Comparative Study between Clinical Outcomes of All Inside Technique and Standard Antero-Medial Technique in Anterior Cruciate Ligament Reconstruction

INTRODUCTION

Meniscal or cartilage damage is more likely to occur in ACL tears (ACLt). Additionally, persistent instability might cause early osteoarthritis. ¹

The ability to resume playing quickly after ACLR is, for many patients, the primary evidence of a successful procedure. One of the following methods could lead to an ACL tear: Valgus trauma is an anteriorly directed force that affects an extended knee; it can also happen after excessive internal tibial rotation (IR) and hyperextension. ²

Direct trauma, as seen in football, may cause this mode of injury. 65 percent of ACL injuries are "noncontact" injuries. This typically occurs when the player pivots (twists his knee), or stops abruptly. ³

The number of active instances that are affected and the complications of injury all contribute to the significance of the ACL. It is crucial to understand that it does not cure on its own, necessitating reconstruction. ³

The trans-tibial, anatomical accessory antero-medial (AAM) portal, and all-inside approaches are the arthroscopic ACLR procedures most often used today. ^{1, 4}

In ACLR, the method most frequently utilised to arthroscopically drill the femoral tunnel was trans-tibial drilling. ² However, due to this technique's inclination of the femoral socket being influenced by the tibial tunnel, which results in a vertical femoral tunnel, its use is currently very limited. Even though the initial results were positive, the non-anatomical graft site led to pain and early onset arthritis. ^{2, 3} This resulted in the knee's typical kinetics being disturbed. ^{5, 6} The inter-condylar and bifurcate ridges are also difficult to see in the lateral portal arthroscopic image. This could result in the graft being placed anteriorly or at a higher level than anticipated. ⁷

"Anatomic" or "footprint" ACLR has achieved because it restores the graft's anatomical position, which also restores the knee's biomechanics ⁸ .

To prepare the femoral tunnel with this approach, an AAM portal is necessary for simultaneous medial visualisation ^{4, 9} . However, instrument crowding and hyperflexion highlighted the method's extreme problems ¹⁰ . The femoral and tibial tunnels are independently hand-drilled ¹¹ . Finding the medial surface of the LFC is crucial for defining tunnel placement ¹⁰ .

The gracilis tendon, a secondary stabiliser for potential use as a graft in the future, is spared by the all-inside method. Reduced discomfort and the preservation of bone on the tibial side without periosteal violation are two additional benefits ¹ .

The aim of this study compared the post-operative clinical outcomes of arthroscopic ACL restoration using the "all-inside approach" versus the "traditional procedure."

PATIENTS AND METHODS

Trial design:

This study was a prospective randomized trial. The trial was a superiority RCT with parallel assignment interventional model.

Responsible party:

The study was conducted in El-Sayed Galal University Hospital, Department of Orthopedic Surgery and Traumatology, Faculty of Medicine, Al-Azhar University.

Sample size, Power, Effect size:

The sample size was determined using the statistical programme MedCalc and data from an earlier study. The study involved detailed analysis. Only a sample size of 30 patients with 15 patients in each arm was done.

Participants:

Of fifty patients assessed for eligibility, only 30 patients were enrolled in the study with torn (ACL) with grade II or III pivot shift test under anesthesia. (Appendix G)

Patient recruitment:

Patient recruitment into the study began on March 2020. Target sample size was reached on December 2021.

Intervention:

Patients were classified into two parallel groups. Fifteen patients were assigned to conventional single bundle ACLR (Control). The other fifteen patients were assigned all-inside ACLR. (Experimental). The two groups were matched for gender, age, and duration of follow up.

Outcomes:

Primary outcome: improvement in Lysholm score.

Inclusion criteria:

Patients with positive Lachman test regardless its grade, positive pivot shift test and finally the diagnosis had been confirmed by MRI of the involved knee.

Exclusion criteria:

Patients 60 years old, patients with no or mild anterolateral instability, revision ACLR, patients with other or multi-ligamentous knee instability, partial ACL rupture (detected by MRI), patients with recent contralateral ACLR as it affects the LKS, established osteoarthritis (Kellgren-Lawrence grade 3 or 4) identified on standing knee X-rays, more than 50% of the medial or lateral meniscus removed during procedure as it affects the LKS, any previous surgery to the knee.

Randomization:

Using Random Allocation Software^TM, a computer-generated randomization list was created (Appendix A). Simple randomization was the method used.

Allocation concealment:

The list was examined in the operating room, and the anticipated treatment plan was implemented following the pivot shift test under anesthesia that confirmed high degree anterolateral instability.

Blinding:

The study participants were blinded. (Single blinded study)

Follow up period:

All cases were followed up for 2, 4 weeks, 12 weeks and 6 months, clinically for functional status using the Lysholm Knee Score.

METHODS

Methods of examination:

History: personal history: Name, age, sex, occupation, address and sport activity, side affected, history of the present illness: pain, swelling, giving way, stiffness, locking, date and mechanism of injury, past medical and surgical history, habits: Smoking, work.

Clinical Examination goes through following steps: Gait and posture: varus, recurvatum…. etc, inspection and Palpation: medial joint pain, Quadriceps wasting, movement: Range of motion, active then passive, effusion, patellofemoral joint: Crepitus, patellar grind test, meniscal Examination: Joint line tenderness, McMurrey test started with the contralateral limb first, instability tests: started with the contralateral limb first.

Lab: routine laboratory tests for surgical preparation.

Radiological evaluation: standing AP and lateral X-rays of the affected knee, MRI of the affected knee.

Methods of treatment:

Under spinal anaesthetic, patients were all operated on while lying flat. During the arthroscopic evaluation of the medial compartment, a post was placed at the operating table's edge to support the thigh while allowing valgus movement.

Fig. 1: Positioning of the patient in supine position with high tourniquet application.

Diagnostic knee arthroscopy:

Following the application of a high tourniquet, the table's edge was prepared just above the knee joint to maintain the patient's free movement. Diagnostic Knee arthroscopy was done using the standard anterolateral and AM portals. We started by treating any intra-articular co-morbidities. A partial arthroscopic menisectomy was used to treat meniscal lesions.

Graft Harvest:

In group I both ipsilateral Gracilis and Semitendinosus autograft were harvested for anatomic single bundle ACL reconstruction. In Group II: only Semitendinosus autograft was harvested.

Fig. 2: Graft harvest for ACLR.

Graft preparation:

On the graft table, an assistant prepared the graft. There were no remaining muscle fibres or connections.

For Group I:

Fig. 3: Suturing the tibial sided part (whip stitches) done through both tendons then as a one unit. For a length of the whole tibial tunnel then Suturing of the femoral sided part after measuring the whole trans osseous femoral portion then the tibial sided part all whip stitched with six suture ends, whereas the shorter suspensory femoral loop fixed to an end button and adjusted thereafter.

For Group II: High-strength sutures (Fiber Wire, Arthrex) secured the graft in a loop.

Fig. 4: Measuring the length and diameter of the graft.

Femoral Socket Creation and graft fixation (common in both groups):

Fig. 5: Arthroscopic view showing ACL graft at the end of the operation and x-ray shows an All-Inside, GraftLink, Double-Tight-Rope ACLR technique.

Postoperative protocol:

Patients got intravenous antibiotics, cryotherapy (using ice packs), anti-edematous modalities, anticoagulation, and started static quadriceps workouts while they were hospitalised for one or two nights. Following surgery, knee flexion of up to 90 degrees was encouraged. Knee extension to a zero degree was permitted right away. Two crutches were used for balancing and full weight bearing was permitted. The suction drain (Redivac) was removed after 1-2 days. Patients were discharged on oral antibiotics analgesics for one week. Oral or injection anti-coagulation prescribed for prevention of DVT prophylaxis was prescribed for both groups for two weeks. After two weeks, one crutch was discarded and at one-month post-operative, weight bearing was allowed without crutches. Sutures were removed after 2 weeks. Physiotherapy was started, following the rehabilitation program for 6 months. All patients followed an identical postoperative rehabilitation protocol created by the Fowler Kennedy Sports Medicine Clinic Physical Therapy Department and Focus was placed on early range of motion and weight bearing as follows:

Method of assessment of the results:

Patients were assessed postoperatively and during the follow up visits subjectively through a questionnaire. The outcome of the study was the LKS at the 4^th, 12^th weeks and at the 6^th months.

Patient Reported Outcome Measures (PROMs):

Patients were assessed using one main sports related PROM scores. The LKS. The LKS is an eight-item patient reported scale that evaluates knee symptoms such as limp, locking, swelling, instability, pain, stair climbing, and squatting. It is one of the most commonly used clinical scores for knee evaluation, introduced in 1982. The LKS is graded as Excellent (95–100), Good (84–94), Fair (65–83), or Poor (<65). The questionnaire was done by us at Sayed Galal University Hospital. This survey has been translated into Arabic. Patients who missed their follow-up appointment were called and requested to show up so they may receive credit for attending. In our study, the results were used to compare Group I with Group II.

Method of statistical analysis:

Data were fed to the computer and analyzed using IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp) Qualitative data were described using number and percent. The Kolmogorov-Smirnov test was used to verify the normality of distribution Quantitative data were described using range (minimum and maximum), mean, standard deviation, median and interquartile range (IQR). Significance of the obtained results was judged at the (0.05) p of value.

RESULTS

t: Student t-test p: p value for comparing between the studied groups; Group I: Conventional,            Group II: All inside

Table 1: Comparison between the two studied groups according to postoperative Lysholm score

Table 2: Comparison between the two studied groups according to postoperative Lysholm score after making categories

Regarding complications, there was no significant difference between both groups regarding overall incidence of complications.

* Statistically significant difference (p < 0.05);       X2 Chi square value, rho: Spearman coefficient.

Table 3: Comparison between the two studied groups according to complications