Confirming Proper Button Deployment of Suspensory Fixation During ACL Reconstruction

Complications following all-inside anterior cruciate ligament reconstruction

PURPOSE

We conducted a comprehensive analysis of possible perioperative complications following all-inside anterior cruciate ligament reconstruction (ACLR). Additional techniques and tips are proposed to prevent and manage complications.

METHODS

Complications following all-inside ACLR performed between December 2015 and December 2020 were retrospectively analysed. Altogether, 348 operations were performed and 275 patients were enrolled with a minimum 12-month follow-up period. Only semitendinosus autograft was utilised in most patients, and semitendinosus-gracilis autograft and allograft were used in five and 31 patients, respectively. Simultaneous meniscal repair, partial meniscectomy, and chondral surgery were performed in 29.5%, 21.1%, and 4.4% of patients, respectively. Complications were observed based on the patient's clinical condition, plain film, and magnetic resonance imaging. Clinical outcomes were assessed pre-operatively and at 12 months post-operatively, using the International Knee Documentation Committee form, Lysholm and Tegner activity scores, and KT1000 side-to-side difference.

RESULTS

Intraoperative and post-operative complications developed in 65 patients (23.6%). The most common complication was cortical button malposition on the femoral side (19.3%). Intra-operative breakage of the retrograde drill was found in two cases (0.73%), with three cases (1.1%) of over-drilling with destruction of the outer cortex. Post-operatively, four (1.5%), 13 (4.7%), and 16 (5.8%) cases of infection, full-thickness re-rupture, and loss of extension, respectively, were recorded. Functional outcome scales showed significant post-operative improvement.

CONCLUSION

Cortical button malposition was the most common but easily preventable complication. All-inside ACLR could be safe and promising after the suggested additional operative techniques and proper perioperative management which decrease complication rates and improve favourable outcomes.

Effect of Soft Tissue Interposition and Postoperative Suspensory Cortical Button Migration on Functional Outcomes and Ligamentization After Single-Bundle ACL Reconstruction

Background:

Soft tissue interposition between a suspensory cortical button and the lateral femoral condyle is the most common cause of postoperative suspensory cortical button migration in patients undergoing anterior cruciate ligament reconstruction (ACLR).

Purpose:

To investigate the effects of soft tissue interposition and suspensory cortical button migration after ACLR on functional outcomes and graft ligamentization.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included were 249 patients who underwent single-bundle ACLR with hamstring tendon autografts. To measure soft tissue imposition, the patients were divided into 2 groups: those in whom the suspensory cortical button was in contact with (group 1) or at least 1 mm away from (group 2) the lateral femoral condyle on 1-day postoperative radiographs. To measure suspensory cortical button migration, the patients in group 2 were further divided into 2 subgroups: those with button migration (group M) and those without migration (group non-M) as observed on 12-month postoperative radiographs. Ligamentization was evaluated according to Howell classification (grades 1-4) on 12-month follow-up magnetic resonance imaging scans. Also recorded were preoperative and 24-month postoperative Lysholm and Tegner scores and 24-month postoperative arthrometer measurements for anterior knee laxity.

Results:

There was no significant difference between groups 1 and 2 or between groups M and non-M in terms of demographic characteristics or additional intra-articular pathologies detected intraoperatively. Normal anterior laxity (<3 mm) was detected in 83.7% of the patients postoperatively, and all patients showed statistically significant pre- to postoperative improvement on the Tegner (from 4.1 to 4.3) and Lysholm (from 44.0 to 89.2) scores (P < .05 for both). No significant difference in postoperative functional results or graft ligamentization was found between either the soft tissue interposition groups (groups 1 and 2) or the suspensory cortical button migration groups (groups M and non-M).

Conclusion:

Differences between patients in soft tissue interposition and suspensory cortical button migration did not significantly affect postoperative clinical or functional outcomes or graft ligamentization after single-bundle ACLR.

Arthroscopic confirmation of femoral button deployment prevents soft tissue interposition in ACL reconstruction

PURPOSE

The purpose of this study was to determine whether direct arthroscopic control of femoral buttons can prevent improper deployment and soft tissue interposition in anterior cruciate ligament (ACL) reconstruction.

METHODS

A retrospective analysis of prospectively collected data from the SANTI study group database was performed. All patients who underwent ACL reconstruction using suspensive femoral fixation between 01/01/2017 and 31/12/2019 were included. Patient assessment included demographics, sports metrics, reoperations performed and femoral button-related specific complications such as iliotibial band (ITB) irritation and/or septic arthritis. Proper deployment of the button and soft tissue interposition were assessed on postoperative radiographs.

RESULTS

A total of 307 patients underwent ACL reconstruction using adjustable femoral button fixation and were analyzed after a mean follow-up of 35.2 ± 11.0 months (14.3-50.2). The mean age was 39.5 ± 10.9-years old (range 13.3-70.6). Postoperative radiographs showed a correctly deployed femoral button without soft tissue interposition for all patients. No septic arthritis was reported. Nine patients (2.9%) suffered from lateral pain related to ITB irritation due to the button. Five of them had their symptoms resolve during rehabilitation. Ultrasound-guided corticosteroid infiltration was necessary for four patients after an average delay of 14.5 ± 4.8 months (11.7-21.7). Three patients were then symptom-free, but one required surgical removal of the implant 27.5 months after the surgery. Regarding unrelated femoral button complications, 15 patients (4.9%) underwent secondary arthroscopic procedures, including meniscectomy (1.6%), surgery for cyclops syndrome (2.6%) and revision ACLR (0.7%).

CONCLUSION

Arthroscopic confirmation of femoral button deployment prevents soft tissue interposition without specific complications.

LEVEL OF EVIDENCE

Level IV.