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Specimens were separated into the following groups (n\u00a0= 5): 9\u2010mm IS only, BP (with and without graft and IS), SB (with and without graft and IS), SA (with and without graft and IS), extramedullary suture button (with and without graft and IS), and extramedullary suture button with BP as backup fixation. Specimens were tested under cyclic loading and then loaded to failure. Maximal load at failure, displacement, and stiffness were compared.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Without a graft, the SB and BP had similar maximal loads (802.46 \u00b1 185.18 N vs 785.67 \u00b1 100.96 N,\n                      <jats:italic>P<\/jats:italic>\n                      \u00a0= .560), and both were stronger than the SA (368.13 \u00b1 77.26 N,\n                      <jats:italic>P<\/jats:italic>\n                      &lt; .001). With graft and an IS, there was no significant difference in maximal load between the BP (1,461.27 \u00b1 173.75 N), SB (1,362.46 \u00b1 80.47 N), and SA (1,334.52 \u00b1 195.80 N). All backup fixation groups were stronger than the control group with IS fixation only (932.91 \u00b1 99.86 N,\n                      <jats:italic>P<\/jats:italic>\n                      &lt; .001). There was no significant difference in outcome measures between the extramedullary suture button groups with and without the BP (failure loads of 721.39 \u00b1 103.32 N and 718.15 \u00b1 108.61 N, respectively).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Subcortical backup fixation in ACL reconstruction has similar biomechanical properties to current methods and is a viable backup fixation alternative. Backup fixation methods work synergistically with IS primary fixation to strengthen the construct. There is no advantage to adding backup fixation to extramedullary button (all\u2010inside) primary fixation when all suture strands are secured to the extramedullary button.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Clinical Relevance<\/jats:title>\n                    <jats:p>This study provides evidence that subcortical backup fixation is a viable alternative for surgeons during ACL reconstruction.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1016\/j.asmr.2022.10.012","type":"journal-article","created":{"date-parts":[[2022,12,15]],"date-time":"2022-12-15T07:51:20Z","timestamp":1671090680000},"update-policy":"https:\/\/doi.org\/10.1016\/elsevier_cm_policy","source":"Crossref","is-referenced-by-count":1,"title":["Subcortical Backup Tibial Fixation in Anterior Cruciate Ligament Reconstruction Has Similar Maximal Strength to Current Techniques"],"prefix":"10.1002","volume":"5","author":[{"given":"Donald F.","family":"Colantonio","sequence":"first","affiliation":[{"name":"Department of Orthopaedic Surgery Walter Reed National Military Medical Center Bethesda Maryland U.S.A."},{"name":"Uniformed Services University of the Health Sciences Bethesda Maryland U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rachel C.","family":"Kicklighter","sequence":"additional","affiliation":[{"name":"Department of Civil and Mechanical Engineering United States Military Academy West Point New York U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anthony H.","family":"Le","sequence":"additional","affiliation":[{"name":"Department of Civil and Mechanical Engineering United States Military Academy West Point New York U.S.A."},{"name":"Extremity Trauma and Amputation Center of Excellence Bethesda Maryland U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Margaret A.","family":"Nowicki","sequence":"additional","affiliation":[{"name":"Department of Civil and Mechanical Engineering United States Military Academy West Point New York U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Matthew A.","family":"Posner","sequence":"additional","affiliation":[{"name":"Uniformed Services University of the Health Sciences Bethesda Maryland U.S.A."},{"name":"John A. Feagin Sports Medicine Fellowship West Point New York U.S.A."},{"name":"Department of Orthopaedic Surgery Keller Army Community Hospital West Point New York U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Liang F.","family":"Zhou","sequence":"additional","affiliation":[{"name":"John A. Feagin Sports Medicine Fellowship West Point New York U.S.A."},{"name":"Department of Orthopaedic Surgery Tripler Army Medical Center Honolulu Hawaii U.S.A."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shawn M.","family":"Gee","sequence":"additional","affiliation":[{"name":"Uniformed Services University of the Health Sciences Bethesda Maryland U.S.A."},{"name":"John A. 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