Is all-inside with suspensory cortical button fixation a superior technique for anterior cruciate ligament reconstruction surgery? A systematic review and meta-analysis

Abstract

Background: To compare the clinical results of all-inside anterior cruciate ligament reconstruction (ACLR) using suspensory cortical button fixation and full tibial tunnel drilling.

Methods: Systematic searches were conducted of published literature up to November 2019 on PubMed, Embase, and Cochrane for studies comparing all-inside ACLR using suspensory cortical button fixation and full tibial tunnel ACLR. Two reviewers independently determined eligibility, extracted the outcome data, and assessed the risk of bias of the eligible studies. The clinical outcome and graft reruptures were pooled by using random effects with mean differences and risk ratios for continuous and dichotomous variables, respectively.

Result: A total of nine studies (five randomized controlled trials and four comparative studies) involving 613 patients were included in the meta-analysis. The postoperative functional outcome, knee laxity measured with arthrometer, and graft reruptures were comparable between patients with all-inside ACLR using suspensory cortical button fixation and full tibial tunnel ACLR. However, a significantly greater thickness of autologous tendon was used and less change in drilling tunnel diameter was noted in patients with suspensory cortical button graft fixation.

Conclusions: All-inside ACLR with suspensory cortical button fixation was not clinically superior to full tibial tunnel ACLR with interference screw fixation in functional outcomes, knee laxity measured with arthrometer, or rerupture rate. However, 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.

Keywords: ACL reconstruction; All-inside; Anterior cruciate ligament; Interference screws; Suspensory fixation.

Fig. 1

The figure illustrates preparation of the tibial tunnel method with retrograde drilling in all-inside ACLR (a) and conventional full tibial tunnel drilling (b). Tibial side graft fixation with suspensory cortical button (c) and with bioabsorbable interference screw (d). Note: Bone tunnel is depicted with a dotted line, and the arrows indicate the drilling direction

Fig. 2

Preferred reporting items for systematic reviews and meta-analysis (PRISMA) flow diagram for the searching and identification of included studies

Fig. 3

Forest plot of the graft size, Random, Heterogeneity: Tau² = 0.000; Chi² = 1.809, df = 2 (p = 0.405); I² = 0%. Test for overall effect: Z = − 6.975 (p < 0.001)

Fig. 4

Forest plot of Lysholm score, Random, Heterogeneity: Tau² = 0.151; Chi² = 13.051, df = 4 (p = 0.011); I² = 69%. Test for overall effect: Z = 0.634 (p = 0.526)

Fig. 5

Forest plot of subjective IKDC score, Random, Heterogeneity: Tau² = 0.204; Chi² = 16.358, df = 4 (p = 0.003); I² = 76%. Test for overall effect: Z = − 0.276 (p = 0.783)

Fig. 6

Forest plot of Tegner score, Random, Heterogeneity: Tau² = 0.001; Chi² = 3.307, df = 3 (p = 0.386); I² = 1%. Test for overall effect: Z = 2.564 (p = 0.01)

Fig. 7

Forest plot of KSS, Random, Heterogeneity: Tau² = 1.887; Chi² = 26.095, df = 1 (p = 0.000); I² = 96%. Test for overall effect: Z = -0.505 (p = 0.614)

Fig. 8

Forest plot of the knee laxity measured by arthrometer, Random, Heterogeneity: Tau² = 0.142; Chi² = 4.674, df = 2 (p = 0.097); I² = 57%. Test for overall effect: Z = 0.573 (p = 0.567)

Fig. 9

Forest plot of the direct postoperative tunnel width, Random, Heterogeneity: Tau² = 3.885; Chi² = 57.712, df = 2 (p = 0.000); I² = 97%. Test for overall effect: Z = -0.720 (p = 0.472)

Fig. 10

Forest plot of the follow-up tunnel width, Random, Heterogeneity: Tau² = 0.712; Chi² = 15.225, df = 2 (p = 0.000); I² = 87%. Test for overall effect: Z = -1.392 (p = 0.164)

Fig. 11

Forest plot of the tunnel diameter change, Random, Heterogeneity: Tau² = 0.000; Chi² = 0.533, df = 1 (p = 0.465); I² = 0%. Test for overall effect: Z = -7.015 (p < 0.001)

Fig. 12

Forest plot of the re-rupture, Random, Heterogeneity: Tau² = 0.540; Chi² = 2962, df = 2 (p = 0.227); I² = 32%. Test for overall effect: Z = -0.398 (p = 0.691)