The controversy over which type of plasty is best for anterior cruciate ligament (ACL) reconstruction continues to rage. The use of cadaver plasties has overall worse results, with higher re-rupture rates. Their use should be limited to revision surgery and cases where multiple ligaments need to be reconstructed.
As for autologous (patient’s own) plasty, the use of patellar tendon plasty (bone-tendon-bone HTH) has the advantage of faster integration and perhaps greater objective stability. The use of tendons from the semitendinosus and internal rectus (IT) hamstring muscles has the main advantage of greater versatility (possibility of bifascicular reconstruction or unifascicular reinforcement plasties in partial ruptures) and greater strength at zero time.
The main difference between both types of plasty is the morbidity of the donor site. Removal of an HTH plasty will result in anterior knee pain in a very high percentage of cases. This causes many surgeons and trauma experts who prefer HTH plasties to resort to cadaver plasties for reconstructions. In addition, the use of HTH may increase the incidence of long-term knee osteoarthritis and may lead to patellar fracture as a complication. The postoperative period is also more painful. In contrast, IT removal has a very low morbidity with a very low incidence of complications.
Preferred Plastia for Anterior Cruciate Ligament
The trend in Spain in the last 15 years has been to use more and more IT and less HTH. However, the clinical results in large comparative series have been equivalent. The current idea is that it cannot be said that one particular plasty is better than the other. There are other factors that influence much more than the type of plasty. The condition of the meniscus is very important, since if a meniscectomy (meniscal resection) is performed, the risk of osteoarthritis is increased, so it is essential to preserve the meniscus by performing different suturing techniques. It is also essential to perform an anatomical technique with a correct position of the bone tunnels.
The idea that it was necessary to perform reconstructions with HTH in contact and high demand athletes is not supported by the current scientific literature. The trend in the U.S., for example, is to perform IT plasty on high-demand athletes including soccer players. Although there is a tendency in the soccer world to perform HTH reconstructions, this is largely due to FIFA recommendations and not necessarily to scientific evidence.
The advantage of the All-Inside technique is the minimal morbidity of the removal of the plasty, since only the semitendinosus tendon is removed, preserving the internal rectus, the minimal size of the incisions and the creation of incomplete tunnels that can improve the biological conditions of the integration of the plasty compared to conventional complete tunnels.