A Review of the Biomechanical and Clinical Outcomes of Tibial-Sided Fixation for Anterior Cruciate Ligament Reconstruction.

» Tibial fixation remains the biomechanically weaker site in ACL reconstruction due to lower bone density and directional loading forces, making fixation choice critical for graft stability.» Interference screws provide aperture fixation close to the joint line but are limited by graft slippage, tunnel widening, and progressive loss of tension over time.» Suspensory devices engage cortical bone and reduce graft damage during insertion; when supplemented with backup fixation, such as knotless suture anchors, they demonstrate greater fixation strength and reduced graft micromotion.» Internal suture augmentation offers promising biomechanical and early clinical benefits by protecting the graft during the vulnerable early healing period, especially in young athletes and revision cases, though long-term effects remain under investigation.» Fixation strategy should be individualized, balancing graft choice, bone quality, and rehabilitation demands to optimize outcomes and reduce risk of failure.