Suspensory Versus Aperture Fixation of a Quadrupled Hamstring Tendon Autograft in Anterior Cruciate Ligament Reconstruction: A Meta-analysis

Background: Hamstring grafts have become a popular choice for anterior cruciate ligament (ACL) reconstruction; however, the most effective means of fixation of these soft tissue grafts is unknown. Purpose: To determine whether suspensory or aperture fixation of hamstring tendon autografts provides better stability and clinical outcomes in ACL reconstruction. Study Design: Meta-analysis. Methods: A literature search of studies reporting single-bundle ACL reconstructions using 4-stranded hamstring tendon autografts with aperture or suspensory fixation with a minimum 24-month follow-up was conducted. Stability and clinical outcomes were compared for aperture versus suspensory fixation. Knee stability was measured with the Lachman or pivot-shift test or KT-1000 arthrometer side-to-side difference (SSD), and outcomes were determined with the International Knee Documentation Committee (IKDC), Tegner, and Lysholm scores as well as graft failures. A random-effects model with a pooled estimate for the between-study variance was used to estimate proportions or means for each outcome and its corresponding 95% CI. Results: Forty-one studies were included, of which 20 utilized suspensory fixation techniques and 21 utilized aperture fixation techniques. A >3-mm SSD was seen more often in the aperture group than the suspensory group, which was statistically significant (P <.0001), but there was no significant difference between groups for a >5-mm SSD (P =.53). The aperture group demonstrated significantly more graft ruptures than did the suspensory group (P =.03). There were no statistically significant differences in Lachman grade 0 (P =.76), grade 1 (P =.89), and grade 2 (P =.55) or pivot-shift grade 0 (P =.72), grade 1 (P =.97), and grade 2 (P =.28). There was no statistically significant difference in mean continuous IKDC (P =.80), Tegner (P =.34), or Lysholm (P =.84) scores. Conclusion: This meta-analysis demonstrated improved overall arthrometric stability and fewer graft ruptures using suspensory fixation compared with aperture fixation of a quadrupled hamstring tendon autograft in ACL reconstruction. There were no differences in IKDC, Lysholm, Lachman, and pivot-shift outcomes between suspensory and aperture fixation.