Button Position Following ACL Reconstruction in Hasan Sadikin Hospital Bandung

Abstract

Background: Anterior cruciate ligament (ACL) reconstruction are done to restore function and preventing secondary osteoarthritis. The use of button has been popular as a method of femoral fixation during ACL reconstruction (ACLR) due to its securely easy and rapid application. The aim of this study was to review correct placement of tunnels for ACLR based on button position from radiographic examination at Hasan Sadikin Hospital Bandung. Methods: From July 2021 to August 2022 consecutive patients undergoing ACLR with single-bundle techniques were enrolled. Follow up were also done year after ACLR, patients underwent radiographic examination after surgery and clinical examination with International Knee Documentation Committee (IKDC) score. Results: There were 27 patients (3 women, 24 men) with mean age of 26.8 years (17 - 59). The angle measured between a line drawn along the femur diaphysis and the button position from anteroposterior x-ray was approximately 42.3o. In lateral view, 13 had shallow and high button placement, 4 had deep and high button placement and 10 had deep and low button placement (optimal). The optimal button placement for deep-shallow direction has a ratio of 42 to 80% (mean 61,14%) and for the high-low direction has ratio of 9 to 41% (mean 24,07%). In this study, all patients with optimal and non optimal position of laterally measured antero-posterior (AP) proximal-distal (PD) angle had increased IKDC (mean score 58.1 to 84.68). Discussion: X-ray, CT, fluoroscopy and direct endoscopic visualisation had been proposed for tunnel evaluation. This study used standard x-ray due to limitations from Badan Penyelenggara Jaminan Sosial-Kesehatan (BPJS) insurance. Button position should be across the tunnel opening with angle measured towards femur diaphysis to be around 39° in AP view. Lateral view should show optimal placement as mean ratio of 27% in the deep-shallow direction and 34% in the high low direction. IKDC was used as an outcome-measuring tool due to its comprehensive and complex questions. Conclusion: Correct button position for ACLR is important for the clinical outcome of the patients. This study shows that radiographic findings and patient’s clinical outcome is relevant to the quality of operative tunnel placement. A record of this finding is important for completeness of the radiological report. Button position from radiographic examination is usefull to evaluate correct placement of tunel for ACL reconstruction.