ACL Reconstruction with Bone Patellar Tendon Bone Autograft - Technique

Drapping and Set Up

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

Exam under anesthesia

• Lachman
• Pivot shift

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