The ‘All Inside ACL’ … the way forward.

For years Arthrex, the American manufacturers, who produce many of the instruments that we use in keyhole surgery, have had their own holy grail to create a new procedure for dealing with cruciate ligament damage in the knee.

And it has been a very exciting project for me to work with their technicians creating tools we can now use to perform what we call the “All Inside ACL Reconstruction operation”.

Our aim was to devise a technique for replacing a damaged Anterior Cruciate Ligament that was truly minimally invasive in terms of the tissue we use for the new ligament, “the Graft”, and the amount of bone that is removed to make the sockets for the new ACL ligament.

In the past it has left many patients with ugly scars, pain, swelling and stiffness in the joint and, in the long term, potential weaknesses in the knee.

Now here at Hampshire Knee we are using the most modern specialist instruments (many of which Adrian Wilson has been involved with developing) and implants to perform “the All Inside operation” which avoids most of those issues.  The ‘All Inside’ ACL procedure needs 50% less tissue than the standard ACL procedure and doesn’t make complete tunnels like the traditional approach, but small sockets which are bone conserving.

The procedure starts with the insertion into
the joint of a small camera. 3

The surgeon then inserts a “cleaning device” the Caliblator, which Mr Wilson designed, and this removes the remnant of the torn ligament.


This tool also acts as a ruler and allows very precise positioning of an aiming arm for a micro drill, “The FlipCutter”, which is then used to make the short sockets for the new ACL at the correct anatomical location.

The replacement ligament is created by taking out one of the hamstrings tendons (the standard procedure requires the removal of both of the hamstring tendons).  We “rob Peter to pay Paul” and patients cope well with this but removing less tissue is obviously better in terms of strength and recovery.

The hamstring tendon is then folded twice and sewn to make the new ACL ligament graft which is then fixed into the knee with small button fixation devices.

Then, instead of drilling a complete tunnel through the side of the femur (thigh bone) and the tibia (shin bone) through which a new ligament would be traditionally be pulled into and fixed with large screws (that a

ct like raw plugs), the low profile drill is used to make the short sockets and the new ACL is pulled in and fixed in place.

The graft is suspended in the sockets with nylon loops attached to the small fixation buttons.



The new ‘All Inside’ is therefore both bone and soft tissue preserving and so far at Basingstoke we have performed it on around 300 patients. All our patients are carefully followed up and objectively scored and our 3-year results are excellent.


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