What Is the Best Femoral Fixation of Hamstring Autografts in Anterior Cruciate Ligament Reconstruction?: A Meta-analysis

Abstract

The literature suggests a trend toward decreased surgical failures with femoral fixation at the joint line with an interference screw. However, there is no difference when postoperative functional outcomes are compared. Future studies are needed with standardized fixation methods and outcomes assessment to determine the importance of femoral fixation.

An international survey on anterior cruciate ligament reconstruction practices

“…Graft fixation methods can be divided to suspensory, joint line or transfemoral [10]. With the use of BPTB or quadruple hamstring tendon grafts that exceed the mechanical strength of the native ACL, graft fixation becomes the weakest link, and the most probable site of failure after ACL reconstruction.…”

“…With the use of BPTB or quadruple hamstring tendon grafts that exceed the mechanical strength of the native ACL, graft fixation becomes the weakest link, and the most probable site of failure after ACL reconstruction. The trend towards early rehabilitation with immediate weight bearing and full range of motion, as well as early return to athletic activity, add to the risk of failure [8,10,13]. The fixation device must provide strong enough fixation to allow early rehabilitation with minimal movement of the graft until biologic fixation is complete.…”

“…Biologic fixation with a BPTB graft (bone-to-bone healing) is thought to be quicker than that of all-tendon grafts [23]. While some biomechanical studies suggested that suspensory fixation (such as Endo-button) are strongest in terms of load to failure [10], others showed that the further the fixation point from the joint line, the more it allows the graft to elongate under cyclic loading [13].…”

“…Peripheral fixation was also found to lead to more tunnel widening, possibly because it allows graft motion within the canal, a phenomenon known as the "bungee effect" [10,13].…”

“…In some cases these screws provoke inflammatory response and pain and require surgical removal [15]. In a meta-analysis of eight studies (745 patients) that compared bio-absorbable IS to metallic ones, intra-operative complications were more common with the use of the former (P00.179), but the clinical outcomes did not differ [10].…”