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Short graft anterior cruciate ligament reconstruction: Current concepts

Open AccessPublished:October 03, 2022DOI:https://doi.org/10.1016/j.jisako.2022.09.002

      Abstract

      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.

      Keywords

      Current concepts

      • Short graft anterior cruciate ligament reconstruction (ACLR) is increasingly popular, with more surgeons practising all-inside ACLR techniques.
      • The outcomes of short graft ACLR thus far are comparable to the transportal ACL reconstruction technique, but with additional benefits.
      • The technique can be performed with soft tissue grafts only.
      • The familiarity with the surgical technique, understanding of optimal graft fixation and biology are all paramount to success.

      Future perspectives

      • Prospective clinical studies are required to determine which patient is best suited for short graft anterior cruciate ligament reconstruction and the ideal graft source.
      • Biomechanical and clinical data are required on the most appropriate short graft to be used with this technique.
      • Methods to improve healing of osseous graft interface with the use of biologics or scaffolds should be studied.
      • The most time and cost-efficient as well strongest graft short graft anterior cruciate ligament reconstruction preparation technique should be determined to allow reproducibility amongst surgeons.

      Introduction

      The short graft anterior cruciate ligament reconstruction (SG ACLR), as the name implies, is the use of a shorter graft length to perform an ACLR. Hence, there will be less graft length passed in both the femur and tibia tunnels. The proposed benefit is a larger ACL graft diameter with the same graft tissue [
      • Matzkin E.G.
      • Lowenstein N.A.
      Optimizing outcomes of anterior cruciate ligament (ACL) reconstruction in female athletes: from graft choice to return to sport criteria.
      ,
      • Goyal T.
      • Das L.
      • Paul S.
      • Choudhury A.K.
      • Sethy S.S.
      Outcomes of retro-drilled all-inside tibial tunnel vs complete tibial tunnel techniques in anterior cruciate ligament reconstruction—a comparative study.
      ] and isolated harvest of the semitendinosus tendon. Now, the use of all soft tissue quadriceps tendon (QT) graft has also been increasingly suggested. With the sparing of the gracilis tendon, there is less pain [
      • Lubowitz J.H.
      • Schwartzberg R.
      • Smith P.
      Randomized controlled trial comparing all-inside anterior cruciate ligament reconstruction technique with anterior cruciate ligament reconstruction with a full tibial tunnel.
      ,
      • Schurz M.
      • Tiefenboeck T.M.
      • Winnisch M.
      • Syre S.
      • Plachel F.
      • Steiner G.
      • et al.
      Clinical and functional outcome of all-inside anterior cruciate ligament reconstruction at a minimum of 2 Years' follow-up.
      ,
      • Kyriakopoulos G.
      • Manthas S.
      • Vlachou M.
      • Oikonomou L.
      • Papadakis S.A.
      • Kateros K.
      Anterior cruciate ligament reconstruction with the all-inside technique: equivalent outcomes and failure rate at three-year follow-up compared to a doubled semitendinosus-gracilis graft.
      ], less donor site morbidity and better knee flexion strength compared to when both hamstring tendons are harvested [
      • Kouloumentas P.
      • Kavroudakis E.
      • Charalampidis E.
      • Kavroudakis D.
      • Triantafyllopoulos G.K.
      Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique.
      ,
      • Monaco E.
      • Redler A.
      • Fabbri M.
      • Proietti L.
      • Gaj E.
      • Daggett M.
      • et al.
      Isokinetic flexion strength recovery after ACL reconstruction: a comparison between all inside graft-link technique and full tibial tunnel technique.
      ].
      The all-inside ACLR (AI ACLR) is the most performed SG ACLR technique. This technique involves the unique preparation method of a short graft, the use of femoral or tibial sockets instead of complete tunnels and the use of cortical suspensory fixation at both ends. Other SG ACLR options include the more recent Tape Locking Screw (TLS) technique [
      • Pacull R.
      • Kalk E.
      • Rongieras F.
      • Bertani A.
      • Gras L.-L.
      Anterior cruciate ligament reconstruction with short hamstring grafts: the choice of femoral fixation device matters in controlling overall lengthening.
      ]. The TLS technique is more challenging due to the need for precise determination of tunnel length and graft length which will affect the tension in the graft after reconstruction. Pacull et al. has also shown the TLS fixation has lower ultimate load to failure than other femoral fixation options [
      • Pacull R.
      • Kalk E.
      • Rongieras F.
      • Bertani A.
      • Gras L.-L.
      Anterior cruciate ligament reconstruction with short hamstring grafts: the choice of femoral fixation device matters in controlling overall lengthening.
      ].
      Most authors describe the use of a quadrupled semitendinosus (ST4) or QT in the SG ACLR [
      • de Sa D.
      • Shanmugaraj A.
      • Weidman M.
      • Peterson D.C.
      • Simunovic N.
      • Musahl V.
      • et al.
      All-inside anterior cruciate ligament reconstruction-A systematic review of techniques, outcomes, and complications.
      ]. This review looks at the current state of SG ACLR to discuss the biology, biomechanics, surgical techniques and outcomes of this technique.

      Body

      Classic technique

      The classical AI ACLR technique was described by Lubowitz, Amhad and Anderson [
      • Lubowitz J.H.
      • Amhad C.H.
      • Anderson K.
      All-inside anterior cruciate ligament graft-link technique: second-generation, no-incision anterior cruciate ligament reconstruction.
      ]. They described a ST4 graft with both ends looped over two adjustable loop cortical suspension devices for the femoral and tibial sockets. High strength ultra-high molecular weight polyethylene sutures are used during special graft preparation. The graft diameter is sized and then marked to the lengths of the tibial and femoral sockets (usually 20–25 mm) for guiding the surgeon during graft passage.
      The femoral and tibial sockets are prepared independently. The femoral tunnel is reamed in either an anterograde or retrograde fashion to create a socket, usually between 20 and 25 mm [
      • Lubowitz J.H.
      • Amhad C.H.
      • Anderson K.
      All-inside anterior cruciate ligament graft-link technique: second-generation, no-incision anterior cruciate ligament reconstruction.
      ]. The tibial socket is created using a retrograde reamer. The prepared graft is shuttled into the knee joint through the anteromedial portal with the proximal sutures entering the femoral socket initially. After the cortical suspensory device engages on the lateral femoral cortex, the graft is then advanced into the femoral socket. This process is then repeated on the tibial side. Finally, the graft is tensioned with the knee in near full extension. Several tips and technical considerations that should be taken into account when performing the SG ACLR are shown in Table 1.
      Table 1Tips when performing a SG ACLR.
      If a graft diameter of less than 8.5 mm or a graft length less than 25 mm is obtained after harvesting only the semitendinosus tendon, consider harvesting the gracilis tendon as well
      Measure the graft length accurately. Add 5 mm when reaming femoral and tibial tunnel socket lengths to avoid bottoming out of the graft, leading to a lax graft
      Leave a small amount of muscle on the graft during graft preparation for better healing as it has been shown to contain pluripotential cells
      Use outside-in femoral drilling in adolescent anterior cruciate ligament reconstruction to avoid physeal damage
      Short Graft ACL with concurrent high tibial osteotomy or Short graft ACL in multiligament reconstruction should be considered.

      Discussion

      SG ACLR graft choice

      The ST4 is the most used autograft for SG ACLR [
      • de Sa D.
      • Shanmugaraj A.
      • Weidman M.
      • Peterson D.C.
      • Simunovic N.
      • Musahl V.
      • et al.
      All-inside anterior cruciate ligament reconstruction-A systematic review of techniques, outcomes, and complications.
      ,
      • Yasen S.K.
      • Borton Z.M.
      • Eyre-Brook A.I.
      • Palmer H.C.
      • Cotterill S.T.
      • Risebury M.J.
      • et al.
      Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction.
      ,
      • Lowenstein N.A.
      • Haber D.B.
      • Ostergaard P.J.
      • Collins J.E.
      • Matzkin E.G.
      All-inside anterior cruciate ligament reconstruction using quadrupled semitendinosus: comparable 2-year outcomes in male and female patients.
      ]. Females generally have smaller hamstring tendons than their male counterparts [
      • Matzkin E.G.
      • Lowenstein N.A.
      Optimizing outcomes of anterior cruciate ligament (ACL) reconstruction in female athletes: from graft choice to return to sport criteria.
      ]. ACL graft diameter has also been found to be critical. A graft of smaller than 8 mm leads to poorer outcomes and increased risk of graft rupture, especially in young athletes [
      • Goyal T.
      • Das L.
      • Paul S.
      • Choudhury A.K.
      • Sethy S.S.
      Outcomes of retro-drilled all-inside tibial tunnel vs complete tibial tunnel techniques in anterior cruciate ligament reconstruction—a comparative study.
      ]. ST4 grafts have an approximate diameter of 8–9.5 mm [
      • Kouloumentas P.
      • Kavroudakis E.
      • Charalampidis E.
      • Kavroudakis D.
      • Triantafyllopoulos G.K.
      Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique.
      ,
      • Cavaignac E.
      • Marot V.
      • Faruch M.
      • Reina N.
      • Murgier J.
      • Accadbled F.
      • et al.
      Hamstring graft incorporation according to the length of the graft inside tunnels.
      ], compared to about of 7.2–8.5 mm in a four-strand hamstring graft [
      • Cavaignac E.
      • Marot V.
      • Faruch M.
      • Reina N.
      • Murgier J.
      • Accadbled F.
      • et al.
      Hamstring graft incorporation according to the length of the graft inside tunnels.
      ]. Additionally, ST4 SG ACLR also allows for the sparing of the gracilis tendon, which leads to the improved recovery of knee flexion strength and less donor site morbidity [
      • Kouloumentas P.
      • Kavroudakis E.
      • Charalampidis E.
      • Kavroudakis D.
      • Triantafyllopoulos G.K.
      Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique.
      ,
      • Monaco E.
      • Redler A.
      • Fabbri M.
      • Proietti L.
      • Gaj E.
      • Daggett M.
      • et al.
      Isokinetic flexion strength recovery after ACL reconstruction: a comparison between all inside graft-link technique and full tibial tunnel technique.
      ]. Koulomentas et al. [
      • Kouloumentas P.
      • Kavroudakis E.
      • Charalampidis E.
      • Kavroudakis D.
      • Triantafyllopoulos G.K.
      Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique.
      ] and Monaco et al. [
      • Monaco E.
      • Redler A.
      • Fabbri M.
      • Proietti L.
      • Gaj E.
      • Daggett M.
      • et al.
      Isokinetic flexion strength recovery after ACL reconstruction: a comparison between all inside graft-link technique and full tibial tunnel technique.
      ] both reported better knee flexion strength with the AI ACLR reconstruction than the standard ACL reconstruction.
      The choice of ACL graft should be tailored to each individual patient, such as their sporting demand, gender or the presence of ligamentous laxity. There is now an increasing use of the QT as the graft of choice for ACL reconstruction. The ACL registry data from New Zealand show a rise in the use QT grafts since 2019 but they still account for only 6.5% of all primary ACL reconstructions [
      ]. The advantages of the QT graft include consistently sufficient length compatible with SG ACLR. It often has a wide diameter of 10 mm [
      • Sprowls G.R.
      • Robin B.N.
      The quad link technique for an all-soft-tissue quadriceps graft in minimally invasive, all-inside anterior cruciate ligament reconstruction.
      ,
      • Diermeier T.
      • Tisherman R.
      • Hughes J.
      • Tulman M.
      • Baum Coffey E.
      • Fink C.
      • et al.
      Quadriceps tendon anterior cruciate ligament reconstruction.
      ] and can be harvested with or without a bone plug [
      • Diermeier T.
      • Tisherman R.
      • Hughes J.
      • Tulman M.
      • Baum Coffey E.
      • Fink C.
      • et al.
      Quadriceps tendon anterior cruciate ligament reconstruction.
      ]. The reported problems with QT harvest include weakness of knee extension, donor site pain and patella fractures [
      • Diermeier T.
      • Tisherman R.
      • Hughes J.
      • Tulman M.
      • Baum Coffey E.
      • Fink C.
      • et al.
      Quadriceps tendon anterior cruciate ligament reconstruction.
      ].
      The QT can be prepared via a proprietary Graft Link technique using cortical suspensory buttons [
      • Sprowls G.R.
      • Robin B.N.
      The quad link technique for an all-soft-tissue quadriceps graft in minimally invasive, all-inside anterior cruciate ligament reconstruction.
      ]. Galan et al. [
      • Galan H.
      • Escalante M.
      • della Vedova F.
      • Slullitel D.
      All inside full thickness quadriceps tendon ACL reconstruction: long term follow up results.
      ] found good to excellent results at 5 years with QT graft AI ACLR in young athletes. The QT graft is considered an option especially in the female athlete, with increased ligamentous laxity and smaller hamstring tendons [
      • Matzkin E.G.
      • Lowenstein N.A.
      Optimizing outcomes of anterior cruciate ligament (ACL) reconstruction in female athletes: from graft choice to return to sport criteria.
      ]. It exhibits less post-operative pivot shift laxity and can be harvested with reliable dimensions [
      • Diermeier T.
      • Tisherman R.
      • Hughes J.
      • Tulman M.
      • Baum Coffey E.
      • Fink C.
      • et al.
      Quadriceps tendon anterior cruciate ligament reconstruction.
      ]. Traditionally, bone patella tendon bone (BPTB) grafts have been considered as the gold standard in ACL reconstruction [
      • Kouloumentas P.
      • Kavroudakis E.
      • Charalampidis E.
      • Kavroudakis D.
      • Triantafyllopoulos G.K.
      Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique.
      ]. Recent literature comparing QT to BPTB grafts has shown that QT grafts have similar properties to BPTB, but with better ultimate load to failure rates and less anterior knee pain [
      • Galan H.
      • Escalante M.
      • della Vedova F.
      • Slullitel D.
      All inside full thickness quadriceps tendon ACL reconstruction: long term follow up results.
      ,
      • Smith P.A.
      • Cook C.S.
      • Bley J.A.
      All-inside quadrupled semitendinosus autograft shows stability equivalent to patellar tendon autograft anterior cruciate ligament reconstruction: randomized controlled trial in athletes 24 Years or younger.
      ].
      The peroneus longus (PL) tendon has also been considered as an alternative to the hamstring graft for AI ACLR [
      • He J.
      • Tang Q.
      • Ernst S.
      • Linde M.A.
      • Smolinski P.
      • Wu S.
      • et al.
      Peroneus longus tendon autograft has functional outcomes comparable to hamstring tendon autograft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis.
      ]. He et al. [
      • He J.
      • Tang Q.
      • Ernst S.
      • Linde M.A.
      • Smolinski P.
      • Wu S.
      • et al.
      Peroneus longus tendon autograft has functional outcomes comparable to hamstring tendon autograft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis.
      ] in their meta-analysis comparing AI ACLR using PL grafts versus hamstring grafts reported donor site morbidity with the use of PL grafts, with a decrease in American Orthopaedic Foot and Ankle Scores (AOFAS). More studies are required before PL grafts can be considered a regular graft option in the SG ACLR.

      Graft preparation

      The SG ACLR technique demands a unique method of preparation. These grafts are recommended to be a maximum length of 70–75 mm after tensioning [
      • Lubowitz J.H.
      • Amhad C.H.
      • Anderson K.
      All-inside anterior cruciate ligament graft-link technique: second-generation, no-incision anterior cruciate ligament reconstruction.
      ], for fear of bottoming out and the grafts becoming slack when sockets are used. The popular methods of graft preparation include the buried-knot method described by Lubowitz [
      • Lubowitz J.H.
      All-inside anterior cruciate ligament graft link: graft preparation technique.
      ] and the continuous loop method [
      • Tiefenboeck T.M.
      • Hirtler L.
      • Winnisch M.
      • Binder H.
      • Koch T.
      • Komjati M.
      • et al.
      The buried knot technique for all inside graft link preparation leads to superior biomechanical graft link stability.
      ] as seen in Fig. 1. Others have also described alternative methods, for example the Sommerfeldt configuration [
      • Graf-Alexiou L.
      • Karpyshyn J.
      • Baptiste J.J.
      • Hui C.
      • Sommerfeldt M.
      • Westover L.
      Biomechanical strength of all-inside ACL reconstruction grafts using side-to-side and backup fixation.
      ] and the Quad Link technique [
      • Sprowls G.R.
      • Robin B.N.
      The quad link technique for an all-soft-tissue quadriceps graft in minimally invasive, all-inside anterior cruciate ligament reconstruction.
      ].
      Fig. 1
      Fig. 1A – Buried-knot technique of a quadrupled semitendinosus graft preparation described by Lubowitz [
      • Lubowitz J.H.
      • Amhad C.H.
      • Anderson K.
      All-inside anterior cruciate ligament graft-link technique: second-generation, no-incision anterior cruciate ligament reconstruction.
      ], with the dotted lines as cerclage sutures, and both ends of the tendon are whipstitched together and then secured to the tibial loop. B – continuous loop method of a quadrupled semitendinosus graft [
      • Tiefenboeck T.M.
      • Hirtler L.
      • Winnisch M.
      • Binder H.
      • Koch T.
      • Komjati M.
      • et al.
      The buried knot technique for all inside graft link preparation leads to superior biomechanical graft link stability.
      ]. C – the quad link method as described by Sprowls using an all-soft tissue quadriceps tendon graft [
      • Sprowls G.R.
      • Robin B.N.
      The quad link technique for an all-soft-tissue quadriceps graft in minimally invasive, all-inside anterior cruciate ligament reconstruction.
      ]. D – use of both a folded gracilis tendon and quadrupled semitendinosus graft (prepared in the same fashion as described by Lubowitz) to form a 6-strand graft in the event that a quadrupled semitendinosus graft is of insufficient thickness.
      The buried-knot method has consistently shown in biomechanical studies to be able to withstand sufficient forces in the post-surgery ACL period [
      • Barrow A.E.
      • Pilia M.
      • Guda T.
      • Kadrmas W.R.
      • Burns T.C.
      Femoral suspension devices for anterior cruciate ligament reconstruction: do adjustable loops lengthen?.
      ], with an ultimate failure load range of 908 N [
      • Wichern C.R.
      • Skoglund K.C.
      • O’Sullivan J.G.
      • Burwell A.K.
      • Nguyen J.T.
      • Herzka A.
      • et al.
      A biomechanical comparison of all-inside cruciate ligament graft preparation techniques.
      ]. Biomechanical studies have shown that the mode of failure with SG ACLR sutured constructs to mostly be at the cortical suspensory fixation loop [
      • Tiefenboeck T.M.
      • Hirtler L.
      • Winnisch M.
      • Binder H.
      • Koch T.
      • Komjati M.
      • et al.
      The buried knot technique for all inside graft link preparation leads to superior biomechanical graft link stability.
      ,
      • Mayr R.
      • Heinrichs C.H.
      • Eichinger M.
      • Smekal V.
      • Schmoelz W.
      • Attal R.
      Preparation techniques for all-inside ACL cortical button grafts: a biomechanical study.
      ,
      • Richardson M.W.
      • Tsouris N.D.
      • Hassan C.R.
      • Elbayar J.H.
      • Qin Y.X.
      • Komatsu D.E.
      • et al.
      A biomechanical comparison of alternative graft preparations for all-inside anterior cruciate ligament reconstruction.
      ]. Richardson et al. [
      • Richardson M.W.
      • Tsouris N.D.
      • Hassan C.R.
      • Elbayar J.H.
      • Qin Y.X.
      • Komatsu D.E.
      • et al.
      A biomechanical comparison of alternative graft preparations for all-inside anterior cruciate ligament reconstruction.
      ] reported majority of failures at the button loop with the buried-knot technique. This demonstrates the adequate strength of the graft/button implant construct strength via the buried-knot method.
      The considerations for optimal SG ACLR graft preparation are:
      • 1)
        choice of a strong graft preparation method such as the buried-knot method, which has greater ultimate failure loads and less elongation as compared to the continuous loop method [
        • Tiefenboeck T.M.
        • Hirtler L.
        • Winnisch M.
        • Binder H.
        • Koch T.
        • Komjati M.
        • et al.
        The buried knot technique for all inside graft link preparation leads to superior biomechanical graft link stability.
        ];
      • 2)
        secure fixation at the terminal ends of the graft to improve ultimate failure loads, stiffness and elongation [
        • Graf-Alexiou L.
        • Karpyshyn J.
        • Baptiste J.J.
        • Hui C.
        • Sommerfeldt M.
        • Westover L.
        Biomechanical strength of all-inside ACL reconstruction grafts using side-to-side and backup fixation.
        ,
        • Bowes J.
        • Mohamed N.
        • Baptiste J.J.
        • Westover L.
        • Hui C.
        • Sommerfeldt M.
        Biomechanical comparison of graft preparation techniques for all-inside anterior cruciate ligament reconstruction.
        ];
      • 3)
        use of 4 instead of 2 cerclage sutures to around the graft at the tibial and femoral ends which protects against graft elongation [
        • Mayr R.
        • Heinrichs C.H.
        • Eichinger M.
        • Smekal V.
        • Schmoelz W.
        • Attal R.
        Preparation techniques for all-inside ACL cortical button grafts: a biomechanical study.
        ];
      • 4)
        use of a larger suture diameter for graft preparation is recommended to gain better load to failure rates; a Fibrewire No 2 had a mean load to failure of 731 N versus a load to failure of 610 N using Fibrewire No 0 [
        • Tiefenboeck T.M.
        • Hirtler L.
        • Winnisch M.
        • Joestl J.
        • Koch T.
        • Komjati M.
        • et al.
        A bigger suture diameter for anterior cruciate ligament all-inside graft link preparation leads to better graft stability: an anatomical specimen study.
        ];
      • 5)
        consideration for graft augmentation with suture or suture tapes, to achieve load sharing, better ultimate failure loads and to protect from graft elongation [
        • Bachmaier S.
        • Smith P.A.
        • Argintar E.H.
        • Chahla J.
        • Higgins L.D.
        • Wijdicks C.A.
        Independent suture augmentation with all-inside anterior cruciate ligament reconstruction reduces peak loads on soft-tissue graft. A biomechanical full-construct study.
        ].
      Grafts fashioned from the use of two separate tendons such as the semitendinosus and gracilis do not fare better than the methods of QT4 graft preparation. However, the use of two separate tendons can be considered if there is insufficient final graft length or diameter, such as due to accidental graft transection during harvesting. Wichern et al. [
      • Wichern C.R.
      • Skoglund K.C.
      • O’Sullivan J.G.
      • Burwell A.K.
      • Nguyen J.T.
      • Herzka A.
      • et al.
      A biomechanical comparison of all-inside cruciate ligament graft preparation techniques.
      ] and Richardson et al. [
      • Richardson M.W.
      • Tsouris N.D.
      • Hassan C.R.
      • Elbayar J.H.
      • Qin Y.X.
      • Komatsu D.E.
      • et al.
      A biomechanical comparison of alternative graft preparations for all-inside anterior cruciate ligament reconstruction.
      ] have demonstrated increased displacement and lower mean ultimate failure loads with different tendon preparation methods for two tendons, in both the four-strand and six-strand constructs.

      Graft length, size and healing

      There are various studies performed to determine a minimum graft length in both the femoral and tibial ACL tunnel. Zantop et al. [
      • Zantop T.
      • Ferretti M.
      • Bell K.M.
      Effect of tunnel-graft length on the biomechanics of anterior cruciate ligament-reconstructed knees: intra-articular study in a goat model.
      ] using goat tendons showed no differences between 15 mm and 25 mm grafts in the femoral tunnel at 12 weeks with regards to stiffness and ultimate failure loads. Yang et al. [
      • Yang D.L.
      • Cheon S.H.
      • Oh C.W.
      • Kyung H.S.
      A comparison of the fixation strengths provided by different intraosseous tendon lengths during anterior cruciate ligament reconstruction: a biomechanical study in a porcine tibial model.
      ] have showed an intraosseous tibial tunnel graft length of 20 mm in a porcine model (compared to 40 mm) had no significant differences in graft slippage or graft movement. They recommended a 20 mm intraosseous graft length to be sufficient for rehabilitation after ACL reconstruction.
      The healing and integration of an ACL soft tissue graft depends on the formation of Sharpey fibres, signalling incorporation. These fibres are found closer to the joint [
      • Cavaignac E.
      • Marot V.
      • Faruch M.
      • Reina N.
      • Murgier J.
      • Accadbled F.
      • et al.
      Hamstring graft incorporation according to the length of the graft inside tunnels.
      ,
      • Zantop T.
      • Ferretti M.
      • Bell K.M.
      Effect of tunnel-graft length on the biomechanics of anterior cruciate ligament-reconstructed knees: intra-articular study in a goat model.
      ], suggesting that perhaps an increased graft in tunnel length does not aid significantly in graft healing. Short grafts should therefore not be biomechanically inferior to conventional ACL reconstruction methods. A widely accepted guideline is a minimum socket length of 20 mm.
      The MOON cohort compared patients with between femoral tunnel grafts lengths more than 25 mm versus patients with between femoral tunnel grafts lengths less than 25 mm [
      • Mariscalco M.W.
      • Magnussen R.A.
      • Mitchell J.
      • Pedroza A.D.
      • Jones M.H.
      • Andrish J.T.
      • et al.
      How much hamstring graft needs to be in the femoral tunnel? A MOON cohort study.
      ]; reported that there were no differences in the follow up KOOS and IKDC scores. Gupta et al. [
      • Gupta P.K.
      • Acharya A.
      • Khanna V.
      • Mourya A.
      Intra-femoral tunnel graft lengths less than 20 mm do not predispose to early graft failure, inferior outcomes or poor function. A prospective clinico-radiological comparative study.
      ] in a recent study revealed no differences between clinical and radiological outcomes for patients with grafts more than 20 mm in the tunnel and patients with grafts less than 20 mm in the tunnel. Moon et al. [
      • Moon H.S.
      • Choi C.H.
      • Yoo J.H.
      • Jung M.
      • Lee T.H.
      • Choi K.H.
      • et al.
      The graft insertion length in the femoral tunnel during anterior cruciate ligament reconstruction with suspensory fixation and tibialis anterior allograft does not affect surgical outcomes but is negatively correlated with tunnel widening.
      ] compared 3 patient cohorts based on the length of graft in the tunnel: less than15mm, 15–20 mm and more than 20 mm. They found no significant differences in post-surgery knee laxity, VAS scores, Lysholm and IKDC scores.

      Tunnel preparation–femur

      In AI ACLR, the femoral tunnel is prepared independently from the tibia; it can be reamed through the anteromedial portal or via outside-in drilling. The additional benefit of drilling the femoral tunnel outside-in is that it can be reamed without the need for knee hyperflexion, therefore requiring less assistance for the surgeon during surgery.
      On the tibia side in AI ACLR, the sockets are usually prepared using a retrograde reaming technique [
      • Lubowitz J.H.
      All-inside anterior cruciate ligament graft link: graft preparation technique.
      ]. Various companies have retrograde reamers to perform sockets preparation. These retrograde reamers require a learning curve [
      • Desai V.S.
      • Anderson G.R.
      • Wu I.T.
      • Levy B.A.
      • Dahm D.L.
      • Camp C.L.
      • et al.
      Anterior cruciate ligament reconstruction with hamstring autograft: a matched cohort comparison of the all-inside and complete tibial tunnel techniques.
      ] to familiarise and also add additional cost to the ACL surgery. In addition, when a socket is reamed on the tibia side, the graft passage will have to be through the arthroscopic portals, rather than the usual passage from the tibia side externally.
      Alternatively, in a variation of the classical technique, even with the use of short grafts, a full tibial tunnel has been proposed. This allows the graft to be passed as usual from the tibia side externally. Comparing the AI ACLR and this technique with complete tibia tunnels, Lubowitz, Schwartzberg and Smith [
      • Lubowitz J.H.
      • Schwartzberg R.
      • Smith P.
      Randomized controlled trial comparing all-inside anterior cruciate ligament reconstruction technique with anterior cruciate ligament reconstruction with a full tibial tunnel.
      ] as well as Desai et al. [
      • Desai V.S.
      • Anderson G.R.
      • Wu I.T.
      • Levy B.A.
      • Dahm D.L.
      • Camp C.L.
      • et al.
      Anterior cruciate ligament reconstruction with hamstring autograft: a matched cohort comparison of the all-inside and complete tibial tunnel techniques.
      ] have shown excellent physical examination findings and outcomes at 2 years follow up, with no significant differences in the clinical outcomes of both groups.

      Fixation devices

      Graft fixation is important for the success of ACL reconstruction. With the use of sockets in SG ACLR, cortical suspensory devices have become the choice of fixation for short grafts. The benefits of using cortical suspension fixation in ACL reconstruction are the high load to failure strength of cortical fixation and less risk of graft fixation compared to interference screw fixation [
      • Lee D.
      • Nyland J.
      • Kendzior M.
      • Nawab A.
      • Caborn D.N.M.
      Intratunnel versus extratunnel fixation of hamstring autograft for anterior cruciate ligament reconstruction.
      ]. A randomised controlled trial by Lubowitz et al. [
      • Lubowitz J.H.
      • Schwartzberg R.
      • Smith P.
      Cortical suspensory button versus aperture interference screw fixation for knee anterior cruciate ligament soft-tissue allograft: a prospective, randomized controlled trial.
      ] compared suspensory cortical fixation to aperture screw fixation and found no significant differences in knee anteroposterior stability or other outcomes. A recent meta-analysis by Fu et al. [
      • Fu C.W.
      • Chen W.C.
      • Lu Y.C.
      Is all-inside with suspensory cortical button fixation a superior technique for anterior cruciate ligament reconstruction surgery? A systematic review and meta-analysis.
      ] comparing cortical suspensory fixation in short grafts to aperture fixation also showed no significant differences between knee outcome scores in both groups.
      Adjustable loop cortical suspension devices are the mainstay of SG ACLR technique. They enable further tightening after insertion to achieve maximum amount of graft in tunnel and do not require precise calculations prior to tunnel reaming. However, there are concerns with regards to lengthening of the adjustable loop devices, with differences observed with cyclic displacement between fixed and adjustable loop ACL fixation devices [
      • Barrow A.E.
      • Pilia M.
      • Guda T.
      • Kadrmas W.R.
      • Burns T.C.
      Femoral suspension devices for anterior cruciate ligament reconstruction: do adjustable loops lengthen?.
      ,
      • Noonan B.C.
      • Dines J.S.
      • Allen A.A.
      • Altchek D.W.
      • Bedi A.
      Biomechanical evaluation of an adjustable loop suspensory anterior cruciate ligament reconstruction fixation device: the value of retensioning and knot tying.
      ]. Barrow et al. [
      • Barrow A.E.
      • Pilia M.
      • Guda T.
      • Kadrmas W.R.
      • Burns T.C.
      Femoral suspension devices for anterior cruciate ligament reconstruction: do adjustable loops lengthen?.
      ] reported that adjustable length fixation devices experienced a clinically significant increase in loop lengthening during cyclic testing, caused by suture slippage into the adjustable length loop. Noonan et al. [
      • Noonan B.C.
      • Dines J.S.
      • Allen A.A.
      • Altchek D.W.
      • Bedi A.
      Biomechanical evaluation of an adjustable loop suspensory anterior cruciate ligament reconstruction fixation device: the value of retensioning and knot tying.
      ] proposed that re-tensioning and knot tying after initial reduction of the tendon graft with an adjustable loop fixation device may help to reduce loop slippage and displacement. These concerns in biomechanical studies are, however, not translated in clinical studies. Boyle et al. [
      • Boyle M.J.
      • Vovos T.J.
      • Walker C.G.
      • Stabile K.J.
      • Roth J.M.
      • Garrett W.E.
      Does adjustable-loop femoral cortical suspension loosen after anterior cruciate ligament reconstruction? A retrospective comparative study.
      ] showed no significant differences in short-term knee stability and graft failure rates between adjustable and fixed loop femoral cortical suspension in their study of 188 ACL reconstruction patients.

      Outcomes

      The results of SG ACLR have consistently shown similar outcomes compared to standard techniques with no significant differences across various papers, summarised in Table 2. There are a total of 19 studies included, with multiple high-quality studies comparing different techniques of ACL reconstruction [
      • Goyal T.
      • Das L.
      • Paul S.
      • Choudhury A.K.
      • Sethy S.S.
      Outcomes of retro-drilled all-inside tibial tunnel vs complete tibial tunnel techniques in anterior cruciate ligament reconstruction—a comparative study.
      ,
      • Lubowitz J.H.
      • Schwartzberg R.
      • Smith P.
      Randomized controlled trial comparing all-inside anterior cruciate ligament reconstruction technique with anterior cruciate ligament reconstruction with a full tibial tunnel.
      ,
      • Schurz M.
      • Tiefenboeck T.M.
      • Winnisch M.
      • Syre S.
      • Plachel F.
      • Steiner G.
      • et al.
      Clinical and functional outcome of all-inside anterior cruciate ligament reconstruction at a minimum of 2 Years' follow-up.
      ,
      • Kyriakopoulos G.
      • Manthas S.
      • Vlachou M.
      • Oikonomou L.
      • Papadakis S.A.
      • Kateros K.
      Anterior cruciate ligament reconstruction with the all-inside technique: equivalent outcomes and failure rate at three-year follow-up compared to a doubled semitendinosus-gracilis graft.
      ,
      • Kouloumentas P.
      • Kavroudakis E.
      • Charalampidis E.
      • Kavroudakis D.
      • Triantafyllopoulos G.K.
      Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique.
      ,
      • Yasen S.K.
      • Borton Z.M.
      • Eyre-Brook A.I.
      • Palmer H.C.
      • Cotterill S.T.
      • Risebury M.J.
      • et al.
      Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction.
      ,
      • Lowenstein N.A.
      • Haber D.B.
      • Ostergaard P.J.
      • Collins J.E.
      • Matzkin E.G.
      All-inside anterior cruciate ligament reconstruction using quadrupled semitendinosus: comparable 2-year outcomes in male and female patients.
      ,
      • Galan H.
      • Escalante M.
      • della Vedova F.
      • Slullitel D.
      All inside full thickness quadriceps tendon ACL reconstruction: long term follow up results.
      ,
      • Smith P.A.
      • Cook C.S.
      • Bley J.A.
      All-inside quadrupled semitendinosus autograft shows stability equivalent to patellar tendon autograft anterior cruciate ligament reconstruction: randomized controlled trial in athletes 24 Years or younger.
      ,
      • Desai V.S.
      • Anderson G.R.
      • Wu I.T.
      • Levy B.A.
      • Dahm D.L.
      • Camp C.L.
      • et al.
      Anterior cruciate ligament reconstruction with hamstring autograft: a matched cohort comparison of the all-inside and complete tibial tunnel techniques.
      ,
      • Volpi P.
      • Bait C.
      • Cervellin M.
      • Denti M.
      • Prospero E.
      • Morenghi E.
      • et al.
      No difference at two years between all inside transtibial technique and traditional transtibial technique in anterior cruciate ligament reconstruction.
      ,
      • Baldassarri M.
      • Perazzo L.
      • Ghinelli D.
      • Ricciarelli M.
      • Pilla F.
      • Buda R.
      Return to sport after ACL surgery: a comparison between two different reconstructive techniques.
      ,
      • Monaco E.
      • Fabbri M.
      • Redler A.
      • Gaj E.
      • de Carli A.
      • Argento G.
      • et al.
      Anterior cruciate ligament reconstruction is associated with greater tibial tunnel widening when using a bioabsorbable screw compared to an all-inside technique with suspensory fixation.
      ,
      • Colombet P.
      • Saffarini M.
      • Bouguennec N.
      Clinical and functional outcomes of anterior cruciate ligament reconstruction at a minimum of 2 Years using adjustable suspensory fixation in both the femur and tibia: a prospective study.
      ,
      • Mayr R.
      • Smekal V.
      • Koidl C.
      • Coppola C.
      • Eichinger M.
      • Rudisch A.
      • et al.
      ACL reconstruction with adjustable-length loop cortical button fixation results in less tibial tunnel widening compared with interference screw fixation.
      ,
      • Roger J.
      • Bertani A.
      • Vigouroux F.
      • Mottier F.
      • Gaillard R.
      • Have L.
      • et al.
      ACL reconstruction using a quadruple semitendinosus graft with cortical fixations gives suitable isokinetic and clinical outcomes after 2 years.
      ,
      • Kulshrestha V.
      • Sood M.
      • Kumar S.
      • Kawale A.
      Original study: early patient-reported functional outcome of all-inside ACL reconstruction as compared to anteromedial portal technique.
      ,
      • Pautasso A.
      • Capella M.
      • Barberis L.
      • Drocco L.
      • Giai Via R.
      • Bistolfi A.
      • et al.
      All-inside technique in ACL reconstruction: mid-term clinical outcomes and comparison with AM technique (Hamstrings and BpTB grafts).
      ,
      • Greif D.N.
      • Shallop B.J.
      • Allegra P.R.
      • Cade W.H.
      • Minesinger K.E.
      • Luxenburg D.
      • et al.
      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.
      ] [
      • Goyal T.
      • Das L.
      • Paul S.
      • Choudhury A.K.
      • Sethy S.S.
      Outcomes of retro-drilled all-inside tibial tunnel vs complete tibial tunnel techniques in anterior cruciate ligament reconstruction—a comparative study.
      ,
      • Lubowitz J.H.
      • Schwartzberg R.
      • Smith P.
      Randomized controlled trial comparing all-inside anterior cruciate ligament reconstruction technique with anterior cruciate ligament reconstruction with a full tibial tunnel.
      ,
      • Schurz M.
      • Tiefenboeck T.M.
      • Winnisch M.
      • Syre S.
      • Plachel F.
      • Steiner G.
      • et al.
      Clinical and functional outcome of all-inside anterior cruciate ligament reconstruction at a minimum of 2 Years' follow-up.
      ,
      • Kyriakopoulos G.
      • Manthas S.
      • Vlachou M.
      • Oikonomou L.
      • Papadakis S.A.
      • Kateros K.
      Anterior cruciate ligament reconstruction with the all-inside technique: equivalent outcomes and failure rate at three-year follow-up compared to a doubled semitendinosus-gracilis graft.
      ,
      • Kouloumentas P.
      • Kavroudakis E.
      • Charalampidis E.
      • Kavroudakis D.
      • Triantafyllopoulos G.K.
      Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique.
      ,
      • Yasen S.K.
      • Borton Z.M.
      • Eyre-Brook A.I.
      • Palmer H.C.
      • Cotterill S.T.
      • Risebury M.J.
      • et al.
      Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction.
      ,
      • Lowenstein N.A.
      • Haber D.B.
      • Ostergaard P.J.
      • Collins J.E.
      • Matzkin E.G.
      All-inside anterior cruciate ligament reconstruction using quadrupled semitendinosus: comparable 2-year outcomes in male and female patients.
      ,
      • Galan H.
      • Escalante M.
      • della Vedova F.
      • Slullitel D.
      All inside full thickness quadriceps tendon ACL reconstruction: long term follow up results.
      ,
      • Smith P.A.
      • Cook C.S.
      • Bley J.A.
      All-inside quadrupled semitendinosus autograft shows stability equivalent to patellar tendon autograft anterior cruciate ligament reconstruction: randomized controlled trial in athletes 24 Years or younger.
      ,
      • Desai V.S.
      • Anderson G.R.
      • Wu I.T.
      • Levy B.A.
      • Dahm D.L.
      • Camp C.L.
      • et al.
      Anterior cruciate ligament reconstruction with hamstring autograft: a matched cohort comparison of the all-inside and complete tibial tunnel techniques.
      ,
      • Volpi P.
      • Bait C.
      • Cervellin M.
      • Denti M.
      • Prospero E.
      • Morenghi E.
      • et al.
      No difference at two years between all inside transtibial technique and traditional transtibial technique in anterior cruciate ligament reconstruction.
      ,
      • Baldassarri M.
      • Perazzo L.
      • Ghinelli D.
      • Ricciarelli M.
      • Pilla F.
      • Buda R.
      Return to sport after ACL surgery: a comparison between two different reconstructive techniques.
      ,
      • Monaco E.
      • Fabbri M.
      • Redler A.
      • Gaj E.
      • de Carli A.
      • Argento G.
      • et al.
      Anterior cruciate ligament reconstruction is associated with greater tibial tunnel widening when using a bioabsorbable screw compared to an all-inside technique with suspensory fixation.
      ,
      • Colombet P.
      • Saffarini M.
      • Bouguennec N.
      Clinical and functional outcomes of anterior cruciate ligament reconstruction at a minimum of 2 Years using adjustable suspensory fixation in both the femur and tibia: a prospective study.
      ,
      • Mayr R.
      • Smekal V.
      • Koidl C.
      • Coppola C.
      • Eichinger M.
      • Rudisch A.
      • et al.
      ACL reconstruction with adjustable-length loop cortical button fixation results in less tibial tunnel widening compared with interference screw fixation.
      ,
      • Roger J.
      • Bertani A.
      • Vigouroux F.
      • Mottier F.
      • Gaillard R.
      • Have L.
      • et al.
      ACL reconstruction using a quadruple semitendinosus graft with cortical fixations gives suitable isokinetic and clinical outcomes after 2 years.
      ,
      • Kulshrestha V.
      • Sood M.
      • Kumar S.
      • Kawale A.
      Original study: early patient-reported functional outcome of all-inside ACL reconstruction as compared to anteromedial portal technique.
      ,
      • Pautasso A.
      • Capella M.
      • Barberis L.
      • Drocco L.
      • Giai Via R.
      • Bistolfi A.
      • et al.
      All-inside technique in ACL reconstruction: mid-term clinical outcomes and comparison with AM technique (Hamstrings and BpTB grafts).
      ,
      • Greif D.N.
      • Shallop B.J.
      • Allegra P.R.
      • Cade W.H.
      • Minesinger K.E.
      • Luxenburg D.
      • et al.
      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.
      ] [
      • Kouloumentas P.
      • Kavroudakis E.
      • Charalampidis E.
      • Kavroudakis D.
      • Triantafyllopoulos G.K.
      Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique.
      ,
      • Yasen S.K.
      • Borton Z.M.
      • Eyre-Brook A.I.
      • Palmer H.C.
      • Cotterill S.T.
      • Risebury M.J.
      • et al.
      Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction.
      ,
      • Lowenstein N.A.
      • Haber D.B.
      • Ostergaard P.J.
      • Collins J.E.
      • Matzkin E.G.
      All-inside anterior cruciate ligament reconstruction using quadrupled semitendinosus: comparable 2-year outcomes in male and female patients.
      ,
      • Galan H.
      • Escalante M.
      • della Vedova F.
      • Slullitel D.
      All inside full thickness quadriceps tendon ACL reconstruction: long term follow up results.
      ,
      • Smith P.A.
      • Cook C.S.
      • Bley J.A.
      All-inside quadrupled semitendinosus autograft shows stability equivalent to patellar tendon autograft anterior cruciate ligament reconstruction: randomized controlled trial in athletes 24 Years or younger.
      ,
      • Desai V.S.
      • Anderson G.R.
      • Wu I.T.
      • Levy B.A.
      • Dahm D.L.
      • Camp C.L.
      • et al.
      Anterior cruciate ligament reconstruction with hamstring autograft: a matched cohort comparison of the all-inside and complete tibial tunnel techniques.
      ,
      • Volpi P.
      • Bait C.
      • Cervellin M.
      • Denti M.
      • Prospero E.
      • Morenghi E.
      • et al.
      No difference at two years between all inside transtibial technique and traditional transtibial technique in anterior cruciate ligament reconstruction.
      ] [
      • Goyal T.
      • Das L.
      • Paul S.
      • Choudhury A.K.
      • Sethy S.S.
      Outcomes of retro-drilled all-inside tibial tunnel vs complete tibial tunnel techniques in anterior cruciate ligament reconstruction—a comparative study.
      ,
      • Lubowitz J.H.
      • Schwartzberg R.
      • Smith P.
      Randomized controlled trial comparing all-inside anterior cruciate ligament reconstruction technique with anterior cruciate ligament reconstruction with a full tibial tunnel.
      ,
      • Schurz M.
      • Tiefenboeck T.M.
      • Winnisch M.
      • Syre S.
      • Plachel F.
      • Steiner G.
      • et al.
      Clinical and functional outcome of all-inside anterior cruciate ligament reconstruction at a minimum of 2 Years' follow-up.
      ,
      • Kyriakopoulos G.
      • Manthas S.
      • Vlachou M.
      • Oikonomou L.
      • Papadakis S.A.
      • Kateros K.
      Anterior cruciate ligament reconstruction with the all-inside technique: equivalent outcomes and failure rate at three-year follow-up compared to a doubled semitendinosus-gracilis graft.
      ,
      • Kouloumentas P.
      • Kavroudakis E.
      • Charalampidis E.
      • Kavroudakis D.
      • Triantafyllopoulos G.K.
      Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique.
      ,
      • Yasen S.K.
      • Borton Z.M.
      • Eyre-Brook A.I.
      • Palmer H.C.
      • Cotterill S.T.
      • Risebury M.J.
      • et al.
      Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction.
      ,
      • Lowenstein N.A.
      • Haber D.B.
      • Ostergaard P.J.
      • Collins J.E.
      • Matzkin E.G.
      All-inside anterior cruciate ligament reconstruction using quadrupled semitendinosus: comparable 2-year outcomes in male and female patients.
      ,
      • Galan H.
      • Escalante M.
      • della Vedova F.
      • Slullitel D.
      All inside full thickness quadriceps tendon ACL reconstruction: long term follow up results.
      ,
      • Smith P.A.
      • Cook C.S.
      • Bley J.A.
      All-inside quadrupled semitendinosus autograft shows stability equivalent to patellar tendon autograft anterior cruciate ligament reconstruction: randomized controlled trial in athletes 24 Years or younger.
      ,
      • Desai V.S.
      • Anderson G.R.
      • Wu I.T.
      • Levy B.A.
      • Dahm D.L.
      • Camp C.L.
      • et al.
      Anterior cruciate ligament reconstruction with hamstring autograft: a matched cohort comparison of the all-inside and complete tibial tunnel techniques.
      ,
      • Volpi P.
      • Bait C.
      • Cervellin M.
      • Denti M.
      • Prospero E.
      • Morenghi E.
      • et al.
      No difference at two years between all inside transtibial technique and traditional transtibial technique in anterior cruciate ligament reconstruction.
      ,
      • Baldassarri M.
      • Perazzo L.
      • Ghinelli D.
      • Ricciarelli M.
      • Pilla F.
      • Buda R.
      Return to sport after ACL surgery: a comparison between two different reconstructive techniques.
      ,
      • Monaco E.
      • Fabbri M.
      • Redler A.
      • Gaj E.
      • de Carli A.
      • Argento G.
      • et al.
      Anterior cruciate ligament reconstruction is associated with greater tibial tunnel widening when using a bioabsorbable screw compared to an all-inside technique with suspensory fixation.
      ,
      • Colombet P.
      • Saffarini M.
      • Bouguennec N.
      Clinical and functional outcomes of anterior cruciate ligament reconstruction at a minimum of 2 Years using adjustable suspensory fixation in both the femur and tibia: a prospective study.
      ,
      • Mayr R.
      • Smekal V.
      • Koidl C.
      • Coppola C.
      • Eichinger M.
      • Rudisch A.
      • et al.
      ACL reconstruction with adjustable-length loop cortical button fixation results in less tibial tunnel widening compared with interference screw fixation.
      ,
      • Roger J.
      • Bertani A.
      • Vigouroux F.
      • Mottier F.
      • Gaillard R.
      • Have L.
      • et al.
      ACL reconstruction using a quadruple semitendinosus graft with cortical fixations gives suitable isokinetic and clinical outcomes after 2 years.
      ,
      • Kulshrestha V.
      • Sood M.
      • Kumar S.
      • Kawale A.
      Original study: early patient-reported functional outcome of all-inside ACL reconstruction as compared to anteromedial portal technique.
      ,
      • Pautasso A.
      • Capella M.
      • Barberis L.
      • Drocco L.
      • Giai Via R.
      • Bistolfi A.
      • et al.
      All-inside technique in ACL reconstruction: mid-term clinical outcomes and comparison with AM technique (Hamstrings and BpTB grafts).
      ,
      • Greif D.N.
      • Shallop B.J.
      • Allegra P.R.
      • Cade W.H.
      • Minesinger K.E.
      • Luxenburg D.
      • et al.
      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.
      ] [
      • Goyal T.
      • Das L.
      • Paul S.
      • Choudhury A.K.
      • Sethy S.S.
      Outcomes of retro-drilled all-inside tibial tunnel vs complete tibial tunnel techniques in anterior cruciate ligament reconstruction—a comparative study.
      ,
      • Lubowitz J.H.
      • Schwartzberg R.
      • Smith P.
      Randomized controlled trial comparing all-inside anterior cruciate ligament reconstruction technique with anterior cruciate ligament reconstruction with a full tibial tunnel.
      ,
      • Schurz M.
      • Tiefenboeck T.M.
      • Winnisch M.
      • Syre S.
      • Plachel F.
      • Steiner G.
      • et al.
      Clinical and functional outcome of all-inside anterior cruciate ligament reconstruction at a minimum of 2 Years' follow-up.
      ,
      • Kyriakopoulos G.
      • Manthas S.
      • Vlachou M.
      • Oikonomou L.
      • Papadakis S.A.
      • Kateros K.
      Anterior cruciate ligament reconstruction with the all-inside technique: equivalent outcomes and failure rate at three-year follow-up compared to a doubled semitendinosus-gracilis graft.
      ,
      • Kouloumentas P.
      • Kavroudakis E.
      • Charalampidis E.
      • Kavroudakis D.
      • Triantafyllopoulos G.K.
      Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique.
      ,
      • Yasen S.K.
      • Borton Z.M.
      • Eyre-Brook A.I.
      • Palmer H.C.
      • Cotterill S.T.
      • Risebury M.J.
      • et al.
      Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction.
      ,
      • Lowenstein N.A.
      • Haber D.B.
      • Ostergaard P.J.
      • Collins J.E.
      • Matzkin E.G.
      All-inside anterior cruciate ligament reconstruction using quadrupled semitendinosus: comparable 2-year outcomes in male and female patients.
      ,
      • Galan H.
      • Escalante M.
      • della Vedova F.
      • Slullitel D.
      All inside full thickness quadriceps tendon ACL reconstruction: long term follow up results.
      ,
      • Smith P.A.
      • Cook C.S.
      • Bley J.A.
      All-inside quadrupled semitendinosus autograft shows stability equivalent to patellar tendon autograft anterior cruciate ligament reconstruction: randomized controlled trial in athletes 24 Years or younger.
      ,
      • Desai V.S.
      • Anderson G.R.
      • Wu I.T.
      • Levy B.A.
      • Dahm D.L.
      • Camp C.L.
      • et al.
      Anterior cruciate ligament reconstruction with hamstring autograft: a matched cohort comparison of the all-inside and complete tibial tunnel techniques.
      ,
      • Volpi P.
      • Bait C.
      • Cervellin M.
      • Denti M.
      • Prospero E.
      • Morenghi E.
      • et al.
      No difference at two years between all inside transtibial technique and traditional transtibial technique in anterior cruciate ligament reconstruction.
      ,
      • Baldassarri M.
      • Perazzo L.
      • Ghinelli D.
      • Ricciarelli M.
      • Pilla F.
      • Buda R.
      Return to sport after ACL surgery: a comparison between two different reconstructive techniques.
      ,
      • Monaco E.
      • Fabbri M.
      • Redler A.
      • Gaj E.
      • de Carli A.
      • Argento G.
      • et al.
      Anterior cruciate ligament reconstruction is associated with greater tibial tunnel widening when using a bioabsorbable screw compared to an all-inside technique with suspensory fixation.
      ,
      • Colombet P.
      • Saffarini M.
      • Bouguennec N.
      Clinical and functional outcomes of anterior cruciate ligament reconstruction at a minimum of 2 Years using adjustable suspensory fixation in both the femur and tibia: a prospective study.
      ,
      • Mayr R.
      • Smekal V.
      • Koidl C.
      • Coppola C.
      • Eichinger M.
      • Rudisch A.
      • et al.
      ACL reconstruction with adjustable-length loop cortical button fixation results in less tibial tunnel widening compared with interference screw fixation.
      ,
      • Roger J.
      • Bertani A.
      • Vigouroux F.
      • Mottier F.
      • Gaillard R.
      • Have L.
      • et al.
      ACL reconstruction using a quadruple semitendinosus graft with cortical fixations gives suitable isokinetic and clinical outcomes after 2 years.
      ,
      • Kulshrestha V.
      • Sood M.
      • Kumar S.
      • Kawale A.
      Original study: early patient-reported functional outcome of all-inside ACL reconstruction as compared to anteromedial portal technique.
      ,
      • Pautasso A.
      • Capella M.
      • Barberis L.
      • Drocco L.
      • Giai Via R.
      • Bistolfi A.
      • et al.
      All-inside technique in ACL reconstruction: mid-term clinical outcomes and comparison with AM technique (Hamstrings and BpTB grafts).
      ,
      • Greif D.N.
      • Shallop B.J.
      • Allegra P.R.
      • Cade W.H.
      • Minesinger K.E.
      • Luxenburg D.
      • et al.
      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.
      ]. A total of 1812 patients were included in the studies. All the studies have shown a significant improvement in outcome scores with SG ACLR compared to the baseline. Graft ruptures ranged across different studies from 2.1% to 12.7% in the SG ACLR technique (Table 2). SG ACLR can be considered as a good, viable alternative to the standard technique.
      Table 2Studies of the all-inside technique.
      AuthorJournal

      Year
      Number of patientsMean age (range if any), yearsFollow up (range), monthsGraft and techniquesComplicationsPost-operative clinical resultsComments
      Lubowitz et al. [
      • Lubowitz J.H.
      • Schwartzberg R.
      • Smith P.
      Randomized controlled trial comparing all-inside anterior cruciate ligament reconstruction technique with anterior cruciate ligament reconstruction with a full tibial tunnel.
      ]
      Arthroscopy

      2013
      148

      AI: 76

      Standard: 72
      AI: 39.3

      Standard: 41.1
      24AI: 2-strand tibialis tendon allograft

      Standard: 2-strand tibialis tendon allograft
      NRAI

      IKDC subjective 86.5

      KSS pain 93.3

      KSS function 97.6

      VAS -2.5

      SF-12 physical 53.3

      SF-12 mental 56.8
      Standard

      IKDC subjective 84.0

      KSS pain 95.9

      KSS function 98.8

      VAS -1.7

      SF-12 physical 52.5

      SF-12 mental 55.3
      No significant difference between both groups in IKDC, KSS, SF-12 scores, femoral and tibial widening, or narcotics consumption

      Significantly lower VAS in AI group

      No significant differences in operative times
      Volpi et al. [
      • Volpi P.
      • Bait C.
      • Cervellin M.
      • Denti M.
      • Prospero E.
      • Morenghi E.
      • et al.
      No difference at two years between all inside transtibial technique and traditional transtibial technique in anterior cruciate ligament reconstruction.
      ]
      Muscles, Ligaments and Tendons Journal

      2014
      40

      AI: 20

      Standard: 20
      AI: 38.4

      Standard: 32.6
      24AI: doubled/tripled ST tendon autograft

      Standard: ST&G
      NRAI

      Lysholm 90.9

      IKDC A 11 (55%)

      IKDC B 8 (40%)

      IKDC C 1 (5%)

      Tegner 5.2

      VAS 81.7
      Standard

      Lysholm 94.9

      IKDC A 10 (50%)

      IKDC B 9 (45%)

      IKDC C 1 (5%)

      Tegner 6.4

      VAS 84.6
      No significant differences between both groups in IKDC, Lysholm, Tegner and VAS scores.
      Schurz et al. [
      • Schurz M.
      • Tiefenboeck T.M.
      • Winnisch M.
      • Syre S.
      • Plachel F.
      • Steiner G.
      • et al.
      Clinical and functional outcome of all-inside anterior cruciate ligament reconstruction at a minimum of 2 Years' follow-up.
      ]
      Arthroscopy

      2016
      79

      Male 53

      Female 26
      29 (18–54)30.4 (24.3–44.8)Quadrupled ST

      AI
      Deep infection – 2

      Numbness – 9
      Lysholm 93.1

      IKDC 89.7

      Tegner 6

      KT-2000 1.7 mm

      VAS score 0.14
      Significant improvements in IKDC, Lysholm, Tegner and VAS scores compared to baseline, p < 0.0001

      12.7% ACL graft ruptures
      Yasen et al. [
      • Yasen S.K.
      • Borton Z.M.
      • Eyre-Brook A.I.
      • Palmer H.C.
      • Cotterill S.T.
      • Risebury M.J.
      • et al.
      Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction.
      ]
      The Knee

      2016
      108

      Male 81

      Female 27
      30.9 (15–61)49.8 (30–66)Quadrupled ST

      AI
      Superficial infection – 1

      Superficial haematoma – 1Hemarthrosis

      – 1
      Lysholm score 88.1

      Tegner score 5.1

      KOOS 87.9

      KT-1000 2.20 mm
      Significant improvements in KOOS, Lysholm and Tegner scores as compared to baseline, p < 0.001

      Significantly improved knee flexion compared to baseline (p < 0.001)

      6.5% ACL graft failure
      Baldassarri et al. [
      • Baldassarri M.
      • Perazzo L.
      • Ghinelli D.
      • Ricciarelli M.
      • Pilla F.
      • Buda R.
      Return to sport after ACL surgery: a comparison between two different reconstructive techniques.
      ]
      Muscles, Ligaments and Tendons Journal

      2018
      40

      AI: 20

      Standard: 20
      AI: 38.4

      Standard: 32.6
      24AI: doubled or tripled ST tendon autograft

      Standard: ST&G
      NRAI

      Lysholm 90.9

      IKDC A 11 (55%)

      IKDC B 8 (40%),

      IKDC C 1 (5%)

      Tegner 5.2

      VAS 81.7
      Standard

      Lysholm 94.9

      IKDC A 10 (50%)

      IKDC B 9 (45%)

      IKDC C 1 (5%)

      Tegner 6.4

      VAS 84.6
      No significant differences between both groups in IKDC, Lysholm, Tegner and VAS scores.
      Monaco et al. [
      • Monaco E.
      • Fabbri M.
      • Redler A.
      • Gaj E.
      • de Carli A.
      • Argento G.
      • et al.
      Anterior cruciate ligament reconstruction is associated with greater tibial tunnel widening when using a bioabsorbable screw compared to an all-inside technique with suspensory fixation.
      ]
      KSSTA

      2018
      44

      AI: 22

      Standard: 22
      AI: 32.5

      Standard: 31.7
      24
      Median values.
      (21–27)
      AI: quadrupled ST tendon autograft

      Standard: doubled ST&G
      NilAI

      Lysholm
      Median values.
      95

      Tegner
      Median values.
      6

      IKDC
      Median values.
      91

      KSS pain
      Median values.
      96

      KSS function
      Median values.
      100

      KT-1000 1.7 mm
      Standard

      Lysholm
      Median values.
      90

      Tegner
      Median values.
      6

      IKDC
      Median values.
      94

      KSS pain
      Median values.
      95

      KSS function
      Median values.
      100

      KT-1000 2.1 mm
      No significant differences between both groups in IKDC, KSS, Lysholm, Tegner and KT-1000 side-to-side.

      Significantly larger increase in tibial tunnel widening in the standard technique.
      Colombet et al. [
      • Colombet P.
      • Saffarini M.
      • Bouguennec N.
      Clinical and functional outcomes of anterior cruciate ligament reconstruction at a minimum of 2 Years using adjustable suspensory fixation in both the femur and tibia: a prospective study.
      ]
      The Orthopaedic Journal of Sports Medicine

      2018
      97

      Male – 64, Female – 33
      30.9 (14.8–56.1)24Quadrupled ST

      AI
      NilLysholm 90.8

      Tegner 6.6

      IKDC 87.6

      Laxity side-to-side 0.8 mm
      Significant improvements in Lysholm, Tegner and IKDC scores compared to baseline

      2.1% ACL graft failure
      Kouloumentas et al. [
      • Kouloumentas P.
      • Kavroudakis E.
      • Charalampidis E.
      • Kavroudakis D.
      • Triantafyllopoulos G.K.
      Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique.
      ]
      European Journal of Orthopaedic Surgery & Traumatology

      2019
      90

      AI: 45

      Standard: 45
      AI: 27.6

      Standard: 29.7
      24AI: quadrupled ST tendon autograft

      Standard: 4-strand ST&G
      NilAI

      Lysholm 97.7

      IKDC: 83.6

      KOOS 95.3

      KSS 83.9
      Standard

      Lysholm 96.6

      IKDC: 78.5

      KOOS 95.8

      KSS 96.6
      No significant differences between both groups in IKDC, KSS, Lysholm and KOOS scores.

      AI group had better flexor peak torque, time-to-peak and isometric flexor/extensor ratio at 90°.

      AI: 2.2% ACL graft failure

      Standard: 4.4% ACL graft failure
      Mayr et al. [
      • Mayr R.
      • Smekal V.
      • Koidl C.
      • Coppola C.
      • Eichinger M.
      • Rudisch A.
      • et al.
      ACL reconstruction with adjustable-length loop cortical button fixation results in less tibial tunnel widening compared with interference screw fixation.
      ]
      KSSTA

      2020
      30

      AI: 16

      Standard: 14
      AI: 25

      Standard: 29
      24AI: quadrupled ST tendon autograft

      Standard: 4-strand ST&G
      AI: intraoperative button mislocation and button loop rupture, septic arthritis, 3 early reruptures

      Standard: intraoperative screw breakage
      AI

      Lysholm 94

      IKDC subjective 88

      Tegner 6

      KT-1000 2.9 mm

      Single leg hop 97
      Standard

      Lysholm 94

      IKDC subjective 89

      Tegner 6

      KT-1000 1.4 mm

      Single leg hop 99
      No significant differences in IKDC, Tegner, Lysholm scores and KT-1000 measurements between both groups.

      Significantly larger tibial tunnel widening in standard group with screw fixation
      Roger et al. [
      • Roger J.
      • Bertani A.
      • Vigouroux F.
      • Mottier F.
      • Gaillard R.
      • Have L.
      • et al.
      ACL reconstruction using a quadruple semitendinosus graft with cortical fixations gives suitable isokinetic and clinical outcomes after 2 years.
      ]
      KSSTA

      2020
      60

      AI: 33

      Standard: 27
      AI: 30.5

      Standard: 30.3
      24AI: quadrupled ST tendon autograft

      Standard: 4-strand ST&G
      Cyclops lesion requiring revision – AI group (3%), STG group (3.7%)AI

      IKDC subjective 80.2
      Standard

      IKDC subjective 83.6
      No statistically significant differences between AI and full tunnel groups for subjective IKDC score, laxity, morbidity, hamstring strength recovery or knee flexion.

      Less tourniquet time in AI group (p < 0.001).
      Galan et al. [
      • Galan H.
      • Escalante M.
      • della Vedova F.
      • Slullitel D.
      All inside full thickness quadriceps tendon ACL reconstruction: long term follow up results.
      ]
      Journal of Experimental Orthopaedics

      2020
      291

      Male – 64, Female – 33
      23.2 (17–42)60QT with bone blockHarvest site pain – 3

      Patellofemoral syndrome-type pain – 12

      Intraoperative patella fractures – 2

      Postoperative infection – 1

      Haematoma – 5
      Lysholm 91

      IKDC A 174 (59.79%), B 102 (35.4%), C 14 (4.81%)

      Tegner
      Median values.
      – 8

      KT-1000 1 mm
      Low complication rate of 5.15% anterior knee pain

      Graft rerupture rate 10.7%
      Smith et al. [
      • Smith P.A.
      • Cook C.S.
      • Bley J.A.
      All-inside quadrupled semitendinosus autograft shows stability equivalent to patellar tendon autograft anterior cruciate ligament reconstruction: randomized controlled trial in athletes 24 Years or younger.
      ]
      Arthroscopy

      2020
      64

      AI: 32

      Standard: 32
      17.7 (13–24)24AI: quadrupled ST tendon autograft

      Standard: BPTB graft
      AI:

      Graft failure – 2

      Standard:

      Removal of tibia iscrew
      AI

      IKDC subjective 94.8

      KOOS function 92.5

      KOOS QoL 83.3

      KOOS symptoms 89.7

      KT-1000 0.3 mm

      Marx 13.3

      SF-12 physical 55.5

      SF-12 mental 58.0
      Standard

      IKDC subjective 89.4

      KOOS function 84.5

      KOOS QoL 82.4

      KOOS symptoms 86.6

      KT-1000 0.0 mm

      Marx 13.1

      SF-12 physical 56.4

      SF-12 mental 58.7
      No statistically significant between both groups in terms of side-to-side difference in laxity, IKDC, KOOS, Marx, SF-12 mental and physical and return to preoperative sporting level.

      Standard group had higher post operative pain on post operative day 2, 3 and 7.
      Desai et al. [
      • Desai V.S.
      • Anderson G.R.
      • Wu I.T.
      • Levy B.A.
      • Dahm D.L.
      • Camp C.L.
      • et al.
      Anterior cruciate ligament reconstruction with hamstring autograft: a matched cohort comparison of the all-inside and complete tibial tunnel techniques.
      ]
      The Orthopaedic Journal of Sports Medicine

      2021
      136

      AI: 82

      Standard: 54
      AI: 25.8

      Standard: 21.1
      24AI: ST&G tendons or ST only

      Standard:

      ST&G tendons or ST only
      AI:

      1 infection, 1 arthrofibrosis, 3 revision meniscal surgery, 2 chondral defects

      Standard:

      1 arthrofibrosis, 2 revision meniscal surgery
      AI

      Lysholm 93.8

      IKDC 93.5

      Tegner 6.4
      Standard

      Lysholm 94.4

      IKDC 93.3

      Tegner 6.8
      No significant differences in IKDC and Lysholm scores between both groups.

      Longer return to sport in AI group as compared to standard group.

      AI: 9.8% ACL reconstruction failure

      Standard: 18.5% ACL reconstruction failure
      Kyriakopoulos et al. [
      • Kyriakopoulos G.
      • Manthas S.
      • Vlachou M.
      • Oikonomou L.
      • Papadakis S.A.
      • Kateros K.
      Anterior cruciate ligament reconstruction with the all-inside technique: equivalent outcomes and failure rate at three-year follow-up compared to a doubled semitendinosus-gracilis graft.
      ]
      Cureus

      2021
      44

      AI: 22

      Standard: 22
      AI: 27.5

      Standard: 26.6
      36AI: ST

      Standard:

      ST&G
      AI: postoperative haematoma requiring surgeryAI

      Lysholm 87

      KT-1000 1.92 mm
      Standard

      Lysholm 86.1

      KT-1000 2.41 mm
      Statistically significant improvements in Lysholm scores in both groups

      AI group had statistically significant lower VAS scores in early postoperative period at 2 weeks.

      No graft failures in either group,
      Kulshrestha et al. [
      • Kulshrestha V.
      • Sood M.
      • Kumar S.
      • Kawale A.
      Original study: early patient-reported functional outcome of all-inside ACL reconstruction as compared to anteromedial portal technique.
      ]
      European Journal of Orthopaedic Surgery & Traumatology

      2021
      80

      AI: 40

      Standard: 40
      30

      AI: 29.3

      Standard: 33
      24AI: quadrupled ST&G

      Standard: quadrupled ST&G
      AI:

      Superficial infection – 1

      Laxity ≥ 5 mm–3

      Standard:

      Superficial infection – 2

      Laxity ≥ 5 mm–5
      AI

      Tegner 5.9

      KSS objective 66.6

      KSS symptoms 13.6

      KSS satisfaction 31.5

      KSS expectation11.3

      KSS function 83.9
      Standard

      Tegner 5.3

      KSS objective 65.3

      KSS symptoms 15.2

      KSS satisfaction 27.9

      KSS expectation 9.4

      KSS function 84.7
      Statistically significant improvement in Tegner activity score in the AI group

      Satisfaction component in KSS better in the AI group than the standard group
      Pautasso et al. [
      • Pautasso A.
      • Capella M.
      • Barberis L.
      • Drocco L.
      • Giai Via R.
      • Bistolfi A.
      • et al.
      All-inside technique in ACL reconstruction: mid-term clinical outcomes and comparison with AM technique (Hamstrings and BpTB grafts).
      ]
      European Journal of Orthopaedic Surgery & Traumatology

      2021
      157

      AI: 51

      Standard HS: 53

      Standard BPTB: 53
      23.4 (16–30)

      AI: 18.1

      Standard HS: 23.0

      Standard BPTB: 25.3
      AI: 36.5

      Standard HS: 38.8

      Standard BPTB: 41.2
      AI: quadrupled ST

      Standard HS: HS

      Standard BPTB: BPTB
      NilAI:

      Lysholm 92.4

      KOOS 89.5

      Tegner 5.5

      KT-1000 3.1 mm
      Standard:

      Lysholm 91.2

      KOOS 89.2

      Tegner 6.1

      KT-1000 3.3 mm
      Standard BPTB:

      Lysholm 91.8

      KOOS 88.8

      Tegner 5.9

      KT-1000 2.5 mm
      Statistically significant improvement in preoperative and postoperative Lysholm, KOOS, Tegner scores in all 3 surgical techniques

      No statistical difference in KT-1000 values, postoperative Tegner, Lysholm and KOOS scores between both knees for all 3 surgical techniques

      Significantly longer surgery duration (p < 0.001) in AI technique as compared to the other 2
      Lowenstein et al. [
      • Lowenstein N.A.
      • Haber D.B.
      • Ostergaard P.J.
      • Collins J.E.
      • Matzkin E.G.
      All-inside anterior cruciate ligament reconstruction using quadrupled semitendinosus: comparable 2-year outcomes in male and female patients.
      ]
      Arthroscopy

      2021
      100

      Male – 38 Female – 62
      31.3 (14–58)24Quadrupled ST autograft (54%) or allograft (46%)NilVAS pain 1.07

      Marx scale 8.75

      KOOS pain 89.03, KOOS symptoms 80.79

      KOOS ADL 95.4, KOOS sports 81.25

      KOOS quality of life 71.56

      WOMAC pain 92.65, WOMAC stiffness 84.13

      WOMAC function 95.4
      Patients who had autograft had better Marx activity scores, KOOS Sport and KOOS ADL scores

      No significant differences in outcomes scores of males and females

      Better Marx scores in males at 1 year, and greater KOOS ADL scores in females at 1 year
      Greif et al. [
      • Greif D.N.
      • Shallop B.J.
      • Allegra P.R.
      • Cade W.H.
      • Minesinger K.E.
      • Luxenburg D.
      • et al.
      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.
      ]
      Arthroscopy 2022124

      Suspensory fixation: 62

      Interference screw fixation: 62
      Suspensory fixation: 27.74

      Interference screw fixation: 31.21
      Suspensory fixation: 31.70

      Interference screw fixation: 31.29
      All soft tissue QT autograftSuspensory fixation: 4 arthrofibrosis, 1 button removal due to infection, 7 anterior knee/kneeling pain

      Interference screw fixation: 1 arthrofibrosis,

      13 anterior knee/kneeling pain
      Suspensory fixation:

      IKDC subjective 92.08

      Lysholm 93.87

      Tegner 6.91
      Interference screw fixation:

      IKDC subjective 90.12

      Lysholm 90.34

      Tegner 6.77
      3 graft failures in interference screw fixation

      1 graft failure in suspensory fixation

      No significant difference in anterior knee/kneeling pain (p = 0.22)

      Significantly better Lysholm scores in suspensory fixation group (p = 0.04)
      Goyal et al. [
      • Goyal T.
      • Das L.
      • Paul S.
      • Choudhury A.K.
      • Sethy S.S.
      Outcomes of retro-drilled all-inside tibial tunnel vs complete tibial tunnel techniques in anterior cruciate ligament reconstruction—a comparative study.
      ]
      European Journal of Orthopaedic Surgery & Traumatology

      2022
      80

      AI: 40

      Standard: 40
      28.3

      AI: 28.3

      Standard 28.4
      24AI: quadrupled ST

      Standard: doubled ST&G
      AI: late infection at tibial side

      Standard: 1 implant failure with tunnel widening
      AI

      Lysholm 98.8

      IKDC subjective 914

      VAS 0.1

      Quad power 40.9bs

      HS power 25.8bs
      Standard

      Lysholm 97.5

      IKDC subjective 90.8

      VAS 0.2

      Quad power 40.5lbs

      HS power 23.5lbs
      Lower VAS score in the AI group at the 2 and 6 weeks follow up mark.

      No significant differences in Tegner, IKDC and Lysholm scores between both groups.

      No significant differences in quadriceps powerSignificant

      difference in HS power (p = 0.002) between both groups
      ACL – anterior cruciate ligament, AI – all-inside; BPTB – bone patella tendon bone graft, HS – hamstrings; KOOS – Knee Injury and Osteoarthritis Outcome Score; KSS – Knee Society Score; KSSTA – Knee Surgery, Sports Traumatology, Arthroscopy; IKDC – International Knee Documentation Committee score; KT-1000 – KT-1000 knee arthrometer, Lysholm – Lysholm scores, Marx–Marx scale, NR – not recorded, QT – quadriceps tendon; SF-12 – 12-item short form survey; ST – semitendinosus; ST&G – semitendinosus and gracilis; Tegner–Tegner activity scale, VAS – visual analogue scale; WOMAC – Western Ontario and McMaster Universities Osteoarthritis Index.
      a Median values.
      Lowenstein et al. [
      • Lowenstein N.A.
      • Haber D.B.
      • Ostergaard P.J.
      • Collins J.E.
      • Matzkin E.G.
      All-inside anterior cruciate ligament reconstruction using quadrupled semitendinosus: comparable 2-year outcomes in male and female patients.
      ] reported that anatomic ST4 AI ACLR had improved functional outcomes at 1 and 2 years post-operatively and is comparable in both male and female patients alike. Smith et al. [
      • Smith P.A.
      • Cook C.S.
      • Bley J.A.
      All-inside quadrupled semitendinosus autograft shows stability equivalent to patellar tendon autograft anterior cruciate ligament reconstruction: randomized controlled trial in athletes 24 Years or younger.
      ] showed that ST4 AI ACLR had equivalent KT-1000 stability testing when compared to gold standard BPTB ACL reconstruction in young athletes. Both groups had similar retear rates. Comparing different graft choices in SG ACLR, Galan et al. [
      • Galan H.
      • Escalante M.
      • della Vedova F.
      • Slullitel D.
      All inside full thickness quadriceps tendon ACL reconstruction: long term follow up results.
      ] achieved similar IKDC outcomes with the QT graft as the ST4 AI ACLR group shown by Volpi [
      • Volpi P.
      • Bait C.
      • Cervellin M.
      • Denti M.
      • Prospero E.
      • Morenghi E.
      • et al.
      No difference at two years between all inside transtibial technique and traditional transtibial technique in anterior cruciate ligament reconstruction.
      ] et al. Galan et al. achieved 59.79% IKDC A, 35.4% IKDC B and 4.81% IKDC C, whereas Volpi et al. obtained scores of 55%, 40%, and 5%, respectively, in their cohort. Greif et al. [
      • Greif D.N.
      • Shallop B.J.
      • Allegra P.R.
      • Cade W.H.
      • Minesinger K.E.
      • Luxenburg D.
      • et al.
      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.
      ] also had good outcomes in their experience with QT grafts in terms of IKDC scores and low rates of graft failure.

      Benefits

      Studies have shown that the AI technique is associated with less pain when compared to standard techniques [
      • Goyal T.
      • Das L.
      • Paul S.
      • Choudhury A.K.
      • Sethy S.S.
      Outcomes of retro-drilled all-inside tibial tunnel vs complete tibial tunnel techniques in anterior cruciate ligament reconstruction—a comparative study.
      ,
      • Lubowitz J.H.
      • Schwartzberg R.
      • Smith P.
      Randomized controlled trial comparing all-inside anterior cruciate ligament reconstruction technique with anterior cruciate ligament reconstruction with a full tibial tunnel.
      ,
      • Kyriakopoulos G.
      • Manthas S.
      • Vlachou M.
      • Oikonomou L.
      • Papadakis S.A.
      • Kateros K.
      Anterior cruciate ligament reconstruction with the all-inside technique: equivalent outcomes and failure rate at three-year follow-up compared to a doubled semitendinosus-gracilis graft.
      ,
      • Kouloumentas P.
      • Kavroudakis E.
      • Charalampidis E.
      • Kavroudakis D.
      • Triantafyllopoulos G.K.
      Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique.
      ,
      • de Sa D.
      • Shanmugaraj A.
      • Weidman M.
      • Peterson D.C.
      • Simunovic N.
      • Musahl V.
      • et al.
      All-inside anterior cruciate ligament reconstruction-A systematic review of techniques, outcomes, and complications.
      ]. This has been postulated to be due to less bone loss with tibial sockets and less tibial periosteal irritation [
      • de Sa D.
      • Shanmugaraj A.
      • Weidman M.
      • Peterson D.C.
      • Simunovic N.
      • Musahl V.
      • et al.
      All-inside anterior cruciate ligament reconstruction-A systematic review of techniques, outcomes, and complications.
      ]. This allows for earlier rehabilitation and faster recovery as well.
      The benefit of SG ACLR with ST4 with the preservation of the gracilis or QT, leads to improved recovery of knee flexion strength [
      • Kouloumentas P.
      • Kavroudakis E.
      • Charalampidis E.
      • Kavroudakis D.
      • Triantafyllopoulos G.K.
      Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique.
      ,
      • Monaco E.
      • Redler A.
      • Fabbri M.
      • Proietti L.
      • Gaj E.
      • Daggett M.
      • et al.
      Isokinetic flexion strength recovery after ACL reconstruction: a comparison between all inside graft-link technique and full tibial tunnel technique.
      ]. This is ideal in female athletes, as it may be difficult to reliably obtain a graft of the required diameter for ACLR.
      Mayr et al. reported less tibial tunnel enlargement in AI ACLR with button fixation compared to screw fixation [
      • Mayr R.
      • Smekal V.
      • Koidl C.
      • Coppola C.
      • Eichinger M.
      • Rudisch A.
      • et al.
      ACL reconstruction with adjustable-length loop cortical button fixation results in less tibial tunnel widening compared with interference screw fixation.
      ]. The preservation of bone stock with the use of sockets as compared to full tunnels in the SG ACLR can also be helpful in the event of revision surgery or even in complex combined osteotomy surgery. ST4 or QT SG ACLR which spare the other tendons were used to reconstruct the other ligaments in multiligament surgery.
      SG ACLR is also versatile in the skeletally immature younger athletes. The physeal sparing AI ACLR technique can be used [
      • Lee Yee Han D.
      • Nawab A.
      Anatomic physeal-sparing ACL reconstruction: a modified technique.
      ]. This allows an anatomical ACL to be performed without crossing the physis to avoid growth arrest. An ST4 SG ACLR is ideal in such patients.

      Conclusion

      To summarise, short grafts have become a popular option these days and should be considered for use in a primary ACL reconstruction, especially in the younger athletes. Outcomes of the short graft are reproducible and consistent, with good biomechanical properties desired in ACL reconstruction.

      Authors contribution

      DL and JT designed the layout of the text and was involved in writing the manuscript and review of the completed paper. DL and JT performed the literature search and wrote the manuscript. ST and TB contributed to writing the manuscript and review of the completed paper.

      Funding

      The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

      Declaration of competing interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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