International Orthopaedics

, Volume 42, Issue 6, pp 1291–1296 | Cite as

Biomechanical comparisons of current suspensory fixation devices for anterior cruciate ligament reconstruction

  • Jin Cheng
  • Siddhartha Venkata Paluvadi
  • SungJae Lee
  • SeungJin Yoo
  • Eun-Kyoo Song
  • Jong-Keun Seon
Original Paper



Cortical suspensory devices are routinely used for femoral side fixation of soft tissue graft in anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to evaluate the biomechanical properties of a new adjustable loop device (GraftMax®) compared with established devices (EndoButton® and TightRope®) in ACL reconstruction and to investigate whether knotting the free end of TightRope could improve biomechanical properties.


The three cortical suspensory devices (GraftMax® Button; Conmed, EndoButton® CL; Smith & Nephew, and TightRope® RT; Arthrex) were tested under cyclic load (50–250 N for 1000 cycles) and pull-to-failure conditions at 50 mm/h in a device-only setup using a tensile testing machine. The TightRope was additionally tested with its free suture ends knotted. The statistical analyses were done with one-way analysis of variance (ANOVA) and post hoc Tukey HSD tests.


There are significant differences in the load-to-failure among the devices. The EndoButton showed the highest mean failure load at 1204.7 N compared to other devices (GraftMax (914.2 N), knotted TightRope (868.1 N) and TightRope (800.1 N) (p < 0.001). The mean total displacement after 1000 cycles was 0.76 mm, 2.11 mm, 1.56 mm and 1.38 mm for the EndoButton, GraftMax, TightRope, and knotted TightRope, respectively. The EndoButton showed significantly better properties than both the GraftMax (p = 0.000) and the TightRope (p = 0.020) but not the knotted TightRope (p = n.s.) in total displacement. However, there was no significant difference between the TightRope and GraftMax (p = n.s.).


The fixed loop (EndoButton) showed significantly better mechanical properties in failure load and displacement than TightRope or GraftMax in this biomechanical study. However, the mechanical properties of the GraftMax is comparable to the TightRope. Moreover, the knotting of TightRope improved mechanical properties in total displacement more than TightRope, but not in failure load.

Clinical relevance

The biomechanical properties of the GraftMax are comparable to the TightRope. The TightRope, when knotted, shows an improvement both in load to failure and cyclic displacement, though the differences are not significant.


ACL reconstruction Cortical suspension Cyclic loading Biomechanics Fixed loop device Adjustable loop device 



There was no funding related to this study.

Compliance with ethical standards

Conflict of interest

The authors declare that we have no potential conflict of interest.


  1. 1.
    Kilinc BE, Kara A, Oc Y, Celik H, Camur S, Bilgin E, Erten YT, Sahinkaya T, Eren OT (2016) Transtibial vs anatomical single bundle technique for anterior cruciate ligament reconstruction: a retrospective cohort study. Int J Surg 29:62–69CrossRefPubMedGoogle Scholar
  2. 2.
    Nyland J, Mattocks A, Kibbe S, Kalloub A, Greene JW, Caborn DN (2016) Anterior cruciate ligament reconstruction, rehabilitation, and return to play: 2015 update. Open Access J Sports Med 24(7):21–32CrossRefGoogle Scholar
  3. 3.
    Ahmad CS, Gardner TR, Groh M, Arnouk J, Levine WN (2004) Mechanical properties of soft tissue femoral fixation devices for anterior cruciate ligament reconstruction. Am J Sports Med 32:635–640CrossRefPubMedGoogle Scholar
  4. 4.
    Kim KI, Lee SH, Bae C, Bae SH (2017) Three-dimensional reconstruction computed tomography evaluation of the tunnel location and angle in anatomic single-bundle anterior cruciate ligament reconstruction: a comparison of the anteromedial portal and outside-in techniques. Knee Surg Relat Res 29:11–18CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Barrow AE, Pilia M, Guda T, Kadrmas WR, Burns TC (2014) Femoral suspension devices for anterior cruciate ligament reconstruction: do adjustable loops lengthen? Am J Sports Med 42:343–349CrossRefPubMedGoogle Scholar
  6. 6.
    Petre BM, Smith SD, Jansson KS et al (2013) Femoral cortical suspension devices for soft tissue anterior cruciate ligament reconstruction: a comparative biomechanical study. Am J Sports Med 41:416–422CrossRefPubMedGoogle Scholar
  7. 7.
    Johnson JS, Smith SD, LaPrade CM, Turnbull TL, LaPrade RF, Wijdicks CA (2015) A biomechanical comparison of femoral cortical suspension devices for soft tissue anterior cruciate ligament reconstruction under high loads. Am J Sports Med 43:154–160CrossRefPubMedGoogle Scholar
  8. 8.
    Gelber PE (2015) A guide to mastering the Graftmax Button adjustable cortical fixation device-An examination of surgical learnings during the first six months of clinical usage. Conmed Corporation. Accessed 22 April 2017
  9. 9.
    Born TR, Biercevicz AM, Koruprolu SC, Paller D, Spenciner D, Fadale PD (2016) Biomechanical and computed tomography analysis of adjustable femoral cortical fixation devices for anterior Cruciate ligament reconstruction in a cadaveric human knee model. Arthroscopy 32:253–261CrossRefPubMedGoogle Scholar
  10. 10.
    Eguchi A, Ochi M, Adachi N, Deie M, Nakamae A, Usman MA (2014) Mechanical properties of suspensory fixation devices for anterior cruciate ligament reconstruction: comparison of fixed-length loop device versus the adjustable-length loop device. Knee 21:743–748CrossRefPubMedGoogle Scholar
  11. 11.
    Daniel DM, Stone ML, Sachs R, Malcom L (1985) Instrumented measurement of anterior knee laxity in patients with acute anterior cruciate ligament disruption. Am J Sports Med 13:401–407CrossRefPubMedGoogle Scholar

Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  • Jin Cheng
    • 1
  • Siddhartha Venkata Paluvadi
    • 1
    • 2
  • SungJae Lee
    • 3
  • SeungJin Yoo
    • 4
  • Eun-Kyoo Song
    • 1
  • Jong-Keun Seon
    • 1
  1. 1.Center for Joint DiseasesChonnam National Univerity Bitgoeul Hospital, Chonnam National University School of MedicineJeolla-NamdoSouth Korea
  2. 2.The Department of Orthopaedic SurgeryPeoples’ College of Medical Sciences and Research CenterBhopalIndia
  3. 3.Inje UniversityBusanSouth Korea
  4. 4.I-Key Co., LtdBusanSouth Korea

Personalised recommendations