Functional outcomes after anterior cruciate ligament reconstruction using adjustable femoral cortical suspensory fixation device: Systemic review and Meta analysis

: Introduction: The anterior cruciate ligament (ACL) injury is considered the most common ligamentous injury in the knee, and its reconstruction is essential for overall knee stability. Adequate graft fixation is essential to facilitate a rehabilitation program that strives for early restoration of knee mobility & strength after ACL reconstruction (ACLR) with all soft tissue grafts. Aim of the study: This research evaluates the functional outcomes of ACLR performed using an adjustable femoral cortical suspensory fixation device. Methods: To find publications contrasting full tibial tunnel ACLR with an all-inside technique employing an adjustable femoral cortical suspensory fixation device, we searched PubMed, Embase, and Cochrane. Eligibility, data extraction, and risk of bias were all performed on potentially relevant papers by two reviewers who were blind to each other's work. Random effects with mean variations as well as risk ratios for continuous, in addition to dichotomous factors, were aggregated for the clinical outcome along with graft ruptures. Results: The meta-analysis includes 10 research studies with a total of 613 individuals. Participants who underwent all-inside ACLR with an adjustable femoral cortical suspensory fixation device or full tibial tunnel ACLR had similar functional outcomes, knee laxity as determined by the arthrometer, and graft rupture rates. Conclusions: Based on this systematic review, we can conclude that using the adjustable suspensory fixation device for ACLR produces favorable functional outcomes as regards knee stability and mobility.


Introduction
A stable graft fixation is essential for a rehabilitation program that aims for early restoration of knee mobility as well as strength after ACLR with all soft tissue grafts.The goal of this reconstruction is to help the patient return to normal knee motion and stability as soon as possible.Throughout the past few years, the employment of suspensory fixation as an alternative to interference screws has become an increasingly appealing choice.This is because it has the potential to speed up tendon-to-bone healing [1,2], and it also protects the graft from harm caused by the insertion of screws [3,4].tensioned, there will be a cavity above the graft since the femoral socket was drilled 6-8 mm longer than necessary to allow for the "flip" movement of the button.This method could potentially contribute to the so-called "bungee cord effect" as well as the windshield wiper effect, which would result in an increased likelihood of tunnel widening (TW) [11].
The second generation of suspensory devices is known as an adjustable-loop device

2.1.Literature search
The results of the online search came to a total of 2937 references.Following the removal of 837 duplicates, the screening of titles and abstracts continued with 2100 records.We had a total of 30 suitable articles for full-text screening, but only 10 of them met the requirements to be included, while the remaining 20 were disqualified.There were no additional articles imported as a result of the manual search of references.In the end, a total of 10 studies were incorporated into the qualitative analysis.

2.2.Study characteristics
Details for the involved studies are summarized in Table 1.

Exclusion criteria
Articles that were originally published in languages other than English.Evaluations, guiding principles, categorizations, case reports, briefcase series, or conference papers are all excluded.

2.4.Statistical analysis
Using the mean & standard deviation, we aggregated data on continuous outcomes.
When just a range was given, the expected standard deviation was determined by using range/4 for small to medium-sized samples (15-70 n) and range/6 for large samples (n > 70).
The extracted results were merged, and the chi-

Results
The meta-analysis results are shown in Table 2.

Discussion
The initial mechanical qualities of the graft, the position of the femoral as well as tibial tunnel, the fixation method, and the postoperative rehabilitation all have a role in whether or not ACLR is successful [26,27].The stability of the knee joint depends on several factors, not the least of which is the graft's initial fixation as well as subsequent absorption into the tunnels.Because of its ease of use, dependability, and superior tensile strength, cortical suspensory fixation using titanium button devices has become increasingly used in ACLR with soft-tissue grafts [28-30] However, in anatomical ACLR using the anteromedial portal technique, deployment of cortical suspensory fixation devices with permanent loops like the EndoButton (EB) may be unsuccessful if the graft tunnel is too short to allow clearance of the device through the femur.
Over-drilling the tunnel, which requires precise tunnel measuring, can increase the likelihood of graft motion in the tunnel [31,32].

Conclusion
Based on this systematic review, we can conclude that using the adjustable suspensory fixation device for ACLR produces favorable functional outcomes as regards knee stability and mobility.
Funding: This study is not funded.

Conflicts of Interest:
All authors declare they have no conflicts of interest.
bone tunnel at the time of the operation.This led to larger bone tunnels after two years, as opposed to the use of extracortical fixation.Moreover, the use of interference screws led to a major early development of the bone tunnel at the time of the procedure [5, 6].This occurs when compared to extra-cortical fixation because interference screws are inserted through the bone rather than through the extra-cortical space.When utilizing interference screws for graft fixation, screw divergence is another technical concern that may contribute to a loss of pullout strength [7, 8].A fixed-loop device (FLD) was used to secure the graft to a metallic button in the initial generation of suspensory devices.There are some pitfalls associated with FLD fixation, even though it offers great stability and a high level of fixation strength [9, 10].Since the length of the loop is predetermined, FLD necessitates precise measurement throughout the tunnel construction process.After the graft has been

Table 2 :
The study outcomes.

2024, 13(1),1 -10 Abdulwahab et al., 2024 7
Hardik et al. (2017) evaluated the effectiveness of arthroscopic ACLR done with a fixed suspensory device compared to that of an adjustable suspensory device for femoral side graft attachment in a study that was prospective and included 62 patients with knees that lacked an ACL [38].Before and after surgery, the Lysholm score and the IKDC score were utilized to evaluate the functional status.Following the procedure, the Lysholm score was 94.23% in the fixed-loop group, and it was 94.32% in the adjustable-loop group.The fixedloop group and the adjustable-loop group both achieved a score of 92.03% on the IKDC, with the latter group achieving a score of 92.16%. FUMJ,