Anterior to Posterior Bone Plug Suture Tunnels Provide Optimal Biomechanics for Bone−Patellar Tendon−Bone Anterior Cruciate Ligament Graft

PURPOSE: To evaluate different bone−patellar tendon−bone (BPTB) plug suture configurations for pull through strength, stiffness, and elongation at failure in a biomechanical model of suspensory fixation. METHODS: Forty nonpaired, fresh-frozen human cadaveric BPTB allografts with an average age of 65.6 years were tested. Tensile testing was performed with the use of a custom-designed fixture mounted in a dynamic tensile testing machine. A preload of 90 N was applied to the graft and held for 5 minutes. Following this, a tensile load-to-failure test was performed. The ultimate failure load, elongation at failure, and mode of failure were recorded, and the resulting load–elongation curve was documented. RESULTS: The drill tunnel through the cortical surface (anterior to posterior) was found to be significantly stronger than the drill tunnel through the cancellous surface (medial to lateral). There were no significant differences found when comparing the strength of the suture augmentation through the tendon and the drill tunnel alone (P = .13 among cancellous groups, P = .09 among cortical groups). The cortical drill tunnel with suture augmentation through the tendon showed significantly greater elongation values (13.7 ± 3.2) at failure when compared with either the cancellous or cortical drill tunnel only test groups (P = .0003 compared with cancellous alone, P = .009 when compared with cortical alone). Conclusions: The BPTB suture configuration with an anterior to posterior–directed suture tunnel without a suture through tendon augmentation provides the optimal strength and stiffness while minimizing graft elongation after fixation in a biomechanical model. This configuration is best for preventing suture pull through and failure when passing sutures through the BPTB plug. CLINICAL RELEVANCE: This study biomechanically evaluates the optimal suture configuration in the proximal bone plug for suspensory fixation in the setting of BPTB grafts.