div class="mh-row clearfix">
h1>a href="/image7/accll10.jpg">img alt="" align="middle" src="/image7/accll10a.jpg"/>/a> a href="/image7/accll11.jpg">img alt="" align="middle" src="/image7/accll11a.jpg"/>/a>hr size="3"/>/h1>
div class="bodycopy">- See: a href="/muscles-tendons/notchplasty/">Notchplasty/a>: br/>
br/>
hr size="3"/>
strong>- Technique:/strong> br/>
- strong>a href="/bones/tibia-fibula/tibial-tunnel-for-acl-reconstruction/">preparation - tibial tunnel/a>:/strong> br/>
- tibial tunnel is created prior to femoral tunnel; br/>
- a more medial to lateral tunnel placement, will cause the a more medial to lateral femoral tunnel; br/>
- femoral tunnel must be oriented in a somewhat lateral direction, in order to have the guide wire to exit distal to tourniquet; br/>
- strong>preparation - femoral tunnel:/strong> br/>
- knee joint is flexed to at least 90 deg, which opens up the notch; br/>
- in saggital plane, guide wire should pierce roof of the inter-condylar notch at a point about 6 mm anterior to posterior edge; br/>
- 6 mm offset guide is useful to achieve a precise measurement; br/>
- in axial plane, the guide wire should pierce notch at 1 to 2 O'clock position (left knee) or the 10-11 O'clock position (right knee); br/>
- if tibial tunnel does not allow easy access to posterior aspect of intercondylar notch, additional knee flexion will move guide wire posteriorly; br/>
- references: br/>
- a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/12579136">Femoral aimer deformation: Potential cause for altered femoral tunnel placement in anterior cruciate ligament surgery./a> br/>
- strong>reaming:/strong> br/>
- a cannulated dill (10 mm) is placed over the guide wire and is reamed initially to a depth of 4-5 mm; br/>
- drill is backed out, and the foot print is examined for possible "blow out" of the back wall br/>
- note that geometry of posterior cortex is in MD's favor, hence if there is doubt about the back wall, surgeon can ream several br/>
millimeters further and then reassess the situation; br/>
- cannulated reamer is then reamed to a depth of about 30 to 35 mm: br/>
br/>
a href="/image4/tdacl49.jpg">img alt="" align="middle" src="/image4/tdacl49a.jpg"/>/a> a href="/image7/accll3.jpg">img alt="" align="middle" src="/image7/accll3a.jpg"/>/a>a href="/image7/accll2.jpg">img alt="" align="middle" src="/image7/accll2a.jpg"/>/a> br/>
br/>
br/>
br/>
a href="/image7/aclrd1.jpg">img alt="" align="middle" src="/image7/aclrd1a.jpg"/>/a>a href="/image7/aclrd2.jpg">img alt="" align="middle" src="/image7/aclrd2a.jpg"/>/a> a href="/image7/aclrd3.jpg">img alt="" align="middle" src="/image7/aclrd3a.jpg"/>/a> a href="/image7/accll11.jpg">strong>img alt="" align="middle" src="/image7/accll11a.jpg"/>/strong>/a>br/>
br/>
br/>
br/>
br/>
br/>
strong>- /strong>a href="/joints/knee/acl-graft-fixation/">strong>Graft Fixation/strong>/a>strong>:/strong> br/>
br/>
hr size="3"/>
br/>
a href="/image7/aclrd1.jpg">img alt="" align="middle" src="/image7/aclrd1a.jpg"/>/a> a href="/image7/aclrd2.jpg">img alt="" align="middle" src="/image7/aclrd2a.jpg"/>/a> a href="/image7/aclrd3.jpg">img alt="" align="middle" src="/image7/aclrd3a.jpg"/>/a> br/>
- as these radiographs demonstrate, it is difficult to place the femoral tunnel at the 2 o'clock (or 10 o'clock) position which is necessary to br/>
properly restore the anatomy br/>
br/>
hr size="3"/>
br/>
a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/12579136">Femoral aimer deformation: Potential cause for altered femoral tunnel placement in anterior cruciate ligament surgery./a> br/>
br/>
a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/11694928">Tibial subluxation in anterior cruciate ligament-deficient knees: Implications for tibial tunnel placement./a> br/>
br/>
a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/9839964">Ensuring accurate femoral guide pin placement in anterior cruciate ligament reconstruction./a> br/>
br/>
a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/12682855">Femoral fixation of hamstring tendon autografts using the TransFix device with additional bone grafting in an anteromedial portal technique./a>/div>br/>hr/>br/>br/>br/>Last updated by Clifford R. Wheeless, III, MD on Tuesday, March 19, 2013 6:23 pmbr/>
/div>