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Table 1 Included studies’ characteristics separated by theme. All the conclusions described on the table are based on a p value < 0.05

From: Tibial-graft fixation methods on anterior cruciate ligament reconstructions: a literature review

Author Study type N Results
Regarding the graft tension
 Yasuda et al. [11] (1997) Clinical trial 70 Initial relative high stress in the graft (about 80 N) decreases laxity
 Bylski-Austrow et al. [12] (1990) Experimental (biomechanical) 6 Stress magnitude is less influencing than fixation angle; there is no correct position or tension
 Gertel et al. [14] (1993) Experimental (biomechanical) 10 Graft strength and joint mobility unchanged by tension magnitude
 Sherman et al. [1] (2012) Review article 69 20–80 N of tension is recommended, depending on the graft, if flexion of 30°; 90 N of tension if in extension
 Brady et al. [15] (2006) Experimental (biomechanical) 12 Tension in extension generated greater compressive forces in the knee (90 N in extension = 3.5 x normal)
 Austin et al. [16] (2007) Experimental (biomechanical) 10 Graft tension did not change knee extension
 Kim et al. [17] (2018) Clinical trial 60 It is most appropriate to maintain a 20 -lb. (90 N) tension for graft fixation
 Noyes et al. [18] (2019) Experimental (biomechanical)   Current tensioning protocols are insufficient; suggests 40 flexion-extension cycles at 90 N for proper graft conditioning
Regarding the knee-flexion angle when fixing the graft
 Debandi et al. [5] (2016) Experimental (biomechanical) 12 Anatomical reconstruction with fixation at 30° of knee flexion was superior (rotational stability)
 Bylski-Austrow et al. [12] (1990) Experimental (biomechanical) 6 Tension at 30° leads to greater stress in the graft than in extension; there is no correct position or tension
 Gertel et al. [14] (1993) Experimental (biomechanical) 10 Graft stress can be avoided with tensioning in extension
 Brady et al. [15] (2006) Experimental (biomechanical) 12 Stresses (15 N) applied at 20° of flexion or extension minimized rotational and axial forces on the knee; tension (90 N) in extension led to greater compressive forces
 Austin et al. [16] (2007) Experimental (biomechanical) 10 Knee flexion at 30° is associated with loss of extension
 Mae et al. [19] (2008) Experimental (biomechanical) 6 Knee flexion at 20° is closely associated to a normal knee
 Kim et al. [17] (2018) Clinical trial 60 Graft length shown to be longer with knee extended and loose in flexion
 Miura et al. [20] (2006) Experimental (biomechanical) 10 Dual band fixation (anteromedial/posterolateral bundles): PM bundle overloaded when fixed at 30°/30° and AM bundle overloaded when fixed at 60°/full extension
 Höher et al. [21] (2001) Experimental (biomechanical) 10 Fixing the graft at 30° of flexion better restored in situ forces and the kinematics of the knee when compared to the extension position
 Asahina et al. [22] (1996) Clinical trial 44 Superior stability and arthroscopic appearance in the group with the graft fixed at 30 ° of flexion; greater number of extension deficits when compared to fixation in extension
Regarding the knee-implant types
 Speziali et al. [23] (2014) Systematic review 19 Clinical outcomes were good or excellent in 2/3 of patients regardless of implants
 Steiner et al. [24] (1994) Experimental (biomechanical) 36 If properly fixed, implants/tendons showed similar strength. Patellar tendon with interference screws showed increased rigidity
 Scheffler et al. [25] (2002) Experimental (biomechanical) 40 Bonding materials should be avoided. Use of bone block fixation or hybrid fixation may decrease chance of failure
 Brand et al. [26] (2000) Review article 98 Interference screws in bone-to-bone fixation seems superior; metallic and bioabsorbable screws with similar results
 Eguchi et al. [27] (2014) Experimental (biomechanical) 4 Fixed-length suspensory devices have a greater mechanical clamping force than those of an adjustable length
 Benedetto et al. [28] (2000) Clinical trial 113 Bioabsorbable polygluconate screws with similar results when compared to metallic screws
 Drogset et al. [29] (2005) Clinical trial 41 Metallic screws showed better results than bioabsorbable screws
 Arama et al. [30] (2015) Clinical trial 40 There are no clinical differences in the use of titanium screws and bioabsorbable screws with hydroxyapatite
 Ma et al. [31] Clinical trial 30 Fixation with interference screws shows no difference in outcomes when compared to suspensory fixation
 Carulli et al. [32] Clinical trial 90 Good and similar results when comparing combined fixation with interference screws/sheath versus interference screw/staple
 Weiss et al. [33] Experimental (biomechanical) 54 Hybrid fixation has biomechanical advantages over simple fixation
 Teo et al. [34] Clinical trial 64 Supplementary tibial-graft fixation did not benefit ACL reconstruction
  1. Legend: ACL anterior cruciate ligament, AM anteromedial, PM posteromedial