All-inside posterior cruciate ligament reconstruction - A systematic review of current practice

Abstract

Purpose: The All-Inside PCL Reconstruction is a surgical technique which overcomes some of the key challenges faced with traditional PCL Reconstruction, and is becoming more relevant as the rate of PCL reconstruction increases.The purpose of this study is to review the technical practices of the all-inside PCL reconstruction since it was first introduced, with respect to the various key components involved in the surgical technique, to provide more information to the surgeon of the various surgical options available in practice.

Materials and methods: A systematic review was performed by the authors in January 2023 as per Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines to identify all studies outlining the all-inside surgical technique in the past decade. The predetermined eligibility criteria were applied in the screening of the literature in Pubmed, Cochrane and Google Scholar databases.

Results: A total of 14 studies were included in the final review, 9 technical studies, 2 case series, 2 book chapters and 1 review. An allograft was the preferred choice in 9 of the 14 studies. The semitendinosus was preferred when an autograft was chosen. Quadruple folding of the graft was the preferred configuration in 11 studies with the graft diameters from 8 to 12 mm and length ranging from 60 to 150 mm. The femur socket length ranged from 15 to 35 mm and the tibia socket length ranged from 20 to 70 mm. All the studies reported the use of at least 3 portals and up to 6 portals was also reported. 13 studies reported the graft docking first into tibia socket followed by the femoral socket. 7 studies reported the graft entry via the AM portal and 6 studies used a lateral portal. 9 studies used augmentation such as suture anchors (6 studies) and suture tape (3 studies). The 30° and 70° arthroscopic lenses were used alternatingly in 8 studies and fluoroscopy was utilized in 10 studies.

Conclusion: The current literature review of all-inside PCL reconstruction consisted mainly technical studies and more clinical outcomes studies are needed to determine its efficacy. It observed a trend to use an allograft, at least 3 portals and docking the graft in the tibia socket first. There is no obvious preference of portal for graft entry.

Fig. 1

Search results PRISMA flow chart. PRISMA, Preferred Reporting Items for Systematic Review and Meta-Analysis.

Fig. 2

Identified key components of the all-inside PCL reconstruction surgical technique.

Fig. 3

Illustration of Graft Double/Triple/Quadruple Fold (Left) vs. Tri-Link method (Right).

Fig. 4

Range of femur and tibia socket lengths (Left), graft diameter (Middle), graft length (Right).