Current Concepts Graft Fixation in Cruciate Ligament Reconstruction

Cruciate ligament reconstruction has progressed dramatically in the last 20 years. Anatomic placement of ligament substitutes has fostered rehabilitation efforts that stress immediate and full range of motion, immediate weightbearing, neuromuscular strength and coordination, and early return to athletic competition (3 months). This has placed extreme importance on secure graft fixation at the time of ligament reconstruction. Current ligament substitutes require a bony or soft tissue component to be fixed within a bone tunnel or on the periosteum at a distance from the normal ligament attachment site. Fixation devices have progressed from metal to biodegradable and from far to nearnormal native ligament attachment sites. Ideally, the biomechanical properties of the entire graft construct would approach those of the native ligament and facilitate biologic incorporation of the graft. Fixation should be done at the normal anatomic attachment site of the native ligament (aperture fixation) and, over time, allow the biologic return of the histologic transition zone from ligament to fibrocartilage, to calcified fibrocartilage, to bone. The purpose of this article is to review current fixation devices and techniques in cruciate ligament surgery. The importance of secure graft fixation in ligament reconstruction has changed dramatically in the last 20 years.Current rehabilitation protocols after knee ligament surgery stress immediate full range of motion, return of neuromuscular function, proprioception, and early weightbearing forces up the kinetic chain. In the early postoperative period, graft fixation is the weak link within the entire system. No commonly used graft fixation has ultimate failure strength or stiffness comparable with the native cruciate ligament (Table 1). Fixation methods must be rigid and stiff to allow current rehabilitation principles. Current fixation techniques involve soft tissue and bone within a bone tunnel or periosteal fixation away from joint