Biomechanical Comparison Between Bashti Bone Plug Technique and Biodegradable Screw for Fixation of Grafts in Ligament surgery

Document Type : RESEARCH PAPER


1 Tehran university of medical sciences

2 Tehran university of medical sciences,Shariati hospital

3 Tehran university of medical sciences,Emam hospital

4 Sharif university of technology.School of biomechanics

5 Sharif university of technology,school of biomechanics

6 Sharif university of technology, school of bimechanics


Background: Ligament reconstruction is a common procedure in orthopedic surgery. Although several popular techniques are currently in use, new methods are proposed for secure fixation of the tendon graft into the bone tunnel.
Purposes: We sought to introduce our new technique of Bashti bone plug for fixation of soft tissue graft in anterior cruciate ligament (ACL) reconstruction and to compare its biomechanical features with conventional absorbable interference screw technique in a bovine model.
Methods: Twenty pairs of bovine knees were harvested after death. Soft tissue was removed and the Achilles tendon was harvested to be used as an ACL graft. It was secured into the bone tunnel on the tibial side via two different methods: Bashti Bone Plug technique and conventional screw method. Biomechanical strength was measured using 200 N and 300 N cyclic loading on the graft. Pull out strength was also tested until the graft fails.
Results: No graft failure was observed after 200 N and 300 N cyclic loading in either fixation methods. When testing for pull out failure, 21 tendons (53%) were torn and 19 tendons (48%) slipped out. No fixation failure occurred, which did not reveal a significant difference between the bone plug or interference screw group (P=0.11). The mean pull out force until failure of the graft was 496±66 N in the screw group and 503±67 N in the bone plug group (P=0.76).
Conclusions: Our suggested fixation technique of Bashti bone plug is a native, cheap, and feasible method that provides comparable biomechanical strength with interference screw when soft tissue fixation was attempted in bovine model.


  1. Jomha NM, Pinczewski LA, Clingeleffer A, Otto DD. Arthroscopic reconstruction of the anterior cruciate ligament with patellar-tendon autograft and interference screw fixation. The results at seven years. J Bone Joint Surg Br. 1999; 81(5):775-9.
  2. Levy IM, Torzilli PA, Warren RF. The effect of medial meniscectomy on anterior-posterior motion of the knee. J Bone Joint Surg Am. 1982; 64(6):883-8.
  3. Middleton KK, Hamilton T, Irrgang JJ, Karlsson J, Harner CD, Fu FH. Anatomic anterior cruciate ligament (ACL) reconstruction: a global perspective. Part 1. Knee Surg Sports Traumatol Arthrosc. 2014; 2(7):1467-82.
  4. Asik M, Sen C, Tuncay I, Erdil M, Avci C, Taser OF. The mid- to long-term results of the anterior cruciate ligament reconstruction with hamstring tendons using Transfix technique. Knee Surg Sports Traumatol Arthrosc. 2007; 15(8):965-72.
  5. Struewer J, Ziring E, Oberkircher L, Schuttler KF, Efe T. Isolated anterior cruciate ligament reconstruction in patients aged fifty years: comparison of hamstring graft versus bone-patellar tendon-bone graft. Int Orthop. 2013; 37(5):809-17.
  6. Erickson BJ, Harris JD, Fillingham YA, Frank RM, Bush-Joseph CA, Bach BR Jr, et al. Anterior Cruciate Ligament Reconstruction Practice Patterns by NFL and NCAA Football Team Physicians. Arthroscopy. 2014; 30(6):731-8.
  7. Angoules AG, Balakatounis K, Boutsikari EC, Mastrokalos D, Papagelopoulos PJ. Anterior-Posterior Instability of the Knee Following ACL Reconstruction with Bone-Patellar Tendon-Bone Ligament in Comparison with Four-Strand Hamstrings Autograft. Rehabil Res Pract. 2013;2013:572083.
  8. Achtnich A, Stiepani H, Forkel P, Metzlaff S, Hanninen EL, Petersen W. Tunnel widening after anatomic double-bundle and mid-position single-bundle anterior cruciate ligament reconstruction. Arthroscopy. 2013; 29(9):1514-24.
  9. Kim SJ, Bae JH, Song SH, Lim HC. Bone tunnel widening with autogenous bone plugs versus bioabsorbable interference screws for secondary fixation in ACL reconstruction. J Bone Joint Surg Am. 2013; 95(2):103-8.
  10. Iorio R, Di Sanzo V, Vadala A, Conteduca J, Mazza D, Redler A, et al. ACL reconstruction with hamstrings: how different technique and fixation devices influence bone tunnel enlargement. Eur Rev Med Pharmacol Sci. 2013; 17(21):2956-61.
  11. Kim HS, Seon JK, Jo AR. Current Trends in Anterior Cruciate Ligament Reconstruction. Knee Surg Relat Res. 2013; 25(4):165-73.
  12. Dingenen B, Janssens L, Claes S, Bellemans J, Staes F. Postural stability during the transition from double-leg stance to single-leg stance in anterior cruciate ligament reconstructed subjects. Br J Sports Med. 2014; 48(7):585.
  13. Lim BO, Shin HS, Lee YS. Biomechanical comparison of rotational activities between anterior cruciate ligament- and posterior cruciate ligament-reconstructed patients. Knee Surg Sports Traumatol Arthrosc. 2014 Mar 26.
  14. Hulstyn M, Fadale PD, Abate J, Walsh WR. Biomechanical evaluation of interference screw fixation in a bovine patellar bone-tendon-bone autograft complex for anterior cruciate ligament reconstruction. Arthroscopy. 1993; 9(4):417-24.
  15. Seil R, Rupp S, Krauss PW, Benz A, Kohn DM. Comparison of initial fixation strength between biodegradable and metallic interference screws and a press-fit fixation technique in a porcine model. Am J Sports Med. 1998; 26(6):815-9.
  16. Nebelung S, Deitmer G, Gebing R, Reichwein F, Nebelung W. Improved outcomes after anterior cruciate ligament reconstruction with quadrupled hamstring autografts and additional bone plug augmentation at five year follow-up. Int Orthop. 2013; 37(3):399-405.
  17. Engebretsen L, Lew WD, Lewis JL, Hunter RE. Knee mechanics after repair of the anterior cruciate ligament. A cadaver study of ligament augmentation. Acta Orthop Scand. 1989; 60(6):703-9.
  18. Emond CE, Woelber EB, Kurd SK, Ciccotti MG, Cohen SB. A comparison of the results of anterior cruciate ligament reconstruction using bioabsorbable versus metal interference screws: a meta-analysis. J Bone Joint Surg Am. 2011; 93(6):572-80.
  19. Kaeding C, Farr J, Kavanaugh T, Pedroza A. A prospective randomized comparison of bioabsorbable and titanium anterior cruciate ligament interference screws. Arthroscopy. 2005; 21(2):147-51.
  20. Said HG, Baloch K, Green M. A new technique for femoral and tibial tunnel bone grafting using the OATS harvesters in revision anterior cruciate ligament reconstruction. Arthroscopy. 2006; 22(7):796.
  21. Markolf KL, Gorek JF, Kabo JM, Shapiro MS. Direct measurement of resultant forces in the anterior cruciate ligament. An in vitro study performed with a new experimental technique. J Bone Joint Surg Am. 1990; 72(4):557-67.