Summary

The study highlights the practicality and usefulness of a simple, and reproducible technique developed by our team to avoid the likely complication of peri patellar soft tissue entanglement while managing the engagement of STG into the tibial socket, also helps to save time, improves the surgeon’s comfort, ergonomics and friendliness towards the otherwise very useful AIACLR surgery.

Abstract

Push back and Pull down to socket manoeuvre. An effective technique to engage graft into tibial socket in All Inside ACL Reconstructions.

Thundathil Sreejith*, Sarath Nidhin**Suresh Nihal***
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Abstract

Objective

All inside ACL Reconstruction (AIACLR) technique employs tightening of Semi tendinosis Graft (STG) into both Femoral and Tibial Sockets in optimal tension, using variable loop Titanium Endo Buttons (TEB). Soft tissue Entangling is a complication, happens often while attempting to manage the STG into tibial socket after engaging the femoral tunnel. Our technique of grasping and pushing the tip of the STG straight back into the posterior horn area of medial semilunar cartilage (MSC) and pulling it guided back into the tibial socket, avoided peri patellar soft tissues. In this long-term study of 356 cases, we standardised and followed this technique in every case of AIACLR done. We had studied the efficiency of this technique and analysed the trajectory of the graft movements along with the biomechanics involved.

Methods

This study was conducted during the period 2011 to 2023 among the patients who underwent arthroscopic primary AIACLR in the Sports Medicine Units. Out of 356 cases studied, STG Auto grafts were used in 342 cases, and ipsilateral Peroneus Longus in the rest. Both the sockets were prepared in Anatomical positions for the post operative isometric behaviour of the graft. The average graft dimensions were 72mm in length and 9.5mm in diameter. Mean tibial socket length was 18mm and Femoral was 24mm. An artery forceps was the instrument used to grasp the tip of the STG and pushing it to the postero medial zone. Attached fibre wires of the variable loop TEB managed to pull and engage the STG into the tibial socket. Graft tip travel trajectory was measured radiologically using k wires.

Results

No cases of STG entanglement into the peri patellar soft tissues were observed in the current study. Average time taken for therapeutic AIACLR was 78 minutes and could save time as there were no cases of entanglements. Average angle of the studied k trajectory of graft tip travel was 48 degrees.

Conclusion

The study highlights the practicality and usefulness of a simple, and reproducible technique developed by our team to avoid the likely complication of peri patellar soft tissue entanglement while managing the engagement of STG into the tibial socket, also helps to save time, improves the surgeon’s comfort, ergonomics and friendliness towards the otherwise very useful AIACLR surgery.

Level of evidence: III.
Keywords
· All Inside ACL Reconstruction
· Variable Loop TEB
· Semitendinosus Graft
· Titanium Endo Button
· Soft tissue Entangling






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*Consultant Arthroscopy Surgeon and Presenting Author, ** Professor and Principal Investigator,***Junior Consultant and Investigator,
Starcare Hospital, Calicut, Kerala, India.