A Percutaneous Technique to Reposition the Cortical Button of Adjustable-Loop Devices in Anterior Cruciate Ligament Reconstruction

Adjustable-loop devices are relatively new but quite popular and have been routinely used for around a decade in arthroscopic anterior cruciate ligament reconstruction for hamstring graft fixation on the femur. They allow surgeons to adapt to different tunnel lengths, eliminate the need for multiple loop sizes, decrease the “bungee cord effect,” maximize the amount of graft within the femoral socket available for incorporation, and allow retensioning of the graft. Apart from these advantages, certain complications are associated with the use of adjustable-loop devices. When the cortical button is being pulled up through the femoral tunnel, it may be pulled up with greater force, causing it to come out of the vastus lateralis, the iliotibial band, or even the skin. When the graft is pulled back from the tibial side, the cortical button may flip in the substance of the vastus lateralis or outside the iliotibial band. This soft-tissue interposition can cause ischemic necrosis of the interposed tissue, soft-tissue irritation, migration of the cortical button, or early loosening of the graft, leading to anterior cruciate ligament reconstruction failure. We describe a percutaneous solution to this common intraoperative technical complication. The outer sheath of a 4.5-mm arthroscope, 4.5-mm acromionizer, or notchplasty burr can be safely used to put the cortical button back against the lateral cortex of the femur.