Article Text

Varying femoral-sided fixation techniques in anterior cruciate ligament reconstruction have similar clinical outcomes: a network meta-analysis
  1. Ajay Shah1,
  2. Daniel Joshua Hoppe2,
  3. David M Burns2,
  4. Joseph Menna2,
  5. Daniel Whelan2,
  6. Jihad Abouali2
  1. 1 Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
  2. 2 Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Ajay Shah, Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON L8S2G7, Canada; ajay.shah{at}


Importance There is significant controversy regarding the optimal femoral fixation method in anterior cruciate ligament (ACL) reconstruction. Given the importance of ACL reconstruction in patient return to sport and quality of life, it is imperative to identify the optimal method of femoral fixation.

Objective The primary objective of this study is to identify the optimal method of femoral fixation in ACL reconstruction with soft tissue grafts. There are three main techniques for femoral-sided fixation in ACL reconstruction: suspensory extracortical buttons (EC), interference screws (IS) and transfemoral crosspins (TF). Previous primary studies have provided conflicting results regarding the superior method, and prior systematic reviews have failed to identify a difference; however, these analyses were only able to make comparisons between two of the treatments directly. This study employed a network meta-analysis technique to maximise sample size and statistical power, increasing the validity of its findings.

Evidence review A network meta-analysis was conducted using results from 19 randomised controlled trials. Only studies with level I or II evidence, directly comparing two interventions in ACL soft tissue graft reconstruction, were included. Graft failure rates, International Knee Documentation Committee scores and KT-1000 knee arthrometer scores were the primary outcomes measured. Secondary outcomes included Lysholm, Tegner, Lachman and Pivot Shift scores.

Findings An overall sample of 1372 patients was analysed. No statistically significant differences were detected among outcomes, except for the KT-1000 analysis which slightly favoured EC over IS and TF fixation (mean difference (MD)=−0.53 mm; 95% CI −0.07 to –0.98), and TF over IS fixation (MD=−0.41 mm; 95% CI −0.05 to –0.76). The clinical consequences of this difference are likely minimal.

Conclusions Based on the results of this network meta-analysis, there is no clear statistically superior method of femoral fixation in soft tissue ACL reconstruction.

Level of evidence Level II (systematic review of level I and II studies).

  • ACL / PCL
  • repair / reconstruction
  • knee
  • tears

Statistics from


  • Contributors JA and DW designed the study and oversaw all elements of writing and revising the manuscript. AS and DJH conducted the literature search, data extraction and wrote sections of the manuscript. DMB conducted statistical analysis and wrote up the relevant sections. JM was responsible for the risk-of-bias assessment and revising the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Author note JA is an orthopaedic surgeon at the University of Toronto, with a special interest in ACL surgery and rehabilitation. DW is an orthopaedic surgeon at the University of Toronto, with a master’s degree in epidemiology. DJH is a fellow in the University of Toronto Orthopaedic and Sports Medicine programme. DMB and JM are orthopaedic surgery residents at the University of Toronto. AS is a medical student at McMaster University.

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