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Address correspondence to Soshi Uchida, M.D., Ph.D., Department of Orthopaedic Surgery, Wakamatsu Hospital of the University of Occupational and Environmental Health Japan, 1-17-1 Hamamachi Wakamatsu Kitakyushu 808-0024 Fukuoka Japan.
Suture button-based femoral cortical suspension constructs of anterior cruciate ligament grafts may facilitate fast and secure fixation. The necessity of Endobutton removal is controversial. Many current surgical techniques do not allow direct visualization of the Endobutton(s), making it challenging to remove; the buttons are fully flipped without soft tissue interposition between the Endobutton and femur. This Technical Note demonstrates endoscopic removal of Endobuttons through the lateral femoral portal. This technique allows direct visualization facilitating easier hardware removal while harnessing the advantages of a less-invasive procedure.
Technique Video
See video under supplementary data.
Suture button–based femoral cortical suspension fixation has been used to provide secure graft fixation while minimizing femoral side intrusion for anterior cruciate ligament (ACL) reconstruction. Reported complications associated with the Endobutton include tunnel enlargement, implant migration, and symptomatic extensor mechanism irritation. A recent systematic review reported that misplacement of the suture button is the most frequent complication.
Recently, 3 techniques have been used to create femoral tunnels: the transtibial technique, transportal technique, and outside-in technique for double-bundle ACL reconstruction. Especially in the case of the transtibial technique, the Endobutton may be positioned more proximally in the thigh muscle. Surgeons may avoid removing Endobuttons because of the relatively invasive nature of this hardware removal. Current surgical techniques do not allow for adequate visualization to reduce the buttons without a formal skin incision. This Technical Note demonstrates an endoscopic technique to remove 2 Endobuttons after double-bundle ACL reconstruction in a step by-step and comprehensible fashion (Video 1).
Surgical Technique
A patient is placed in a supine position under general or spinal anesthesia. A 30° arthroscope is introduced through the anterolateral portal. A standard arthroscopic examination is performed through the anteromedial portal and anterolateral portal (ALP). Other pathologic findings, including osteochondral lesions and meniscus tears, are treated concomitantly.
An arthroscope is placed in the lateral gutter through the ALP (Fig 1 A and B). The lateral femoral portal is created through the femoral guide pin incision on the lateral aspect of femur (Fig 1C). Viewing from the ALP, the lateral capsule is incised with a scalpel, and the arthroscope lens is positioned at the external surface of the knee capsule at the lateral aspect of the distal femur (Fig 2 A and B). We sometimes use fluoroscopy or sonography to aid locating the Endobutton(s). Typically, these buttons are embedded in the postoperative scar tissue. We utilize a radiofrequency (RF) probe (Super Multivac Coblation Wand, The Quantum 2 system; Smith & Nephew, Andover, MA) to expose the Endobutton (Fig 3 A-C). If there are more than 2 buttons for double-bundle ACL reconstruction, both Endobuttons are endoscopically visualized before commencement of hardware extraction.
Fig 1An 18-year-old female runner underwent anterior cruciate ligament (ACL) double-bundle reconstruction with semitendinosus tendon autograft. (A) Double-bundle autografts with Endobutton CL (Smith & Nephew, Co, Ltd. Andover, MA) at the time of initial surgery. (B) Arthroscopic view of double-bundle ACL reconstruction at the time of surgery. (C) (D) Anterior-posterior and lateral radiography view before endoscopic Endobutton removal surgery.
Fig 2(A) Diagram showing the lateral femoral skin incision to make the lateral femoral (LF) portal. (B) Patient is placed in a supine position. A 30° arthroscope is placed in the lateral gutter. Viewing from the AL portal, the blade was inserted through the LF portal to reach out to the Endobuttons. (C) A radiofrequency probe (Super Multivac Coblation Wand, The Quantum 2 system; Smith & Nephew, Andover, MA) was introduced through the LF portal to expose the Endobuttons. LF, lateral femoral; AL, anterolateral.
Fig 3(A) Diagram showing the radiofrequency (RF) (Super Multivac Coblation Wand, The QUANTUM 2 System; Smith & Nephew, Andover, MA) probe introduced through the LF portal to expose Endobuttons. (B and C) The arthroscope is placed in the lateral gutter. Arthroscopic viewing from the anterolateral portal. The RF probe is used to remove soft tissue surrounding Endobuttons.
Metzenbaum scissors are used to cut the continuous loop (artificial ligament), and then a rongeur is used to remove the buttons (Fig 4 A-C). After removal, bleeding surrounding the Endobutton is coagulated using an RF probe. Postoperative radiography confirms removal of the Endobutton(s) (Fig 5).
Fig 4(A) Diagram showing Metzenbaum scissors introduced through the LF portal. (B) Arthroscopy is placed in the lateral gutter on a supine position. Metzenbaum scissors are used to cut the continuous loop (continuous tape). (C) A rongeur is used to remove them.
This Technical Note presents an endoscopic technique that successfully removes Endobuttons through a small lateral skin incision of the distal thigh. This minimally invasive approach allows us to better visualize the Endobutton removal than the open approach.
Several studies have shown that Endobutton over the soft tissue sometimes can induce tissue irritation or pain.
A recent Technical Note showed an arthroscopic technique to reduce Endobutton migration during the ACL reconstruction procedure. This proposed technique is very similar in terms of portal setting and how to approach the location of Endobutton.
The indication for this technique is most of the postoperative status after ACL reconstruction surgery. The contraindications are as follows: (1) Endobutton is located in the posterior aspect of the lateral femoral condyle close to the peroneal nerve, and (2) Endobutton is located far from the proximal attachment of the lateral capsule to the femoral cortex.
Advantages and disadvantages are shown in Table 1. Procedural pearls and pitfalls are shown in Table 2. Potential complications include lateral fluid extravasation because this technique is performed in the extra-articular space and damage to the Endobutton loop by using an RF probe.
Table 1Advantages and Disadvantage of Endoscopic Removal of Endobutton
Advantages
This minimally invasive procedure can facilitate a quicker recovery.
Direct visualization of Endobutton(s)
Direct visualization to coagulate bleeding surrounding Endobuttons.
Disadvantages
Excessive introduction of fluid may increase the risk of fluid extravasation
Potential risk of skin and subcutaneous tissue burn injuries resulting from prolonged activation of radiofrequency probe.
In conclusion, the proposed procedure is less invasive and could be beneficial for removing Endobuttons after ACL reconstruction of the knee joints. It can facilitate a quicker recovery.
This movie shows an endoscopic technique to remove Endobutton after anterior cruciate ligament (ACL) reconstruction. An 18-year-old female runner underwent ACL double bundle reconstruction with semitendinosus tendon autograft. Double-bundle autografts were fixed with an Endobutton continuous loop (CL). The arthroscopic view from the anterolateral portal shows double-bundle ACL reconstruction. Plain X-ray films show double Endobuttons.
A 30° arthroscope is introduced through the anterolateral portal (ALP). A standard arthroscopic examination is performed through the anteromedial portal and ALP. And then, an arthroscope is placed in the lateral gutter through the ALP. The lateral femoral portal is created through the femoral guide pin incision, which was made at the previous surgery on the lateral aspect of femur.
Viewing from the ALP, the lateral capsule is incised with a scalpel, and the arthroscope lens is positioned at the external surface of the knee capsule at the lateral aspect of the distal femur. We sometimes use fluoroscopy or sonography to aid locating the Endobutton(s). Typically, these buttons are embedded in the postoperative scar tissue.
A radiofrequency probe is used to expose the Endobutton. If there are more than 2 buttons for double-bundle ACL reconstruction, both Endobuttons are endoscopically visualized before commencement of hardware extraction. Metzenbaum scissors are used to cut the CL, and then a rongeur is used to remove the buttons.
If it is hard to introduce Metzenbaum scissor between Endobutton and bone surface, a rongeur is used to expose the CL site. And then, scissors are used to cut the CL, which is finally removed by using a rongeur.
After removal, bleeding surrounding the Endobutton is coagulated using an RF probe. Postoperative radiography confirms removal of the Endobutton(s).
References
Yassa R.
Adam J.R.
Charalambous C.P.
Complications following suture button use for femoral graft fixation in arthroscopic anterior cruciate ligament reconstruction: A systematic review.
The authors report the following potential conflict of interest or source of funding: S.U. reports other from Smith & Nephew and ConMed. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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