Propensity Score-Matched Comparison of Six-Strand All-Inside and Conventional Four-Strand Hamstring Autografts for ACL Reconstruction

<b>Background/Objectives:</b> All-inside ACL reconstruction has emerged as a minimally invasive alternative to conventional techniques, with potential advantages in graft configuration and reduced surgical trauma. This study aimed to compare the clinical outcomes of all-inside and full tibial tunnel ACL reconstruction, focusing on graft diameter, postoperative stability, and functional recovery. We hypothesized that the all-inside technique would allow for thicker grafts and yield superior postoperative knee stability and functional outcomes, with postoperative anterior laxity as a major outcome of interest. <b>Methods:</b> This retrospective comparative study reviewed patients who underwent ACL reconstruction between January 2020 and February 2024. From January 2020 to September 2022, a four-strand hamstring autograft with full tibial tunnel technique (FT-4) was used, while from September 2022, a six-strand hamstring autograft with the all-inside technique (AI-6) was adopted to enable thicker grafts and optimize fixation. Among a total of 103 patients, 1:1 propensity score matching (PSM) was performed based on age, sex, BMI, laterality, ALL reconstruction, meniscal lesion, and preoperative anterior laxity (SSD). Graft diameter and clinical outcomes, including knee stability and functional scores, were compared between the matched groups. <b>Results:</b> After PSM, two comparable groups of 29 patients each were established. Graft diameter was significantly larger in the AI-6 group (9.5 ± 0.7 mm) compared to the FT-4 group (7.8 ± 0.8 mm, <i>p</i> < 0.001), while other baseline characteristics remained well balanced between the groups. At the final follow-up, both groups exhibited significant improvements in anterior laxity, functional scores, and pivot shift grades (all <i>p</i> < 0.001). The AI-6 group demonstrated superior outcomes with a significantly higher Lysholm score (82.2 ± 6.7 vs. 75.6 ± 8.9, <i>p</i> = 0.002), lower WOMAC score (8.0 ± 4.3 vs. 12.9 ± 10.5, <i>p</i> = 0.023), and reduced anterior laxity (1.6 ± 1.1 mm vs. 2.5 ± 1.4 mm, <i>p</i> = 0.005) compared to the FT-4 group, whereas no significant differences were observed in the IKDC, Tegner, Korean knee score, or pivot shift test results. A simple linear regression revealed a significant negative correlation between graft diameter and postoperative anterior laxity (B = -0.398, <i>p</i> = 0.048). <b>Conclusions:</b> The present study demonstrated that the use of a six-strand hamstring graft configuration in the AI-6 technique resulted in significantly thicker grafts and was associated with reduced postoperative anterior knee laxity compared to the FT-4 technique. While interpretation of these findings requires caution in light of MCID thresholds, the AI-6 group showed favorable outcomes in anterior laxity and selected functional scores, such as the Lysholm and WOMAC. This technique may offer practical clinical value, particularly in populations prone to smaller graft diameters, as it facilitates adequate graft thickness through multifold preparation, with the all-inside approach accommodating the inherent graft shortening.