Hamstring autograft utilization in reconstructing anterior cruciate ligament: Review of harvesting techniques, graft preparation, and different fixation methods

Table 4 Hamstring graft fixation techniques: summary of results

Graft fixation
Ref.	Study design	Results/conclusion
Boutsiadis et al[72], 2018	Cohort study; level of evidence, 3	No difference in postoperative anterior knee laxity at a minimum 2 yr follow-up between interference screw and ALSF device for femoral fixation. The preoperative pivot shift is the only significant risk factor for postoperative residual anterior knee laxity more than 3 mm.
Shanmugaraj et al[81], 2020	Systematic review and meta-analysis	No significant differences in complication rates between femoral press-fit and femoral metal interference screw fixation. Press-fit fixation had significant improvements in functional outcome scores postoperatively and had significantly reduced postoperative bone tunnel enlargement compared to bioabsorbable fixation.
Debieux et al[70], 2016	Review	No difference in self-reported knee function and levels of activity between bioabsorbable and metallic interference screws. Bioabsorbable screws may be associated with more overall treatment failures, including implant breakage during surgery.
Han et al[62], 2012	Level II, systematic review of level I and II studies	At a minimum of 2 yr follow-up, comparable outcomes based on objective IKDC, Lysholm knee scale, and Tegner activity level survey results were found, as well as anterior knee joint laxity measurements between intra-tunnel and extra-tunnel fixation. Intra-tunnel fixation began jogging/running earlier than patients who received extra-tunnel fixation. However, return to sports timing was comparable between the groups.
Hu et al[80], 2017	Systematic review and meta-analysis	The significantly decreased instrumented side-to-side anterior–posterior laxity difference achieved by cross-pin transfixation appears to be of limited clinical significance when compared with interference screw fixation in primary hamstring ACLR.
Fu et al[73], 2020	Systematic review and meta-analysis	Suspensory cortical button fixation was not clinically superior to interference screw fixation in functional outcomes, knee laxity measured with arthrometer, or re-rupture rate. The advantage of using suspensory cortical button fixation was that a thicker graft could be used for reconstruction, and brought less tibia tunnel widening compared with bioabsorbable interference screw fixation.
Saccomanno et al[63], 2014	Systematic review of randomized controlled trials	There are no short- to medium-term differences in knee-specific outcome measures between cortical button femoral graft fixation and suspensory transfemoral fixation In addition, radiological evidence of tunnel widening does not seem to affect short- to medium-term clinical outcomes.
Speziali et al[79], 2014	Systematic review of level I and II therapeutic studies	Side-to-side anterior-posterior tibial translation was 1.9 ± 0.9, 1.5 ± 0.9, 1.5 ± 0.8, 2.2 ± 0.4 mm for metallic interference screw, bioabsorbable screw, cross-pin and suspensory device, respectively. Rate of failure was 6.1%, 3.3%, 1.7% and 1.2% for bioabsorbable interference screw, metallic interference screw, cross-pin and suspensory device, respectively.
Baumfeld et al[74], 2008	Retrospective review	There was significantly more femoral tunnel widening associated with the use of the endobutton suspensory fixation system compared to the use of double cross-pins fixation.
Milano et al[64], 2006	Biomechanical analysis	Corticocancellous suspension fixation offer the best results in terms of graft elongation, fixation strength, and stiffness. Cancellous suspension fixation was homogeneous with other suspension fixation mechanisms but significantly weaker. Interference screws, both metallic and absorbable, showed low failure load but greatest graft elongation.
Sabat et al[75], 2011	Level II, prospective comparative study	Femoral tunnel widening was significantly less in the Transfix group compared with the endobutton group.
Saygi et al[76], 2015	Therapeutic case series, level IV	Undersize drilling technique is preferred in button fixation in order to reduce tunnel widening and improve clinical satisfaction.
Shen et al[77], 2008	Biomechanical comparison study	The cross-pin fixation is a good option for early aggressive rehabilitation following ACL reconstruction due to has significantly less displacement of femur–graft–tibia complex than that of endobutton-CL fixation in response to the cyclic loading test.
Vertullo et al[78], 2019	Controlled laboratory study	The suspensory fixation constructs exhibited small yet statistically significant biomechanical differences among each other. Tibial screw fixation had lower ultimate failure load and higher total elongation.

ALSF: Adjustable-loop suspensory fixation; IKDC: International Knee Documentation Committee; ACLR: Anterior cruciate ligament rupture; ACL: Anterior cruciate ligament; CL: Cruciate ligament.