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Multiple options for the femoral fixation of a soft tissue graft are in use. The RetroButton (Arthrex, Inc, Naples, Florida) is to a cortical suspension device.1,2 Suspensory devices have attracted increasing interest with the popularity of outside-in femoral drilling for better replication of the anatomy of the native anterior cruciate ligament (ACL).3,4 However, insufficient information exists regarding the intraoperative difficulties and complications encountered using this suspensory device. This information is important because these difficulties can be avoided if the mechanism can be understood and some technical tips are practiced. The authors encountered incomplete sitting, pulling at the outside portion of iliotibial band, or slipping during distal pulling due to incomplete transverse flipping in the early period.
To obtain complete and safe flipping of the RetroButton, flipping was viewed arthroscopically using a superolateral portal, and a probe and knot pusher were used to assist in flipping via a small skin incision site for retro reaming of the femoral tunnel using a FlipCutter (Arthrex, Inc).
Materials and Methods
Without the technique described herein, more than 100 EndoButton loops (Smith & Nephew, London, United Kingdom) and 25 Retro-Buttons were used for femur fixation in ACL reconstruction. This technique was used in 12 recent double-bundle ACL reconstructions (24 RetroButtons) using an outside-in technique.
Surgical Technique
A hamstring autograft was used for the anteromedial bundle, and tendinous portion of the Achilles allograft was used for the posterolateral bundle. The graft's free ends were sutured with #5 Ethibond (Ethicon, Inc, Somerville, New Jersey) approximately 3 cm in length. The smallest 15-mm RetroButton loop was used routinely to maximize the tendon-to-bone contact. The grafts are normally adjusted to 7 mm for the anteromedial tunnel and 6 mm for the posterolateral tunnel.
The anteromedial and posterolateral tunnels of the femur were each created at 90° of knee flexion. The arthroscope was inserted via the anteromedial portal, and the femoral guide set (RetroConstruction Drill Guide Set; Arthrex, Inc) was inserted via an anterolateral portal at a 90° angle using a FlipCutter drill guide system. The tip of the guide hook was pointed at the central portion of the footprint of each bundle using an outside-in technique (Figure 1A). If the footprint was not easily seen, the lateral intercondylar ridge and lateral bifurcate...