Tibial-Sided Suspension Fixation increases Risk of Cyclops Lesion following Anterior Cruciate Ligament Reconstruction

Cyclops lesions are a common postoperative complication that occurs in up to 47% of patients after anterior cruciate ligament reconstruction (ACLR), often resulting in painful extension loss. While risk factors for cyclops lesions have been identified, the influence of graft fixation technique on the development of symptomatic cyclops lesions remains unknown. A retrospective cohort study was conducted on 1,245 patients who underwent primary ACLR between January 1, 2015 and December 31, 2021. Patient demographics, pre-/postoperative metrics, graft type, and fixation methods were collected. The primary outcome was development of symptomatic cyclops lesions, confirmed by clinical exam and magnetic resonance imaging or surgical debridement. Statistical analysis included Kaplan-Meier survival analysis and mixed-effects logistic regression to determine predictors of lesion development. All-suspension fixation showed a significantly higher cyclops lesion rate (12.34%) compared with the other methods (4.2%, p < 0.01) and was the strongest predictor of cyclops lesion development (odds ratio [OR]: 9.208, 95% CI [1.773, 47.836]). Female sex and Black race were also significant predictors. Graft type did not significantly affect lesion risk in multivariable analysis. The all-suspension tibial-sided fixation technique significantly increases the risk of symptomatic cyclops lesion development, independent of graft type, or patient-specific factors. Biomechanical factors such as sagittal plane micro-motion and local tissue response may contribute to this increased risk. Recognition of fixation-related risk may inform surgical decision-making and postoperative management.