Intra-tunnel fixation versus extra-tunnel fixation of hamstring anterior cruciate ligament reconstruction: a meta-analysis.

Hamstring anterior cruciate ligament (ACL) reconstructions fixed inside both bone tunnels have a shorter initial working length, and thus should be stiffer than those fixed outside both bone tunnels. We used meta-analysis to compare 4-stranded hamstring ACL reconstructions using the 2 fixation methods with reconstructions using patellar tendon autografts. A Medline database search of English-language articles published through June 2004 yielded 36 studies that met the inclusion criteria: 5 intratunnel fixation studies (569 patients), 10 extra-tunnel fixation studies (604 patients), and 24 patellar tendon studies (1592 patients). Three studies included both patellar tendon and hamstring reconstructions. Demographically, all 3 groups were similar. There was no significant difference in the percentage of knees restored to normal instrumented laxity measurements between the 3 groups, nor was there a difference in graft failure rate. Patient satisfaction and return to preinjury activity rates were similar between the intratunnel fixation and patellar tendon groups and were significantly lower for the extra-tunnel fixation group. Good International Knee Documentation Committee scores did not correlate with good patient satisfaction or return to preinjury activity.