Clinical and Functional Outcomes After Anterior Cruciate Ligament Reconstruction Using Cortical Button Fixation Versus Transfemoral Suspensory Fixation: A Systematic Review of Randomized Controlled Trials

Abstract

To compare clinical and functional outcomes after anterior cruciate ligament (ACL) reconstruction using cortical button versus transfemoral suspensory fixation. This systematic review was conducted following the Cochrane handbook guidelines and PROSPERO registration. Only Level I and II randomized controlled trials comparing cortical button and transfemoral suspensory fixation in hamstring ACL reconstruction were included. A literature search was performed using electronic databases. The methodologic quality of included studies was assessed using The Cochrane Collaboration's risk-of-bias tool. All outcomes reported by each study were evaluated. Primary outcome measures were postoperative International Knee Documentation Committee (IKDC) and Lysholm knee scores. Statistical analysis was performed using RevMan software (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen). Dichotomous data were reported as risk ratio and 95% confidence intervals. Heterogeneity was assessed using I(2). Five studies involving 317 patients were included. The mean follow-up period was 21.7 ± 7.0 months (range, 12 to 38 months). The mean age of participants was 26.7 ± 1.89 years (range, 16 to 48 years). The Lysholm score, Tegner activity score, and IKDC score were compiled. Clinical assessment was performed by Lachman testing, assessment of side-to-side differences on KT-1000 (MEDmetric, San Diego, CA) testing, and measurements of thigh atrophy, as well as imaging (radiography and computed tomography) to assess for femoral tunnel widening. Pooled statistical analysis was possible only for postoperative IKDC and Lysholm scores. No significant differences were found between the cortical button and transfemoral fixation groups. Included studies did not report differences in clinical outcomes between the 2 groups. Radiographic results suggest increased femoral tunnel widening in the cortical button group. However, tunnel widening was not found to affect clinical results. The present evidence suggests that there are no short- to medium-term differences in knee-specific outcome measures between patients treated with cortical button femoral graft fixation and those treated with suspensory transfemoral fixation when undergoing ACL reconstruction. In addition, radiologic evidence of tunnel widening does not seem to affect short- to medium-term clinical outcomes. Level II, systematic review of Level I and II studies.