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Vivek Sharma, M.D. 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.
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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.
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