Clinical Results of Hamstring Autografts in Anterior Cruciate Ligament Reconstruction: A Comparison of Femoral Knot/Press-Fit Fixation and Interference Screw Fixation


      To compare the clinical outcomes of femoral knot/press-fit anterior cruciate ligament (ACL) reconstruction with conventional techniques using femoral interference screws.


      Among patients who underwent arthroscopic ACL reconstruction with hamstring autografts, 73 were treated with either a femoral knot/press-fit technique (40 patients, group A) or femoral interference screw fixation (33 patients, group B). The clinical results of the 2 groups were retrospectively compared. The inclusion criteria were primary ACL reconstruction in active patients. The exclusion criteria were fractures, multiligamentous injuries, patients undergoing revision, or patients with contralateral ACL-deficient knees. In the femoral knot/press-fit technique, semitendinosus and gracilis tendons were prepared as 2 loops with knots. After passage through a bottleneck femoral tunnel, the grafts were fixed with a press-fit method (grafts' knots were stuck in the bottleneck of the femoral tunnel). A tie with Mersilene tape (Ethicon, Somerville, NJ) over a bone bridge for each tendon loop and an additional bioabsorbable interference screw were used for tibial fixation.


      The mean follow-up period was 38 months (range, 24 to 61 months). A significant improvement in knee function and symptoms was reported in most patients, as shown by improved Tegner scores, Lysholm knee scores, and International Knee Documentation Committee assessments ( P < .01). The results of instrumented laxity testing, thigh muscle assessment, and radiologic assessment were clearly improved when compared with the preoperative status ( P < .01). No statistically significant difference in outcomes could be observed between group A and group B ( P = not significant).


      In this nonrandomized study, femoral knot/press-fit ACL reconstruction did not appear to provide increased anterior instability compared with that of conventional femoral interference screw ACL reconstruction. Favorable outcomes with regard to knee stability and patient satisfaction were achieved in most of our ACL-reconstructed patients using femoral knot/press-fit fixation with hamstring tendon autograft.

      Level of Evidence

      Level IV, therapeutic case series.


        • Duquin T.R.
        • Wind W.M.
        • Fineberg M.S.
        • Smolinski R.J.
        • Buyea C.M.
        Current trends in anterior cruciate ligament reconstruction.
        J Knee Surg. 2009; 22: 7-12
        • Maletis G.B.
        • Cameron S.L.
        • Tengan J.J.
        • Burchette R.J.
        A prospective randomized study of anterior cruciate ligament reconstruction: A comparison of patellar tendon and quadruple-strand semitendinosus/gracilis tendons fixed with bioabsorbable interference screws.
        Am J Sports Med. 2007; 35: 384-394
        • Ahn J.H.
        • Lee S.A.
        • Choi S.H.
        • et al.
        Femoral cross-pin breakage and its effects on the results of anterior cruciate ligament reconstruction using a hamstring autograft.
        Arthroscopy. 2012; 28: 1826-1832
        • Dujardin J.
        • Vandenneucker H.
        • Bellemans J.
        Tibial cyst and intra-articular granuloma formation after anterior cruciate ligament reconstruction using polylactide carbonate osteoconductive interference screws.
        Arthroscopy. 2008; 24: 238-242
        • Jayadev C.
        • Kochhar T.
        • Back D.L.
        • Ratnakumar K.
        Supracondylar femoral fracture after anterior cruciate ligament reconstruction with transfemoral fixation.
        J Knee Surg. 2009; 22: 364-366
        • Lee Y.S.
        • Ha J.K.
        • Kim Y.J.
        • Yang S.J.
        • Lee M.Y.
        • Kim J.G.
        Comparative outcome analysis of malpositioned and properly positioned fixation groups after hamstring autograft ACL reconstruction with femoral cross-pin fixation.
        Knee. 2011; 18: 30-33
        • Mae T.
        • Kuroda S.
        • Matsumoto N.
        • et al.
        Migration of EndoButton after anatomic double-bundle anterior cruciate ligament reconstruction.
        Arthroscopy. 2011; 27: 1528-1535
        • Yanmiş I.
        • Tunay S.
        • Oğuz E.
        • Yildiz C.
        • Ozkan H.
        • Kirdemir V.
        Dropping of an EndoButton into the knee joint 2 years after anterior cruciate ligament repair using proximal fixation methods.
        Arthroscopy. 2004; 20: 641-643
        • Paessler H.H.
        • Mastrokalos D.S.
        Anterior cruciate reconstruction using semitendinosus and gracilis tendons, bone patellar tendon, or quadriceps tendon-graft with press-fit fixation without hardware. A new and innovative procedure.
        Orthop Clin North Am. 2003; 34: 49-64
        • Paessler H.H.
        ACL reconstruction using a quadruple semitendinosus and gracilis tendon graft with no-hardware fixation. New techniques in knee surgery.
        Springer-Steinkopff Verlag, Darmstadt, Germany2003: 21-37
        • Kilger R.H.
        • Thomas M.
        • Hanford S.
        • Alaseirlis D.A.
        • Paessler H.H.
        • Woo S.L.
        The effectiveness of reconstruction of the anterior cruciate ligament using the novel knot/press-fit technique: A cadaveric study.
        Am J Sports Med. 2005; 33: 856-863
        • Fu F.H.
        • Harner C.D.
        • Vince K.G.
        Anderson AF Rating scales.
        in: Knee surgery. Williams & Wilkins, Baltimore, MD1994: 275-296
        • Irrgang J.J.
        • Anderson A.F.
        • Boland A.L.
        • et al.
        Development and validation of the International Knee Documentation Committee subjective knee form.
        Am J Sports Med. 2001; 29: 600-613
        • Tegner Y.
        • Lysholm J.
        Rating systems in the evaluation of knee ligament injuries.
        Clin Orthop. 1985; 198: 43-49
        • Lysholm J.
        • Gillquist J.
        Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale.
        Am J Sports Med. 1982; 10: 150-154
        • Ahlbäck S.
        Osteoarthrosis of the knee. A radiographic investigation.
        Acta Radiol Diagn. 1968; : 7-72
        • Chen C.H.
        • Liu H.W.
        • Tsai C.L.
        • Yu C.M.
        • Lin I.H.
        • Hsiue G.H.
        Photoencapsulation of bone morphogenetic protein-2 and periosteal progenitor cells improve tendon graft healing in a bone tunnel.
        Am J Sports Med. 2008; 36: 461-473
        • Chen C.H.
        Graft healing in anterior cruciate ligament reconstruction.
        Sports Med Arthrosc Rehabil Ther Technol. 2009; 1: 21
        • Hunt P.
        • Rehm O.
        • Weiler A.
        Soft tissue graft interference fit fixation: Observations on graft insertion site healing and tunnel remodeling 2 years after ACL reconstruction in sheep.
        Knee Surg Sports Traumatol Arthrosc. 2006; 14: 1245-1251
        • Weiler A.
        • Hoffmann R.F.
        • Bail H.J.
        • Rehm O.
        • Südkamp N.P.
        Tendon healing in a bone tunnel. Part II: Histologic analysis after biodegradable interference fit fixation in a model of anterior cruciate ligament reconstruction in sheep.
        Arthroscopy. 2002; 18: 124-135
        • Ahmad C.S.
        • Gardner T.R.
        • Groh M.
        • Arnouk J.
        • Levine W.N.
        Mechanical properties of soft tissue femoral fixation devices for anterior cruciate ligament reconstruction.
        Am J Sports Med. 2004; 32: 635-640
        • Hoher J.
        • Livesay G.A.
        • Ma C.B.
        • Withrow J.D.
        • Fu F.H.
        • Woo S.L.
        Hamstring graft motion in the femoral bone tunnel when using titanium button/polyester tape fixation.
        Knee Surg Sports Traumatol Arthrosc. 1999; 7: 215-219
        • Kleweno C.P.
        • Jacir A.M.
        • Gardner T.R.
        • Ahmad C.S.
        • Levine W.N.
        Biomechanical evaluation of anterior cruciate ligament femoral fixation techniques.
        Am J Sports Med. 2009; 37: 339-345
        • Kousa P.
        • Jarvinen T.L.
        • Vihavainen M.
        • Kannus P.
        • Jarvinen M.
        The fixation strength of six hamstring tendon graft fixation devices in anterior cruciate ligament reconstruction.
        Am J Sports Med. 2003; 31: 174-181
        • Milano G.
        • Mulas P.D.
        • Ziranu F.
        • Piras S.
        • Manunta A.
        • Fabbriciani C.
        Comparison between different femoral fixation devices for ACL reconstruction with doubled hamstring tendon graft: A biomechanical analysis.
        Arthroscopy. 2006; 22: 660-668
        • Baumfeld J.A.
        • Diduch D.R.
        • Rubino L.J.
        • et al.
        Tunnel widening following anterior cruciate ligament reconstruction using hamstring autograft: A comparison between double cross-pin and suspensory graft fixation.
        Knee Surg Sports Traumatol Arthrosc. 2008; 16: 1108-1113
        • Buelow J.U.
        • Siebold R.
        • Ellermann A.
        A prospective evaluation of tunnel enlargement in anterior cruciate ligament reconstruction with hamstrings: Extracortical versus anatomical fixation.
        Knee Surg Sports Traumatol Arthrosc. 2002; 10: 80-85
        • Fauno P.
        • Kaalund S.
        Tunnel widening after hamstring anterior cruciate ligament reconstruction is influenced by the type of graft fixation used: A prospective randomized study.
        Arthroscopy. 2005; 21: 1337-1341
        • Frosch S.
        • Rittstieg A.
        • Balcarek P.
        • et al.
        Bioabsorbable interference screw versus bioabsorbable cross pins: Influence of femoral graft fixation on the clinical outcome after ACL reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 2251-2256
        • Harilainen A.
        • Sandelin J.
        • Jansson K.A.
        Cross-pin femoral fixation versus metal interference screw fixation in anterior cruciate ligament reconstruction with hamstring tendons: Results of a controlled prospective randomized study with 2-year follow-up.
        Arthroscopy. 2005; 21: 25-33
        • Harilainen A.
        • Sandelin J.
        A prospective comparison of 3 hamstring ACL fixation devices—Rigidfix, BioScrew, and Intrafix—randomized into 4 groups with 2 years of follow-up.
        Am J Sports Med. 2009; 37: 699-706
        • Nebelung W.
        • Becker R.
        • Merkel M.
        • Ropke M.
        Bone tunnel enlargement after anterior cruciate ligament reconstruction with semitendinosus tendon using EndoButton fixation on the femoral side.
        Arthroscopy. 1998; 14: 810-815
        • Simonian P.T.
        • Erickson M.S.
        • Larson R.V.
        • O'Kane J.W.
        Tunnel expansion after hamstring anterior cruciate ligament reconstruction with 1-incision EndoButton femoral fixation.
        Arthroscopy. 2000; 16: 707-714
        • Chuang T.Y.
        • Ho W.P.
        • Chen C.H.
        • Shieh M.H.
        • Liau J.J.
        • Huang C.H.
        Non-hardware posterior cruciate ligament reconstruction using knot/press-fit technique with periosteum-enveloped hamstrings tendon autograft.
        Am J Sports Med. 2011; 39: 1081-1089