Arthroscopic Visualization of Femoral Cortical Button Deployment During Anterior Cruciate Ligament Reconstruction

Up to 25% of femoral cortical suspensory fixation devices are reported to be deployed inappropriately during anterior cruciate ligament (ACL) reconstruction. Most techniques for visualizing suspensory button deployment reported in the literature are for adjustable loop buttons and outside-in femoral tunnel technique. Intraoperative radiographs are inconvenient and involve exposure to radiation. No "gold standard" technique for visualization of femoral cortical button deployment has been described yet.

This technique can be employed for all patients requiring ACL reconstruction surgery.

The femoral tunnel is prepared from the anteromedial portal. With the knee in flexion, a beath pin loaded with a suture loop is passed via the anteromedial portal through the femoral tunnel; the eyelet of the pin with the suture loop is retained in the femoral tunnel. The knee is extended without fear of bending the beath pin. The arthroscope is shifted into the lateral gutter. An outside-in lateral parapatellar portal is made at the level of the center of the patella, 1 cm lateral to its lateral edge. The joint capsule and soft tissues in the lateral gutter are resected using a shaver. The beath pin is identified without fear of lacerating the suture loop. The exit point of the pin depends on the knee flexion at the time of femoral tunnel preparation, and more flexion results in more anterior pin exit and vice versa. The rest of the surgery is performed as planned. The definitive sutures of the desired femoral cortical suspensory device are passed from the tibial tunnel into the femoral tunnel. The arthroscope is then positioned in the lateral gutter and the cortical button is deployed appropriately under vision, onto the lateral femoral cortex. If required, the cortical button can be manipulated to seat it appropriately, using an instrument from the lateral parapatellar portal. The remainder of the surgery is performed as per the surgeon's preference.

We routinely perform this step during ACL reconstruction. It adds 2 to 4 minutes to the surgical time. We have not encountered any complications of this procedure.

This maneuver is effective in facilitating appropriate deployment of femoral cortical suspensory devices under vision.