All-inside Anterior Cruciate Ligament Reconstruction Research Articles

Accuracy of femoral tunnel placement using three different techniques in performing arthroscopic all-inside Anterior Cruciate Ligament Reconstruction; A Randomized study

Accuracy of femoral tunnel placement using three different techniques in performing arthroscopic all-inside Anterior Cruciate Ligament Reconstruction; A Randomized study

Inside‐out tibial tunnel drilling technique is a reliable approach for all‐inside ACL reconstruction: A longitudinal MRI assessment

AbstractPurposeTo longitudinally evaluate sockets localization, tunnel morphological changes and graft maturation after the inside‐out tibial tunnel drilling technique for all‐inside Anterior Cruciate Ligament Reconstruction (ACLR). We hypothesized that due the necessary angle for the inside‐out reaming procedure, the described technique could input changes in the tibial socket.MethodsFourteen knees treated with the same all‐inside ACLR technique were randomly assigned for a magnetic resonance evaluation. All patients were operated by the same surgeon and performed the same follow‐up rehabilitation protocol. Socket's localization, shape and widening, as well as graft maturation and integration, were evaluated intraoperatively at 6 months and 4 years after surgery.ResultsBoth femoral and tibial tunnels had an expected increase at 6 months follow‐up. The widening was larger in the tibial tunnel (12.6 ± 10.0% vs. 9.1 ± 8.5%), yet this difference was not statistically different. Tibial tunnel was well centred in the tibial plateau and the integration of the graft was higher in the tibial socket. Four years after surgery, there was a general reduction of diameter in both tunnels. The tunnel occlusion rate was 33.3% for tibia and 16.7% for femur.ConclusionsOverall, our results show that within a 4‐year follow‐up period, the inside‐out tibial tunnel drilling technique for all‐inside ACLR represents a safe technique that did not influence the tibial socket position nor tunnel widening or graft maturation in the long term.Level of EvidenceLevel IV.

All-inside Technique versus Conventional Full-tunnel Reconstruction for Anterior Cruciate Ligament Tears of the Knee: A Systematic Review and Meta-analysis

Introduction: There is a paucity of evidence in literature regarding the efficacy of all-inside anterior cruciate ligament reconstruction (AIACLR) vis-à-vis the traditionally used full-tunnel (FT) technique. The primary aim of this review, thus, was to shed light on this discrepancy and determine which of the two methods had more optimum results. Methods: PubMed and Cochrane Library databases were systematically searched by two independent reviewers. Selection criteria were laid down as per the patient, intervention, control, and outcome (PICO) format. All included studies were checked for quality and methodological strength using well-defined risk-of-bias assessment tools. Techniques were compared with respect to their graft and tunnel dimensions, functional outcome scores, and complication rates. Data analysis was carried out using the RevMan 5.3® software. Results: A total of 12 articles (six randomized control trials or randomized clinical trials and six prospective/retrospective cohort studies) with 880 knees were included in this study. In most instances of AIACLR, a short and thick quadrupled semitendinosus graft was used for reconstruction. Suspensory fixation devices alone or in combination with interference screws were used for graft fixation. The two techniques were comparable in terms of their functional outcomes, with a slightly lower graft failure rate with AIACLR. Conclusion: The AI technique provides a safe and reliable alternative to conventional ACLR in terms of comparable functional results, reduced postoperative pain, and lower graft failure rates. However, more comparative trials with long-term follow-ups are needed before a definitive statement can be put forward.

All-Inside Anterior Cruciate Ligament Reconstruction Using Full-Thickness All-Soft-Tissue Quadriceps Tendon Autograft With Independent Suture Tape Augmentation

The anterior cruciate ligament (ACL) is the most frequently injured knee ligament that requires surgical intervention. Surgical options to address ACL ruptures include reconstruction using autograft or allograft or performing primary repair. Subsequent ACL graft failure is a significant postoperative concern in the younger patient population. The addition of suture tape to the final construct is thought to protect the graft during moments of high stress by increasing graft stiffness under high load and preventing substantial graft elongation. Given the normal anatomic lengthening of the ACL from knee flexion to full extension, final fixation of both the suture tape and the graft is done with the knee hyperextended to avoid overconstraint. The use of adjustable loop fixation for both femoral and tibial fixation with the all-inside technique allows the graft to be retensioned after final suture tape fixation and subsequent knee cycling. This ensures that the suture tape is slightly laxer than the graft so that the graft experiences loads that are essential for its healing, with the suture tape sharing the load only during times of high stress.

A Simplified Technique for All-Inside Tibial Socket Retrograde Drill Guiding Using a 2- to 3.5-mm Concentric Cannula Without the All-Inside Tibial Guide Ring

The all-inside anterior cruciate ligament (ACL) technique is a minimally invasive surgical procedure that has gained popularity due to its reduced invasiveness and improved patient outcomes. The establishment of tibial sockets remains a crucial step in ACL reconstruction, which has always been difficult in ACL reconstruction research. For doctors who are not very experienced, this technique of positioning and making sockets requires a special guide ring, and the tunnel entrance is prone to be anterior. Herein, we report a simplified technique using a self-made 2- to 3.5-mm concentric cannula to help surgeons easily master the all-inside technique. Our technique for tibial socket construction does not require the specific tibial guiding ring but uses a traditional tibial guiding ring for full-length tibial tunnel construction. With a 2-mm Kirschner wire and the traditional tibial guiding ring initially locating the tunnel position, the self-made concentric cannula helps combine the Kirschner wire with the guide pin sleeve, thereby impacting the guide pin sleeve into the tibial cortex at a controlled depth. Then, retrograde drilling is performed to create the socket. This technique provides feasible approaches for surgeons to transition from traditional full-long tunnel creation to the semi-long socket construction for the all-inside ACL technique.

Comparison of the Clinical Outcomes between All-inside and Standard Technique in Anterior Cruciate Ligament Reconstruction with 6-strand Hamstring Tendon Autograft.

All-inside and standard techniques with 4-strand hamstrings graft have been widely used in anterior cruciate ligament (ACL) reconstruction. However, the graft diameter of less than 8 mm will significantly increase the rate of surgical failure, and the 6-strand graft can solve this problem. The purpose of this study is to compare all-inside ACL reconstruction using suspensory cortical button fixation on both tibia and femur with standard ACL reconstruction using suspensory femoral fixation and a bioabsorbable tibial interference screw with a 6-strand hamstring tendon autograft in postoperative clinical outcomes. From January 2020 to December 2020, 48 patients performed ACL reconstruction were divided into the all-side group and the standard group according to the different surgical techniques. Magnetic resonance imaging (MRI) and subjective function scores was used to assess clinical outcomes at least 24 months following ACL reconstruction. MRI was used to measure the value of bone tunnel widening in articular and middle portions. Subjective function scores included the Lysholm knee score, the International Knee Documentation Committee (IKDC) score, the Knee Society Score (KSS) for pain and function, and KT-1000. The t-test was used assuming the distribution of the patients which follows the normal distribution and we used non-parametric tests if these two conditions were not satisfied. At the final follow-up, there were 22 patients in the all-inside group and 24 patients in the standard group. No significant differences were found with respect to femoral tunnel widening and subjective function scores. However, a significant increase in tibial tunnel widening was found in the middle portion of the standard group (2.25 ± 0.74) compared to the all-inside group (0.76 ± 0.24) (p < 0.01) and also in the articular portion of the standard group (2.07 ± 0.77) compared to the all-inside group (1.52 ± 0.54) (p = 0.02). In addition, the value of the KT-1000 was 1.81 ± 0.45 for the all-inside group and 2.12 ± 0.44 in the standard group (p = 0.016). The objective stability of the knee was relatively better in the all-inside group than in the standard group. And tunnel widening after ACL reconstruction was significantly greater in the standard technique when compared to the all-inside technique on the tibia side.

All-Inside ACL Reconstruction: Short Femoral and Tibial Socket Technique

Background: Recently, there has been an increase in interest in all-inside anterior cruciate ligament (ACL) reconstruction (ACLR). Regarding graft maturity, graft contact with the bone tunnel is important. All-inside ACLR with short femoral and tibial sockets might allow to increase the contact between the graft and the socket (ie, no interference screw and contact between the graft and bottom of the socket) and can improve graft maturing. Indications: All-inside ACLR with short sockets technique is indicated in patients with primary ACL rupture or ACL graft re-rupture. Technique Description: The patient was placed in supine position. Following examination under anesthesia, diagnostic arthroscopy was performed to assess for meniscus injuries and chondral defects. The surgical technique required 6 steps: (1) graft preparation (4-strand semitendinosus tendon, graft length was about 45 mm, grafts larger than 8 mm), (2) creating femoral socket (5-10 mm), (3) creating tibial tunnel socket (10-15 mm), (4) passing the graft, (5) tensioning the graft, and (6) graft fixation and skin closure. Patients were partial weightbearing with crutches for 3 weeks and used a hinged knee brace for 6 weeks after surgery. Return to activities was based on functional strength recovery, with a return to running targeted at 4 to 5 months after surgery. Results: All-inside ACLR with short sockets technique provides a better chance of return to preinjury level of activity with accompanied patient satisfaction as compared with anteromedial portal technique at 2 years of follow-up. This technique has favorable functional and clinical outcomes with improvement of graft maturing. Discussion/Conclusion: In conclusion, we propose that ACLR with short tibial and femoral socket technique is simple and safe with favorable clinical outcomes. This is an advantageous ACLR technique that can preserve the gracilis muscle and reduce muscle strength loss of affected limbs. In addition, the all-inside technique is circumferential filling of the socket with the graft, which might increase bone to graft contact compared with interference screws. Further study is needed to show the better clinical outcome and the earlier graft maturation compared with ordinary ACLR. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Comparison of bone age assessment methods using a hand radiography in patients with active growth plate and anteromedial knee instability

Background Bone age is essential for pediatric patients with active growth zones and anteromedial instability to facilitate optimal treatment strategy and minimize postoperative complications. However, many people are unaware of various tools for determining bone age, including classical methods and modern machine learning techniques.The objective was to show and compare different methods for calculating bone age and determining surgical strategy for patients with anteromedial instability of the knee joint.Material and methods All-Inside anterior cruciate ligament reconstruction was performed for 20 patients. Wrist radiographs were performed for bone age assessment using the "point scoring system" of Tanner and Whitehouse and the "atlas matching" method of Greulich and Pyle. Machine learning programs were used in addition to standard bone age assessments.Results The findings showed an average difference of 21 months (80 %) in a group of 20 individuals with bone age ahead of the passport age and an average difference of 18 months (20 %) in patients with retarded bone age.Discussion The findings showed the difference between chronological and bone age and could be encountered in scientific articles on endocrinology and pediatrics. No scientific studies on the use of the methods could be found in the specialty “trauma and orthopaedics”.Conclusion Bone age assessment, prediction of children's target height are essential for surgical treatment of patients with open growth plates.

All-Inside Anterior Cruciate Ligament Reconstruction Had Clinical Outcome Similar to the Transtibial Technique Except for Improved Side-to-Side Difference and Tegner Activity Scale: A Systematic Review and Meta-analysis

PurposeTo compare clinical outcomes of the all-inside technique with the transtibial technique in anterior cruciate ligament reconstruction based on available literature on this topic. MethodsAccording to the PRISMA checklist, we conducted a systematic search for randomized controlled trials and Cohort studies. Our comprehensive search encompassed PubMed, Embase, Cochrane Library, and Web of Science. We included RCTs and cohort studies that compared the two techniques with a minimal one-year follow-up. Two independent authors assessed RCTs using the risk of bias tool developed by the Cochrane Collaboration, and evaluated the quality of cohort studies using the Newcastle-Ottawa Scale for Assessing the Quality of Nonrandomized Comparative Trials. The subjective and objective outcomes, complication, and graft failure were obtained. The R software was used to perform the analysis. ResultsThe present analysis enrolled 9 RCTs (n= 687) and 11 cohort studies (n= 910) . After a minimal one-year follow-up in RCTs, functional outcomes such as IKDC subjective score, Lysholm score, Tegner activity scale, Knee society score, and Hop test were found to be similar between two techniques. The laxity outcomes including the IKDC objective grade and Pivot-shift test, were suggested to be comparable. There was a significant difference favoring the transtibial technique in terms of side-to-side difference (P=0.04, 95% CI= 0.08 to 0.90). The pooled data from cohort studies indicated equivalent results in terms of IKDC subjective score, Lysholm score, Side-to-side difference, IKDC objective grade, Complication, and Graft failure, with the exception of statistical difference in the Tegner activity scale (P=0.03, 95% CI= -0.50 to -0.04). ConclusionOur findings suggest that there is no difference in most outcome scores between the all-inside and transtibial techniques for anterior cruciate ligament reconstruction. There are statistically significant differences in side-to-side difference and Tegner activity scale favoring all-inside technique.

All-inside anterior cruciate ligament reconstruction with and without anterolateral ligament reconstruction: a prospective study.

There is no clear consensus regarding the superiority of a combined anterior cruciate ligament reconstruction (ACLR) with anterolateral ligament reconstruction (ALLR) versus an isolated ACLR. In this study, we compared the postoperative stability profile, complications, and patient-reported outcomes of these procedures. Twenty-one patients with an anterior cruciate ligament (ACL) tear who were either treated by an isolated all-inside ACLR (n = 21) or a combined all-inside ACLR and ALLR (n = 20) were included. The outcomes were evaluated in the last follow-up and included the postoperative stability profile evaluated by the Lachman test, pivot shift test, and KT-1000 side-to-side difference, postoperative complications, and patient-reported outcomes evaluated by the International Knee Documentation Committee (IKDC) score and Lysholm knee scale. The baseline characteristics of the two groups were not significantly different. The residual Lachman and pivot shift were not significantly different between the two groups (P = 0.41 and P = 0.18, respectively). The mean KT-1000 side-to-side difference was 1.93 ± 1.9mm in the isolated and 1.635 ± 0.91mm in the combined group (P = 0.01). The mean improvement of the IKDC score was not significantly different between the isolated and combined groups (24.7 vs. 25.2, P = 0.28). The mean improvement of the Lysholm scale was not significantly different between the isolated and combined groups (33.5 vs. 34.1, P = 0.19). ACL re-rupture occurred in three patients of the isolated group and no patient of the combined group. The outcomes of patients in the present study support performing a combined ALL and ACL reconstruction.

Clinical Outcomes of Anatomic, Anterior Cruciate Ligament Reconstruction through All-inside Technique in Armed Forces Personnel

Abstract Context: Reconstruction of the anterior cruciate ligament (ACL) allows patients to resume their sports activity and delay the onset of osteoarthritis associated with loss of meniscal function. The all-inside approach for ACL reconstruction (ACLR) is to increase the graft diameter by folding several strands when sufficient graft diameter is not secured. Aims: The aim of this study is to evaluate the clinical and functional outcomes in patients undergoing of anatomic, all-inside ACLR procedure. Settings and Design: This was a prospective clinical study conducted in a Tertiary Care Hospital for 12 months on patients undergoing all-inside anatomic arthroscopic ACLR with hamstring autograft using BUTTONFIX® fixation button with adjustable loop (Chetan Meditech Pvt. Ltd., Ahmedabad, Gujarat, India). Subjects and Methods: Patients were evaluated for functional status using Lysholm Knee Score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Tegner Activity Scale at 3-month, 6-month, and 12-month postsurgery. Statistical Analysis Used: All the statistical analyses were performed using SPSS version 23 (IBM 2013). Results: Forty patients were included in the study with a mean age of 29.38 ± 5.47. There was a gradual increase in the scores at the follow-up starting from baseline with a mean difference of Lysholm knee score from 43.58 ± 5.23 to 93.50 ± 3.00 at the 12-month follow-up period. Similarly, the KOOS at baseline showed a mean of 44.03 ± 5.20, which increased gradually up to 93.05 ± 2.83 at 12 months, and the Tegner activity score at baseline was 3.55 ± 0.6 and gradually increased to 7.28 ± 0.85 at 12-month period. Conclusions: All-inside surgical techniques for the anatomic ACLR showed favorable clinical and functional outcomes.

Finite element analysis of anterior cruciate ligament reconstruction techniques: A comparison of the mechanical properties of all-inside fixation and traditional fixation.

The main purpose of this study was to explore the mechanical properties of the anterior cruciate ligament and its attachments following reconstruction with the all-inside technique after anterior cruciate ligament injury. Knee joint computed tomography data were collected from healthy volunteers, and knee joint models were created using Mimics software. A normal knee joint model, an all-inside reconstructed anterior cruciate ligament model, and a traditional reconstructed anterior cruciate ligament model were established. A tensile force of 134N and a bending moment of 5N/m were applied at the anterior aspect of the proximal tibia in these three models. The knee joint was subjected to external rotation, internal rotation, varus, valgus, flexion, and extension under this bending moment. The magnitude and distribution of stress on the ligament or graft and the magnitude and distribution of stress on the graft attachments were observed under different loading conditions. Under different external forces, the maximum stress on the ligament in the normal model fluctuated from 1.949 to 18.302MPa, with an uncertain distribution of maximum stress. The maximum stress on the graft in the all-inside reconstructed anterior cruciate ligament model fluctuated from 0.705 to 3.465MPa and was mainly distributed at the junction of the graft and the tibial footprint. In the traditional reconstructed anterior cruciate ligament model, the maximum stress on the graft fluctuated from 5.012 to 59.269MPa and was primarily distributed at the junction of the interference screw and the graft. The concentration of stress on the loop and plate in the all-inside reconstructed anterior cruciate ligament model fluctuated from 70.461 to 346.363MPa, with maximum stress distributed at the junction of the loop and the tibial surface. The maximum stress on the interference screw in the traditional reconstructed anterior cruciate ligament model fluctuated from 10.184 to 92.298MPa, with maximum stress primarily distributed at the end of the interference screw. Under different external forces, the graft used in all-inside anterior cruciate ligament reconstruction is subjected to fewer external forces than that used in traditional anterior cruciate ligament reconstruction, which may indicate a relatively stable mechanical environment. The strength of the loop and plate can theoretically tolerate daily knee joint movements of patients without injury.

Physeal-Sparing, All-Inside Anterior Cruciate Ligament Reconstruction Using Quadrupled Semitendinosus Autograft and Suture Tape Augmentation for Skeletally Immature Patients

The anterior cruciate ligament (ACL) is the primary soft-tissue structure for anterior stabilization of the knee and is one of the most frequently injured structures. The incidence of ACL injuries in children and adolescents ranges from 92 to 151 per 100,000 person-years. The choice of surgical treatment for this population group is controversial, with a widespread concern that adult reconstruction techniques may damage the epiphyseal plate, compromise growth, or cause deformity. In this article, we describe a physeal-sparing, all-inside ACL reconstruction technique for skeletally immature patients. This technique is supported by retrograde drilling of the femoral tunnel and retrograde drilling of the tibial tunnel, both of which are able to avoid the epiphyseal growth line. Fixation of the quadrupled semitendinosus autograft and suture tape augmentation are achieved by soft-tissue buttons on the femur and tibia. The surgical details of this reproducible reconstruction technique are elaborated.

THE ALL-INSIDE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH FIBER-LOOP AUGMENTATION

Objectives: To evaluate the functional outcomes in patients who underwent anterior cruciate ligament (ACL) reconstruction with fiber-loop augmented to reinforce the ligament, acting as a secondary stabilizer. Methods: A retrospective study was conducted on 25 patients who underwent the all-inside ACL reconstruction with the addition of fiber-loop inside the ACL graft in the Department of Joint Surgery, Military Hospital 103, from August 2022 to August 2023. Patients were evaluated pre-operatively and finally post-operatively via the Lachman test, Pivot shift test, and Lysholm score. Results: The mean follow-up was 9.84 months; the mean age was 33.04 ± 9.95 years. 24 patients (96%) were post-operatively Lachman negative. The pivot-shift test showed 96% of patients absent or glide after surgery. The Lysholm knee score at the last visit was good and very good in 96% of the patients; the mean score was 92.56 ± 4,53. Conclusion: This study showed good functional outcomes of arthroscopic ACL reconstruction with fiber-loop augmentation to reinforce the ligamental graft. There is a need for more comparative studies with longer follow-ups and large sample sizes.

A Modified Technique for All-Inside Anterior Cruciate Ligament Reconstruction (ACLR): True Femoral Socket

Anterior cruciate ligament reconstruction (ACLR) performed via arthroscopy is the primary treatment for anterior cruciate ligament injury. In traditional ACLR, the surgeon must create bone tunnels in both the femur and tibia, which increases the risk of bleeding and pain. The advent of all-inside technology has introduced the concept of bone sockets. However, the femoral socket created by the traditional all-inside technique is not a true femoral socket since the tunnel ends are still connected to achieve suspensory fixation. We are dedicated to achieving a true femoral socket in the all-inside ACLR technique. The AperFix Implant fixation system offers the potential for a genuine femoral socket by securely holding the ligaments in place through compression fixation. In this report, we present an all-inside ACLR using the AperFix Implant fixation system, which allows for a single exit of the femur side tunnel. This technique effectively reduces “windshield wiper” effect, “bungee cord” effect, as well as surgical time and minimizes the risk of bleeding, pain, and local microfractures.

Research progress of tibial-graft fixation methods on anterior cruciate ligament reconstruction

To review the studies about the tibial-graft fixation methods on anterior cruciate ligament (ACL) reconstruction, in order to provide clinical reference. The literature about the tibial-graft fixation methods on ACL reconstruction at home and abroad was extensively reviewed, and the factors that affect the selection of fixation methods were summarized. The knee flexion angle, graft tension, and graft fixation device are mainly considered when the tibial-graft was fixed on ACL reconstruction. At present, the graft is mainly fixed at 0°/30° of knee flexion. The study shows that the knee joint is more stable after fixed at 30°, while the incidence of knee extension limitation decrease after fixed at 0°. In terms of graft tension, a good effectiveness can be obtained when the tension level is close to 90 N or the knee flexion is 30° to recover the affected knee over-restrained 2 mm relative to the healthy knee. In terms of the graft device, the interference screw is still the most commonly used method of tibial-graft fixation, with the development of all-inside ACL reconstruction in recent years, the cortical button fixation may become the mainstream. Arthroscopic reconstruction is the main treatment of ACL rupture at present. However, there is no optimal fixation method for the tibial-graft, the advantages and disadvantages of each fixation methods need to be further studied.

All-Inside Anterior Cruciate Ligament Reconstruction Technique: Tips and Tricks.

The all-inside anterior cruciate ligament reconstruction (ACLR) technique was developed to improve patient outcomes by reducing the procedure's invasiveness, minimizing complications and pain, and enabling faster postoperative recovery. This study presents a detailed description of the all-inside ACLR technique, which involves the use of quadrupled semitendinosus (ST) graft and suspension devices at both tibial and femoral sites, as well as valuable tips for avoiding complications that may arise during the procedure. The surgical procedure employs retrograde drills to create bony sockets for graft passage, which are then fixed with suspension devices at both the tibial and femoral sites. This technique has no specific restrictions and may be applied to all patients with anterior cruciate ligament (ACL) injuries. The literature reports the advantages, good clinical outcomes, and medium- to long-term graft survival achieved with the all-inside ACLR technique. However, the complications and disadvantages associated with the technique must be considered.

Anterior Cruciate Ligament Reconstruction Using Fixed Loop All-Inside (FLAI) Technique

The aim of this surgical technical note is to provide a more secure option to prevent possible graft loosening with all-inside anterior cruciate ligament (ACL) reconstruction. A triple strategy is used. First, a fixed loop cortical device is used on the femoral side. Second, an internal brace augmentation for ACL graft is employed to prevent graft loosening during early postoperative period. Lastly, tying off the sutures of tibial adjustable loop after retensioning to secure its locking mechanism from slippage.

Biomechanical Comparison of 3 Adjustable-Loop Suspensory Devices for All-Inside ACL Reconstruction: A Time-Zero Full-Construct Model.

Little is known about the stability of adjustable-loop devices (ALDs) for anterior cruciate ligament (ACL) reconstruction (ACLR). To evaluate the stabilization behavior of 3 different types of ALDs for all-inside ACLR in a full-construct surgical technique-based manner. Controlled laboratory study. The femoral and tibial devices of Ultrabutton (Smith & Nephew), Infinity (Conmed), and TightRope II (Arthrex) were applied to quadrupled bovine tendon grafts (n = 8 each) with tibial-sided traction applied (350 N) for graft tensioning in a simulated fully extended knee. Knotless femoral graft fixation was based on either a suture-locking device (SLD; Ultrabutton), button-locking device (BLD; Infinity), or dual-locking device (DLD; TightRope II). All constructs were progressively loaded (50 N/500 cycles) from 50 to 300 N for 3000 cycles (0.75 Hz), including complete unloading situations and pull to failure (50 mm/min). Construct elongation, stiffness, and ultimate load were analyzed. BLD showed significantly greater initial elongation (-2.69 ± 0.15 mm) than DLD (-3.19 ± 0.21 mm; P < .001) but behaved similarly to SLD (-2.93 ± 0.23 mm). While DLD and SLD had the smallest initial elongation at the same significance level, they behaved opposite to each other with gradually increasing peak loading. At the end of testing, DLD had the lowest (-0.64 ± 0.32 mm) and SLD the highest (3.41 ± 1.01 mm) total elongation (P < .003 for both). SLD displayed significantly higher dynamic elongation (6.34 ± 0.23 mm) than BLD (3.21 ± 0.61 mm) and DLD (2.56 ± 0.31 mm) (P < .001 for both). The failure load of BLD (865.0 ± 183.8 N) was significantly lower (P < .026) compared with SLD and DLD (>1000 N). The predominant failure mode was suture rupture and tibial bone breakage with button subsidence (SLD, n = 4). No significant difference in stiffness between constructs was found. While DLD successfully restricted critical construct elongation, BLD partially and SLD completely exceeded the clinical failure threshold (>3 mm) of plastic elongation with loop lengthening during increasing cyclic peak loading with complete unloading. Higher failure loads of SLD and DLD implants (>1000 N) were achieved at similar construct stiffness to BLD. A detailed biomechanical understanding of the stabilization potential is pertinent to the continued evolution of ALDs to improve clinical outcomes.

Post-Operative Modified All-Inside ACL Reconstruction Technique's Clinical Outcomes and Isokinetic Strength Assessments.

Anterior cruciate ligament (ACL) injuries are very common among the athletic population. ACL reconstruction (ACLR) performed because of these injuries is one of the procedures performed by orthopedic surgeons using different grafting methods. This study aims to compare the data related to post-operative 6-month isokinetic strength values, strength-related asymmetry rates, time parameters, and joint angle in athletes who underwent ACLR with the Modified All-inside (4ST) technique, on both the healthy knee (HK) and the ACLR-applied sides. A total of 20 athletes from various sports on whom the 4ST ACLR technique had been applied by the same surgeon were evaluated retrospectively. Lysholm, Tegner, and International Knee Documentation Committee (IKDC) scores of the patients were obtained pre-operative and at 6 months post-operative. Isokinetic knee extension (Ex) and flexion (Flx) strengths on the HK and ACLR sides of the patients were evaluated with a series of four different angular velocities (60, 180, 240, and 300°/s). In addition to peak torque (PT) and hamstring/quadriceps ratio (H/Q) parameters, the findings were also evaluated with additional parameters such as joint angle at peak torque (JAPT), time to peak torque (TPT), reciprocal delay (RD), and endurance ratio (ER). There was a significant improvement in the mean Lysholm, Tegner, and IKDC scores after surgery compared with pre-operative levels (p < 0.05). As for PT values, there were significant differences in favor of the HK in the 60, 180, and 300°/s Ex phases (p < 0.05). In terms of the H/Q and (hamstring/hamstring)/(quadriceps/quadriceps) (HH/QQ) ratios, there were significant differences at 300°/s (p < 0.05). In terms of JAPT, there were significant differences in the 300°/s Ex and 180°/s Flx phases (p < 0.05). In terms of TPT, there were significant differences in the 300°/s Ex phase (p < 0.05). In terms of RD and ER, no significant difference was observed between the HK and ACLR sides at any angular velocity. Although differences were observed in PT values, particularly in the Ex phase, this did not cause a significant change in H/Q ratios. Similar results were observed for additional parameters such as JAPT, TPT, RD, and ER. The results show that this ACLR technique can be used in athletes in view of strength gain and a return to sports.