Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 27, Issue 11, pp 3592–3598 | Cite as

Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique

  • Panagiotis KouloumentasEmail author
  • Efstratios Kavroudakis
  • Efstathios Charalampidis
  • Dimitris Kavroudakis
  • Georgios K. Triantafyllopoulos



To compare the “all-inside technique” for anterior cruciate ligament (ACL) reconstruction using a short, quadrupled semitendinosus tendon (ST4) autograft and suspensory cortical fixation on both the femoral and tibial side vs the “conventional technique” using a semitendinosus/gracilis (ST/G) autograft fixed with a suspensory device on the femoral side and with an interference screw on the tibial side, in terms of clinical and functional outcomes.


A total of 90 patients were enrolled, randomised into two groups, and prospectively followed. Group A comprised 45 patients treated with the all-inside technique and Group B included 45 patients treated with the conventional ACL technique (55 males, 35 females; mean age 28.7 ± 11.3 years). Patients completed the Lysholm knee score, the International Knee Documentation Committee (IKDC) score, the Knee Injury and Osteoarthritis Score (KOOS), and the Knee Society Score (KSS) preoperatively and at 2 years postoperatively. Anterior tibial translation measurement (KT-1000 arthrometer) and isokinetic testing of the operative vs non-operative limb were also conducted and the limb symmetry index (LSI) was determined.


At 24 months, the Lysholm, IKDC, KOOS, and KSS scores between the two groups were similar (n.s.). Anterior tibial translation between the operative and non-operative knee was also similar among the two groups (n.s.). Patients of Group A had significantly higher mean LSIs in terms of flexor peak torque (1.0 ± 0.1 vs 0.9 ± 0.1; p < 0.001), time-to-peak (0.9 ± 0.1 vs 0.8 ± 0.1; p < 0.001) and total work (0.9 ± 0.1 vs 0.8 ± 0.1; p < 0.001) at 180°/s, and significantly better mean LSI for isometric flexor/extensor ratio at 90° (1.1 ± 0.3 vs 0.8 ± 0.2; p < 0.001).


The all-inside ACL reconstruction with an ST4 autograft and cortical button fixation on both ends is a viable alternative to the conventional technique. It affords preservation of knee flexor strength, which is of advantage, especially when treating athletes with ACL injury.

Level of evidence



Anterior cruciate ligament reconstruction All-inside Cortical button fixation Short graft 


Author contributions

PK conceived and designed the study, performed all surgeries, and helped to draft the manuscript. EK and EC performed data collection. DK performed the statistical analysis. GT performed the randomisation and drafted the manuscript. All authors have read and approved the final manuscript.


No funding was received for the present study.

Compliance with ethical standards

Conflict of Interest

The authors have no conflicts of interest in relation with this study.

Ethical approval

The study was approved by the Institutional Ethics Committee, Metropolitan Hospital, ID number: 2501101214.


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  • Panagiotis Kouloumentas
    • 1
    Email author
  • Efstratios Kavroudakis
    • 1
  • Efstathios Charalampidis
    • 1
  • Dimitris Kavroudakis
    • 2
  • Georgios K. Triantafyllopoulos
    • 1
  1. 1.Orthopaedics and Sports Orthopaedics ClinicMetropolitan HospitalPiraeusGreece
  2. 2.Department of GeographyUniversity of the AegeanMytileneGreece

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