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Press-fit fixation in anterior cruciate ligament reconstruction yields low graft failure and revision rates: a systematic review and meta-analysis

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Press-fit fixation is a hardware-free technique in anterior cruciate ligament reconstruction (ACLR). The purpose of this review was to quantitatively assess the risk profile and outcomes of press-fit fixation and provide an update on its effectiveness compared to more standard fixation techniques of ACLR.

Methods

The electronic databases PUBMED, MEDLINE, and EMBASE were searched on March 26, 2020 for therapeutic randomized controlled trials (RCT) addressing press-fit fixation for primary ACLR. The Grading of Recommendations Assessment, Development and Evaluation tool was used to assess the quality for randomized studies. A meta-analysis with a random-effects model was used to pool applicable outcomes data.

Results

A total of six eligible RCTs were included in this review. There were 292 patients (72.9% male) with a mean age of 28.8 ± 3.8 years and a mean follow-up of 81.3 ± 88.3 months that underwent press-fit ACLR on the femoral, tibial or both tunnels. Femoral fixation techniques included press-fit fixation (96.6%) and cross-pin fixation (3.4%). Tibial fixation techniques included press-fit (37.0%), staples (28.1%), interference screws (21.2%) and abarticular post-screws (13.7%). Graft options included bone–patellar tend–-bone autografts (73.6%) and semitendinosus and gracilis tendon autograft (26.4%). Significant improvements (p < 0.05) from baseline to follow-up were found for clinical outcomes. Significantly less postoperative bone tunnel enlargement (p < 0.05) was found with tibial press-fit fixation when compared to biodegradable screws. The overall complication rate was 13.3%. There were no significant differences in complication rates [odds ratio = 0.84 (95%CI 0.43–1.66); p = n.s.] (I2 = 0%) between patients undergoing femoral press-fit fixation and femoral metal interference screw fixation.

Conclusion

The overall graft failure and revision rates with press-fit ACLR were low. There were no significant differences in complication rates between patients undergoing femoral press-fit and femoral metal interference screw fixation. Included studies found that patients undergoing press-fit fixation for ACLR had significant improvements in functional outcome scores postoperatively and had significantly reduced postoperative bone tunnel enlargement compared to patients undergoing bioabsorbable fixation. Thus, early evidence suggests that press-fit fixation appears to be a good option for patients undergoing ACLR.

Level of evidence

I.

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Abbreviations

ACL:

Anterior cruciate ligament

ACLR:

Anterior cruciate ligament reconstruction

RCT:

Randomized controlled trial

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

GRADE:

Grading Recommendations Assessment, Development and Evaluation

ICC:

Intraclass correlation coefficient

CI:

Confidence interval

OR:

Odds RATIO

BPTB:

Bone–patellar tendon–bone

STG:

Semitendinosus and gracilis

IKDC:

International Knee Documentation Committee

CT:

Computed tomography

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No funding was received for the implementation of this study.

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Authors and Affiliations

  1. Department of Surgery, Division of Orthopaedic Surgery, McMaster University, 1200 Main St W, Room 4E15, Hamilton, ON, L8N 3Z5, Canada

    Ajaykumar Shanmugaraj, Chetan Gohal, Nolan Horner, Nicole Simunovic & Olufemi R. Ayeni

  2. Faculty of Medicine, University of Toronto, Toronto, ON, Canada

    Mathepan Mahendralingam

  3. Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Volker Musahl

  4. Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden

    Kristian Samuelsson

  5. Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamitlon, ON, Canada

    Olufemi R. Ayeni

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  1. Ajaykumar Shanmugaraj
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All authors contributed substantially to the conception and design, or acquisition of data, or analysis and interpretation of data; drafted the article or revised it critically for important intellectual content; provided the final approval of the version to be published; and agreed to act as guarantor of the work (ensuring that questions related to any part of the work are appropriately investigated and resolved).

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Correspondence to Olufemi R. Ayeni.

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ORA is an educational consultant for the Speaker’s Bureau of Conmed.

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Shanmugaraj, A., Mahendralingam, M., Gohal, C. et al. Press-fit fixation in anterior cruciate ligament reconstruction yields low graft failure and revision rates: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 29, 1750–1759 (2021). https://doi.org/10.1007/s00167-020-06173-4

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