Impact of tibial supplementary fixation in anterior cruciate ligament reconstruction for soft tissue auto and allografts: Modest enhancement in stability and increased incidence of pain: A systematic review and meta‐analysis

TL;DR

Adding extra tibial fixation in ACL surgery slightly improves knee stability but increases pain compared to standard methods.

Contribution

A systematic review and meta-analysis comparing tibial supplementary fixation with standard screw fixation in ACL reconstruction.

Findings

Supplementary fixation showed modest improvement in knee stability but no significant difference in joint function.

Patients with supplementary fixation experienced significantly higher rates of kneeling pain.

Ligament retear rates were similar between the two fixation methods.

Abstract

To evaluate whether the joint function, stability and safety of tibial supplementary fixation in anterior cruciate ligament reconstruction is superior compared with tibial screw fixation alone.

PubMed, Cochrane Library, EMBASE and Web of Science were searched, tracking until 12 April 2025. Eligible studies included published randomized controlled trials (RCTs) and low‐risk cohort studies comparing clinical outcomes and complications between tibial screw interference with supplementary fixation (Group I) and tibial screw interference alone or with a sheath (Group II). RCTs were assessed using the Cochrane Risk of Bias tool, while cohort studies were evaluated with the Newcastle–Ottawa Scale and Methodological index for non‐randomized studies. Model selection (random or fixed‐effects) was based on data heterogeneity.

This meta‐analysis included eight studies with 943 patients (Group I: 386, Group II: 557). Group I showed no significant differences in side‐to‐side difference (SSD) in the sheath subgroup at 24 months, SSD <3 mm at 9.1 kg at 12 and 24 months, or manual maximum testing at 24 months, Pivot test at 8–12 and 24 months, Lachman test at 8–12 months, International Knee Documentation Committee objective and subjective score at 24 months compared to Group II. Group I demonstrated statistically significant reductions in SSD (mean difference: −1.02; 95% CI: −1.79 to −0.25; p = 0.009) in the no‐sheath subgroup and lower Lachman test positivity (odds ratio [OR] = 0.30; 95% confidence interval [CI]: 0.13–0.71; p = 0.01) at 24 months. Ligament retear rates were similar; however, Group I experienced a substantially higher incidence of kneeling pain (OR = 6.28; 95% CI: 1.86–2.25; p < 0.01), an outcome that could adversely affect patient comfort and long‐term functional recovery.

Enhanced supplementary tibial fixation with soft tissue autografts and allografts offers similar joint function and a modest enhancement of stability compared to tibial interference screw fixation alone, but is associated with a higher incidence of pain.

Level III, retrospective cohort studies have been analysed, alongside RCTs, and thus this is the level of evidence.

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