Impact of tibial supplementary fixation in anterior cruciate ligament reconstruction for soft tissue auto and allografts: Modest enhancement in stability and increased incidence of pain: A systematic review and meta-analysis.

Purpose: To evaluate whether the joint function, stability and safety of tibial supplementary fixation in anterior cruciate ligament reconstruction is superior compared with tibial screw fixation alone. Methods: PubMed, Cochrane Library, EMBASE and Web of Science were searched, tracking until 12 April 2025. Eligible studies included published randomized controlled trials (RCTs) and low-risk cohort studies comparing clinical outcomes and complications between tibial screw interference with supplementary fixation (Group I) and tibial screw interference alone or with a sheath (Group II). RCTs were assessed using the Cochrane Risk of Bias tool, while cohort studies were evaluated with the Newcastle-Ottawa Scale and Methodological index for non-randomized studies. Model selection (random or fixed-effects) was based on data heterogeneity. Results: This meta-analysis included eight studies with 943 patients (Group I: 386, Group II: 557). Group I showed no significant differences in side-to-side difference (SSD) in the sheath subgroup at 24 months, SSD <3 mm at 9.1 kg at 12 and 24 months, or manual maximum testing at 24 months, Pivot test at 8-12 and 24 months, Lachman test at 8-12 months, International Knee Documentation Committee objective and subjective score at 24 months compared to Group II. Group I demonstrated statistically significant reductions in SSD (mean difference: -1.02; 95% CI: -1.79 to -0.25; Conclusion: Enhanced supplementary tibial fixation with soft tissue autografts and allografts offers similar joint function and a modest enhancement of stability compared to tibial interference screw fixation alone, but is associated with a higher incidence of pain. Level of Evidence: Level III, retrospective cohort studies have been analysed, alongside RCTs, and thus this is the level of evidence.