An unidentified pitfall of Endobutton use: case report.

We report a case study of a patient who underwent bone-patellar tendon-bone ACL reconstruction using an Endobutton. Although the fact that the Endobutton did not pass outside the femoral cortex was realized after the operation, Lachman's test was negative. The Endobutton appeared to hang onto the femoral tunnel as an anchor, and it was decided to observe rather than intervene. One year later no laxity had developed, and a second-look arthroscopy showed a good ligament reconstruction. Although it is quite easy to perform, Endobutton fixation in ACL surgery requires that maximum care be taken to ensure that the Endobutton has flipped.