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

Knee Surg Sports Traumatol Arthrosc. 2019 Nov;27(11):3592-3598. doi: 10.1007/s00167-019-05456-9. Epub 2019 Mar 19.


Purpose: To 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.

Methods: A 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.

Results: At 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).

Conclusion: The 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 evidence: I.

Keywords: All-inside; Anterior cruciate ligament reconstruction; Cortical button fixation; Short graft.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Adolescent
  • Adult
  • Anterior Cruciate Ligament Injuries / physiopathology
  • Anterior Cruciate Ligament Injuries / surgery*
  • Anterior Cruciate Ligament Reconstruction / adverse effects
  • Anterior Cruciate Ligament Reconstruction / methods*
  • Female
  • Femur / surgery
  • Follow-Up Studies
  • Hamstring Tendons / transplantation*
  • Humans
  • Joint Instability / diagnosis
  • Knee / physiology*
  • Lysholm Knee Score
  • Male
  • Muscle Strength / physiology*
  • Osteoarthritis, Knee / diagnosis
  • Postoperative Complications / diagnosis
  • Prospective Studies
  • Tibia / surgery
  • Torque
  • Transplantation, Autologous
  • Young Adult