Aperture and Suspensory Fixation Equally Efficacious for Quadriceps Tendon Graft Fixation in Primary ACL Reconstruction: A Systematic Review

Abstract

This review is aimed to compare suspensory and aperture quadriceps tendon autograft femoral and tibial fixations in primary anterior cruciate ligament reconstruction (ACL-R), and the clinical outcomes and complication profiles of each fixation method. Greater understanding of the optimal graft fixation technique for quadriceps tendon (QT) autografts may assist surgeons in improving outcomes after ACL-R. PubMed, Embase, and Medline were searched from database inception to September 2017, and again to July 2018, and identified 3,670 articles, 21 studies of which satisfied inclusion/exclusion criteria. Across included studies, 1,155 QT ACL-R patients (mean age, 28.7 years [range, 15–59 years], with mean postoperative follow-up of 36.1 months [range, 3.4–120 months]), were analyzed. Suspensory fixation on both sides demonstrated a higher percentage of patients (81.7%) achieving the highest rating of “A or B” on the International Knee Documentation Committee (IKDC) knee ligament examination form compared with aperture fixation on both sides (67.7%). Moreover, suspensory fixation had a lower side-to-side difference in anterior laxity (1.6 mm) when compared with aperture fixation (2.3 mm). Among studies which reported graft failure, all of which employed aperture fixation, the rate was 3.2%. Across available data, primary ACL-R using QT grafts appears to have successful short-term outcomes with a short-term graft failure rate of 3% independent of fixation method. While there is limited data regarding the comparison of aperture and suspensory soft-tissue quadriceps tendon (SQT) fixation in ACL-R, the findings of this systematic review suggest that suspensory fixation and aperture fixation in both the femoral and tibial tunnels are equally efficacious based on clinical outcome data on IKDC grade and measured laxity. This is a level IV, systematic review study.

Quadriceps tendon has a lower re-rupture rate than hamstring tendon autograft for anterior cruciate ligament reconstruction – A meta-analysis

“…Another systematic review looking at graft fixation found no difference in graft re-rupture rate or clinical outcomes between aperture versus suspensory fixation of QT. 40 None of the aforementioned reviews compared all soft-tissue QT to QT grafts including a bone plug, and further studies will be valuable in this area. Theoretical benefits to all-soft tissue QT include mitigated risk of patellar fracture and reduced donor site morbidity, although these are rarely reported, and can be minimized by harvesting less than 30% of the patella 41 .…”

ACL Reconstruction and Modified Lemaire Tenodesis Utilizing Common Suspensory Femoral Fixation

“…Nevertheless, adjustable suspensory femoral fixation has been long used in ACL reconstruction, with great biomechanical and clinical results using the QT graft, 16 hamstring graft, 17 , 18 and bone-patella-tendon-bone graft. 19 …”

No Difference in Knee Kinematics Between Anterior Cruciate Ligament–First and Posterior Cruciate Ligament–First Fixation During Single-Stage Multiligament Knee Reconstruction: A Biomechanical Study

“…For preparation of the hamstring tendon graft, the gracilis and semitendinosus strands were looped through a closed-loop extracortical button suspensory device 3,11,45,53 and then doubled and whip-stitched together using braided polyester No. 2 suture (Arthrex).…”

“…Soft tissue autografts 57 were harvested from the tested knee, with the quadriceps tendon used for ACL 3,11 reconstruction (sized to 9.0 mm), while for the PCL, a hamstring tendon autograft (semitendinosus and gracilis, quadrupled loop) was used in the majority of cases, and an additional allograft strand was added, if needed, to reconstruct the PCL 36,51 (sized to 9.5 mm) (Figure 1).…”