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Journal of Experimental Orthopaedics
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Fixed-loop vs. adjustable-loop cortical button devices for femoral fixation in ACL reconstruction – a systematic review and meta-analysis

Journal of Experimental Orthopaedics volume 9, Article number: 106 (2022) Cite this article

A Correction to this article was published on 26 November 2022

This article has been updated

Abstract

Purpose

Button implants with either a fixed-loop device (FLD) or adjustable-loop device (ALD) are used frequently in Anterior Cruciate Ligament Reconstruction (ACLR). Since revision ACLR is associated with poorer clinical outcomes, it is important to investigate the difference in risk of revision between FLDs and ALDs. Therefore, this paper aims to systematically assess the risk of revision ACLR between ALDs and FLDs as well as secondary outcomes such as knee stability and patient reported outcomes (PROMs).

Methods

The online databases Embase, Medline (PubMed), and SPORTDiscus were searched, comparing FLDs and ALDs for femoral fixation in patients undergoing primary ACLR with hamstring autografts. Risk of bias was assessed with the ROBINS-I tool for non-randomised studies. Due to heterogeneity a meta-analysis on revision rates were not possible. A random-effect meta-analysis was performed for the secondary outcomes and the quality of evidence was evaluated using the GRADE approach.

Results

Fifteen cohort studies with a total of 2686 patients were included. None of the studies found a clinical difference between ALDs and FLDs in either revision rates, knee stability or PROMS. However, the quality of evidence was graded “very low” due to study designs, risk of bias, and heterogeneity.

Conclusion

Studies of better quality are needed to investigate the risk of revision ACLR between ALDs and FLDs. There was no difference in knee stability and PROMs between the ALDs and FLDs; however, the interpretation of these results is challenging due to low quality of evidence.

Level of evidence

Level III.

Introduction

Anterior cruciate ligament reconstruction (ACLR) is a commonly performed surgical procedure that aims to re-establish knee stability after an ACL tear. Cortical button devices are frequently used to fixate the ACL graft onto the femur bone with either a fixed-loop device (FLD) or an adjustable-loop-device (ALD) [13]. When using the FLDs, there is the need for an additional drilling depth for button flipping, which results in extra femoral bone loss. Therefore, the ALDs were designed with an adjustable loop allowing for loop re-tensioning after graft insertion and adjustment of the loop’s length [39]. This provides surgical advantages that potentially lead to reduced bone removal [27], reduced femoral tunnel widening [14, 25], and improved graft healing [23]. Biomechanical studies found ALDs to be inferior to FLDs in terms of maximum displacement after cyclic loading, ultimate load to failure, and stiffness [7, 8, 29, 38]. In contrast, clinical studies reported similar knee laxity and patient-reported outcome measures between ALDs and FLDs [1, 5, 9]. These findings have previously been reported in systematic reviews [30, 37].

However, there are no reviews with revision ACLR as primary outcome measure even though revision surgery is the ultimate failure outcome [26]. Furthermore, revision surgery is associated with poorer patient-reported outcomes (PROM) and a higher incidence of cartilage injury with subsequent development of osteoarthritis [24, 42]. Therefore, the rate of revision surgery is an important outcome when evaluating if ALDs are as safe to use in ACLR as FLDs. New clinical studies that include revision rates have been published in recent years [11, 28, 31, 43]. These studies may allow for conducting a meta-analysis that has hitherto been difficult due to heterogeneity between studies.

A systematic review which updates the latest research and include revision surgery as primary outcome measure would contribute to the existing research. Thus, this study aimed to review and perform a meta-analysis of studies that compared revision rates between ALDs and FLDs. Knee laxity and PROMs were included as secondary outcomes. The hypothesis was that the ALDs showed similar revision rates compared with FLDs.

Materials and methods

The study was performed as a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria [32].

Literature search strategy

This systematic review was registered on the Prospero registration site (ID: CRD42021285255). Literature searches were conducted between 30 November and 15 December 2021 in the following electronic databases: Embase (Embase.com), Medline (PubMed host), and SPORTDiscus (EBSCO host). The search was limited to full articles and published studies written in English. The full line search was: “((((“ACL”) OR (“anterior cruciate ligament”)) OR (“Anterior Cruciate Ligament”[Mesh] OR “Anterior Cruciate Ligament Reconstruction”[Mesh] OR “Anterior Cruciate Ligament Injuries”[Mesh])) AND (((“Endobutton”) OR (“Retrobutton”) OR (“XO button”) OR (“Rigidloop”)) OR ((“fixed” OR “fixation”) AND (loop OR button OR “length”)))) AND ((“Zipploop” OR “Tight Rope” OR “Rigidloop” OR “UltraButton”) OR ((“Adjustable” OR “variable”) AND (loop OR button OR length))).”

The Population, Intervention, Comparison, and Study (PICOS) principles guided the search strategy [10]. Databases were searched for studies that met the following criteria: investigating revision surgery, knee laxity, or PROMs for patients receiving ACLR performed with hamstring tendon autografts and comparing adjustable-loop devices to fixed-loop devices for femoral graft fixation.

The reference list of included studies and systematic reviews, conducted on the same area known by the authors, were searched for additional studies.

Selection process

The selection process was conducted using the online software Covidence. Two authors (SE) and (TN) independently conducted title and abstract screening and any discrepancies were resolved through discussions. Full text screening of included studies was carried out in the same way. The reference list from included studies and from existing reviews [30, 37] on the same topic known by the authors were searched for additional eligible studies by a single assessor (SE). Studies identified from the reference lists were screened in full text by both assessors to reach a final agreement. Studies were considered eligible is they met the PICOS criteria. The identification and screening process are outlined in Fig. 1.

Fig. 1
figure 1

Flow chart of study selection and inclusion process

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Data extraction

Data extractions were performed using a predefined data extraction form created on the online software, Covidence. The following data was extracted through the extraction form: type of study, fixation-device fabricant, tibial fixation, number of included patients, distribution of sex and age, follow-up time, and outcome data. The rate of revision surgery was the primary outcome and was defined as a second ACLR performed on the same knee as the primary ACLR. Secondary outcomes included anterior knee laxity, measured with arthrometers (KT-1000 or Rolimeter) as the side-to-side difference (SSD) in mm between the reconstructed and healthy knee, and PROMs as measured by the International Knee Documentation Committee (IKDC) [21] and Lysholm score [6]. Two reviewers (SE) and (TN) conducted data extractions independently and discrepancies were discussed to reach a consensus.

Quality assessment

The Cochrane Risk of Bias In Non-Randomized Studies of Interventions (ROBINS-I) [40] was used to evaluate the risk of bias in each of the included studies. A single assessor (SE) completed the bias assessment and made an overall risk of bias assessment for each article. The results were afterwards presented to the co-authors. If a decision was unclear, the authors discussed it to reach an agreement.

The ROBINS-I contains the following seven domains of bias: due to confounding, in selecting participants, in classifying interventions, due to deviations from intended interventions, due to missing data, in measuring outcomes, and in selecting the reported result. Bias was assessed separately for each of the three outcomes: revision surgery, knee laxity, and PROMs. The important factors included in the confounding domain for each outcome were chosen after a discussion between the authors. Important confounders of revision rates and knee laxity included the use of more than one tibial fixation device, the different surgical techniques used (i.e. anteromedial, transtibial, outside-in), age, and surgery on other ligaments (i.e. posterior cruciate ligament, medial collateral ligament, or lateral collateral ligament). Important confounders for the PROMs were age and knee comorbidities (osteoarthritis/cartilage damage, meniscus injury, other ligament injuries). Rehabilitation was considered an important co-intervention for all outcomes. If the study included different rehabilitation programmes or did not report on the rehabilitation protocol, it was considered as having a moderate risk of bias in the domain of deviations from the intended intervention. For the missing data domain, it was decided that missing data for 10–19% of the participants resulted in a moderate risk of bias and missing data for > 20% of the participants resulted in a serious risk of bias. The overall risk of bias was determined by the worst degree of bias assessed across all bias domains [40].

The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the quality of evidence for each meta-analysis [17]. A single assessor (SE) conducted the GRADE evaluation, after all authors approved it.

Data analysis

The rates of revision surgery are reported as categorical data. The risks ratio of revision surgery is presented by an Odds ratio (OR) with a 95% confidence interval (CI). If the included studies did not report the OR, it was calculated by using the proportions stated in the study. A meta-analysis of the pooled effect size of revision rates was not estimated due to high heterogeneity between the included studies. Knee laxity by SSD and PROMs are reported as continuous data by a mean difference (MD). Random effect models were used to estimate the pooled effect of the MD for the SSD and PROMs with a 95% CI at the 2-years follow-up. Heterogeneity due to variations across the studies were assessed using the I2 test [19]. Publication bias assessed using funnel plots were not possible due to the low number of studies included. The statistical analyses were conducted using Stata version 17 (StataCorp, College Station, Texas).

Results

A total of 15 studies were included in this systematic review [1, 3,4,5, 9, 11, 14, 25, 28, 31, 33, 34, 36, 41, 43]. All studies were screened in full text. Four studies did not meet eligibility criteria: one could not be retrieved in full text [20], one was not written in English [12], one was conducted with several graft types [44], and presented other clinical outcomes than those included by this review [45]. Three additional studies were identified from the reference list of included studies [4, 14, 33]. Key characteristics for each of the included studies are presented in Table 1.

Table 1 Study characteristics
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Revision surgery

Three studies [4, 5, 43] included revision surgery in their outcome and two studies [28, 34] reported on the number of patients undergoing revision surgery during the study period. Only the study by Asmussen et al. [4] analysed the rate of revision surgery with an OR and found that ALDs had 0.51 (95% CI: 0.24–1.13) lower odds of having a revision surgery compared to FLDs. However, this was not statistically significant [4]. Boyle et al. [5] and Ranjan et al. [34] did not present an OR for the risk of having a revision surgery in the ALD group compared to the FLD group. However, this study calculated an OR based on the proportions of revision surgery reported by both Boyle et al. [5] and Ranjan et al. [34]. The results are presented in Table 2. Mohamed et al. [28] found only one.

Table 2 Revision rates presented as proportions and odds ratio
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case of revision surgery and this was in the ALD group. Uribe et al. [43] reported no cases of revision surgery in either of the groups.

Knee laxity

The SSD are reported at the 6 months follow-up in three studies [5, 34, 43], at the 1-year follow-up in three studies [4, 25, 43], and at the 2-years follow-up in five studies [5, 9, 11, 14, 34]. There was no difference in the mean SSD between the ALDs and FLDs in either of the studies Table 3.

Table 3 KT-1000 side-to-side difference measured at 6 months, 1 year and 2 years follow-up
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The meta-analysis revealed an overall MD in the SSD at the 2-years follow-up of -0.15 mm (95% CI: -0.54—0.24) lower in the ALD group compared to the FLD group (Fig. 2). The I2 test revealed a high heterogeneity of 61% across the studies.

Fig. 2
figure 2

Meta-analysis of knee laxity and PROMs with the Lysholm and IKDC score

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Patient-reported outcomes

Five studies reported the PROMs with the Lysholm score at the 1-year follow-up [25, 28, 31, 33, 36] and seven studies reported them at the 2-years follow-up [1, 2, 9, 11, 14, 34, 41] (Table 4). The meta-analysis for the 2-years Lysholm scores revealed an overall MD in the Lysholm score of 0.17 points (95% CI: -040 – 0.75) higher for the ALD group compared to the FLD group (Fig. 2). Three studies reported the PROMs with the IKDC score at the 1-year follow-up [25, 33, 36] and six studies reported it at the 2-years follow-up [1, 2, 11, 14, 34, 41] as presented in Table 4.

Table 4 Lysholm and IKDC scores at 1 and 2-years follow-up
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The meta-analysis for the 2-years IKDC scores revealed an overall MD in the IKDC score of 0.48 points (95% CI: -1.06 – 2.01) higher for the ALD group compared to the FLD group (Fig. 2).

Quality assessment

The overall risk of bias assessment showed that the included studies ranged from an overall moderate risk of bias to an overall serious risk of bias depending on the outcome measure (Fig. 3).

Fig. 3
figure 3

Individual risk of bias assessment for all included outcomes

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For the bias assessment of revision rates and knee laxity, the overall serious risk of bias judgement was mainly due to confounding. Two studies were judged as having a serious risk of bias due to confounders. One used several tibial fixation methods [4] and the other used two different surgical techniques [43]. Most of the studies had a low or moderate risk of bias regarding selection of participants, deviations from intervention, measurement of outcomes, and selection in reported results. For the knee laxity outcome, one study had a serious risk of bias due to missing data [5].

In the bias assessment of the PROMs, the overall risk of bias was serious for all studies. This was mainly because of bias due to confounders and in measurement of the outcome since this was a subjective measure and thereby could be influenced by knowledge of intervention. Most of the studies had a low or moderate risk of bias regarding selection of participants, deviations from intervention, and selection in reported results. One study had a serious risk of bias due to missing data [2]. The risk of bias in classifying interventions was at a low risk for all studies in all outcomes.

The GRADE evaluation demonstrated a “very low” quality of evidence for each of the three meta-analyses (Table 5).

Table 5 Summary of findings table
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All outcomes were initially downgraded to “low” quality of evidence because of the study design (i.e. observational studies). The meta-analysis of knee laxity was further downgraded to “very low” due to high heterogeneity (I2 = 61%). The two meta-analyses of PROMs by the Lysholm score and the IKDC score had a serious risk of bias and was thus downgraded further to “very low”.

Discussion

The most important finding of this systematic review and meta-analysis was that there was no difference in revision surgery rates comparing ALDs to FLDs for femoral graft fixation using hamstring tendon autografts in ACLR. Furthermore, this systematic review found that the overall risk of bias assessment ranged from moderate to serious and that the quality of evidence in the meta-analyses was “very-low”.

Five studies reported the rate of revision surgery for ALDs and FLDs. Asmussen et al. [4] included the largest patient population in their registry-based cohort study and was the only study that compared the rate of revision surgery between ALDs and FLDs using statistics. They found that ALDs had a lower risk of revision surgery compared to FLDs. This result was not statistically significant, and the study had a serious overall risk of bias. Uribe et al. [43] was the only study that reported no cases of revision surgery; however, their study included the fewest number of patients, which may explain this finding. None of the included studies specified rehabilitation protocols and return-to-sport criteria. Two studies [5, 28] reported that patients returned to sports from 6 months postoperatively and the remaining three studies [4, 34, 43] did not report whether the patients returned to sports. The lack of information in the studies on rehabilitation protocols and return-to-sport criteria is of importance since higher sport activity levels and an early return to sports before meeting the appropriate criteria are associated with a greater risk of reinjury and a possible revision surgery [15, 18]. A meta-analysis was not performed due to heterogeneity of the study design i.e. surgical technique for tunnel drilling, differences in tibial fixation methods, number of patients, and different follow-up time. To reduce bias, studies that only performed ACLR with hamstring tendon autografts were included, since allografts have demonstrated a greater risk of graft failure compared to autografts [16, 22].

Secondary, this systematic review found no difference between ALDs and FLDs in knee laxity and PROMs. The results from the meta-analysis of knee laxity showed that there was no significant difference between ALDs and FLDs in the SSD in anterior knee laxity when measured with the KT-1000 arthrometer. However, due to study design and a large heterogeneity from the I2 test, the GRADE evaluation demonstrated a “very low” quality of evidence. The large heterogeneity may be partially explained by differences in the force applied during the KT-1000 measurements. The studies by Choi et al. [9] and Firat et al. [14] stated that the KT-1000 measurements were performed at maximal force as opposed to the studies by Ranjan et al. [34] and Djordjevíc et al. [11], who did not specify the force applied. The inter-reader reliability with the KT-1000 arthrometer was found poor by Runer et al. [35], who stated that this could partially be explained by differences in the force that the assessors applied. The meta-analysis conducted on PROMs showed that ALDs did not improve the PROMs compared to the FLDs when using either the IKDC or the Lysholm score. The GRADE assessment graded the result as a “very low” quality of evidence due to study design and serious risk of bias in the confounding and measurement of outcome domains. Since PROMs are subjective, the measures are considered to run a high risk of bias by the ROBINS-I tool.

To the authors’ knowledge, this review is the first to provide a schematic overview and to update the knowledge on the differences in revision rates between ALDs and FLDs from the latest research. Also, this review is the first to provide a thorough bias assessment with the ROBINS-I [40] bias assessment tool, specifically developed to assess bias in non-randomized studies. Furthermore, this systematic review provides a detailed meta-analyses of knee laxity and PROMs and is the first to evaluate these results using the recognized GRADE approach [17].

The primary aim of this systematic review was to use a meta-analysis to evaluate the risk of revision surgery between ALDs and FLDs. However, this was not possible due to the low number of studies evaluating revision surgery rates and high heterogeneity between the studies. Furthermore, none of the studies presented a sample size calculation based on detecting a difference in revision rates, which raises concerns about the statistical power of these studies. Studies with a powered sample size and a longer follow-up period would contribute to existing research. Another limitation is that all studies included in this systematic review and meta-analysis were cohort studies, thereby impacting the quality of evidence evaluated by GRADE. Following the GRADE approach, it is recommended to grade observational studies as “low” because of their limitations compared to randomised controlled trials.

Despite the low quality of evidence, the results of this systematic review and meta-analysis are in accordance with the findings of previous systematic reviews [30, 37]. Biomechanical studies have previously raised concerns about the use of ALDs due to elongation. However, based on the results from this systematic review and meta-analysis, ALD usage as femoral fixation during ACL reconstruction is not associated with greater knee laxity and higher revision rates than FLD usage.

This systematic review and meta-analysis provide clinicians with a detailed and schematic summary on clinical outcomes between ALDs and FLDs. Furthermore, it indicates that further research on revision rates of better quality could benefit the existing knowledge.

Conclusion

This systematic review found that there was no difference in revision rates between ALDs and FLDs in either of the included studies. Furthermore, the meta-analysis showed no differences regarding knee laxity and PROMs. These data suggest that both types of loop devices are safe to use in ACLR, supporting the existing research. However, the available clinical studies’ quality is low and shows serious bias risk.

Change history

Abbreviations

ACLR:

Anterior cruciate ligament reconstruction

ALD:

Adjustable-loop device

FLD:

Fixed-loop device

PROM:

Patient-reported outcome measures

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-analyses

PICOS:

Population, Intervention, Comparison, and Study

SSD:

Side-to-side difference

IKDC:

International Knee Documentation Committee

ROBINS-I:

Risk of Bias In Non-Randomised Studies – of Interventions

GRADE:

Grading of Recommendations Assessment, Development, and Evaluation

CI:

Confidence interval

OR:

Odds ratio

MD:

Mean difference

References

  1. Ahn HW, Seon JK, Song EK, Park CJ, Lim HA (2019) Comparison of Clinical and Radiologic Outcomes and Second-Look Arthroscopic Findings After Anterior Cruciate Ligament Reconstruction Using Fixed and Adjustable Loop Cortical Suspension Devices. Arthroscopy 35:1736–1742

    Article  PubMed  Google Scholar 

  2. Ahn JH, Ko TS, Lee YS, Jeong HJ, Park JK (2018) Magnetic Resonance Imaging and Clinical Results of Outside-in Anterior Cruciate Ligament Reconstruction: A Comparison of Fixed- and Adjustable-Length Loop Cortical Fixation. Clin Orthop Surg 10:157–166

    Article  PubMed  PubMed Central  Google Scholar 

  3. Ahn JH, Ko TS, Lee YS, Jeong HJ, Park JK (2018) Magnetic resonance imaging and clinical results of outside-in anterior cruciate ligament reconstruction: A comparison of fixed-and adjustable-length loop cortical fixation. CiOS Clinics in Orthopedic Surgery 10:157–166

    Article  PubMed  Google Scholar 

  4. Asmussen CAP, Attrup ML, Thorborg K, Hölmich P (2018) Passive Knee Stability After Anterior Cruciate Ligament Reconstruction Using the Endobutton or ToggleLoc With ZipLoop as a Femoral Fixation Device: A Comparison of 1654 Patients From the Danish Knee Ligament Reconstruction Registry. Orthop J Sports Med 6:2325967118778507

    Article  PubMed  PubMed Central  Google Scholar 

  5. Boyle MJ, Vovos TJ, Walker CG, Stabile KJ, Roth JM, Garrett WE Jr (2015) Does adjustable-loop femoral cortical suspension loosen after anterior cruciate ligament reconstruction? A retrospective comparative study. Knee 22:304–308

    Article  PubMed  Google Scholar 

  6. Briggs KK, Lysholm J, Tegner Y, Rodkey WG, Kocher MS, Steadman JR (2009) The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med 37:890–897

    Article  PubMed  Google Scholar 

  7. Chang MJ, Bae TS, Moon YW, Ahn JH, Wang JH (2018) A Comparative Biomechanical Study of Femoral Cortical Suspension Devices for Soft-Tissue Anterior Cruciate Ligament Reconstruction: Adjustable-Length Loop Versus Fixed-Length Loop. Arthroscopy 34:566–572

    Article  PubMed  Google Scholar 

  8. Cheng J, Paluvadi SV, Lee SJ, Yoo SJ, Song EK, Seon JK (2018) Biomechanical comparisons of current suspensory fixation devices for anterior cruciate ligament reconstruction. Int Orthop 42:1291–1296

    Article  Google Scholar 

  9. Choi NH, Yang BS, Victoroff BN (2017) Clinical and Radiological Outcomes After Hamstring Anterior Cruciate Ligament Reconstructions: Comparison Between Fixed-Loop and Adjustable-Loop Cortical Suspension Devices. Am J Sports Med 45:826–831

    Article  PubMed  Google Scholar 

  10. da Costa Santos CM, de Mattos Pimenta CA, Nobre MR (2007) The PICO strategy for the research question construction and evidence search. Rev Lat Am Enfermagem 15:508–511

    Article  PubMed  Google Scholar 

  11. Djordjević D, Petrović M, Žunčić SD, Stojiljković P, Golubović I, Kadija M et al (2021) Application of two types of suspensory fixation in reconstruction of anterior cruciate ligament with a semitendinosus-gracilis graft – A randomized prospective study. Vojnosanit Pregl 78:1053–1059

    Article  Google Scholar 

  12. Eslami S, Mousavi SH, Ghadimi K (2019) Comparing outcomes of reconstruction of anterior cruciate ligament rupture with fixed loop and adjustable loop. Tehran Univ Med J 77:548–552

    Google Scholar 

  13. Eysturoy NH, Nissen KA, Nielsen T, Lind M (2018) The Influence of Graft Fixation Methods on Revision Rates After Primary Anterior Cruciate Ligament Reconstruction. Am J Sports Med 46:524–530

    Article  PubMed  Google Scholar 

  14. Firat A, Catma F, Tunc B, Hacihafizoglu C, Altay M, Bozkurt M et al (2014) The attic of the femoral tunnel in anterior cruciate ligament reconstruction: a comparison of outcomes of two suspensory femoral fixation systems. Knee Surg Sports Traumatol Arthrosc 22:1097–1105

    Article  PubMed  Google Scholar 

  15. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA (2016) Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med 50:804–808

    Article  PubMed  Google Scholar 

  16. Group TM (2014) Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the Multicenter ACL Revision Study (MARS) Cohort. Am J Sports Med 42:2301–2310

    Article  Google Scholar 

  17. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J et al (2011) GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 64:383–394

    Article  PubMed  Google Scholar 

  18. Hadley CJ, Rao S, Tjoumakaris FP, Ciccotti MG, Dodson CC, Marchetto PA et al (2022) Safer Return to Play After Anterior Cruciate Ligament Reconstruction: Evaluation of a Return-to-Play Checklist. Orthop J Sports Med 10:23259671221090412

    Article  PubMed  PubMed Central  Google Scholar 

  19. Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. Bmj 327:557–560

    Article  PubMed  PubMed Central  Google Scholar 

  20. Ibrahim MF, Md Yusof BA, Mat Dom F (2017) Fixed loop versus adjustable loop fixation in ACL reconstruction: Functional outcome. Malaysian Orthopaedic J 11

  21. Irrgang JJ, Ho H, Harner CD, Fu FH (1998) Use of the International Knee Documentation Committee guidelines to assess outcome following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 6:107–114

    Article  CAS  PubMed  Google Scholar 

  22. Kaeding CC, Pedroza AD, Reinke EK, Huston LJ, Spindler KP (2015) Risk Factors and Predictors of Subsequent ACL Injury in Either Knee After ACL Reconstruction: Prospective Analysis of 2488 Primary ACL Reconstructions From the MOON Cohort. Am J Sports Med 43:1583–1590

    Article  PubMed  PubMed Central  Google Scholar 

  23. Kamitani A, Hara K, Arai Y, Atsumi S, Takahashi T, Nakagawa S et al (2021) Adjustable-Loop Devices Promote Graft Revascularization in the Femoral Tunnel After ACL Reconstruction: Comparison With Fixed-Loop Devices Using Magnetic Resonance Angiography. Orthop J Sports Med 9:2325967121992134

    Article  PubMed  PubMed Central  Google Scholar 

  24. Kievit AJ, Jonkers FJ, Barentsz JH, Blankevoort L (2013) A cross-sectional study comparing the rates of osteoarthritis, laxity, and quality of life in primary and revision anterior cruciate ligament reconstructions. Arthroscopy 29:898–905

    Article  PubMed  Google Scholar 

  25. Lanzetti RM, Monaco E, De Carli A, Grasso A, Ciompi A, Sigillo R et al (2016) Can an adjustable-loop length suspensory fixation device reduce femoral tunnel enlargement in anterior cruciate ligament reconstruction? A prospective computer tomography study. Knee 23:837–841

    Article  CAS  PubMed  Google Scholar 

  26. Lind M, Menhert F, Pedersen AB (2012) Incidence and outcome after revision anterior cruciate ligament reconstruction: results from the Danish registry for knee ligament reconstructions. Am J Sports Med 40:1551–1557

    Article  PubMed  Google Scholar 

  27. Mayr R, Smekal V, Koidl C, Coppola C, Eichinger M, Rudisch A et al (2020) ACL reconstruction with adjustable-length loop cortical button fixation results in less tibial tunnel widening compared with interference screw fixation. Knee Surg Sports Traumatol Arthrosc 28:1036–1044

    Article  PubMed  Google Scholar 

  28. Mohamed R, El-Din El-Shafie MH, El-Sheikh MA (2020) Clinical Outcome of Fixed Versus Adjustable Loop Cortical Suspension Devices in Arthroscopic Anterior Cruciate Ligament Reconstruction. Ortop Traumatol Rehabil 22:181–185

    Article  PubMed  Google Scholar 

  29. Nye DD, Mitchell WR, Liu W, Ostrander RV (2017) Biomechanical Comparison of Fixed-Loop and Adjustable-Loop Cortical Suspensory Devices for Metaphyseal Femoral-Sided Soft Tissue Graft Fixation in Anatomic Anterior Cruciate Ligament Reconstruction Using a Porcine Model. Arthroscopy 33:1225-1232.e1221

    Article  PubMed  Google Scholar 

  30. Onggo JR, Nambiar M, Pai V (2019) Fixed- Versus Adjustable-Loop Devices for Femoral Fixation in Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy 35:2484–2498

    Article  PubMed  Google Scholar 

  31. Ono Y, Sato Y, Mukai H, Enomoto T, Kimura S, Nakagawa R et al (2021) Randomized comparative study of suspension femoral fixation device in graft position maintenance in anterior cruciate ligament reconstruction: EndoButton CL vs TightRope RT. Asia Pac J Sports Med Arthrosc Rehabil Technol 25:42–46

    PubMed  PubMed Central  Google Scholar 

  32. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71

    Article  PubMed  PubMed Central  Google Scholar 

  33. Pokharel B, Bhalodia M, Raut A, Gajjar S (2018) Comparative study on fixed versus adjustable-length loop device for femoral fixation of graft in anterior cruciate ligament reconstruction. Int J Orthopaedics Sci 4:889–892

    Article  Google Scholar 

  34. Ranjan R, Gaba S, Goel L, Asif N, Kalra M, Kumar R et al (2018) In vivo comparison of a fixed loop (EndoButton CL) with an adjustable loop (TightRope RT) device for femoral fixation of the graft in ACL reconstruction: A prospective randomized study and a literature review. J Orthop Surg (Hong Kong) 26:2309499018799787

    Article  PubMed  Google Scholar 

  35. Runer A, Roberti di Sarsina T, Starke V, Iltchev A, Felmet G, Braun S et al (2021) The evaluation of Rolimeter, KLT, KiRA and KT-1000 arthrometer in healthy individuals shows acceptable intra-rater but poor inter-rater reliability in the measurement of anterior tibial knee translation. Knee Surg Sports Traumatol Arthrosc 29:2717–2726

    Article  PubMed  PubMed Central  Google Scholar 

  36. Sheth H, Salunke AA, Barve R, Nirkhe R (2019) Arthroscopic ACL reconstruction using fixed suspensory device versus adjustable suspensory device for femoral side graft fixation: What are the outcomes? J Clin Orthop Trauma 10:138–142

    Article  PubMed  Google Scholar 

  37. Singh S, Shaunak S, Shaw SCK, Anderson JL, Mandalia V (2020) Adjustable Loop Femoral Cortical Suspension Devices for Anterior Cruciate Ligament Reconstruction: A Systematic Review. Indian J Orthop 54:426–443

    Article  PubMed  PubMed Central  Google Scholar 

  38. Smith PA, Piepenbrink M, Smith SK, Bachmaier S, Bedi A, Wijdicks CA (2018) Adjustable- Versus Fixed-Loop Devices for Femoral Fixation in ACL Reconstruction: An In Vitro Full-Construct Biomechanical Study of Surgical Technique-Based Tibial Fixation and Graft Preparation. Orthop J Sports Med 6:2325967118768743

    Article  PubMed  PubMed Central  Google Scholar 

  39. Sonnery-Cottet B, Rezende FC, Martins Neto A, Fayard JM, Thaunat M, Kader DF (2014) Arthroscopically confirmed femoral button deployment. Arthrosc Tech 3:e309-312

    Article  PubMed  PubMed Central  Google Scholar 

  40. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M et al (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 355:i4919

    Article  PubMed  PubMed Central  Google Scholar 

  41. Sundararajan SR, Sambandam B, Singh A, Rajagopalakrishnan R, Rajasekaran S (2018) Does Second-Generation Suspensory Implant Negate Tunnel Widening of First-Generation Implant Following Anterior Cruciate Ligament Reconstruction? Knee Surg Relat Res 30:341–347

    Article  PubMed  PubMed Central  Google Scholar 

  42. Svantesson E, Hamrin Senorski E, Kristiansson F, Alentorn-Geli E, Westin O, Samuelsson K (2020) Comparison of concomitant injuries and patient-reported outcome in patients that have undergone both primary and revision ACL reconstruction-a national registry study. J Orthop Surg Res 15:9

    Article  PubMed  PubMed Central  Google Scholar 

  43. Uribe-Echevarria B, Magnuson JA, Amendola A, Bollier MJ, Wolf BR, Hettrich CM (2020) Anterior Cruciate Ligament Reconstruction: A Comparative Clinical Study Between Adjustable and Fixed Length Suspension Devices. Iowa Orthop J 40:121–127

    PubMed  PubMed Central  Google Scholar 

  44. Wise BT, Patel NN, Wier G, Labib SA (2017) Outcomes of ACL Reconstruction With Fixed Versus Variable Loop Button Fixation. Orthopedics 40:e275–e280

    Article  PubMed  Google Scholar 

  45. Yavari P, Mohammadsharifi G, Fadaei B, Talebi S, Akbari M (2020) A survey on prognosis of anterior cruciate ligament (ACL) reconstruction surgeries following fixed loop and adjustable loop methods. Int J Physiol Pathophysiol Pharmacol 12:173–177

    PubMed  PubMed Central  Google Scholar 

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  1. Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark

    Simone Birkebæk Elmholt, Torsten Grønbech Nielsen & Martin Lind

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  1. Simone Birkebæk Elmholt
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  2. Torsten Grønbech Nielsen
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  3. Martin Lind
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SE: Project design and planning, literature search, literature selection, data extraction, bias and grade assessment, data analyses and interpretation, manuscript writing. TN: Literature selection, data extraction, data interpretation, manuscript revision. ML: Project design and planning, data interpretation, manuscript revision. The author(s) read and approved the final manuscript.

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Elmholt, S.B., Nielsen, T.G. & Lind, M. Fixed-loop vs. adjustable-loop cortical button devices for femoral fixation in ACL reconstruction – a systematic review and meta-analysis. J EXP ORTOP 9, 106 (2022). https://doi.org/10.1186/s40634-022-00544-1

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