Printer-friendly format

The anterior cruciate ligament (ACL) is the most important ligament in the knee for knee stability. Because knee stability is critical for pivoting and cutting sports, ACL tears are dreaded injuries for athletes. ACL tears necessitate surgery to restore stability to these knees.

ACL surgery requires the replacement of the ACL with a tendon graft. Thus, it is termed ACL reconstruction. These tendon grafts can be harvested from the patients' knees (autografts) or cadaveric grafts (allografts) can be utilized. ACL reconstruction has seen an evolution over the last several decades. Initial procedures were open knee procedures. Arthroscopic advancements allowed the procedures to become less invasive. But these procedures have still been quite painful and have involved lengthy recuperations. A new procedure brings the promise of less pain and scarring. This most minimally invasive ACL surgery is termed All-Inside ACL Reconstruction.

In order to understand all-inside ACL surgery, a brief discussion of traditional ACL techniques is warranted. To accomplish anatomic replacement of the ACL with a tendon graft, it has been necessary to drill a socket in the femur at the origin of the ACL. This socket would be the same diameter as the ACL graft. The ACL graft is inserted into this socket and then securely fixed to this origin with a variety of fixation devices. Then, a tunnel is drilled in the proximal tibia from the outer tibial cortex and into the knee joint. This requires a small yet formal incision. This tunnel exits at the insertion of the ACL on the tibia. The tendon graft is then tensioned and securely fixed on the tibia.

A significant source of pain in ACL surgery can be related to this full tibial tunnel that is drilled. This tunnel violates the tibial cortex by drilling a hole in it that is often eight to ten millimeters in diameter. The reason that this may cause a great deal of pain is that the periosteum over the area is sensitive, a formal incision through the overlying tissues is required and the violation of the tibial cortex is similar to a fracture. These issues have been negated by the development of all-inside ACL reconstruction.

With all-inside ACL reconstruction, a full tibial tunnel is not created. Rather, a special reamer has been designed to allow creation of a tibial socket. This socket begins in the joint and stops short of coursing through the tibial cortex. An array of special instrumentation has been developed to accomplish this completely arthroscopic ACL reconstruction. The procedure requires no formal incisions. It requires only three to four small arthroscopy incisions. These are typically five to seven millimeters in diameter.

The advantages of all-inside ACL reconstruction are several. First, the surgery may be less painful than previous ACL reconstruction techniques. The reasons include the lack of violation of the tibial cortex with a large diameter tunnel, the minimal violation of the overlying tibial periosteum and the absence of a formal incision. Second, the instrumentation designed can facilitate a more predictably anatomic ACL reconstruction. Last, all-inside ACL reconstruction is the most cosmetic ACL surgery available. The result looks as if the person had a simple knee arthroscopy.

The disadvantage of all-inside ACL reconstruction is the added technical difficulty and learning curve. Because of this, the author and other all-inside ACL pioneers regularly teach sports medicine orthopaedic surgeons throughout the United States the technique in lecture and cadaver lab settings. To evaluate all-inside ACL reconstruction in an evidence based manner, the author is currently participating in a multicenter prospective, randomized trial comparing all-inside ACL reconstruction and standard ACL reconstruction. The author is also planning a new randomized study specifically evaluating postoperative pain after all-inside ACL reconstruction.

In summary, all-inside ACL reconstruction is a new and advanced arthroscopic technique that provides the least invasive approach to ACL reconstruction to date. It offers anatomic ACL reconstruction, lesser postoperative pain and great cosmesis.



Randy S. Schwartzberg, M.D., attended the University of Michigan for his undergraduate education. He earned his medical degree from the University of Florida College of Medicine. After medical school, Dr. Schwartzberg completed his orthopaedic surgery residency in Orlando. Following his residency program, Dr. Schwartzberg pursued his subspecialty interests in sports medicine and engaged in sports medicine training and fellowship training at the American Sports Medicine Institute in Birmingham, Alabama. Dr. Schwartzberg's commitment to sports medicine extends into academics. He is the Director of Sports Medicine Education for the Orlando Health orthopaedic surgery residency program and he gives frequent sports medicine presentations to physicians as well as other health care professionals. Dr. Schwartzberg is a member of the American Academy of Orthopaedic Surgeons, the American Orthopaedic Society of Sports Medicine, Arthroscopy Association of North America, the National Athletic Trainers' Association and the Athletic Trainers' Association of Florida. He is board certified in orthopaedic surgery and board certified in sports medicine. He specializes in sports medicine, knee and shoulder injuries at Orlando Orthopaedic Center. The 15 physician orthopaedic group at Orlando Orthopaedic Center is ready to meet your needs with 5 locations throughout central Florida.

Tags:

None

Login and voice your opinion!