All-inside anterior cruciate ligament reconstruction: Second-generation minimally invasive anterior cruciate ligament reconstruction

Chapter synopsis

Important points

• An essential advantage of this all-inside GraftLink technique is the ability to retension the graft intraoperatively after final fixation. Specifically, this is done with the shortening strands of the ALD both on the femoral and tibial sides after putting the knee through a full range of motion and stressing the graft. In turn, this eliminates any creep in the construct to provide ultimate ACL stability.

• Since the all-inside construct is inherently shorter, the semitendinosis alone provides adequate graft length, thereby leaving the gracilis intact.

• It is a flexible procedure as the femoral socket can easily be performed either with medial portal drilling or outside in. Also, the all-inside technique can be done easily with a soft tissue quadriceps tendon graft, or an allograft if preferred.

Indications

• Primary or revision ACL reconstruction. It would be amendable to a double bundle construct if so desired utilizing the gracilis tendon as an autograft or a soft tissue allograft, if preferred, prepared the same way for a second all-inside graft bundle.

Contraindications

• Avoid a revision scenario with significantly large residual ACL femoral and tibial tunnels which could compromise graft incorporation without supplemental bone grafting.

Clinical and surgical pearls

• It is straightforward to pass the graft into the femur and not use intraoperative x-ray to confirm the ALD suspensory button “has flipped”. To do so, measure the intraosseous distance of the femur drilling outside-in off the drill guide, or off the calibrated spade pin when drilling the femur from the anteromedial portal. Mark this distance with methylene blue on the ALD shortening strands from the back end of the suspensory button. When passing the graft, at the point the methylene blue line hits the aperture of the femoral socket, the button will flip on the femoral cortex frequently with a jump. Also, pull the femoral passing sutures of the ALD toward the opposite knee as you pull back on the tibial end of the graft to fully seat on the lateral femur.

Clinical and surgical pitfalls

• We highlight the importance of the intraarticular measuring device. It is critical with the all-inside technique to not “bottom-out” your graft by not allowing enough room in the femoral and tibial sockets for tensioning. The surgeon needs to know the depth of the femoral and tibial sockets and the intraarticular distance between them via the measuring device, and make sure the total distance is at least 5–7 cm longer than the length of your graft. In this way, it can be retensioned upon completion and not “bottom out” on one end and in turn be lax.

Video available

• Video 86.1 : All-inside anterior cruciate ligament quadrupled semitendinosus.