A Review of the Biomechanical and Clinical Outcomes of Tibial-Sided Fixation for Anterior Cruciate Ligament Reconstruction

» Tibial fixation remains the biomechanically weaker site in ACL reconstruction due to lower bone density and directional loading forces, making fixation choice critical for graft stability. » Interference screws provide aperture fixation close to the joint line but are limited by graft slippage, tunnel widening, and progressive loss of tension over time. » Suspensory devices engage cortical bone and reduce graft damage during insertion; when supplemented with backup fixation, such as knotless suture anchors, they demonstrate greater fixation strength and reduced graft micromotion. » Internal suture augmentation offers promising biomechanical and early clinical benefits by protecting the graft during the vulnerable early healing period, especially in young athletes and revision cases, though long-term effects remain under investigation. » Fixation strategy should be individualized, balancing graft choice, bone quality, and rehabilitation demands to optimize outcomes and reduce risk of failure.