ACL Reconstruction: From Traditional Tunnels to the All-Inside Technique

Not at all, this is a different situation from minimally invasive spine or brain surgery. Arthroscopy actually gives a clearer view of the joint than open surgery would; even opening the knee completely to repair the posterior horn of the meniscus does not give as clear a view as the arthroscope does. In twenty years of practice, an arthroscopy has never needed conversion to an open procedure, provided the surgeon is patient and knows the anatomy well.

All surgery carries some residual risk, similar to how buying a car involves a small residual risk of a road accident that is rarely front of mind. The reassuring fact is that all the major blood vessels and nerves sit outside the knee and shoulder joint capsule, so as long as the anatomy is well understood and the surgery carefully planned, arthroscopy is one of the safest procedures available. Most arthroscopies are done as day-care procedures, with patients going home the same day.

Hip arthroscopy is a little different because the hip is a deeper joint, but designated portals developed over many years of anatomical study make it safe as long as a surgeon sticks to those landmarks. Labral repairs, loose body removal and cartilage surgery can all be done through the hip arthroscope. Surgeons early in their hip arthroscopy experience can use a safer mini-open approach, a small skin incision leading to the joint before introducing the scope.

With the newer all-inside technique and fiber tape augmentation, patients can weight-bear from day one using a walking aid for three to four days until pain settles, though supervised physiotherapy is still required. Full graft incorporation into bone takes about six weeks. Running and jogging can resume at three months, and return to sport is not advised before three months, since many failures happen when patients return to pivoting activity too soon.

For the knee, heavily loaded squats, especially with all the focus on upper body and inadequate lower limb conditioning, high-speed incline treadmill running, twisting exercises on a disc twister, and overloaded quadriceps extension machines are the most common causes of ACL ruptures and quadriceps or patellar tendon injuries. For the shoulder, wide-grip flies taken too far posteriorly can stress the joint, especially in anyone with a prior subluxation history. The most important message is to stop when the body signals pain rather than pushing through it.

It is a method that creates sockets, rather than complete through-and-through tunnels, on the femoral and tibial sides using a flip cutter, with the graft fixed cortically using buttons and threads. This significantly reduces bone loss compared with older techniques.

Because fixation is cortical rather than dependent on strong internal bone stock, it carries less concern about graft loosening even when there is bone marrow oedema after the injury, allowing surgery sooner rather than waiting three to six weeks or longer for the oedema to settle.