Fixed-loop and adjustable-loop femoral fixation provide comparable outcomes after anterior cruciate ligament reconstruction: A meta-analysis of comparative studies

Purpose: To compare clinical outcomes, knee stability, and complications between fixed-loop and adjustable-loop femoral suspensory fixation in anterior cruciate ligament (ACL) reconstruction. Methods: A systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Comparative studies evaluating adjustable- versus fixed-loop femoral fixation in patients undergoing ACL reconstruction were included. Random-effects meta-analyses were performed. Primary outcomes were the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner Activity Scale, KT-1000 arthrometer measurements, and Lachman and pivot-shift test grades. Secondary outcomes included graft failure and reoperation rates. Results: Twenty-two comparative studies including 16,105 patients (3938 adjustable-loop and 12,167 fixed-loop) were analysed. No significant differences were observed in age or follow up. Patient-reported outcomes were comparable, including Tegner (5.7 vs. 5.8; P = 0.828), Lysholm (91.6 vs. 91.5; P = 0.918), and IKDC scores (85.7 vs. 86.2; P = 0.786). KT-1000 measurements were similar (1.7 vs. 1.6 mm; P = 0.894). Adjustable-loop fixation showed a higher proportion of grade 0 Lachman examinations (72.7% vs. 65.0%; P = 0.026), whereas grade 1 laxity was more frequent with fixed-loop fixation (31.1% vs. 24.4%; P = 0.043). Pivot-shift grades, graft failure, and reoperation rates were comparable. Conclusions: Adjustable-loop and fixed-loop femoral fixation provide comparable clinical, functional, and stability outcomes following ACL reconstruction. Although adjustable-loop fixation was associated with more grade 0 Lachman examinations, this did not translate into differences in objective stability or patient-reported outcomes. Fixation choice should be guided by surgical considerations rather than expectations of superior outcomes.