Optimal graft fixation—The effect of gap size and screw size on bone plug fixation in ACL reconstruction

Butler, James C.; Branch, Thomas P.; Hutton, William

doi:10.1016/s0749-8063(05)80007-6

Cited by 65 publications

(27 citation statements)

References 4 publications

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“…A stable fixation of the graft is imperative for early aggressive rehabilitation to minimize quadriceps atrophy and restrictions in the range of motion postoperatively. However, initial graft fixation strength remains the weakest link following anterior cruciate ligament (ACL) reconstruction with the hamstring tendon graft before bony incorporation of the graft [1]. Many devices for soft tissue tendon fixation have been developed to facilitate initial graft fixation, including Cross-pin (TransFix, Arthrex, Germany), Endobutton-CL (a titanium button with a 20-mm continuous polyester loop, Acufex; Smith and Nephew, Andover, MA), Endopearl, Biotransfix pin, interference screw and Bioscrew etc [2][3][4][5].…”

Section: Introductionmentioning

confidence: 99%

Biomechanical Comparison of Cross-Pin and Endobutton-CL Femoral Fixation of a Flexor Tendon Graft for Anterior Cruciate Ligament Reconstruction—A Porcine Femur-Graft-Tibia Complex Study

Shen

Chang

Lee

et al. 2010

Journal of Surgical Research

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Section: Introductionmentioning

confidence: 99%

Biomechanical Comparison of Cross-Pin and Endobutton-CL Femoral Fixation of a Flexor Tendon Graft for Anterior Cruciate Ligament Reconstruction—A Porcine Femur-Graft-Tibia Complex Study

Shen

Chang

Lee

et al. 2010

Journal of Surgical Research

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“…A positive correlation between ultimate failure load and screw diameter related specifically to screw insertion torque has been demonstrated. 9,10,17,20,41,55,66 However, comparing 7 mm and 9 mm metal interference screws, Hulstyn et al 35 found no statistically significant influence of screw diameter on maximal load to failure in a bovine model. Shapiro et al 72 similarly showed no load to failure differences comparing these screw diameters placed in bovine femurs with 2 mm circumferential bone plug-tunnel gaps.…”

Section: Screw Diameter and Lengthmentioning

confidence: 99%

Graft Fixation Alternatives

Risinger¹,

Verma²,

Bach³

2005

Techniques in Orthopaedics

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Stable graft fixation is critical to successful ACL reconstruction. Graft migration must be prevented during the 6 to 12-week postoperative period that is required for graft-tunnel incorporation. Maximizing interference screw fixation, avoiding pitfalls of screw insertion, managing graft-tunnel mismatch, and alternative fixation techniques are discussed. Key Words: Anterior cruciate ligament-GraftFixation.Contemporary rehabilitation protocols after anterior cruciate ligament (ACL) reconstruction stress early postoperative knee motion and weight bearing to reduce morbidity secondary to stiffness, delayed strength recovery, and anterior knee pain. In the first weeks after surgery the weakest link of the reconstructed ACL is not the graft itself but rather the fixation sites. Resultant graft forces during an accelerated rehabilitation protocol are estimated to range between 150 N and 450 N. 24,28,51,52,61,68 Therefore, the stability of initial graft fixation is critical and must be strong enough to withstand these forces and prevent graft migration during the six to twelve week period that is required for graft-tunnel incorporation. 16,44,50,67 Patellar tendon allograft incorporation may be delayed compared with autografts, 37 and when this graft is used fixation may need to provide additional primary stability beyond 12 weeks.It has been estimated that ACL graft failure is responsible for 0.7% to 8% of cases of recurrent instability after reconstruction. Furthermore, errors in surgical technique are the primary cause of early graft failure. 29,32,34 In addition to inadequate primary fixation, technical factors which should be considered include nonanatomic tunnel placement, graft impingement from an inadequate notchplasty, improper graft tensioning, graft material problems and failure to address injured secondary stabilizers.In the absence of these problems early construct failures are almost universally related to loss of fixation.The purpose of this manuscript is to discuss interference screw fixation with a focus on avoiding pitfalls of insertion, strategies for managing graft-tunnel mismatch, and graft fixation alternatives which may be required in primary or revision situations. INTERFERENCE SCREW FIXATIONIn 1983 Lambert 46 introduced interference fixation using 6.5 mm AO cancellous metal screws (Synthes, Paoli, PA). In the landmark human cadaveric study by Kurosaka et al.,44 novel headless fully threaded 9-mm interference screws demonstrated superior fixation strength compared with 6.5 mm AO cancellous screws, sutures over buttons, and staples. The maximal load to failure was 436 Ϯ 90 N. Other authors have subsequently shown that the single load to failure strength of metal interference screws with human in vitro models is up to 703 N. 14,41,54,75 Despite the fact that specimen donors in these studies were on average older with decreased bone density compared with the ACL reconstruction patient population, fixation strength was adequate for accelerated rehabilitation.Multiple factors are related to the ultima...

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Section: Introductionmentioning

confidence: 99%

“…are factors affecting the primary fixation strength [11][12][13]. Some studies examined the effect of the bone density on the primary fixation, and many of these reported a direct correlation between the failure load and bone density [11][12][13][14]. It was reported that the optimal fixation strength can be achieved when the bone mineral density (BMD) is >0.6 g/cm 2 for ACL fixation even though this value is not constant in all subjects [11,15,16].…”

Section: Introductionmentioning

confidence: 99%

Computed tomography based evaluation of the bone mineral density around the fixation area during knee ligament reconstructions: Clinical relevance in the choice of fixation method

et al. 2012

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Optimal graft fixation—The effect of gap size and screw size on bone plug fixation in ACL reconstruction

Cited by 65 publications

References 4 publications

Biomechanical Comparison of Cross-Pin and Endobutton-CL Femoral Fixation of a Flexor Tendon Graft for Anterior Cruciate Ligament Reconstruction—A Porcine Femur-Graft-Tibia Complex Study

Biomechanical Comparison of Cross-Pin and Endobutton-CL Femoral Fixation of a Flexor Tendon Graft for Anterior Cruciate Ligament Reconstruction—A Porcine Femur-Graft-Tibia Complex Study

Graft Fixation Alternatives

Computed tomography based evaluation of the bone mineral density around the fixation area during knee ligament reconstructions: Clinical relevance in the choice of fixation method

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