Anterior Cruciate Ligament Reconstruction With Additional Remnant-Preserving Stump Repair Using a Button and Suture-Tensioning Technique

Anterior cruciate ligament injuries or ruptures significantly impair knee mobility and overall joint function. Surgical reconstruction is the standard treatment, most commonly performed using autologous semitendinosus and gracilis tendons. Recently, remnant-preserving anterior cruciate ligament reconstruction has gained popularity as a result of favorable clinical outcomes, and it is increasingly adopted by surgeons. The essential steps of the button with suture-tensioning technique are as follows: before graft passage, sutures are preloaded through the button portals; after drilling the bone tunnels, the preloaded sutures are advanced through the tibial tunnel into the joint cavity and retrieved for later use; once the graft is fixed in the standard manner, the femoral stump is sutured arthroscopically, tensioned, and secured at the femoral tunnel aperture. This method is cost-effective, reproducible, and technically straightforward. By pulling back the prepositioned sutures, the button's flipping mechanism can be tested, minimizing the risk of incomplete seating against the femoral cortex caused by interposed soft tissue. Simultaneously, this maneuver tensions the residual stump, enhances joint stability, seals the femoral tunnel opening, prevents joint fluid backflow, and decreases the likelihood of graft impingement during knee extension.