**4. Graft fixation issues**

**4.1** Composite grafts with bone plugs are commonly fixed in the tunnels either with absorbable or metal interference screws.. This method provides the highest strength and rigidity. However there is concern that a too rigid construct may alter the full range of knee motion and some surgeons prefer suspensory fixation with sutures tied on post or buttons or buttons with build in tissue loops. Soft tissue grafts fixation relies on numerous different methods: interference screws, suspensory devices, cross pins. On the femoral side suspensory devices with build in tissue loop, like the Endobutton® Continuous Loop provides the strongest and stiffest fixation. With hamstring grafts, graft slippage at the tibial fixation site may occur explaining the slight increase in laxity compared to BTB.
