All-Inside ACL Reconstruction

Due to the critical importance of the anterior cruciate ligament (ACL) to knee stability, and because the slightest tear requires surgery and months of physical rehabilitation, advancements in ACL repair have always piqued the interest of orthopedic surgeon, Christopher Bagby, MD, with Northland Bone & Joint.

All-inside ACL reconstruction is a novel approach,” says Dr. Bagby, the only Northland surgeon who performs the outpatient procedure. “It is a minimally invasive procedure, creating less tissue trauma, less swelling, less pain for the patient and a faster rehabilitation. It is also more anatomic.”

All-Inside vs. Traditional

Traditional ACL reconstruction surgery involves a distal, lateral femoral incision and drilling a full tunnel from the outer tibial cortex into the knee joint. “One of the biggest differences of the all-inside ACL is that we don’t drill a full tibial tunnel inside the joint,” explains Dr. Bagby. “Instead, we drill a blind-ended tunnel from the inside of the knee joint into the tibia. Only a very narrow slot passes through the tibial cortex. That’s why it’s called “all-inside.”

One of the biggest differences, inside the joint, with the all-inside ACL is that we don't drill a full tibial tunnel. Instead, we drill a blind-ended tunnel from the inside of the knee joint into the tibia."

Christopher Bagby, MD

A preassembled ACL graft is the primary component of the all-inside method. The graft is assembled with allograft or autologous tissue. “While I always leave the choice up to the patient, I recommend the allograft because patients avoid the additional trauma and recovery time that results from harvesting hamstring tendon, and implant rejection is extremely rare,” says Dr. Bagby.

Another difference between the two methods is long-term stability. Drilling a traditional, full tibial tunnel leaves a large amount of open space in the bone which can fill with fluid over time, resulting in widening or loosening of the reconstruction. “With the all-inside technique, more bone is left in place,” notes Dr. Bagby.

The Procedure

TightropeThe all-inside technique takes approximately one hour. It requires general anesthesia and a femoral nerve block that also works as post-operative pain control for the knee. Dr. Bagby creates three portals and the procedure is done primarily through the medial portal. 

After debriding the torn ACL, he drills 3 cm into the femur and connects a guide pin from the medial portal to the back of the femur, where the ACL normally attaches. Using a surgical reamer that is the same diameter as the tendon – typically 9 mm – he drills into the tibia, creating a blind-ended tibial socket. He also drills a 25-30 mm tunnel into the femur to create a femoral socket.

To position the graft, Dr. Bagby uses a TightRope Attachable Button System, a two-piece system that facilitates implantation. Each end of the tightrope has a metal button and two tensioning strands that are attached to opposite ends of the graft. “The TightRope System allows me to dial in how much I want to tighten the graft,” Dr. Bagby says. 

Using a suture, he pulls the femoral end of the graft from the medial portal into the femoral socket until the metal button passes completely through. He tightens the graft with the tensioning strands and sutures it. Once the femoral end of the graft is secure, Dr. Bagby pulls the suture into the blind end of the tibial socket. He tightens the tibial end of the graft by pulling the tensioning strands alternatively until the metal button braces against the tibia. “Once the graft is in place, I put the knee through a full range of motion, both a 90 degree bend and a full extension, to check the tension,” he says.


Because there is less trauma to the bone than with traditional surgery, and incisions are minimal, there is less pain, less scarring, less swelling and an easier rehabilitation. Patients are able to walk immediately after surgery and typically begin physical therapy the following day. Six month recovery period is recommended before returning to sports or activities that require pivoting.


Dr. Bagby has performed hundreds of all-inside ACL reconstruction procedures since its inception more than five years ago. “To me, every patient with a torn ACL is a potential candidate for the all-inside technique,” he says. Dr. Bagby has treated the spectrum of patients, from high school athletes to active adults in their 50s. “Traditionally, if you were over 40 and had arthritis and a torn ACL, you were not a candidate for this surgery. But the tide is turning. I don’t think there is any real age limit now. It really depends on the patient’s level of activity as to whether ACL reconstruction is a good fit,” says Dr. Bagby.

Christopher Bagby, MD

Christopher Bagby, MDDr. Bagby earned his medical degree from the University of Missouri – Kansas City. He completed his internship in General Surgery and his residency in Orthopedic Surgery at the University of Missouri – Columbia and received a Sports Medicine fellowship from The Christ Hospital, Ohio. Previously, he was the assistant team physician for the Cincinnati Bengals NFL football team and an assistant team physician for the University of Cincinnati and Miami University, Ohio.

To learn more, call 816.214.9300.