Hybrid Suspensory Fixation for Anterior Cruciate Ligament Reconstruction: Fixed Femoral Endobutton with Self-made Adjustable Tibial Suture-disc

Abstract

Cortical suspensory fixation in anterior cruciate ligament reconstruction (ACLR) must provide secure graft seating while permitting appropriate tensioning. We describe a cost-conscious hybrid construct combining a fixed femoral Endobutton with a surgeon-made adjustable tibial suture-disc. A 21-year-old man presented with 2 years of right-knee pain and instability after a slip-and-fall injury. Examination showed positive Lachman and anterior drawer tests, and magnetic resonance imaging confirmed a complete ACL tear with Grade II posterior-horn medial-meniscus signal. Arthroscopy showed a stable posterior horn without an unstable surface-reaching tear; the meniscus was left in situ . ACLR was performed with an ipsilateral semitendinosus-gracilis autograft prepared as a quadrupled four-strand graft measuring 8.5 mm × 80 mm. The femoral tunnel measured 8.5 mm × 40 mm, with approximately 25 mm of graft seated using a 15-mm fixed-loop Endobutton. The tibial tunnel measured 8.5 mm × 45 mm. Tibial fixation used a suture disc and No. 2 Ethibond braided coated polyester suture configured as eight load-sharing strands with two free tensioning limbs, secured with five alternating reversing half-hitches after sequential retensioning. At 12 weeks, range of motion was 0°–135° without extension lag; Lachman and pivot-shift tests were Grade 0 with a firm endpoint; Lysholm score was 95 and Tegner activity level was 4. No postoperative complication was documented. The International Knee Documentation Committee subjective score was not available. This early result supports technical feasibility but not superiority; comparative biomechanical testing and longer prospective follow-up are required.