Review Article

Page 1 of 13

Biomechanical comparison of anterior cruciate ligament

reconstruction fixation methods and implications on clinical
outcomes
Emily McDermott1, Mikalyn T. DeFoor1, Olivia K. Blaber2, Zachary S. Aman2, Nicholas N. DePhillipo3,
Travis J. Dekker4
1
Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA; 2Sidney Kimmel Medical College at Thomas
Jefferson University, Philadelphia, PA, USA; 3University of Pennsylvania, Department of Orthopedics, Philadelphia, PA, USA; 4Department of
Orthopaedic Surgery, 10th Medical Group, US Air Force Academy, CO, USA
Contributions: (I) Conception and design: E McDermott, MT DeFoor; (II) Administrative support: E McDermott, MT DeFoor; (III) Provision of
study materials or patients: E McDermott, MT DeFoor, OK Blaber, ZS Aman; (IV) Collection and assembly of data: E McDermott, MT DeFoor,
OK Blaber, ZS Aman; (V) Data analysis and interpretation: E McDermott, MT DeFoor, OK Blaber, ZS Aman; (VI) Manuscript writing: All authors;
(VII) Final approval of manuscript: All authors.
Correspondence to: Maj. Travis J. Dekker, MD. U.S. Air Force Academy, 2304 Cadet Drive Colorado Springs, CO 80840, USA.
Email: [email protected].

Abstract: Anterior cruciate ligament reconstruction (ACLR) is one of the more common surgeries
encountered by orthopaedic surgeons, which has its inherent challenges due to the complex anatomy and
biomechanical properties required to reproduce the function and stability of the native ACL. Multiple
biomechanical factors from graft choice and tunnel placement to graft tensioning and fixation methods are
vital in achieving a successful clinical outcome. Common methods of ACLR graft fixation in both the primary
and revision setting are classified into compression/interference, suspensory, or hybrid fixation strategies with
multiple adjunct methods of fixation. The individual biomechanical properties of these implants are crucial
in facilitating early post-operative rehabilitation, while also withstanding the shear and tensile forces to avoid
displacement and early graft failure during graft osseointegration. Implants within these categories include the
use of interference screws (IFSs), as well as suspensory fixation with a button, posts, surgical staples, or suture
anchors. Outcomes of comparative studies across the various fixation types demonstrate that compression
fixation can decrease graft-tunnel motion, tunnel widening, and graft creep, at the risk of damage to the graft
by IFSs and graft slippage. Suspensory fixation allows for a minimally invasive approach while allowing similar
cortical apposition and biomechanical strength when compared to compression fixation. However, suspensory
fixation is criticized for the risk of tunnel widening and increased graft-tunnel motion. Several adjunct
fixation methods, including the use of posts, suture-anchors, and staples, offer biomechanical advantages
over compression or suspensory fixation methods alone, through a second form of fixation in a second plane
of motion. Regardless of the method or implant chosen for fixation, technically secure fixation is paramount
to avoid displacement of the graft and allow for appropriate integration of the graft into the bone tunnel.
While no single fixation technique has been established as the gold standard, a thorough understanding of the
biomechanical advantages and disadvantages of each fixation method can be used to determine the optimal
ACLR fixation method through an individualized patient approach.

Keywords: Anterior cruciate ligament (ACL); ACLR fixation; ACLR biomechanics; graft fixation

Received: 30 November 2022; Accepted: 13 April 2023; Published online: 20 April 2023.
doi: 10.21037/aoj-22-52
View this article at: https://dx.doi.org/10.21037/aoj-22-52

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Page 2 of 13 Annals of Joint, 2023

Introduction ACLR fixation types based on biomechanics and clinical

outcomes. Therefore, the purpose of this review was to
Anterior cruciate ligament (ACL) injury is one of the most
highlight the unique advantages and disadvantages of each type
common knee injuries encountered in orthopaedic surgery,
of graft fixation method and provide perspective on the role
typically occurring during non-contact sport participation,
that the available biomechanical properties play in optimizing
specifically with cutting and pivoting exercises (1).
fixation strategies based on reported clinical outcomes.
Therefore, ACL reconstruction (ACLR) is a common
orthopaedic surgical procedure performed to restore the
native function of the ACL and provide translational and Compression fixation
rotatory stability of the knee (2,3). The incidence of primary
One commonly used method of securing a graft both in the
and revision ACLR is increasing annually, with an estimated
femur and tibia during ACLR is interference screw (IFS)
80,000 to 100,000 people in the United States undergoing
fixation, which employs a compression technique. IFSs have
this procedure per year (1,4), with revision rates between
a long history of successful outcomes with a reproducible
4.1% and 13.3% of all primary ACLRs (5,6).
technique that involves placing a screw in the tunnel to
There are multiple reconstruction techniques with compress the graft against the cancellous tunnel wall
the goal of restoring rotational and translational knee (7,14,15). There are different types of IFS fixation to include
stability and function (2,7). There is a myriad of technical metallic (often titanium), polyetheretherketone (PEEK),
challenges to consider during ACLR that impact clinical or bioabsorbable screws. Advantages and disadvantages of
outcomes including graft selection, tunnel positioning, IFS types can be seen in Table 1. Historically, metal screws
graft tensioning, fixation methods, and healing properties were used in up to 1 in 10 ACLR in adolescents and young
(1,2,8,9). In addition to a wide array of fixation methods, adults (16), but they have decreased in popularity due to
several devices have also been developed for graft the higher rate of clinical sequalae, and consequence of
fixation (1). The different types of fixation methods projection artifact on magnetic resonance imaging (MRI).
in ACLR are typically categorized into compression, As such, newer bioabsorbable materials have been utilized
suspension, post, or hybrid fixation (10,11). Regardless of to allow for superior post-operative MRI assessment and
the implant chosen for fixation, secure fixation is paramount to allow for gradual resorption with bone replacement and
to avoid displacement of the graft and allow for graft less likelihood of graft injury during time of insertion (15).
integration into the bone tunnel, which typically occurs While bioabsorbable screws have demonstrated good
around three months after surgery (2). Therefore, the clinical outcomes (17-22) and are MRI compatible, they are
biomechanical properties of these implants are particularly rarely completely replaced by bone or absorbed by the body,
important in facilitating early post-operative rehabilitation can cause hyperinflammation and cystic changes, and may
after ACLR that is necessary for a successful clinical be predisposed to breakage, migration and osteolysis (19,23).
outcome, while also withstanding the shear and tensile PEEK screws, on the other hand, are non-bioresorbable
forces to avoid displacement and early graft failure during and MRI compatible. The product is biocompatible and
graft osseointegration (12). demonstrates appropriate strength for ACLR (15).
The overall reported ACL graft rupture rate at longer In a randomized controlled trial, Shumborski et al. (15)
than 10-year follow-up was 6.2%, with 10.3% clinical compared PEEK and titanium IFS fixation among
failure (13). While many different factors can lead to ACLR 133 adult patients who were randomized to either PEEK
failure, graft fixation is one important factor. Currently, or titanium IFS fixation during primary ACLR with
there is no consensus on the optimal graft fixation technique. 4-strand hamstring tendon autograft. Authors reported no
The reasons for lack of consensus may be attributed to differences in ACLR re-rupture rate as well as subjective
several factors including but not limited to different types of or objective clinical outcomes (P>0.05). The authors also
ACLR grafts used, surgeon preference, industry influence/ noted that post-operative MRI evaluation of the ACLR
competition, lack of evidence-based recommendations from graft was improved in the PEEK group due to less artifact
clinical outcomes studies, and variations in the reported than titanium IFS. The absence of metal artifact on MRI,
biomechanical effectiveness for different fixation types. modulus of elasticity similar to human bone, biological
Therefore, it is important for surgeons to understand the compatibility, and equivalent clinical outcomes suggest
reported advantages and disadvantages of using different that PEEK implants may be an excellent choice of ACLR

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Annals of Joint, 2023 Page 3 of 13

Table 1 The advantages and disadvantages of the different types of interference screws used for anterior cruciate ligament reconstruction
Interference screw type Advantages Disadvantages

Metal • No breakdown • MRI artifact

• Rigid fixation • Irrigation/need for removal

Biocomposite • MRI compatible • Tissue reaction

• ↓ Removal • Breakage
• ↓ Graft injury • Osteolysis

PEEK • Biocompatible • Breakage

• Non-resorbable
• MRI compatible
↓, decreased.

graft fixation. Shen et al. (19) compared bioabsorbable and ACLR in the clinical setting. This finding was confirmed
metallic IFS fixation in a meta-analysis of 10 randomized in additional studies that demonstrated graft slippage
controlled trials comprising 790 patients undergoing and weakened biomechanical properties of the soft tissue
single-bundle ACLR. When tested biomechanically with graft after fixation of all-soft tissue grafts with IFS (11,28).
a KT-1000/-2000 arthrometer, there were no statistically Contrary to these findings, Micucci et al. (29) showed no
significant differences between bioabsorbable and metallic significant differences in ultimate fixation strength or graft
screw fixation (P>0.05). Also, there were no significant slippage of multiple tested IFSs of varying diameter in the
differences in infection or knee joint instability, which has fixation of soft tissue grafts for ACLR. Studies commenting
been corroborated by other recent studies (24,25). Other on compression fixation can be seen in Table 2.
biomechanical studies comparing metal and bioabsorbable
IFS fixation of a soft tissue graft found no differences
Suspensory fixation
in ultimate load to failure or construct stiffness (17,18).
Similarly, Drogset et al. (21) found no significant differences Suspensory fixation of an ACLR graft is another commonly
in functional outcomes between bioabsorbable and metal used technique that typically involves the use of an extra-
IFS fixation in their prospective randomized study utilizing cortical bone plug on the femur, tibia, or both that is
bone-patellar tendon-bone (BTB) autograft for ACLR. connected to the graft by suture. Studies examining
The utilization of compression fixation specifically suspensory fixation are highlighted in Table 3. The
in the setting of all-soft tissue grafts has become a point development of suspensory fixation has led to a more
of concern as surgeons questioned whether IFSs would minimally invasive approach such as utilizing an all-inside
provide adequate fixation without risking injury to the graft ACLR technique (21). In the realm of suspensory fixation,
at time of insertion. To further investigate this concern, fixed-loop devices (FLDs) and adjustable-loop devices
Brand et al. (26) found that bioabsorbable screws were (ALDs) are both commercially available. In FLDs, the graft
comparable or superior to titanium screws for IFS fixation is attached to a suture loop that is connected to a button
with respect to load-to-failure for soft tissue grafts and that is flipped against cortical bone. In ALDs, the graft is
that the bioabsorbable implant produced less screw thread- secured to an adjustable loop of suture and a button such
induced laceration of the soft tissue graft during testing. that the tension in the construct can be set after flipping
Another study also concluded that either screw could be the button against the cortex (30). FLDs keep the graft on
used effectively (17). In another biomechanical study, tension by connecting it at a constant length to the cortical
Kruppa et al. (27) examined force exerted across soft tissue button to maintain the interface between the graft and the
grafts that were secured with a tibial IFS. Authors reported bone for healing (31). Multiple studies have found that
that the graft force decreased substantially over the first FLDs have been associated with a higher load-to-failure
twenty-four hours after fixation and that this diminished (30-32). The disadvantage of FLDs include the potential for
force was not affected by screw diameter or length. As a inaccurate graft and tunnel measurements leading to graft
result, the authors concluded that IFS fixation for all-soft laxity and poor osseointegration as FLDs are a set length
tissue grafts may lead to early postoperative laxity following and cannot be adjusted once implanted. Newer ALDs have

© Annals of Joint. All rights reserved. Ann Joint 2023;8:15 | https://dx.doi.org/10.21037/aoj-22-52

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Table 2 Studies on compression fixation in anterior cruciate ligament reconstruction

Reference Year Study type Study purpose Conclusion

Scheffler (11) 2002 Biomechanical Evaluate tensile properties with incremental • Fixation with interference screws allows
study cyclic loading based on level and method of graft slippage
graft fixation
• Can be limited by bone block or application
of hybrid fixation, especially on tibial side

Shumborski 2019 Randomized Compare the clinical performance of ACL • No significant differences in graft
(15) controlled trial reconstruction with PEEK and titanium rerupture rate, contralateral ACL rupture
interference screws at 2 years rate, subjective outcomes, or objective
outcomes.

Kramer (16) 2020 Retrospective Retrospectively analyze the complications • Screw-site pain most common complication
review associated with tibial bioabsorbable
• Reoperation for screw-related symptoms
interference screw use in adolescents after
was 5%
ACLR

Laxdal (17) 2006 Randomized Compare the clinical/radiographic results in • No biomechanical significant differences on
controlled trial metal versus bioscrew IFS for ACLR arthrometer

• No differences in functional outcome

Kaeding (18) 2005 Prospective Compare bioscrew and metal IFS • No functional/biomechanical differences
study between groups

Shen (19) 2010 Meta-analysis Investigate the outcomes between • No significant difference in knee joint
bioabsorbable and metallic screw fixation in stability or knee joint function outcome
ACL reconstruction. between bioabsorbable and metallic
interference screws

Myers (20) 2008 Randomized Prospectively assess the outcome of ACLR • No differences in functional/radiographic
controlled trial by use of bioscrew and titanium IFS outcomes

Drogset (21) 2011 Prospective Compare long-term clinical outcome after • No significant differences between the
study ACL-reconstructions with BPTB-grafts groups in any parameter measured
fixed with metal interference screws or
• Better Pivot shift results in the bioscrew
bioabsorbable screws
group

Kousa (22) 2001 Biomechanical Evaluate initial fixation strength among • PEEK screw was the strongest in the
study hamstring tendon graft tibial fixation single-cycle load-to-failure test
devices

Xu (23) 2021 Meta-analysis Compare metal and bioscrew IFS • No difference between two in knee function
or laxity

• Metallic screws had fewer complications

Benedetto (24) 2000 Randomized Compare a bioabsorbable to a metal screw • No significant functional or patient reported
controlled trial in anterior cruciate ligament reconstruction differences were found between the groups
at 1 year

Arama (25) 2015 Randomized Compare clinical/radiologic outcomes of the • No difference in any clinical outcome
controlled trial PLLA-HA screw versus titanium screw for measure at 2- or 5-year follow-up between
hamstring tendon ACLR the 2 groups

Brand (26) 2005 Biomechanical Compare the biomechanical properties of • Bioscrew was similar in load-to-failure with
study eccentrically positioned bioabsorbable and metallic screw
titanium interference screws for hamstring
• Less graft thread-induced laceration in
tendon graft
bioscrew

Table 2 (continued)

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Table 2 (continued)

Reference Year Study type Study purpose Conclusion

Kruppa (27) 2020 Biomechanical Investigate the force in soft tissue grafts • Graft force in soft tissue grafts secured
study secured with a tibial interference screw with a tibial interference screw decreased
substantially

• Screw length/diameter had no affect

Sawyer (28) 2013 Biomechanical Investigate the biomechanics in soft tissue • Single insertion of interference screws
study grafts secured with a tibial interference for soft tissue graft fixation weakens the
screw biomechanical properties of the graft itself

Micucci (29) 2010 Biomechanical Evaluate the effect that interference screw • No statistically significant differences
study diameter has on fixation strength of a soft- in ultimate strength and graft slippage
tissue ACL graft between screws
ACLR, anterior cruciate ligament reconstruction; IFS, interference screw; bioscrew, bioabsorbable screw; ACL, anterior cruciate ligament;
BPTB, bone-patellar tendon-bone; PLLA-HA, poly(L-lactic acid) and hydroxyapatie.

Table 3 Studies on suspensory fixation in anterior cruciate ligament reconstruction

Reference Year Study type Study purpose Conclusion

Houck (30) 2018 Meta-analysis Compare the biomechanical • Adjustable loop device had strongest “time zero”
results of fixed- versus ultimate load to failure when compared to fixed
adjustable-loop femoral cortical loop device
suspension devices in studies
simulating ACLR

Onggo (31) 2019 Systematic review Compare biomechanical and • Superior biomechanical properties of FLDs
clinical outcomes between ALD
and FLD in the femoral fixation • ALDs and FLDs yielded similar clinical outcome
scores and graft rerupture rates

Eguchi (32) 2014 Biomechanical Evaluate the mechanical strength • FLD greater mechanical strength than ALD
study of two cortical suspension
• Increased cyclic displacement in ALD
devices

Smith (33) 2020 Biomechanical Compare loop elongation and • FLD had highest failure load
study load at failure of ALDs/FLDs
• No differences in elongation between devices

Singh (34) 2018 Biomechanical Compare elongation of ALD/FLD • No statistically significant differences among the
study devices for total or dynamic elongation

Johnson (35) 2015 Biomechanical Compare five femoral • Significant differences were observed between
study suspensory fixation devices current fixed-loop and adjustable-loop
cortical suspension devices for soft tissue
femoral fixation when subjected to high loads
experienced during rehabilitation

Petre (36) 2013 Biomechanical Compare four femoral • Each ALD/FLD had the necessary biomechanical
study suspensory fixation devices properties with regard to ultimate failure strength,
displacement, and stiffness for initial fixation of
soft tissue grafts in the femoral tunnel

Barrow (37) 2014 Biomechanical Compare ALD/FLD to native • The ultimate load of all graft-fixation devices
study knee physiologic loads exceeded the forces likely to be experienced in
a patient's knee during the early postoperative
rehabilitation period
ACLR, anterior cruciate ligament reconstruction; ALD, adjustable loop device; FLD, fixed loop device.

© Annals of Joint. All rights reserved. Ann Joint 2023;8:15 | https://dx.doi.org/10.21037/aoj-22-52

Page 6 of 13 Annals of Joint, 2023

a one-way locking system that allows for customization of studies that include post fixation. When analyzing tibial
the tension in the construct, theoretically improving graft sided graft fixation techniques, Weiss et al. (12) compared
incorporation by minimizing micromotion (31). IFS fixation, screw-post and washer fixation, and screw-
In a systematic review comparing FLDs and ALDs, post and washer fixation with an additional IFS in an ACLR
Onggo et al. (31) reported superior biomechanical graft animal model. In their analysis, the hybrid fixation of a post
properties in FLDs including higher graft stiffness and and IFS yielded significantly higher final stiffness and higher
higher ultimate load-to-failure. It is important to note that yield load than the other fixation methods. In addition, the
the authors found biomechanical improvement with re- post only group was found to be biomechanically superior
tensioning of ALDs after tibial fixation as per manufacturer to the IFS cohort. Another comparison study on cross-
instructions and that both constructs possessed the pin fixation, IFS, and suspensory fixation found the cross-
necessary biomechanical strength of a native ACL. Despite pin to have optimal stability regarding stress and strain at
the differences in biomechanical properties, there were the femoral fixation site (38). In a systematic review on the
no significant differences in clinical outcomes, ACLR re- effect of fixation methods on clinical outcomes, Speziali
rupture rates, or radiographic evaluation between the two et al. (39) reported a failure rate of 17.3% when a cross-
implants. Other biomechanical studies comparing ALDs pin was used on the femoral side, which is in contrast to
and FLDs demonstrated no differences in device elongation 5.8% with suspensory fixation (39). Suture anchors have
when cycled on an Instron machine. This is clinically also been used as a post fixation, with one cadaveric study
relevant as graft/construct elongation will produce laxity demonstrating that suture anchor fixation with suture
and resultant clinical failure (33,34). tape augmentation restored normal knee kinematics (40).
While suspensory fixation can be used with either bony There were no significant differences when compared to
or all-soft tissue grafts, biomechanical comparison of traditional BTB reconstruction and suspensory fixation
femoral cortical suspension in all-soft tissue grafts noted alone.
significant differences between FLDs and ALDs (33-36).
FLDs had less cyclic displacement when compared with
Hybrid/adjunct fixation
ALDs (35,36). Petre et al. (36) also biomechanically
compared suspension devices in soft tissue grafts in a A combination of fixation techniques, or hybrid fixation,
porcine model looking at ultimate load to failure, stiffness, is another method of securing a graft during ACLR
and displacement. They found that all devices tested had (Table 5). Throughout the evolution of ACLR, hybrid
the necessary physiologic biomechanical properties with fixation techniques have gained popularity, specifically
regard to displacement, failure strength, and stiffness for when considering IFS fixation in isolation with concern of
initial fixation in ACLR when compared to the native ACL. graft slippage with parallel fixation in a different plane (2).
This study did note that FLDs allowed less initial and As such, hybrid fixation methods have been explored to
cyclic displacement but attributed this difference in initial determine if adjunct fixation improves graft stiffness and
displacement to the critical step of re-tensioning the ALDs increase the fixation strength of the construct. Specifically,
after cycling the knee and fixing the tibial side. ALDs have hybrid fixation has been used to address concerns with tibial
been shown to possess the physiologic strength necessary fixation, as the tibia has lower bone density than the femur,
to be used in ACLR when cyclically tested in vitro and and the graft is subject to slippage with parallel fixation
compared to the native knee (36,37). (2,7,12). Multiple studies have found that suspensory
fixation combined with an IFS fixation is biomechanically
superior to suspensory fixation alone (41,42). In a porcine
Post fixation
model, Walsh et al. (42) demonstrated that soft tissue grafts
Post fixation is another method of ACLR, which is usually fixed with an IFS and suspensory cortical button were able
a metal screw, with or without a washer, or a cross pin to withstand higher initial and ultimate loads to failure.
that acts as a stable, inflexible point of fixation in the bone Similarly, hybrid fixation of an IFS with a post has also been
separate from the tunnel aperture that acts as a point of shown to be biomechanically superior (12).
fixation for the graft. Post methods of fixation allow for Suture anchors are reliable backup fixation in the tibia as
cortical fixation of the graft to the bone often through the well. Biomechanical analysis of these implants reveals that
use of sutures as an intermediary (12). Table 4 depicts the they possess equivalent pull out strength when compared

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Table 4 Studies on post fixation in anterior cruciate ligament reconstruction

Reference Year Study type Study purpose Conclusion

Weiss (12) 2019 Biomechanical Comparative biomechanical analysis • Hybrid fixation group presented a significantly
study of tibial fixation strength for ACLR higher final stiffness in comparison
with interference screw compared
• Higher yield load compared to the interference
with screw post and washer, and
screw group
compared with the associated
fixation of both methods (hybrid
fixation)

Zainal Abidin 2021 Biomechanical Analyze the biomechanical effects • Cross-pin was found to have optimum stability
(38) study of different types of fixators (cross- in terms of stress and strain at the femoral
pin, interference screw, and cortical fixation site
button) towards stability after ACLR

Speziali (39) 2014 Systematic Systematically review the • Femoral side cross-pin, metallic interference
review fixation techniques for the ACL screw, bioabsorbable interference screw,
reconstruction and associated and suspensory device were used in 32.3%,
clinical outcomes at the early 27.3%, 24.8%, 15.5% of patients, respectively
follow-up
• Tibial side fixation was achieved with metallic
interference screw, bioabsorbable interference
screw, screw and plastic sheath, screw post
and cross-pin in 38.7%, 31%, 15.7%, 12.8%,
and 1.7% of patients, respectively

Muench (40) 2022 Biomechanical Compare knee kinematics in a • No significant differences between the three
study cadaveric model of ACL repair using techniques
an ALD or suture anchor fixation
with suture tape augmentation
ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; ALD, adjustable loop device, FLD, fixed loop device.

to a traditional bicortical post implant and are a viable fixation may not benefit the construct.
option for ACLR tibial hybrid fixation (43). Cyclic testing
of suture anchors demonstrates that the tension set with
Comparison of fixation methods
these anchors at the time of insertion remains constant (44).
Transosseous tunnels using only suture have also been Due to the high technical demands of ACLR with
described as a backup tibial fixation combined with IFSs, as significant clinical implications for graft failure, the
have staple fixation (45-47). biomechanical properties of overall graft fixation by
Staple fixation has more recently been described as an compression, suspensory, post and hybrid fixation
adjuvant to another method of fixation through cortical techniques have been compared throughout the literature.
anchoring of the graft loop parallel to the tibial tunnel in the The major biomechanical advantages and disadvantages
longitudinal position. This method is indicated for patients of these fixation methods are highlighted in Table 6.
with good cortical bone stock and is often reserved for While each method of graft fixation possesses its own
patients with open physes (48). Gerich et al. (49) described advantages and disadvantages, there is no clear superior
its use in cases where a bone block protrudes out of the fixation technique from a biomechanical perspective when
tibial tunnel. Stiffness of the construct was significantly performed technically correct. However, one study suggests
higher with the use of a surgical staple than with an IFS and that graft tension levels close to 90 N and graft fixation
they concluded that staple fixation is comparable. Contrary at a 30-degree knee-flexion angle are recommended to
to these finding, Teo et al. (47) compared solitary IFS with achieving overall satisfactory clinical outcomes (2).
an IFS and backup surgical staple and found that there was Comparison of IFS compression fixation and suspensory
no biomechanical advantage and that the supplementary fixation techniques have been evaluated extensively

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Page 8 of 13 Annals of Joint, 2023

Table 5 Studies on hybrid fixation in ACLR

Reference Year Study type Study purpose Conclusion

Pereira (2) 2021 Systematic Review the current evidence on tibial-graft • No consensus on the best method
review fixation for tibial fixation of the grafts in ACL
reconstructions regarding tension

Brand (7) 2000 Review Review of literature on graft fixation devices • Fixation should be done at normal
anatomic attachment

• No consensus on best device

Weiss (12) 2019 Biomechanical Comparative biomechanical analysis of tibial • Hybrid fixation group presented a
study fixation strength for ACLR with interference significantly higher final stiffness
screw compared with screw post and
washer, and compared with the associated • Also had a higher yield load compared to
fixation of both methods (hybrid fixation) the interference screw group

Oh (41) 2006 Biomechanical Evaluate the effect of hybrid femoral fixation • Hybrid femoral fixation with suspensory
study with bioabsorbable interference screws fixation and a bioabsorbable interference
screw is stronger than interference or
suspensory fixation alone with respect to
ultimate tensile strength, stiffness, and
slippage

Walsh (42) 2009 Biomechanical Compare biomechanical screw/suspensory • Combined screw/suspensory had higher
study fixation versus either alone load-to-failure

• Combined yield stiffer construct

Verioti (43) 2015 Biomechanical Compare three methods of tibial-sided • No significant difference between IFS, IFS
study fixation + post, or IFS + suture anchor

Athiviraham 2021 Biomechanical Determine whether initial tensioning of suture • Final tension of the suture tape construct
(44) study tape before fixation with a knotless suture appears to be reproducible and consistent,
anchor significantly affects final tension of independent of the initial tension
the suture tape introduced with suture anchor placement

Eisen (45) 2008 Technique article Describes transosseous backup suture • Technique for backup tibial fixation
fixation for ACLR precludes the need for external hardware

Carulli (46) 2017 Randomized Compare the clinical/radiological outcomes • No significant differences between groups
controlled trial of patients with tibial fixation by a centrally
placed resorbable screw/sheath to a
resorbable interference screw/staple fixation

Teo (47) 2017 Retrospective Determine whether supplementary tibial graft • No significant difference in the objective
review fixation with a staple is routinely necessary and subjective outcome assessments
for ACLR between staple/no staple

Diego (48) 2017 Technique article Describe femoral fixation with a combined • Technique for combined IFS/staple femoral
metal IFS and staple fixation

Gerich (49) 1997 Biomechanical Evaluate the primary biomechanical • Staple fixation resulted in comparable max
study parameters of this technique compared with load to failure, graft slippage, and stiffness
a standard IFS fixation to IFS
ACLR, anterior cruciate ligament reconstruction; IFS, interference screw.

in the biomechanical and clinical literature. Overall, and biomechanical studies have yet to account for the
biomechanical implications on clinical decision making for “windshield-wiper” effect leading to higher risk of tunnel
ACLR soft tissue graft fixation has remained a challenge, widening observed for suspensory devices. Prior research has

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Table 6 The advantages and disadvantages of various anterior cruciate ligament reconstruction graft fixation methods
Fixation method Advantages Disadvantages

Compression • ↓ Graft-tunnel micromotion • Risk of screw-tunnel divergence

• ↓ Tunnel widening • Graft damage
• ↓ Graft creep • Cancellous fixation
• Graft slippage

Suspensory • Minimally invasive • ↑ Graft-tunnel motion

• ↑ Tension between graft/bone interface • “Windshield wiper phenomenon”
• Cortical fixation • Tunnel widening
• Similar biomechanics to compression

Suture anchor • Maintenance of tension • Anchor pull-out

Post/staple • Useful in open physes • Hardware irritation

• Useful in graft-tunnel mismatch • More invasive
• Stable, inflexible fixation
↓, decreased; ↑, increased.

demonstrated that tunnel osteolysis or widening occurs no another study that found it to be biomechanically inferior
matter what graft type (i.e., bone or soft tissue) or fixation to suspensory fixation (57).
method is used and is a reported natural phenomenon.
However, there is higher risk of tunnel osteolysis due to
Strengths and limitations
this windshield-wiper effect when using soft-tissue grafts
and suspensory fixation devices where the graft is not fixed This review provides the most comprehensive and thorough
directly in the closed socket tunnel (50). Furthermore, presentation of the available literature in terms of available
heterogenous suspensory devices have been compared to ACLR fixation methods based on known biomechanical
IFS fixation which has led to inconsistent conclusions in the properties and related clinical outcomes. This review gives
literature. Mayr et al. (51) noted that grafts fixed with tibial surgeons a comprehensive presentation of the advantages
ALDs resulted in higher graft elongation but had higher and disadvantages of the various fixation methods necessary
ultimate failure loads in comparison with those fixed with to provide a patient-specific approach to ACLR, though
IFSs at time zero. In contrast, a recent biomechanical study it was not without limitations. This review was limited
reported that tibial and femoral fixation with three unique by the heterogeneity of the current available literature.
adjustable-loop suspensory devices demonstrated higher Comparison studies combined different methods of fixation
ultimate failure loads and lower graft elongation when and with inconsistent reporting of similar outcomes.
compared to a construct with femoral fixed-loop suspensory Biomechanical testing, when performed, was not performed
fixation and tibial IFS fixation (52). Contrary to these in the same manner across all studies and different outcome
findings, other studies have found that the fixation method measures were used across these models to assess graft
biomechanical properties are similar between groups with success (i.e., load to failure, cyclic loading, graft stiffness,
no definitive clinical impact (53,54). etc.) Because an ACL graft can be successfully secured
Studies have also compared IFS, suspensory, post, and with any of the above listed categories of fixation or a
cross-pin fixation for ACLR. Ma et al. (55) compared the combination of methods, it is difficult to provide consistent
three modes of fixation with a hamstring ACLR and found and direct comparisons. Finally, there was a paucity of
no significant differences in clinical outcomes among IFS, studies with high-level evidence, thus lowering the overall
suspensory, or post fixation with at least 2 years of follow- level of evidence presented.
up. Cyclic load testing showed similar amounts of graft
displacement across all tested types of femoral fixation (56).
Conclusions
Specifically examining femoral-sided fixation, one study
found that cross-pin was found to have optimum stability There remains no clear consensus on the optimal ACLR
with regard to stress and strain (38). This is in contrast to graft fixation technique or implants when comparing

© Annals of Joint. All rights reserved. Ann Joint 2023;8:15 | https://dx.doi.org/10.21037/aoj-22-52

Page 10 of 13 Annals of Joint, 2023

compression, suspensory, post and hybrid fixation methods. distributed in accordance with the Creative Commons
The lack of consensus suggests that the ideal fixation Attribution-NonCommercial-NoDerivs 4.0 International
method should likely be individualized based on patient- License (CC BY-NC-ND 4.0), which permits the non-
specific factors and demands, patient expectations and commercial replication and distribution of the article with
desired outcomes, as well as surgeon experience with the the strict proviso that no changes or edits are made and the
goal of restoring anatomic ACL position and function. By original work is properly cited (including links to both the
having a thorough understanding of the biomechanical formal publication through the relevant DOI and the license).
properties and associated clinical outcomes of the various See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
described ACLR fixation methods, the advantages and
disadvantages of each fixation method can be used to
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Translational Large-Animal Model. Arthroscopy

doi: 10.21037/aoj-22-52
Cite this article as: McDermott E, DeFoor MT, Blaber OK,
Aman ZS, DePhillipo NN, Dekker TJ. Biomechanical
comparison of anterior cruciate ligament reconstruction fixation
methods and implications on clinical outcomes. Ann Joint
2023;8:15.

© Annals of Joint. All rights reserved. Ann Joint 2023;8:15 | https://dx.doi.org/10.21037/aoj-22-52