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

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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.


To determine whether suspensory or aperture fixation of hamstring tendon autografts provides better stability and clinical outcomes in ACL reconstruction.

Study Design:



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.


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.


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.

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