Is Intraoperative Fluoroscopy Necessary to Confirm Device Position for Femoral-Sided Cortical Suspensory Fixation during Anterior Cruciate Ligament Reconstruction?

Abstract

Increased laxity within the graft construct system can lead to graft failure after anterior cruciate ligament (ACL) reconstruction. Suboptimal cortical device positioning could lead to increased laxity within the system, which could influence the mechanics and function of the graft reconstruction. This study evaluates the benefit of intraoperative fluoroscopy to confirm device position on the femur during ACL reconstruction using cortical suspensory fixation. One hundred consecutive patients who underwent soft tissue ACL reconstruction using a suspensory cortical device for femoral fixation were retrospectively evaluated. Patients were split into two groups: Group A utilized anteromedial portal visualization and had intraoperative fluoroscopic imaging performed at the time of ACL graft fixation to confirm femoral device placement on the lateral femoral metaphyseal cortex. Group B utilized anteromedial portal visualization alone. Both groups had radiographic X-rays performed at the first postoperative visit to evaluate device location and all images were independently evaluated by three fellowship trained orthopaedic surgeons. Device position was classified as optimal if there was complete apposition of the entire device against the femoral cortex and suboptimal if it was > 2 mm off the cortex. Fisher's exact test, analysis of variance, and 95% confidence intervals were calculated to compare the groups for statistical significance. The results showed 0/60 (0%) patients in group A had suboptimal device position at postoperative follow-up, while 4/40 (10%) patients in group B had suboptimal device position (p = 0.013). There were no graft failures in group A and one graft failure in group B. There was a significant difference in cortical device position in patients who had intraoperative fluoroscopic imaging versus patients who had no intraoperative imaging. The use of confirmatory intraoperative imaging may be beneficial to confirm appropriate device location when using a femoral cortical suspensory fixation technique for ACL reconstruction.

Risk Factors for Femoral Cortical Button Malposition in Posterior Cruciate Ligament Reconstruction

“…and M.Y.). In consensus with other studies, 1 , 17 the button was considered malpositioned if the distance from the inferior surface of the cortical button to the medial femoral cortex was longer than 2 mm ( Figure 2 ). Data were recorded with an accuracy of 0.01 mm using specialized software (Centricity Enterprise Web Version 3.0; GE Medical Systems).…”

Confirming Proper Button Deployment of Suspensory Fixation During ACL Reconstruction

“…32 Instead, this study supports the use of intraoperative fluoroscopy to verify the position of the suture button after button flipping. Previous studies have also championed the use of intraoperative fluoroscopy in this role, 2,17,24,28,33,34 but this study adds to the literature by demonstrating that intraoperative fluoroscopic imaging is an effective method to both identify and rectify the malpositioning.…”

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

“…Intraoperative fluoroscopic control of the femoral button is the most frequently reported solution in the literature [ 9 , 34 , 35 ]. In the event of soft tissue interposition or improper deployment, a new attempt to correctly flip the implant can be attempted after the interposed tissue is bypassed [ 9 ].…”

“…In the event of soft tissue interposition or improper deployment, a new attempt to correctly flip the implant can be attempted after the interposed tissue is bypassed [ 9 ]. A larger lateral surgical approach could also be performed over the guide pin to obtain direct visual control of the button [ 34 ]. Some authors have used this approach as an accessory arthroscopic portal, allowing its size to be limited while keeping the implant deployment visualized [ 19 , 35 ].…”

“…These techniques are efficient and can limit potential complications related to the femoral button [ 9 , 19 , 34 , 35 ]. However, intraoperative fluoroscopy is irradiating for both the patient and the surgeon and requires the involvement of trained personnel [ 37 , 38 ].…”