Skip to main content
SpringerLink
Log in

The All-Inside Technique: Surgical Technique and Outcomes

  • Chapter
  • First Online:
Posterior Cruciate Ligament Injuries

  • 1668 Accesses

Abstract

As surgical reconstruction of the posterior cruciate ligament (PCL) evolves, the debate continues regarding the relative efficacy of different surgical techniques. Current considerations include single-bundle or double-bundle repair as well as the all-inside technique versus the historic counterpart the open tibial inlay.Extensive research has been conducted to elucidate the anatomic features of the anterolateral and posteromedial bundles of the PCL, as well as their role in knee biomechanics. As it stands, the degree to which single-bundle reconstruction replicates normal function in vitro when compared to double-bundle reconstruction is a point of contention. Clinically, however, a preponderance of the evidence suggests that there is no significant difference in outcomes between single-bundle and double-bundle reconstruction.

The all-inside technique yields several advantages. By use of smaller incisions, the all-inside technique is less invasive and can avoid additional operative time. It also allows the surgeon to drill away from neurovascular structures by use of a reverse-drill technique which leads to less bone removal through potential creation of a socket as opposed to the traditional tunnel. The all-inside technique also has shown promising clinical results.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 89.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Race A, Amis AA. The mechanical properties of the two bundles of the human posterior cruciate ligament. J Biomech. 1994 Jan;27(1):13–24.

    Article  CAS  PubMed  Google Scholar 

  2. Edwards A, Bull AMJ, Amis AA. The attachments of the fiber bundles of the posterior cruciate ligament: an anatomic study. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2007 Mar;23(3):284–90.

    Article  Google Scholar 

  3. Takahashi M, Matsubara T, Doi M, Suzuki D, Nagano A. Anatomical study of the femoral and tibial insertions of the anterolateral and posteromedial bundles of human posterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc Off J ESSKA. 2006 Nov;14(11):1055–9.

    Article  Google Scholar 

  4. Papannagari R, DeFrate LE, Nha KW, Moses JM, Moussa M, Gill TJ, et al. Function of Posterior Cruciate Ligament Bundles During In Vivo Knee Flexion. Am J Sports Med. 2007 Sep 1;35(9):1507–12.

    Article  PubMed  Google Scholar 

  5. Gill TJ, DeFrate LE, Wang C, Carey CT, Zayontz S, Zarins B, et al. The biomechanical effect of posterior cruciate ligament reconstruction on knee joint function. Kinematic response to simulated muscle loads. Am J Sports Med. 2003 Aug;31(4):530–6.

    PubMed  Google Scholar 

  6. Mannor DA, Shearn JT, Grood ES, Noyes FR, Levy MS. Two-bundle posterior cruciate ligament reconstruction. An in vitro analysis of graft placement and tension. Am J Sports Med. 2000 Dec;28(6):833–45.

    CAS  PubMed  Google Scholar 

  7. Markolf KL, McAllister DR, Young CR, McWilliams J, Oakes DA. Biomechanical effects of medial-lateral tibial tunnel placement in posterior cruciate ligament reconstruction. J Orthop Res Off Publ Orthop Res Soc. 2003 Jan;21(1):177–82.

    Article  Google Scholar 

  8. Lopes OV Jr, Ferretti M, Shen W, Ekdahl M, Smolinski P, Fu FH. Topography of the femoral attachment of the posterior cruciate ligament. J Bone Joint Surg Am. 2008 Feb;90(2):249–55.

    Article  PubMed  Google Scholar 

  9. Race A, Amis AA. PCL reconstruction. In vitro biomechanical comparison of “isometric” versus single and double-bundled “anatomic” grafts. J Bone Joint Surg Br. 1998 Jan;80(1):173–9.

    Article  CAS  PubMed  Google Scholar 

  10. Harner CD, Janaushek MA, Kanamori A, Yagi M, Vogrin TM, Woo SL. Biomechanical analysis of a double-bundle posterior cruciate ligament reconstruction. Am J Sports Med. 2000 Apr;28(2):144–51.

    CAS  PubMed  Google Scholar 

  11. Whiddon DR, Zehms CT, Miller MD, Quinby JS, Montgomery SL, Sekiya JK. Double Compared with Single-Bundle Open Inlay Posterior Cruciate Ligament Reconstruction in a Cadaver Model. J Bone Jt Surg. 2008 Sep 1;90(9):1820–9.

    Article  Google Scholar 

  12. Wijdicks CA, Kennedy NI, Goldsmith MT, Devitt BM, Michalski MP, Årøen A, et al. Kinematic analysis of the posterior cruciate ligament, part 2: a comparison of anatomic single- versus double-bundle reconstruction. Am J Sports Med. 2013 Dec;41(12):2839–48.

    Article  PubMed  Google Scholar 

  13. Bergfeld JA, Graham SM, Parker RD, Valdevit ADC, Kambic HE. A biomechanical comparison of posterior cruciate ligament reconstructions using single- and double-bundle tibial inlay techniques. Am J Sports Med. 2005 Jul;33(7):976–81.

    Article  PubMed  Google Scholar 

  14. Shelbourne KD, Clark M, Gray T. Minimum 10-year follow-up of patients after an acute, isolated posterior cruciate ligament injury treated nonoperatively. Am J Sports Med. 2013 Jul;41(7):1526–33.

    Article  PubMed  Google Scholar 

  15. Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med. 1986 Feb;14(1):35–8.

    Article  CAS  PubMed  Google Scholar 

  16. Boynton MD, Tietjens BR. Long-term followup of the untreated isolated posterior cruciate ligament-deficient knee. Am J Sports Med. 1996 Jun;24(3):306–10.

    Article  CAS  PubMed  Google Scholar 

  17. Keller PM, Shelbourne KD, McCarroll JR, Rettig AC. Nonoperatively treated isolated posterior cruciate ligament injuries. Am J Sports Med. 1993 Feb;21(1):132–6.

    Article  CAS  PubMed  Google Scholar 

  18. Dejour H, Walch G, Peyrot J, Eberhard P. The natural history of rupture of the posterior cruciate ligament. Rev Chir Orthopédique Réparatrice Appar Mot. 1988;74(1):35–43.

    Google Scholar 

  19. Sekiya JK, Whiddon DR, Zehms CT, Miller MD. A clinically relevant assessment of posterior cruciate ligament and posterolateral corner injuries. Evaluation of isolated and combined deficiency. J Bone Joint Surg Am. 2008 Aug;90(8):1621–7.

    Article  PubMed  Google Scholar 

  20. Fanelli GC, Beck JD, Edson CJ. Current concepts review: the posterior cruciate ligament. J Knee Surg. 2010 Jun;23(2):61–72.

    Article  PubMed  Google Scholar 

  21. Noyes FR. Noyes' Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes. Elsevier Health Sciences; 2009:4415.

    Google Scholar 

  22. Lubowitz JH, Konicek J. A 3.5-mm-diameter anterior cruciate ligament tibial retrograde socket drilling pin is more accurate than a 2.4-mm-diameter pin. Arthrosc J Arthrosc Relat Surg. 2011 May;27(5):666–71.

    Article  Google Scholar 

  23. Zehms CT, Whiddon DR, Miller MD, Quinby JS, Montgomery SL, Campbell RB, et al. Comparison of a double bundle arthroscopic inlay and open inlay posterior cruciate ligament reconstruction using clinically relevant tools: a cadaveric study. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2008 Apr;24(4):472–80.

    Article  Google Scholar 

  24. Kim S-J, Park I-S. Arthroscopic reconstruction of the posterior cruciate ligament using tibial-inlay and double-bundle technique. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2005 Oct;21(10):1271.

    Article  Google Scholar 

  25. Ritchie JR, Bergfeld JA, Kambic H, Manning T. Isolated sectioning of the medial and posteromedial capsular ligaments in the posterior cruciate ligament-deficient knee. Influence on posterior tibial translation. Am J Sports Med. 1998 Jun;26(3):389–94.

    CAS  PubMed  Google Scholar 

  26. Park SE, Stamos BD, DeFrate LE, Gill TJ, Li G. The effect of posterior knee capsulotomy on posterior tibial translation during posterior cruciate ligament tibial inlay reconstruction. Am J Sports Med. 2004 Sep;32(6):1514–9.

    Article  PubMed  Google Scholar 

  27. Lin Y-C, Chen S-K, Liu T-H, Cheng Y-M, Chou PP-H. Arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction using patellar tendon graft compared with hamstring tendon graft. Arch Orthop Trauma Surg. 2013 Apr;133(4):523–30.

    Google Scholar 

  28. Boutefnouchet T, Bentayeb M, Qadri Q, Ali S. Long-term outcomes following single-bundle transtibial arthroscopic posterior cruciate ligament reconstruction. Int Orthop. 2013 Feb;37(2):337–43.

    Article  PubMed Central  PubMed  Google Scholar 

  29. Kim S-J, Kim T-E, Jo S-B, Kung Y-P. Comparison of the clinical results of three posterior cruciate ligament reconstruction techniques. J Bone Joint Surg Am. 2009 Nov;91(11):2543–9.

    Article  PubMed  Google Scholar 

  30. Li B, Wen Y, Wu H, Qian Q, Wu Y, Lin X. Arthroscopic single-bundle posterior cruciate ligament reconstruction: retrospective review of hamstring tendon graft versus LARS artificial ligament. Int Orthop. 2009 Aug;33(4):991–6.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  31. Zhao J, Huangfu X. Arthroscopic single-bundle posterior cruciate ligament reconstruction: Retrospective review of 4- versus 7-strand hamstring tendon graft. The Knee. 2007 Aug;14(4):301–5.

    Article  PubMed  Google Scholar 

  32. Wu C-H, Chen AC-Y, Yuan L-J, Chang C-H, Chan Y-S, Hsu K-Y, et al. Arthroscopic Reconstruction of the posterior cruciate ligament by using a quadriceps tendon autograft: A minimum 5-year follow-up. Arthrosc J Arthrosc Relat Surg. 2007 Apr;23(4):420–427.e2.

    Article  Google Scholar 

  33. MacGillivray JD, Stein BES, Park M, Allen AA, Wickiewicz TL, Warren RF. Comparison of tibial inlay versus transtibial techniques for isolated posterior cruciate ligament reconstruction: minimum 2-year follow-up. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2006 Mar;22(3):320–8.

    Article  Google Scholar 

  34. Seon J-K, Song E-K. Reconstruction of isolated posterior cruciate ligament injuries: a clinical comparison of the transtibial and tibial inlay techniques. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2006 Jan;22(1):27–32.

    Article  Google Scholar 

  35. Chan Y-S, Yang S-C, Chang C-H, Chen AC-Y, Yuan L-J, Hsu K-Y, et al. Arthroscopic reconstruction of the posterior cruciate ligament with use of a quadruple hamstring tendon graft with 3- to 5-year follow-up. Arthrosc J Arthrosc Relat Surg. 2006 Jul;22(7):762–70.

    Article  Google Scholar 

  36. Kim Y-M, Lee CA, Matava MJ. Clinical results of arthroscopic single-bundle transtibial posterior cruciate ligament reconstruction: a systematic review. Am J Sports Med. 2011 Feb;39(2):425–34.

    Article  PubMed  Google Scholar 

  37. Yoon KH, Bae DK, Song SJ, Cho HJ, Lee JH. A prospective randomized study comparing arthroscopic single-bundle and double-bundle posterior cruciate ligament reconstructions preserving remnant fibers. Am J Sports Med. 2011 Mar;39(3):474–80.

    Article  PubMed  Google Scholar 

  38. Wang C-J, Weng L-H, Hsu C-C, Chan Y-S. Arthroscopic single- versus double-bundle posterior cruciate ligament reconstructions using hamstring autograft. Injury. 2004 Dec;35(12):1293–9.

    Article  PubMed  Google Scholar 

  39. Fanelli GC, Beck JD, Edson CJ. Single compared to double-bundle PCL reconstruction using allograft tissue. J Knee Surg. 2012 Mar;25(1):59–64.

    Google Scholar 

  40. Kim S-J, Jung M, Moon H-K, Kim S-G, Chun Y-M. Anterolateral transtibial posterior cruciate ligament reconstruction combined with anatomical reconstruction of posterolateral corner insufficiency: Comparison of single-bundle versus double-bundle posterior cruciate ligament reconstruction over a 2- to 6-year follow-up. Am J Sports Med. 2011 Mar;39(3):481–9.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Penn State Hershey Medical Center, Hershey, PA, USA

    Ranjodh Dhami

  2. TRIA Orthopaedic Center, Minneapolis, MN, USA

    Robby S. Sikka

  3. Orthopaedic Surgery, ORA Orthopedics, Bettendorf, IA, USA

    Ryan P. Dunlay

  4. Orthopaedic Surgery, University of Minnesota, Bloomington, MN, USA

    Joel L. Boyd

Authors
  1. Ranjodh Dhami
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Robby S. Sikka
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ryan P. Dunlay
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Joel L. Boyd
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Joel L. Boyd .

Editor information

Editors and Affiliations

  1. GHS Orthopaedics, Danville, Pennsylvania, USA

    Gregory C. Fanelli, MD

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Dhami, R., Sikka, R., Dunlay, R., Boyd, J. (2015). The All-Inside Technique: Surgical Technique and Outcomes. In: Fanelli, MD, G. (eds) Posterior Cruciate Ligament Injuries. Springer, Cham. https://doi.org/10.1007/978-3-319-12072-0_13

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-12072-0_13

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-12071-3

  • Online ISBN: 978-3-319-12072-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation