Arthur Jacob, Zale Connor, Zhou Liang, Bottoni Craig R, Gee Shawn M
Tripler Army Medical Center, Honolulu, Hawaii, USA.
Department of Orthopaedics, Fort Belvoir Community Hospital, Fort Belvoir, Virginia, USA.
Orthop J Sports Med. 2023 Oct 27;11(10):23259671231205926. doi: 10.1177/23259671231205926. eCollection 2023 Oct.
Malpositioning of the femoral button is a known technical complication after anterior cruciate ligament (ACL) reconstruction with cortical suspensory fixation. The incidence of malpositioning, as well as the efficacy of methods to prevent malpositioning of cortical suspensory fixation devices, has not been reported.
To determine the rate of malpositioned cortical suspensory fixation devices after ACL reconstruction, investigate which intraoperative technique yields the lowest rate of malpositioning, and determine the return-to-duty rate for active-duty service members with malpositioned buttons and the revision rate for malpositioned buttons.
Case series; Level of evidence, 4.
The records of patients who underwent primary ACL reconstruction with a cortical suspensory fixation device between 2008 and 2018 were reviewed at our institution. Postoperative radiographs were reviewed for evidence of malpositioned femoral buttons. Malpositioned buttons were classified as (1) fully positioned in the bone tunnel, (2) partially positioned in the bone tunnel, (3) >2 mm from cortical bone, or (4) deployed over the iliotibial band. Operative reports were reviewed to determine the intraoperative methods undertaken to verify the button position. The rate of malpositioned cases with subjective instability and revision surgery performed were determined. The ability of patients to return to full military duty was reviewed for active-duty personnel.
A total of 1214 patients met the inclusion criteria. A 3.5% rate (42 cases) of malpositioned cortical suspensory fixation devices (femoral buttons) was identified. For patients with malpositioned buttons, 7 (16.7%) patients underwent revision surgery in the immediate postoperative period. Techniques used to avoid malpositioning included direct arthroscopic visualization, direct open visualization, intraoperative fluoroscopy, and first passing the button through the skin before positioning on the femoral cortex. There was a 4.6% malposition rate using direct arthroscopic visualization and a 5.1% malposition rate using passage of the button through the skin, while no malpositioning occurred with intraoperative fluoroscopy or direct open visualization ( < .05). Overall, 12 (28.6%) patients with malpositioned buttons ultimately underwent revision surgery. Despite having been diagnosed with malpositioned buttons, 21 (63.6%) active-duty members were able to return to full duty.
Malpositioning of femoral buttons during ACL reconstruction occurred in 3.5% of patients in this series. The techniques of intraoperative fluoroscopy and direct open visualization are encouraged to prevent malpositioning.
在采用皮质悬吊固定进行前交叉韧带（ACL）重建术后，股骨纽扣位置不当是一种已知的技术并发症。纽扣位置不当的发生率以及预防皮质悬吊固定装置位置不当方法的有效性尚未见报道。
确定ACL重建术后皮质悬吊固定装置位置不当的发生率，研究哪种术中技术导致位置不当的发生率最低，并确定纽扣位置不当的现役军人重返工作岗位的比率以及纽扣位置不当的翻修率。
病例系列；证据等级，4级。
回顾了2008年至2018年间在本机构接受初次ACL重建并使用皮质悬吊固定装置的患者记录。复查术后X线片以寻找股骨纽扣位置不当的证据。位置不当的纽扣分为以下几类：（1）完全位于骨隧道内；（2）部分位于骨隧道内；（3）距皮质骨>2mm；或（4）置于髂胫束上方。查阅手术报告以确定为核实纽扣位置而采取的术中方法。确定有主观不稳定症状的位置不当病例的发生率以及进行翻修手术的情况。对现役人员恢复全职军事任务的能力进行了评估。
共有1214例患者符合纳入标准。确定皮质悬吊固定装置（股骨纽扣）位置不当的发生率为3.5%（42例）。对于纽扣位置不当的患者，7例（16.7%）在术后早期接受了翻修手术。用于避免位置不当的技术包括直接关节镜直视、直接开放直视、术中透视以及在将纽扣置于股骨皮质上之前先使其穿过皮肤。直接关节镜直视的位置不当发生率为4.6%，纽扣穿过皮肤的位置不当发生率为5.1%，而术中透视或直接开放直视未发生位置不当（P<0.05）。总体而言，12例（28.6%）纽扣位置不当的患者最终接受了翻修手术。尽管被诊断为纽扣位置不当，但21例（63.6%）现役军人能够恢复全职工作。
本系列中3.5%的患者在ACL重建期间发生股骨纽扣位置不当。鼓励采用术中透视和直接开放直视技术以防止位置不当。
