ACL Reconstruction

First incision over distal half of patella & inferior pole, around 3-4 cm long
Second incision just medial to tibial tubercle, to allow access to tubercle & to tibial tunnel

Expose patellar tendon & define its medial & lateral borders
Incise patellar tendon longitudinally to provide desired graft thickness (10mm in big man)
Measure 25mm bone plugs within patella & proximal tibia
Start off bone by using osteotome to make using the dowel cutter easier
Use dowel cutter to harvest plugs
Drill holes in mid point of plugs prior to removing them
Use osteotome to harvest plugs
Place 5 Ethibond sutures through drill holes & mark graft appropriately

Normal arthroscopy portals
Exclude meniscal or other problems
Clean up medial wall of lateral femoral condyle – use combination of curette & arthroscope. Clean up ligamentum mucosum
Establish graft entry point: 2-3mm of posterior wall should remain, at 11 o’clock in right knee & 1 o’clock in left knee. Make hole with awl. Commercial instruments are available to assist with femoral tunnel placement
Get goldfinger & position with point just medial to lateral tibial spine. May need to clean up ACL stump a little but don’t get rid of all of it. Set angle to 45-55° & introduce other end via tibial incision. Drill wire through; should emerge into axilla of goldfinger. Note that another suggested tibial tunnel exit is just medial to the anterior horn of the lateral meniscus. Hale says should be posterior to intermeniscal ligament. JBJSB 2003 – Allum says the guide wire should emerge posterior to the posterior edge of the anterior horn of the lateral meniscus, 5-7mm anterior to the PCL & in the posterior half of the ACL stump if this is present. Formerly, graft placement in the anterior half of the footprint was advised
Drill out tunnel with drill 1mm bigger than graft. This makes graft placement much simpler
Drill wire into awl hole with the knee flexed
Drill out hole in femur, passing wire out the proximal femur
Clean out holes thoroughly with curettes & arthroscope

Run graft through tunnels. Secure in femur with RCI screw
Extend knee & see if graft impinges. If it does, will need to perform notch plasty
Then extend knee & fix graft in tibia