I'd like to thank my co-authors and also like to thank the education committee allowing us to present our research. Our disclosures are listed on the media app online. So historically, bone tendon bone with patellar tendon and interference screw fixation has typically been the gold standard for ACL reconstruction. Certainly it's still an excellent graft choice and method of fixation, but it's not without potential complications which have also been well documented. Those include graft harvest complications, donor site morbidity, implant prominence and other complications, and certainly the most commonly quoted post-operative anterior knee pain. Due to these complications, the various all-inside techniques have been developed to be less invasive with minimal hardware prominence. There are various different types of techniques available including adjustable and fixed loop devices, but the key concept is that they all use a typical type of cortical suspensory fixation as you see depicted here to create the construct. This construct has been validated in multiple biomechanical and clinical studies. This is one of the more recent biomechanical studies where they looked at adjustable loop cortical buttons versus metallic interference screws. They did this in eight porcine distal femurs in each group, and they tested both load to failure and linear stiffness. The results showed similar time zero failure loads with less than one millimeter displacement difference between the two groups. This was a randomized controlled trial evaluating 148 patients, 76 in the all-inside suspensory fixation group and 74 in a full tibial tunnel group. They showed no clinical differences in clinical failures or re-tears, no differences in all of their outcome measures, no differences in socket on the tibial femoral side or tunnel widening with the screws. The only statistically significant difference was lower VAS pain scores at the initial post-operative visits with the all-inside suspensory fixation technique. The key concept with this construct, for those of you that have not done it before or have recently learned it, is that the fixation construct relies on cortical apposition of the device or that metal button against the bone. The surgeon can confirm device placement intraoperatively either using intraoperative fluoroscopy or via direct or indirect intra- or extra-articular visualization. So the purpose of our study was to evaluate the benefit of intraoperative fluoroscopy to confirm device position on the femur using this cortical suspensory fixation technique. Our hypothesis was that there would be a significant difference in optimal device location in the patients who had intraoperative fluoroscopic imaging performed. This was a retrospective review of 100 consecutive soft tissue ACL reconstructions by three surgeons. They all had the same fixation technique and construct as you see depicted in the top right. Two patient groups, group A, had intramedial portal visualization to visualize device placement and deployment, as you see in the bottom right-hand corner of the screen with the device going through the femoral socket, and then had confirmatory intraoperative fluoroscopy to confirm placement against the cortex. Group B utilized just intramedial portal visualization alone. All patients then had radiographs at the first postoperative visit, which were independently reviewed by three fellowship-trained sports surgeons. Device position was then categorized on postoperative radiograph in one of two groups. Optimal position was the device opposed to the cortex. Suboptimal position was device greater than 2 millimeters off the cortex, as you see depicted in the bottom right-hand picture. Statistical evaluations were performed using Fisher's exact test, repeated measures and analysis of variance, 95% confidence intervals to determine inter-observer reliability, and then the SAS version. Our results showed in the first group, the group that had intraoperative fluoroscopic imaging performed, there were 60 patients in the group. All had optimal position with no clinical failures. The second group, which did not have intraoperative fluoroscopy performed, there were 40 patients in the group, four of which, or 10%, had suboptimal positioning, which was statistically significant. There was one clinical failure in that group of four, which was not statistically significant. The inter-observer reliability was strong at 0.91. There are certainly limitations. This is a retrospective review, so certainly subject to observer bias. The inter-observer reliability was high, which hopefully adds to some of the validity of the data. There was no randomization of technique. This was each surgeon typically uses intraoperative fluoroscopy or not, and so the same surgeon utilized the same technique that they were comfortable with based on their particular patient case. Because of this, that led to unequal patient numbers in the groups. This was a consecutive patient case series, which hopefully limited some recall bias, but then certainly led to unequal patient numbers in the groups. So in conclusion, there was a significant difference in cortical device position in patients who had intraoperative fluoroscopic imaging performed versus patients who did not. Therefore, confirmatory intraoperative imaging may be beneficial to confirm appropriate device location when using femoral cortical suspensory fixation in ACL reconstruction. Thank you.

femoral cortical suspensory fixation

ACL reconstruction surgery

intraoperative fluoroscopy

complications

all-inside techniques