Anterior Cruciate Ligament Reconstruction: Fixation Techniques

Anterior cruciate ligament reconstruction (ACLR) is among the most common procedures performed by orthopaedic sports medicine surgeons and has inherent challenges due to the complex anatomy and biomechanical properties required to reproduce the function and stability of the native ACL. Awareness of the anatomic and biomechanical factors, including graft selection and tunnel placement, along with graft tensioning and fixation techniques, is vital in achieving a successful clinical outcome. Common techniques for ACLR graft fixation include intratunnel fixation with interference screws, suspensory fixation, or hybrid fixation strategies, along with several supplemental fixation techniques. Interference screw fixation may decrease graft-tunnel motion, tunnel widening, and graft creep and may be performed with metallic, PEEK (polyether ether ketone), or bioabsorbable screws. Suspensory fixation techniques primarily include suture-buttons, anchors, staples, and screws/washers. Suspensory fixation allows adequate biomechanical strength, although some techniques have been linked to increased graft-tunnel motion and potential tunnel widening. Supplemental fixation techniques may be performed in the setting of concerns for adequacy of primary fixation and includes the use of suture anchors, staples, and screw/washer devices. Regardless of the implant chosen for fixation, secure fixation is paramount to avoid displacement of the graft and allow for integration into the bone tunnel and facilitates early postoperative rehabilitation. It is important for orthopaedic sports medicine surgeons performing primary and revision ACLR to be familiar with multiple fixation techniques.