Anterior Cruciate Ligament (ACL) Rupture: Modern ALL INSIDE Repair Technique with Numerous Benefits for the Patient

The application of the advanced arthroscopic technique ALL INSIDE yields significantly better functional and aesthetic outcomes in the repair of Anterior Cruciate Ligament (ACL) ruptures.

This is an even less invasive technique that causes minimal tissue damage, replaces the torn ligament with only one (1) tendon graft instead of two (2) or the patellar tendon, involves less bone removal, and can even be applied to adolescents who are not yet skeletally mature.

Less postoperative pain, excellent stability, and a faster return to daily and athletic activities are some of the many advantages for the patient.

ACL Rupture & Treatment

An ACL rupture is one of the most common knee injuries, especially in athletes. The appropriate treatment—whether conservative or surgical—depends on the patient’s individual needs: age, type of work, level of physical activity, possible coexisting injuries, and the degree of knee instability.

In young athletes and active individuals with a complete ACL tear, surgical intervention is recommended. Because the ACL has limited healing capacity compared to other ligaments, conservative treatment usually fails to restore knee stability and function.

The All INSIDE Arthroscopic Technique

The orthopedic surgeon will replace the torn anterior cruciate ligament (a procedure known as ligamentoplasty) with a graft from the patient’s own tissue. The surgery is performed arthroscopically, using a minimally invasive technique through a few millimeter-sized holes and a small incision.

The modern ALL INSIDE arthroscopic technique is considered technically demanding, and its success largely depends on the surgeon’s specialization and experience.

Details:

Graft Selection

The graft is taken from the patient’s hamstring tendon instead of the patellar tendon, which requires an incision on the front of the knee and has been associated with anterior knee pain.

A single tendon graft from the semitendinosus (rather than two tendons used in the classic method) is placed to replace the torn ACL. The gracilis tendon is preserved, resulting in better knee function, greater muscle strength, and less postoperative pain.

Despite using only one tendon, the semitendinosus has sufficient thickness and can be configured as a quadruple-bundle graft for enhanced strength.

Graft Fixation

The graft is secured using special “buttons” (suspensory fixation devices) placed outside the bone, on both the femur and tibia. No screws or other materials are inserted into the bone.

As a result, the bone tunnels are significantly smaller than those created for internal fixation devices. Smaller tunnels mean less pain and faster healing. The bone cortex remains almost intact, contributing to better graft stabilization and stronger integration.

Revision Surgery

In case of a new injury and rupture of the graft, revision ACL reconstruction is easier with this method.

For Children & Adolescents

In this age group, the growth plate (epiphyseal plate) of the tibia is minimally affected, virtually eliminating the risk of growth disturbances.

Advantages over the Classic Technique

• Preserves a second tendon that would otherwise be used as a graft
• Significantly smaller bone tunnels, preserving more of the native bone
• No implants inserted into the bone
• Easier revision surgery in case of graft failure

Patient Benefits

• Less postoperative pain
• Faster and stronger graft integration into the bone
• Better cosmetic result
• Quicker and more effective rehabilitation
• Excellent knee stability
• No effect on growth in children and adolescents