Editorial Commentary: With Appropriate Anterior Cruciate Ligament Graft Selection, All-Inside Reconstruction Results in Excellent Outcomes: Stay “Inside” and Be Cognizant of Hamstring Graft Diameter Expectations in Shorter Patients

Abstract

All-inside anterior cruciate ligament (ACL) reconstruction is a minimally invasive and anatomic technique with predictably excellent results. The array of graft choices that exists for skilled arthroscopists include semitendinosis autograft with or without gracilis, quadriceps tendon autograft, and patellar tendon autograft and allograft. The advantages of all-inside ACL reconstruction include independent femoral socket creation and less pain compared with a full tibial tunnel in the early postoperative period. This is a technique that should not trump appropriate graft selection. It is expected that autografts will fare better in younger patients who participate in activities at greater risk for ACL injuries. Selection of a semitendinosis autograft results in predictably excellent results when graft diameters are 8 mm or greater. Quadrupling the semitendinosis and adding the gracilis when needed can provide sufficient graft diameter in many patients. However, caution should be taken when harvesting hamstring grafts from shorter patients. Semitendinosis tendons in such patients are sometimes not long enough to quadruple and can result in a diameters less than 8 mm even when the gracilis is added. With appropriate graft selection, staying “inside” for ACL reconstruction is expected to result in great objective and subjective outcomes for our patients.