ACL Reconstruction with Bone Patellar Tendon Bone Autograft - Technique

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Drapping and Set Up

  • Supine
  • Turniquete
  • Lateral post
  • Foot rest
  • Contralateral leg sling

Exam under anesthesia

Patella Harvest

  • Midline incision from mid-patella to tibial tubercle
  • Create sub-Q flaps
  • Incise peritenon and expose to edges of patella tendon and place Kelly under patella tendon.
  • Retract with army-navy and sins
  • Harvest middle 1cm of patella tendon mark c ruller and cut superior to patella and 2.5-3 cm into patella. Cut down to tibial tubercle and 2.5-3cm into tibial tubercle.
  • Use 1cm saw blader and cut tibial tubercle 1 cm deep c rhomboid cut and remove with use of 0.5 cm straight osteotome.
  • Remove infrapatella tendon fat up to patella.
  • Use 1cm saw blade and cut straight down on patella about 0.5-1 cm. Use 0.5 cm blade and cut underneath patella to release graft.
  • Remember to expose medial side of tibia for graft portal placement.

Prepare Patella graft

  • Squench graft to fit through tunnel about 10mm and remove non-collagen debri.
  • Drill one hole on patella side of graft and place ethabond suture and hemostat. Cut off needle.
  • Drill two holes on tibial tubercle side of graft and place two ethibonds and clip with hemostats.
  • Mark with blue pen transition b/t bone and tendon on patellar side.

Scope Knee

  • Create standard inferior lateral and medial portals through skin.
  • Diagnostic scope and pictures.
  • Perform notch plasty.

Tibial Tunnel

  • Set tibial tunnel finder at set degree (40-45 degrees)
  • Place tibial tunnel guide through medial arthroscopy portal. Tip should line up with anterior horn of the lateral meniscus and 7 mm anterior to PCL.
  • Starting point on tibia should be 1-2 cm medial to tibial tubercle.
  • Use beef pin and make pilot drill, watch with scope.
  • Drill tunnel with drill or acorn bit to appropriate size.
  • Clean tunnel with rasp or

Femoral Tunnel

  • Flex knee to greater than 90 degrees.
  • Use over the top guide to leave 2mm of posterior wall of femoral tunnel, and place at 11 o'clock (R knee) or 1 c'clock (L knee). 
  • Use beef pin through over the top guide and out through skin.
  • Drill femoral tunnel to 30 mm. Clean tunnel.

Graft Placement

  • Pull graft through tunnel and stop when blue mark reaches femoral bone tunnel.
  • Make notch anterior for screw pin.
  • Place screw pin into notch and tap for appiture fixation
  • Place femoral tunnel screw.
  • Pull tension on distal aspect of graft and range the knee.
  • Place tibial screw pin, tap and place tibial appiture fixation.
  • Trim tip of graft if needed.

Closure

  • Close peritenon
  • Close skin
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