Suspensory Versus Interference Tibial Fixation of Hamstring Tendon Autografts in Anterior Cruciate Ligament Reconstruction: Results From the New Zealand ACL Registry

Abstract

Background: The hamstring tendon is frequently used to reconstruct the anterior cruciate ligament (ACL), but there is a lack of consensus on the optimal method of fixation. Registry studies have shown that the type of femoral fixation device can influence the risk of revision ACL reconstruction (ACLR), but it is unclear whether the type of tibial fixation has an effect. In New Zealand, over 95% of hamstring tendon grafts are fixed with an adjustable loop suspensory device on the femoral side, with variable usage between suspensory and interference devices, with or without a sheath, on the tibial side. Purpose: To investigate the association between the type of tibial fixation device and the risk of revision ACLR. Study Design: Cohort Study; Level of evidence, 2. Methods: Prospective data recorded in the New Zealand ACL Registry were analyzed. Only primary ACLRs performed with a hamstring tendon autograft fixed with a suspensory device on the femoral side were included. A Cox regression survival analysis with adjustment for patient factors was performed to analyze the effects of the type of tibial fixation device, the number of graft strands, and graft diameter on the risk of revision. Results: A total of 6145 primary ACLRs performed between 2014 and 2019 were analyzed. A total of 59.6% of hamstring tendon autografts were fixed with a suspensory device on the tibial side (n = 3662), 17.6% with an interference screw with a sheath (n = 1079), and 22.8% with an interference screw without a sheath (n = 1404). When compared with suspensory devices, a higher revision risk was observed when using an interference screw with a sheath (adjusted hazard ratio [HR], 2.05; P = .009) and without a sheath (adjusted HR, 1.81; P = .044). The number of graft strands and a graft diameter of ≥8 mm were associated with the rate of revision on the univariate analysis; however, after adjusting for confounding variables on the multivariate analysis, they did not significantly influence the risk of revision. Conclusion: In this study of hamstring tendon autografts fixed with an adjustable loop suspensory device on the femoral side during primary ACLR, the use of an interference screw, with or without a sheath, on the tibial side resulted in a higher revision rate when compared with a suspensory device.

Dynamic Anterior Stabilization Using Transosseous Bone Tunnel Technique With the Adjustable Loop Length Cortical Button Incorporating High-Strength Suture Augmentation for Recurrent Shoulder Instability

“…compared the fixation strength of suspensory devices versus interference screw on tibial side graft fixation and found greater revision rates with the usage of an interference screw when compared to suspensory fixation. 20 Tunnel widening is reported with both suspensory devices and interference screws, but tunnel widening has greater consequences in the case of interference screw fixation, as fixation depends on graft compression against the tunnel wall. 19 Although Frank et al.…”

Quadruple Hamstring Autograft Technique for Anterior Cruciate Ligament Reconstruction Reduces Allograft Augmentation

“…While this posed an additional change in the studied surgeon’s technique, literature has come out in support of this suspensory type fixation. 17 A prospective randomized control trial comparing allograft augmented versus autograft alone during ACLR using suspensory fixation is needed.…”

Metal interference screw fixation combinations show high revision rates in primary hamstring tendon ACL reconstruction

“…Several factors contributing to ACL revision risk have been identified, including patient-, technical-, and injury-related factors [ 1 – 4 ]. Two often discussed technical decisions impacting ACLR revision rates are graft choice and fixation method [ 3 , 5 ]. While by far the most frequently used graft type in Sweden continues to be hamstring tendon autograft, preferences regarding fixation vary widely among surgeons and healthcare institutions [ 6 ].…”

“…Fixation methods in ACLR have been shown to impact revision rate, specifically in the early postoperative period [ 7 , 10 ]. Most prior literature has either grouped together femoral and tibia-sided fixation types or evaluated femoral-sided fixation or tibial-sided fixation separately [ 5 , 11 , 12 ]. However, previous studies have not investigated the role of specific femoral and tibial fixation combinations on ACLR revision rates within the early postoperative period.…”