Minimally Invasive ACL Surgery

Vivek Sharma MD is a fellowship trained Orthopaedic surgeon from Brigham and Women’s Hospital, Harvard Medical School, who performed first minimally invasive “all inside” ACL reconstruction surgery at Southside Regional Medical Center. This innovative technique for ACL reconstruction is designed to hasten rehabilitation and recovery time.

“For patients, the typical goal is to return to activities quickly and without pain, but, if they’re going to have reconstruction surgery, the repair should be durable and should allow them to return to normal activity without limitations,” said Sharma. “The All-Inside Retro-construction procedure is minimally invasive and achieves all of these goals.”

The results my patients are getting from this procedure are dramatic,” said Sharma. “Recovery time has been reduced and there is less pain because there’s not the damage to the tissue that a standard ACL reconstruction can cause.”

Each year, approximately 1 in 3000 people in the United States alone ruptures their ACL. Among a younger population (age 15 to 45 years old), the incidence of ACL injury is even higher, elevated to one in 1,750. Furthermore, women are at a two to eight times greater risk for ACL injury than men while participating in the same sports. This high incidence in females, coupled with the increasing number of female participants in sports, has led many people to consider this an epidemic.

The anterior cruciate ligament (ACL) is the most important ligament in the knee for knee stability. Because knee stability is critical for pivoting and cutting sports, ACL tears are dreaded injuries for athletes. ACL tears necessitate surgery to restore stability to these knees.

ACL surgery requires the replacement of the ACL with a tendon graft. Thus, it is termed ACL reconstruction. These tendon grafts can be harvested from the patients’ knees (autografts) or cadaveric grafts (allografts) can be utilized. ACL reconstruction has seen an evolution over the last several decades. Initial procedures were open knee procedures. Arthroscopic advancements allowed the procedures to become less invasive. But these procedures have still been quite painful and have involved lengthy recuperations. A new procedure brings the promise of less pain and scarring. This most minimally invasive ACL surgery is termed All-Inside ACL Reconstruction.

In order to understand all-inside ACL surgery, a brief discussion of traditional ACL techniques is warranted. To accomplish anatomic replacement of the ACL with a tendon graft, it has been necessary to drill a socket in the femur at the origin of the ACL. This socket would be the same diameter as the ACL graft. The ACL graft is inserted into this socket and then securely fixed to this origin with a variety of fixation devices. Then, a tunnel is drilled in the proximal tibia from the outer tibial cortex and into the knee joint. This requires a small yet formal incision. This tunnel exits at the insertion of the ACL on the tibia. The tendon graft is then tensioned and securely fixed on the tibia.

A significant source of pain in ACL surgery can be related to this full tibial tunnel that is drilled. This tunnel violates the tibial cortex by drilling a hole in it that is often eight to ten millimeters in diameter. The reason that this may cause a great deal of pain is that the periosteum over the area is sensitive, a formal incision through the overlying tissues is required and the violation of the tibial cortex is similar to a fracture. These issues have been negated by the development of all-inside ACL reconstruction.

With all-inside ACL reconstruction, a full tibial tunnel is not created. Rather, a special reamer has been designed to allow creation of a tibial socket. This socket begins in the joint and stops short of coursing through the tibial cortex. An array of special instrumentation has been developed to accomplish this completely arthroscopic ACL reconstruction. The procedure requires no formal incisions. It requires only three to four small arthroscopy incisions. These are typically five to seven millimeters in diameter.

The advantages of all-inside ACL reconstruction are several. First, the surgery may be less painful than previous ACL reconstruction techniques. The reasons include the lack of violation of the tibial cortex with a large diameter tunnel, the minimal violation of the overlying tibial periosteum and the absence of a formal incision. Second, the instrumentation designed can facilitate a more predictably anatomic ACL reconstruction. Last, all-inside ACL reconstruction is the most cosmetic ACL surgery available. The result looks as if the person had a simple knee arthroscopy.

The disadvantage of all-inside ACL reconstruction is the added technical difficulty and learning curve. Specialized

In summary, all-inside ACL reconstruction is a new and advanced arthroscopic technique that provides the least invasive approach to ACL reconstruction to date. It offers anatomic ACL reconstruction, lesser postoperative pain and great cosmesis.