Intraoperative Manual Resistance and Direct Intra-articular Visualization Maneuvers for Anterior Cruciate Ligament Reconstruction: A Retrospective Cohort Study

BACKGROUND: The use of femoral suspensory fixation devices is a popular technique in anterior cruciate ligament reconstruction (ACLR), but there is no consensus on the best intraoperative method for confirming proper button deployment. Recent literature suggests that manual resistance alone is at a high risk of causing button malpositioning or floating without utilizing intraoperative fluoroscopic imaging. PURPOSE: To investigate the incidence of femoral suspensory button malpositioning in patients undergoing ACLR when intraoperative manual resistance and direct intra-articular visualization maneuvers without imaging are used to confirm fixation as well as to compare the rates of button malpositioning between fixed- and adjustable-loop fixation devices. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All patients who underwent ACLR by 3 board-certified, sports medicine fellowship-trained orthopaedic surgeons at a single institution were included. All 3 surgeons used intraoperative manual resistance and direct intra-articular visualization maneuvers to verify button device positioning. Patients were identified using prospectively collected administrative data from an institutional orthopaedic database. Patients were excluded if they did not have suspensory fixation devices used for reconstruction or if they lacked postoperative radiographs. Improper device deployment was defined as a button that was not flipped on radiography; malpositioned buttons were defined as those whose centers measured >2 mm from the femoral cortex. RESULTS: A total of 922 patients met inclusion criteria for this study. All 922 patients (100.0%) had properly deployed button devices, and 36 patients (3.9%) had malpositioned buttons. There was no difference in the rates of button malpositioning between fixed- and adjustable-loop button devices. Neither ACLR type (primary vs revision) nor graft type correlated with button malpositioning. CONCLUSION: Intraoperative manual resistance and direct intra-articular visualization maneuvers were an effective method for properly deploying suspensory button devices during ACLR. The low rates of improper deployment and malpositioning with these maneuvers do not warrant the use of intraoperative fluoroscopic imaging, resulting in safer, faster, and more cost-effective surgical procedures for patients.