The effect of additional staple in the tibial fixation of anterior cruciate ligament reconstruction: a biomechanical study in sheep tibia

Year 2022, Volume: 8 Issue: 3, 326 - 332, 04.05.2022

Onur Oto , Hasan Bombacı , Ergun Bozdağ Sema Ertan Birsel Dilara Bayır Rıdvan Mete Oral

https://doi.org/10.18621/eurj.904343

Abstract

Objectives: The aim of this study was to evaluate the necessity of staple use and the importance of screw diameter in the anterior cruciate ligament (ACL) reconstruction.

Methods: Twenty-eight sheep hind legs were divided into four groups in terms of tibial side fixation type as 7 mm bioabsorbable screw (Group 1), 7 mm bioabsorbable screw and staple (Group 2), 8 mm screw (Group 3), and 8 mm screw and staple (Group 4). The maximum force causing insufficiency in the graft, and the fixation strength between the groups were recorded. The results were compared among the groups.

Results: As a result of the statistical analysis regarding the necessity of using staple, group 2, with 7 mm screws and staple, was found to be significantly more resistant than group 1 (p = 0.018). In consequence of the biostatistics study, staple use was found not to create a statistically significant difference between group 3 in which an 8 mm bioabsorbable screw was used and group 4 (p = 0.805). In the statistical study to understand the significance of screw diameter, the samples of group 1 and group 3, in which no staple was used, were compared. It was found that group 3 samples with 8 mm screws had higher strength than those with 7 mm screws (p = 0.011). Between group 2 and group 4 in which a staple was used, despite the increase in screw diameter, the value of maximum strength had no remarkable difference statistically (p = 1.00).

Conclusions: Fixation strength is higher when fixation was done with a screw 1 mm larger than tibial tunnel diameter. However, using either a screw with 1 mm wider than tibial tunnel diameter and the screw in the same diameter with the tibial tunnel and additional staple have similar fixation strength on the tibial side. Therefore, we conclude that screw width is more important in maintaining stability of the graft fixation.

Keywords

ACL reconstruction, tibial fixation, staple, biomechanics, screw

References

• 1. Fabbriciani C, Mulas PD, Ziranu F, Deriu L, Zarelli D, Millano G. Mechanical analysis of fixation methods for anterior cruciate ligament reconstruction with a hamstring tendon graft. An experimental study in sheep knees. Knee 2005;12:135-8.
• 2. Lee JJ, Otarodifard K, Jun BJ, McGarry MH, Hatch GF, Lee TQ. Is supplementary fixation necessary in anterior cruciate ligament reconstructions? Am J Sports Med 2011;39:360-5.
• 3. Patkowski M, Królikowska A, Reichert P. Comparison of bioabsorbable interference screws composed of poly-l-lactic acid and hydroxyapatite (PLLA-HA) to WasherLoc tibial fixation in patients after anterior cruciate ligament reconstruction of the knee joint. Polim Med 2016;46:53-8.
• 4. Sun T, Zhang H. Biomechanical comparison of a novel tibial fixation technique versus interference screw fixation for ACL reconstruction using soft tissue grafts. Orthop J Sports Med 2021;9:23259671211028559.
• 5. Brand J Jr, Weiler A, Caborn DN. Graft Fixation in cruciate ligament reconstruction. Am J Sports Med 2000;28:761-74.
• 6. Micucci CJ, Frank DA, Kompel J, Muffly M, Demeo PJ, Altman GT. The effect of interference screw diameter on fixation of soft-tissue grafts in anterior cruciate ligament reconstruction. Arthroscopy 2010;26:1105-10.
• 7. Siebold R, Dejour D, Zaffagnini S. Anterior Cruciate Ligament Reconstruction. A Practical Surgical Guide. Heidelberg: Springer, 2014.
• 8. Herrera A, Martinez F, Iglesias D, Cegonino J, Ibarz E, Gracia L. Fixation strength of biocomposite wedge interference screw in ACL reconstruction: effect of screw length and tunnel/ screw ratio. A controlled laboratory study. BMC Musculoskelet Disord 2010; 11:139.
• 9. Suk N, Heywood CS, Bravman JT, Ieyasa K, Kummer FJ, Meislin RJ. The effect of interference screw diameter on soft tissue graft fixation. Bull NYU Hosp Jt Dis 2006;63:153-5.
• 10. Morris MW, Williams JL, Thake AJ, Lang Y, Brown JN. Optimal screw diameter for interference fixation in a bone tunnel: a porcine model. Knee Surg Sports Traumatol Arthrosc 2004;12:486-9.
• 11. Simonian PT, Wickiewicz TL, O’Brien SJ, Dines JS, Schatz JA, Warren RF. Pretibial cyst formation after anterior cruciate ligament surgery with soft tissue autografts. Arthroscopy 1998;14:215-20.
• 12. Hunt P, Scheffler SU, Unterhauser FN, Weiler A. A model of soft-tissue graft anterior cruciate ligament reconstruction in sheep. Arch Orthop Trauma Surg 2005;125:238-48.
• 13. Steiner ME, Hecker AT, Brown CH Jr, Hayes WC. Anterior cruciate ligament graft fixation: comparison of hamstring and patellar tendon grafts. Am J Sports Med 1994;22:240-6.
• 14. Kurosaka M, Yoshiya S, Andrish JT. A biomechanical comparison of different surgical techniques of graft fixation in anterior cruciate ligament reconstruction. Am J Sports Med 1987;15:225-9.
• 15. Gerich TG, Cassim A, Lattermann C, Lobenhoffer HP. Pullout strength of tibial graft fixation in anterior cruciate ligament replacement with a patellar tendon graft: interference screw versus staple fixation in human knees. Knee Surg Sports Traumatol Arthrosc 1997;5:84-8.
• 16. Bauer LAR, Alberti HAA, Corotti VGP, Franco APGO, Stieven FE, Cunha LAMD. Biomechanical analysis of a double fixation method for tendon graft in porcine tibia using an interference screw plus staple. Rev Bras Ortop 2018;53:564-9.
• 17. Hill PF, Russell VJ, Salmon LJ, Pinczewski LA. The influence of supplementary tibial fixation on laxity measurements after anterior cruciate ligament reconstruction with hamstring tendons in female patients. Am J Sports Med 2005;33:94-101.
• 18. Prado M, Martín-Castilla B, Espejo Reina A, Serrano-Fernández JM, Pérez-Blanca A, Ezquerro F. Close-looped graft suturing improves mechanical properties of interference screw fixation in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2013; 21:476-84.
• 19. Teo W, Yeoh C, Wee T. Tibial fixation in anterior cruciate ligament reconstruction. J Orthop Surg (Hong Kong) 2017;25: 2309499017699743.
• 20. Graf-Alexiou L, Karpyshyn J, Baptiste JJ, Hui C, Sommerfeldt M, Westover L. Biomechanical strength of all-inside ACL reconstruction grafts using side-to-side and backup fixation. Orthop J Sports Med 2021;9:23259671211006521.
• 21. Bowes J, Mohamed N, Baptiste JJ, Westover L, Hui C, Sommerfeldt M. Biomechanical comparison of graft preparation techniques for all-inside anterior cruciate ligament reconstruction. Orthop J Sports Med 2020;8:2325967120938039.
• 22. Martini L, Fini M, Giavaresi G, Giardino R. Sheep model in orthopedic research: a literature review. Comp Med 2001;51:292-9.