and open wedge HTO at the same time. Therefore, we described our technique of simultaneous open-wedge HTO and ACLR using double suspensory graft fixation.

Comparative Results of Anterior Cruciate Ligament Reconstruction with Full Tibial Tunnel: Quadrupled Semitendinosus Suspensory Femoral and Tibial Fixation versus Quadrupled Semitendinosus and Gracilis Suspensory Femoral and Tibial Screw and Staple Fixation

This study compared the clinical outcomes of patients treated with described "modified all-inside" anterior cruciate ligament reconstruction (ACLR) technique with those of patients treated with suspensory femoral fixation and a bioabsorbable tibial interference screw with the ACLR technique. From 2017 to 2019, 98 patients who underwent ACLR surgery by two surgeons using either of the techniques were included in this study. Patients in group 1 were treated with the "modified all-inside" ACLR technique. In this technique, only the semitendinosus tendon was harvested as a four-strand graft and fixed to the tibia and femur with suspensory buttons. Patients in group 2 were treated with suspensory femoral fixation and a bioabsorbable tibial interference screw ACL reconstruction technique. Patients' functional outcomes were evaluated by the Lysholm score, Tegner activity scale, and International Knee Documentation Committee (IKDC) subjective score. Postoperative knee stability of the patients was evaluated using the Lachman test and the pivot-shift test. The mean ages of the patients were 31.1 (16-55) and 28.7 (18-48) years in groups 1 and 2, respectively. The average follow-up durations were 26 (20-30) and 25.9 (22-30) months for both groups. There was no significant difference between the preoperative and postoperative Lysholm's score, Tegner's activity score, and IKDC subjective score in groups 1 and 2. There were no major complications or reruptures in either group. ACLR incorporating the "modified all-inside" ACLR technique obtained significant clinical outcomes compared to ACLR with a suspensory femoral fixation and a bioabsorbable tibial interference screw.

Post-Operative Results of ACL Reconstruction Techniques on Single-Leg Hop Tests in Athletes: Hamstring Autograft vs. Hamstring Grafts Fixed Using Adjustable Cortical Suspension in Both the Femur and Tibia

Background and Objectives: Anterior cruciate ligament (ACL) tears are common injuries in the athletic population, and accordingly, ACL reconstruction (ACLR) is among the most common orthopedic surgical procedures performed in sports medicine. This study aims to compare the semitendinosus/gracilis (ST/G) and ACL hamstring grafts fixed using adjustable cortical suspension in both the femur and tibia (MAI) ACLR techniques. We aimed to compare the results of single-leg hop tests (SLHT) applied in different directions and limb symmetry indices (LSI) in athletes with a 6-month post-operative ACLR history. Materials and Methods: A retrospective cohort of 39 athletes from various sports branches who underwent MAI (n = 16) and ST/G (n = 23) ACLR techniques by the same surgeon were evaluated. The knee strength of the participants on the operated and non-operated sides was evaluated with five different SLHTs. The SLHT included the single hop for distance (SH), triple hop for distance (TH), crossover triple hop for distance (CH), medial side triple hop for distance (MSTH), and medial rotation (90°) hop for distance (MRH). Results: There was a significant improvement in the mean Lysholm, Tegner, and IKDC scores in the post-operative leg for both techniques (p < 0.05) compared to the pre-operative levels. When there was a difference between the SH of the operative and the non-operative legs in the ST/G technique (p < 0.05), there was no significant difference in the other hop distance for both ST/G and MAI (p > 0.05). There was no difference between the techniques regarding the LSI scores. Conclusions: The fact that our research revealed similar LSI rates of the SLHTs applied in different directions in the ST/G and MAI techniques assumes that the MAI technique can be an ACLR technique which can be functionally used in athletes.

A Comparison of Two-Year Anterior Cruciate Ligament Reconstruction Clinical Outcomes Using All-Soft Tissue Quadriceps Tendon Autograft With Femoral/Tibial Cortical Suspensory Fixation Versus Tibial Interference Screw Fixation

PURPOSE

To contribute to future quadriceps tendon harvest and fixation guidelines in the setting of anterior cruciate ligament reconstruction by comparing 2-year patient-reported subjective knee outcome scores and incidence of graft-related complications between the shorter harvest all-inside tibial-femoral suspensory fixation (TFSF) approach versus the longer harvest standard tibial interference screw fixation technique.

METHODS

Patients who underwent primary anterior cruciate ligament reconstruction with all soft tissue quadriceps tendon autograft from January 2017 to May 2019 were identified for inclusion. Patients were matched into 2 cohorts of 62 based on reconstruction technique. All patients completed baseline and minimum 2-year International Knee Documentation Committee, Tegner Activity Level, and Lysholm questionnaires and were queried regarding subsequent procedures and complications to the operative knee.

RESULTS

Average graft length for the all-inside TFSF was 69.55 (95% confidence interval 68.99-70.19) mm versus 79.27 (95% confidence interval 77.21-81.34) mm in the tibial screw fixation cohort (P = .00001). Two-year Lysholm scores were greater in the TFSF cohort (P = .04) but were not clinically significant. There was no difference in 2-year International Knee Documentation Committee (P = .09) or Tegner (P = .69) scores between cohorts, but more patients in the TFSF cohort returned to or exceeded their baseline activity level compared with the tibial screw fixation cohort (73% vs 61%, P = .25). Seven patients in the TFSF cohort versus 13 in the tibial screw fixation cohort reported anterior knee pain or kneeling difficulty (P = .22). There were no differences in reported complications.

CONCLUSIONS

All-inside soft-tissue quadriceps tendon autograft with TFSF resulted in clinically comparable subjective outcome scores at 2 years to tibial screw fixation. There were also no differences in complications or reports of anterior knee pain or kneeling difficulty. All-inside TFSF can be a viable alternative to tibial screw fixation for all-soft tissue quadriceps autograft.

LEVEL OF EVIDENCE

III, comparative therapeutic trial.

Transportal versus all-inside techniques of anterior cruciate ligament reconstruction: a systematic review

Background

Transportal (TP) and all-inside techniques (AIT) are the most commonly used anterior cruciate ligament (ACL) reconstruction procedures in current clinical practice. However, there is an ongoing debate over which procedure is superior. Therefore, the purpose of this systematic review was to evaluate and compare the clinical outcomes and complications of these two techniques to propose recommendations for future application. Our primary hypothesis was that AIT is a superior ACLR technique compared to TP.

Methods

A systematic literature review, using PRISMA guidelines, was conducted using PubMed, Medline, Google Scholar, and EMBASE, up to February 2021 to identify studies focusing on AIT and TP techniques of ACL reconstruction. We excluded animal experiments, cadaveric studies, retrospective studies, case reports, technical notes, and studies without quantitative data. Patients’ characteristics, surgical technical features, along with postoperative follow-up and complications were extracted and reported accordingly. Methodological quality of the included studies was assessed using the Modified Coleman Methodology Score (MCMS).

Results

A total of 44 studies were selected for this review, of which four were comparative studies. A total of 923 patients underwent AIT and 1678 patients underwent the TP technique for ACLR. A single semitendinosus graft was commonly used in the AIT compard to combined semitendinosus and gracilis graft in the TP group. The postoperative increase in International Knee Documentation Committee (IKDC), Lysholm, KT-1000, and Short Form-12 (physical and mental) scores were similar in the AIT group and the TP group. Contrastingly, the VAS pain score was significantly lower in the AIT group compared to the TP group. Furthermore, the pooled complication rates from all studies were similar between the two groups (AIT: 54 patients, 8.26% vs. PT: 55 patients, 6.62%). However, the four studies that prospectively compared AIT and TP techniques showed lesser complications in the AIT group than the TP group.

Conclusion

Since the future trend in orthopedic surgery is toward less invasive and patients’ satisfaction with good outcomes, AIT is a good alternative method considering preserving bony tissue and gracilis tendon with less post-operative pain, along with more knee flexor strength and equal outcomes compared to conventional ACL reconstruction surgery.

Level of Evidence II.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02872-x.

Original study: early patient-reported functional outcome of all-inside ACL reconstruction as compared to anteromedial portal technique

BACKGROUND

Anteromedial portal technique (AMP) using hamstring autograft is a popular technique of arthroscopic ACL reconstruction allowing anatomical placement of femoral. In this technique, a cortical suspensory fixation of graft is used on the femoral side and interference screw fixation on the tibial side using a complete bone tunnel. All-inside translateral technique is a recently introduced technique which uses a closed loop of quadrupled semitendinosus graft with an adjustable cortical suspensory fixation on both sides allowing optimum tensioning of graft and near-complete filling of retrosockets created by the flip cutter on both femoral and tibial sides. With its proposed but unproven benefits, our study was planned to compare the two techniques.

METHODS

A total of 80 young active males requiring ACL reconstruction surgery were equally randomized to AMP and All-inside technique. The primary objective of the study was to compare the ability to return to pre-injury level of activity using Tegner activity scale and patient-reported outcome using new Knee Society Score (KSS) at two years of follow-up.

RESULTS

The mean improvement in Tegner score was significantly better (p = 0.0005) in all-inside group (2.34 ± 0.97) as compared to AMP group (1.5 ± 1.30). Among components of new KSS, patient satisfaction was better in all-inside group.

CONCLUSION

All-inside ACL reconstruction provides a better chance of return to pre-injury level of activity with accompanied patient satisfaction as compared to AMP technique at two years of follow-up.

LEVEL OF EVIDENCE

Level I, therapeutic study.

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

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.

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

BACKGROUND

To compare the clinical results of all-inside anterior cruciate ligament reconstruction (ACLR) using suspensory cortical button fixation and full tibial tunnel drilling.

METHODS

Systematic searches were conducted of published literature up to November 2019 on PubMed, Embase, and Cochrane for studies comparing all-inside ACLR using suspensory cortical button fixation and full tibial tunnel ACLR. Two reviewers independently determined eligibility, extracted the outcome data, and assessed the risk of bias of the eligible studies. The clinical outcome and graft reruptures were pooled by using random effects with mean differences and risk ratios for continuous and dichotomous variables, respectively.

RESULT

A total of nine studies (five randomized controlled trials and four comparative studies) involving 613 patients were included in the meta-analysis. The postoperative functional outcome, knee laxity measured with arthrometer, and graft reruptures were comparable between patients with all-inside ACLR using suspensory cortical button fixation and full tibial tunnel ACLR. However, a significantly greater thickness of autologous tendon was used and less change in drilling tunnel diameter was noted in patients with suspensory cortical button graft fixation.

CONCLUSIONS

All-inside ACLR with suspensory cortical button fixation was not clinically superior to full tibial tunnel ACLR with interference screw fixation in functional outcomes, knee laxity measured with arthrometer, or rerupture rate. However, the advantage of using suspensory cortical button fixation was that a thicker graft could be used for reconstruction, and brought less tibia tunnel widening compared with bioabsorbable interference screw fixation.

Clinico-radiological outcomes following anatomical anterior cruciate ligament reconstruction using the TransLateral, all-inside technique

We present early clinical outcomes of patients following anatomical anterior cruciate ligament reconstruction using a TransLateral, single bundle, all-inside technique with a one-year follow-up and radiological evaluation of socket position. Eligible Patients who underwent a primary ACL reconstruction, using the TransLateral, all-inside technique alone, between Jan 2013 and Feb 2016 were included in this study. Of this group, all patients underwent isolated semitendinosus graft harvest. The Lysholm knee scores were measured preoperatively and at one-year follow-up in 40 patients who underwent ACL reconstruction. Postoperatively, antero-posterior and lateral radiographs were obtained to evaluate the position of the femoral socket (using the Bernard and Hertel Grid) and tibial socket (using the Amis-Jakob line). There were 36 males and 4 females with a mean age of 27.1 years (range 16-49). There was a single non-surgical related mortality prior to the one year follow up. We report no postoperative infections or graft failure at one year. The mean preoperative Lysholm score was 68.7 (Range: 29-95). The mean Lysholm score increased to 92.5% (Range: 59-100, p < 0.05). Evaluation of femoral sockets revealed accurate positioning on the Bernard and Hertel Grid with a mean ACL center of 27% along Blumensaat's line and 34% of the height of the intercondylar notch. The mean tibial socket position was 41.8% (Range: 32%-47%) along the Amis-Jakob Line. Our single surgeon case series utilizing the all-inside, TransLateral ACLR technique highlights good early outcomes with no postoperative complications or graft failure at one year.

Arthroscopic primary repair of the anterior cruciate ligament in adults: a systematic review

BACKGROUND

The most common procedure to manage a torn anterior cruciate ligament (ACL) is surgical reconstruction. Primary repair of the ACL is returning on the forefront in the management of acute ACL, aiming to be less invasive and preserve the original ligament. Several techniques have been reported; the present systematic review investigates the clinical outcomes of ACL primary repair in adults.

SOURCES OF DATA

Following an electronic search through Medline, Cochrane and Google Scholar databases, articles of interest were retrieved and evaluated, including case series, retrospective studies, case-control studies and randomized controlled trials. The main outcome data were extracted and summarized in tables and text. The methodology of the studies was assessed using the Coleman methodology score (CMS).

AREAS OF AGREEMENT

Of the articles included, one was of level I, two of level III and the remaining of level IV. The direct intraligamentary stabilization technique was the most widely and accurately reported technique, with acceptable success and improvement of functional outcomes. The CMS averaged 58.75 (range 48 to 69), with no significant association with year of publication (Pearson's regression r = -0.397, P = 0.207).

AREAS OF CONTROVERSY

Concerning stump sutures and suture anchors repair, although leading to good results, also in comparison with ACL reconstruction, no sufficient evidence was available to support these techniques.

GROWING POINTS

The overall good results were reported also for other techniques are not supported by adequate evidence. More and better trials are required to improve our knowledge and understanding in this controversial area.

Anterior Cruciate Ligament Reconstruction With Hamstring Autograft: A Matched Cohort Comparison of the All-Inside and Complete Tibial Tunnel Techniques

Background:

Surgical reconstruction of the anterior cruciate ligament (ACL) is one of the most common orthopaedic procedures, with an estimated 100,000 to 175,000 procedures performed annually. Recently, the all-inside reconstruction technique has come into favor and is theorized to be superior to the complete tibial tunnel technique.

Purpose:

To compare clinical and patient-reported outcomes (PROs) for hamstring autograft ACL reconstruction (ACLR) performed with an all-inside versus a complete tibial tunnel technique.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients who underwent hamstring autograft ACLR via either an all-inside approach (femoral and tibial sockets) or a complete tibial tunnel approach (femoral socket and full-length, transtibial tunnel) at a single institution between July 2011 and July 2015 were reviewed. Demographic information, preoperative comorbidities, surgical details, physical examination findings, and follow-up outcomes were extracted from the medical record. Physical examination data included pivot-shift, Lachman, and range of motion examinations, whereas PROs included the Tegner activity scale, Lysholm score, and International Knee Documentation Committee (IKDC) score at a minimum of 2 years after surgery. Return to sport and risk factors for failure were analyzed.

Results:

A total of 82 patients (mean ± SD age, 25.8 ± 10.2 years) who underwent all-inside reconstruction (median PRO follow-up, 30.1 months; range, 24.7-72.9 months) and 54 patients (mean ± SD age, 21.1 ± 7.3 years) who underwent complete tibial tunnel reconstruction (median PRO follow-up, 25.8 months; range, 23.9-74.5 months) met the inclusion criteria. PRO scores at latest follow-up were comparable between the all-inside versus the complete tibial tunnel groups (Lysholm score, 93.8 vs 94.4, P = .621; IKDC score, 93.5 vs 93.3, P = .497; Tegner activity score, 6.4 vs 6.8, P = .048). Complications (including graft failure) were experienced by 20% of patients in the all-inside group compared with 24% in the complete tibial tunnel group (P = .530). Graft failure before the final follow-up was experienced by 10% of patients in the all-inside group compared with 19% in the complete tibial tunnel group (P = .200). Mean return to sport was 12.5 months in the all-inside group versus 9.9 months in the complete tibial tunnel group (P = .028).

Conclusion:

All-inside and complete tibial tunnel hamstring autograft ACLR resulted in excellent physical examination findings and PROs at minimum 2-year follow-up. Both techniques successfully restored knee stability and patient function.

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

The all-inside ACL reconstruction technique is a relatively new development in ACL surgery. Some features of this technique include closed-socket tunnels, dual suspensory graft fixation, decreased bone removal, and smaller skin incisions. The purpose of this review was to compare the unique features of the all-inside ACL versus standard ACL techniques using biomechanical and clinical studies. The all-inside ACL appears to have similar overall results on subjective and objective outcomes studies compared to standard ACL techniques and may be associated with decreased post-operative pain. There is also a concern for a higher graft failure rate with the all-inside ACL.