Intratunnel versus extratunnel autologous hamstring double-bundle graft for anterior cruciate ligament reconstruction: a comparison of 2 femoral fixation procedures

Am J Sports Med. 2015 Jan;43(1):161-8. doi: 10.1177/0363546514554189. Epub 2014 Oct 27.


Background: Anatomic double-bundle anterior cruciate ligament (ACL) reconstruction provides excellent results for restoring normal kinematics to the knee. Nevertheless, strong evidence supporting an ideal method for fixation of the ACL graft is lacking.

Hypothesis: Intratunnel femoral fixation of the ACL graft via a cross-pin fixation technique would provide better clinical and objective results than the extratunnel femoral fixation with cortical buttons.

Study design: Randomized clinical trial; Level of evidence, 2.

Methods: Seventy patients with a unilateral ACL-deficient knee were randomly assigned to 1 of 2 femoral fixation groups. Group A (35 patients) was fixed with 2 bioabsorbable Rigidfix pins, 1 cross-pin per bundle, while group B (35 patients) was secured with 1 EndoButton cortical button per bundle. All femoral tunnels were created via an anteromedial portal, and a bioabsorbable Biointrafix interference screw was used for tibial fixation for both groups. The evaluation of the patients was performed by history details, clinical examination findings, measurement of the joint laxity by KT-1000 arthrometer, and use of validated patient outcome questionnaires. Statistical analysis was carried out with Fisher exact and Mann-Whitney U tests, with P<.05 considered the cutoff level of significance.

Results: At a mean follow-up of 30 months, 34 and 32 patients of group A and B, respectively, were available for evaluation. There were no statistically significant differences between the treatment groups regarding the subjective and objective outcomes, except for KT-1000 arthrometer values. The median KT-1000 value of patients in the cross-pin fixation group was 1.30 mm, while the median value in the cortical button fixation group was 1.95 mm (P<.001). Four patients with ACL grafts that were fixed with cortical buttons demonstrated failure of stability via the instrumented knee laxity testing, while patients from the other group had no failures.

Conclusion: Intratunnel femoral fixation of the double-bundle ACL graft from the cross-pin fixation technique provided better instrumented knee laxity results than did the extratunnel femoral fixation with cortical buttons. Future larger studies comparing these 2 techniques should be conducted to ensure the availability of stronger evidence supporting the findings of this study.

Keywords: anterior cruciate ligament; arthroscopy; double bundle; knee; reconstruction.

Publication types

  • Comparative Study
  • Randomized Controlled Trial

MeSH terms

  • Absorbable Implants
  • Adult
  • Anterior Cruciate Ligament Injuries*
  • Anterior Cruciate Ligament Reconstruction / adverse effects
  • Anterior Cruciate Ligament Reconstruction / methods*
  • Arthrometry, Articular
  • Athletic Injuries / complications
  • Athletic Injuries / rehabilitation
  • Athletic Injuries / surgery*
  • Autografts
  • Bone Nails
  • Bone Screws
  • Femur / surgery
  • Humans
  • Joint Instability / etiology*
  • Knee Injuries / complications
  • Knee Injuries / rehabilitation
  • Knee Injuries / surgery*
  • Knee Joint / physiopathology
  • Knee Joint / surgery*
  • Lysholm Knee Score
  • Male
  • Muscle, Skeletal / surgery
  • Osteotomy
  • Prospective Studies
  • Surveys and Questionnaires
  • Tendons / transplantation
  • Tibia / surgery
  • Treatment Outcome
  • Young Adult