The surgical technique of Endobutton (Acufex Microsurgical, Inc,. Mansfield, MA) button fixation for anterior cruciate ligament reconstruction is described. TECHNIQUE FOR ACL RECONSTRUCTION USING THE. ACUFEX DIRECTOR DRILL GUIDE AND ENDOBUTTON CL. 데 . A doubled surgeon’s knot is used. The surgical technique of Endobutton (Acufex Microsurgical, Inc, Mansfield, MA) button fixation for anterior cruciate ligament reconstruction is described.
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Suture button—based femoral cortical suspension constructs of anterior cruciate ligament grafts can facilitate a fast and secure fixation. We describe an arthroscopic technique for making femoral tunnels through the outside-in method that reduces the migration of the EndoButton through a lateral femoral portal.
This technique may assist surgeons in understanding how to deal with and potentially avoid EndoButton migration during anterior cruciate ligament reconstruction.
ENDOBUTTON CL ULTRA | Smith & Nephew – US Professional
Suture button—based femoral cortical suspension fixation of anterior cruciate ligament ACL grafts can facilitate a fast and secure graft fixation for ACL reconstruction. Fortunately, the patient had no ACL instability. Endobjtton they suggested that an increased angle of knee flexion was more likely to result in soft-tissue interposition endpbutton flipping, they did not describe any complications resulting from the failure of flipping.
Postoperative clinical examination before revision srugical range of motion without increased resistance. They determined that migration of the EndoButton was more common with the presence of soft-tissue interposition and clinical outcomes were unaffected by migration and soft-tissue interposition.
Current surgical techniques do not allow adequate visualization of the button in its final position to confirm that it is correctly flipped over without soft-tissue interposition between the EndoButton and the suggical band ITB or vastus lateralis. Several techniques have been proposed to ensure surgocal placement of the EndoButton and lessen the probability of malpositioning.
Some surgeons have recommended the use of intraoperative fluoroscopy to assess the position of the wndobutton and its relation to the femoral cortex. However, this technique requires a longer intraoperative time and a relatively higher level of surgical skills that may limit its use to more experienced surgeons.
This Technical Note describes an arthroscopic technique to prevent migration of the EndoButton using a femoral guide pin incision on the lateral aspect of the femur as an endoscopic portal. The described ACL reconstruction technique was arthroscopically performed by the senior surgeon. A standard arthroscopic examination is performed through anteromedial and anterolateral portals.
Other injuries, including osteochondral lesions and meniscal tears, are managed concomitantly depending on their severity. Care is taken to ensure that the femoral and tibial tunnels are created anatomically in every patient. An ipsilateral semitendinosus and gracilis autograft is used in every endobuyton. A fixed-loop tfchnique suspension device, the EndoButton CL, is used for femoral fixation. The position of the EndoButton is confirmed with fluoroscopy after manual assessment to ensure that the button has been flipped.
In the case in which the EndoButton migrates from the lateral aspect of the femoral cortex Fig 1 Aa lateral femoral LF portal is created through the femoral guide pin incision on the lateral aspect of the femur.
An arthroscope is inserted into the LF portal to evaluate for EndoButton migration from the lateral aspect of the femoral cortex Fig 2 A and B. A Vulcan probe can also be inserted through the same portal to help manipulate endobuttom fit the EndoButton into the proper position at the lateral cortex of the femur by pulling the graft on the tibial side Fig 2 D and E.
A Anteroposterior radiograph of a right Rt knee during operation showing migrated EndoButtons of anteromedial and posterolateral graft arrow.
Endobutton button endoscopic fixation technique in anterior cruciate ligament reconstruction.
B Anteroposterior radiograph of a right Rt knee showing reduced position of migrated EndoButtons after arthroscopic reduction.
The arrow indicates the EndoButtons of the anteromedial and posterolateral graft. Right Rt knee with endoscopic visualization from lateral femoral LF portal. B The arthroscope is inserted through an LF portal, and a Vulcan probe arrowhead is inserted through another LF portal. C The Vulcan probe arrowheadintroduced through the second LF portal, can remove the interposed soft tissue surrounding the EndoButton arrow. D Removed soft tissue beneath migrated EndoButton arrow.
The arrowhead indicates the Vulcan probe. E The position of the EndoButton arrow is fixed to the lateral aspect of the femoral cortex. Postoperative anteroposterior radiograph of a right Rt knee showing reduced EndoButton to lateral aspect of femoral cortex. The arrow shows the EndoButtons of the anteromedial and posterolateral graft. A standardized postoperative protocol is implemented for each patient. Physical therapy, consisting of exercise without resistance, to improve range of motion is initiated immediately after surgery.
Weight-bearing exercise as tolerated with crutches is also initiated immediately.
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This Technical Note presents an arthroscopic technique that successfully removes interposed soft tissue between the EndoButton and the lateral aspect of the femoral cortex and reduces EndoButton migration from the lateral aspect of the femoral cortex of the knee.
This minimally invasive approach assists in the correction of the migrated EndoButton to the femoral cortex to the proper position. Several studies have shown that EndoButton malpositioning over the soft tissue around the knee induces either tissue irritation or migration of the button. The previous studies showed a positive correlation between a malpositioned EndoButton and a higher rate of button migration.
In general, suspension of the EndoButton over soft tissue, such as the ITB, was weaker than that on the femoral cortex. Weakening of femoral fixation before graft integration might cause loosening of the reconstructed ACL and failure of the ACL reconstruction. However, arthroscopic ACL reconstruction is more technically complex, and inexperienced surgeons may have difficulty identifying the interposed soft tissue and EndoButton.
There is a paucity of available literature regarding how to best remove interposed soft tissue and reduce the position of the EndoButton. Our arthroscopic reduction technique allows the surgeon to assess for malpositioning and migration of the EndoButton directly through the LF portal and remove any soft tissue interposed between the EndoButton and the lateral cortex of the femur.
This more accurate technique not only allows for better visualization but also leads to a decrease in the rate of failure of the ACL eendobutton.
The advantages of this arthroscopic technique include small incisions and direct visualization that can help remove any soft-tissue interposition and reduce a migrated EndoButton.
There appears to be a short recovery time, which is especially beneficial for athletes who must quickly recover back to their preinjury activity level.
A disadvantage of using our arthroscopic technique is the potential risk of compartment syndrome after excessive introduction of fluid in the LF portal. In addition, there is a small possibility of injury to the srugical superior genicular artery. Another potential complication is lateral extravasation because this technique is performed in the extra-articular space. There is also a risk of damage to the EndoButton loop by using the Vulcan.
Endobutton button endoscopic fixation technique in anterior cruciate ligament reconstruction.
This technique requires careful cleaning of the soft tissue over the lateral cortex of the femur. The proposed procedure is routinely used in our practice and continues to tecunique promise. We believe this arthroscopic reduction technique could be beneficial in the case of a migrated EndoButton during ACL surgicla of the knee; however, studies on long-term surgixal outcomes with a larger cohort will be necessary to fechnique its efficacy.
The authors report the following potential conflict of interest or source of funding: After passage of the anterior cruciate ligament ACL graft through the tibial tunnel, the position of the EndoButton is confirmed by fluoroscopy after the EndoButton is felt to be flipped in a right knee. If soft tissue is interposed between the EndoButton and lateral aspect of surgjcal femoral cortex, a radiofrequency RF probe Vulcan is inserted through another Endobutton portal to remove the soft tissue.
A probe can be inserted through the same portal to help techniqje the EndoButton into the proper position at the lateral cortex of the femur by pulling the graft on the tibial side. National Center for Biotechnology InformationU.
Journal List Arthrosc Tech v. Published online Oct Yasuo OhnishiM. Find articles by Angela Chang. Find articles by Hajime Utsunomiya. Find articles by Hitoshi Suzuki. Author information Article notes Copyright and License information Disclaimer. Received Mar 31; Accepted Jul Associated Data Supplementary Materials Video 1 After passage of the anterior cruciate ligament ACL graft through the tibial tunnel, the position of the EndoButton is confirmed by fluoroscopy after the EndoButton is felt to be flipped in a right knee.
Abstract Suture button—based femoral cortical suspension constructs of anterior cruciate ligament grafts can facilitate a fast and secure fixation. Make an LF portal by longitudinally extending the guide pin incision.
Confirm the migration of the EndoButton to the lateral cortex of the knee through the LF portal. Introduce a shaver through another LF portal to clean up the soft tissue around the EndoButton.
Switch the shaver to a Vulcan probe to remove any interposed soft tissue beneath the EndoButton. Reduce the migrated EndoButton to the proper position, and fit the EndoButton to the lateral cortex of the knee by pulling the graft on the tibial side. Injury to arteries, such as the lateral superior genicular artery, is possible. Open in a separate window.
Surgical Technique The described ACL reconstruction technique was arthroscopically performed by the senior surgeon. Postoperative Rehabilitation A standardized postoperative protocol is implemented for each patient. Discussion This Technical Note presents an arthroscopic technique that successfully removes interposed soft tissue between the EndoButton and the lateral aspect of the femoral cortex and reduces EndoButton migration from the lateral aspect of the femoral cortex of the knee.
The techniques allows direct visualization of the reduction of the migrated EndoButton. There is a risk of damage to the EndoButton loop by using the Vulcan. Our technique cannot be applied in the case of a migrated EndoButton resulting from malpositioning of the femoral bone tunnel. Footnotes The authors report the following potential conflict of interest or source of funding: Supplementary Data Video 1: Click here to view.
ICMJE author disclosure forms: Clinical and functional outcomes after anterior cruciate ligament reconstruction using cortical button fixation versus transfemoral suspensory fixation: A systematic review of randomized controlled trials. Femoral suspension devices for anterior cruciate ligament reconstruction: Do adjustable loops lengthen?
Am J Sports Med. Three femoral fixation devices for anterior cruciate ligament reconstruction: Comparison of fixation on the lateral cortex versus the anterior cortex. An unidentified pitfall of Endobutton use: Knee Surg Sports Traumatol Arthrosc.
Potential pitfall of the EndoButton. Intra-articular detachment of the Endobutton more than 18 months after anterior cruciate ligament reconstruction.