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INTRODUCTION
The optimal treatment of anterior cruciate
ligament (ACL) rupture remains controversial
in literature [1, 2]. Different techniques for
anterior cruciate ligament reconstruction
(ACLR) are described: trans-tibial (TT),
outside-in (OI), inside-out (IO) and all-inside
technique. The aim of the surgery is to restore
the knee stability and kinematics in order to
facilitate the return to work and sport
activities [1].
Van eck
& al.
[3] define the concept of the
“anatomic reconstruction” as the “functional
restoration of ACL to its native dimensions,
collagen orientation and insertion sites”. The
principal advantage of anatomic ACL
reconstruction is to restore the normal knee
kinematic and stability. Several studies report
that anatomic reconstruction more closely
recovers normal biomechanics than does non-
anatomic reconstruction, probably reducing the
risk of osteoarthritis [4]. In this context, the OI,
IO and all-inside technique should be preferred
to the TT one [2]. However, the results of these
techniques are still controversial. Data from the
Danish Knee Ligament Reconstruction
Register show that the relative risk for revision
ACL surgery in IO group is 2,04 compared to
the TT group. This finding could be explained
because the IO procedure is more technically
demanding, thus some technical errors may
lead to a non anatomical reconstruction [5].
SURGICAL TECHNIQUE
The patient is prepared for general or local-
regional anaesthesia, placed in the supine
position on the operating table. The tourniquet
is positioned on the proximal thigh. The knee is
placed at 90° flexion with a foot-rest and a
lateral thigh post.
Usually, the bone-patellar tendon-bone (BPTB)
or hamstring tendons are harvested in a
standard fashion depending on the charac
teristics of the patient (type and level of sport
activity, age, previous ACL surgery). During
BPTB, the central third of the patellar tendon
(10mm) is harvested using a catamaran blade.
A trapezoidal tibial bone block (10mm wide
and 20mm long) and a rectangular patellar
bone block (10mm wide and 15mm long) are
then cut with an oscillating saw. Hamstring
tendons are harvested with a tendon stripper
possibly maintaining their distal insertion
(depending on their length) or detaching it. We
prefer to leave the graft attached at its tibial
insertion obtaining a 13cm long double-
stranded graft.
WHY DO I PREFER OUTSIDE-IN IN
ANTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION?
G. LA BARBERA, M. VALOROSO, G. DEMEY, D. DEJOUR