All-inside anterior cruciate ligament reconstruction exhibited superior functional outcomes but increased knee laxity to the traditional technique in mid-to-long term: A systematic review and meta-analysis.

Abstract

The purpose of this study was to investigate the clinical value of the all-inside anterior cruciate ligament reconstruction (ACLR) compared with the traditional ACLR. We conducted a systematic search of PubMed, Embase, the Cochrane Library, and Web of Science (before 1 April 2025) for randomised controlled trials (RCTs) on all-inside ACLR. The study population consisted of patients with primary ACL rupture undergoing all-inside ACLR. The risk of bias was assessed by two independent reviewers using Cochrane Collaboration's tool. Analysed outcomes included International Knee Documentation Committee (IKDC) subjective score, Lysholm score, Tegner Activity Scale (TAS) score, knee laxity, tibial tunnel width, Knee Society score, hop test and adverse effects. Meta-analyses were performed using Review Manager version 5.4. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We finally included 12 RCTs and 949 patients in total. The results indicated a comparable effect of all-inside ACLR with traditional ACLR in subjective clinical outcomes and functional tests in undifferentiated follow-up durations. However, the all-inside ACLR was associated with greater knee laxity (mean difference [MD] = 0.71, 95% CI = [0.24-1.19], p = 0.003) and a tendency in increasing serious adverse events, especially the risk of re-rupture (OR = 2.25, 95% CI = [0.76-6.65], p = 0.14). Subgroup analysis regarding follow-up durations documented significant difference of all-inside ACLR in improving the IKDC subjective score (MD = 2.94, 95% CI = [0.53-5.35], p = 0.02) in mid-to-long term. Our meta-analysis supported that all-inside ACLR potentially promoted mid-to-long-term subjective outcomes in patients and reduced mild adverse effects. However, all-inside ACLR was inferior in preventing excessive knee laxity compared with traditional ACLR and potentially increased the incidence rate of re-rupture. Level I, meta-analysis of Level I-II studies.