We have a ruler. So I'm going to measure it total length as well as the tendon length and the and the bone plug length. So total length is right about 90-91. Both bone plugs are sitting right at about 20. So this is about a 50 millimeter tendon so it's kind of a kind of a long tendon, not terrible. So on the tibial side, I like to use the tibial side on the femur because it's got this ledge here so I can push on it with a screwdriver or mallet. I drilled one hole a little bit eccentric and I'm putting kind of a high grade suture. These will come out. I don't leave these in once we're done but I'm just going to pass this through here with a needle. This is so I get good control of it. I only put one in the proximal plug, the femoral plug, because I'm pulling in. I'm pushing. Whereas I put three in the distal plug and I offset these. You can see I've kind of made a triangle. I don't want to pull all these in one line in the bone. And I've got our graft. So now I have our graft. I'm going to mark with a marking pen the intra-articular edges. So I'm just going to put a line, just a little blue line. Well I think I am. A little blue line right there. A little line right here on the on the other end. And then I'm going to mark the end of the graft that I'm going to try to see at the end of the case as we're putting the tunnel, the screw in the in the tibial tunnel. So I'm going to keep this wrapped up in an antibiotic saline while we're waiting. So I wrap the whole graft and I just put all the sutures and everything in there. So next we're going to make a little spot for our tibial tunnel. So this is done. You can see we've closed up the peritoneum and the tendon. So I'm feeling up here I want to know where I'm going to make my portals. So I can feel the tibial surface here. I've got the tibial tubercle here. I've got hamstrings down there. So we're just going to make a little periosteal window here so we're not affecting the tendon. This is where we're going to drill our tibial tunnel and I'm just making a little window. We'll close that at the end of the case. This is a fixed angle 45 degree guide that aims at the elbow of the guide. This is an old guide. I've used this for a long time but you can do the same thing with a tip aimer. Everybody talks about 53 degrees because that's the angle the tissue is inside the knee. We've never done that. We've always used a lesser angle. It gives us a better angle to get to the back when we're trying to drill trans-tibially. So this is an important part of this technique. Being an elbow aimer you can see the lateral aspect of the anterior horn of the lateral meniscus. I'm going to set this just behind there and then Houston's going to put this bullet in that hits our little area there. I'm going to hold my hand just about perpendicular or parallel to the tibia and he's going to advance us a guide wire that's going to come up to the elbow. Okay there we go. So now I'm going to check and see if I like that. So here I've got I'm straightening the knee out and I've got a great look at the native ACL. So I like that position. I may have to lateralize it just a hair but I actually really like that position. I like the angle it's going. I'm certainly going to get a good angle to my femur and you can see from that from the scope I'm looking straight down. So I've got my eyes looking straight down at the at the tibia. So that's about as straight on a look as we're going to get. All right so flexing the up let's have the 10 reamer. So I'm going to try to cinch this over just a hair once I get it in the tibia. So I'm going to push my hand a little medial to try to push this pin just a little bit and you can see it moving there just a hair. So I don't mind if it comes up right there but I'm going to go slow. We don't want to just break into the knee. This isn't a jailbreak situation. So I like where I am there and I'm going to shave all that out. You can see the inner meniscal ligament up here underneath us. That's where we want to see that. So we want to be kind of just under it. I never really have thought that taking the inner meniscal ligament was that big of a deal. I'm sure there are people that would disagree. So I want to trim out the back side these little ridges back here. We use an acorn reamer so it creates a little bit of a ridge on the back side of the tunnel and that'll make it easier for me to come up to my femoral tunnel. So now I've got my tibial tunnel and I'm going to come look at my femoral tunnel and I like my angle. We're going to straighten the knee out a little bit. So I'm not using a guide or a guide pin. Yep, so we got the knee at about 30 degrees. Flex it up a little bit. I really like my position there. So I'm just going to do a little bit of a straight dunk this in there just a little bit. Yeah, so I like that position. Flex it up just a hair and we're just going to slowly advance the reamer. Come on back. So I'm back there pretty good. I could probably even come a little forward to be honest. All right, flex it up. Come on back. Yeah, I think we're good. He's got a really hard bone. Really hard bone. So I went all the way up to 25 there. So we got what 25, 26 at the entrance to the tunnel. All right, come on back. So we're going to shave. So basically through that 45 degree tibial tunnel, I can get a really good angle to my femur. And this being a patellar tendon graft, the worst position for me is to be down here where my graft material. So let me see a probe. So I think this is super important and Mark Clatworthy really showed us a lot of this, but this is something that Russ Warren and us and everybody have seen over and over. When you're doing patellar tendon grafts, you're putting a bone plug in and your graft material is going to sit about right here. This is where your graft material is going to be on the femur. If you're doing a soft tissue graft, this is probably a little high because the thing takes up the whole tunnel. You probably need to be from here to here. This is where the native ACL attaches. But the worst position is to be down here. You don't want to be anywhere close to there. So it's actually better to be a little high than a little low. But I think that because of the way we do this, we're putting our graft materials going to be sitting right about there. This is the low aspect of the tunnel. So I like our position there and you're going to see this is going to clear the wall very nicely. So let me see the measuring stick. All right, let me see here. Flex it up. So we know we're going to get up here to 30. So what do we have here? 82, 83. All right, let me see a 6, an 8, and a 10. So I'm going to try to take this tunnel. We have a 90 millimeter graft and we got about 82 at the entrance to the tunnel lengthwise. So I'm going to take this tunnel up a little higher and so I'm going to take a six millimeter reamer and just go at the front edge of the tunnel where it is and just try to go a little bit further. I'm going to try to go about another five millimeters and I'm still in bone there but I'm up to 35. So basically what I'm doing is I'm bumping off the back wall of the femur but I'm going anterior in my 10. So I've got plenty of room. So I'm going to take a 6, then an 8. I'm just going to sequentially enlarge this up to 35, you know, up to 10. So I've essentially gotten, you know, 10 more millimeters of tunnel which is going to be good for us with our 90 millimeter graft. But I can do all of this through the tibia without a guide, without a guide pin. And, you know, one of the things people will say is this is a curved tunnel. It is probably a little bit curved because we go through a little bit of flexion as we're making it. But in 25 years, I've never thought, oh my gosh, if only that tunnel wasn't curved a little bit, we would be okay. So that doesn't seem to be a problem. So I'm just going to take out all this debris from the from the tunnel. This is promoted, this will, some of this stuff will really promote some inflammatory response. So I want to get as much of that bone debris out as I can. All right, now we'll do the beef pin. You can see PCL there. We'll take the pin. Again, we're going purely trans-tibial. I'm going to make sure I head butt the end of my tunnel. There we go. Now we'll take our graft. So I'm very conscious not to put the graft down on the table. So I'm going to hold the graft while he puts the sutures through the end of the beef pin. So all right, thank you, sir. Pull hard. Yeah, keep going. Okay, so now that we got our graft up in there, we're going to turn it a little bit, just so you can see our lines. All right, hit that. We're going to make a little notch for our screw. Yeah, keep going. Get it way up there. Good. Now I'm going to take a guide wire up here. Okay, screwdriver. Is that thing going in the tunnel? Yeah. All right, flexing the knee up, hit the thing. We're going to push this plug up into the tunnel. So Houston's pulling. Keep going. Keep going. Keep going. Keep going. Now I can kind of tell when it stops, and I'm all the way up in the bone tunnel there. All right, so now we got a good graft tunnel deal. Length match. I'm going to put our graft protector on. Come on down here, Houston. And we're going to go up to about 30. Keep going. Keep going. Push. Okay, come on back. Keep going. Yeah, that's good. Good. All right, now I'm going to get some pictures here with the graft at about 90. So I'm looking straight left, got my hand parallel to the floor, and I want to see kind of the whole notch. So that's kind of my view. We're going to look down at it. Now let's extend it nice and slow. I'm going to look down, and I'm watching to see is the graft moving as I'm doing that, and it's not. So I've got this guy in full hyperextension. His graft easily clears the notch. Tap. Yeah, let's get down there. Pull this. Yep. Are you behind the plug? Good. That's good. You get too far in there, you'll break your sutures. Good. No pivot. Full range. So this is nice and tight. My criteria for success here are it does not impinge the PCL. It does not impinge the wall. It does not impinge the notch and extension. It is aimed in the right direction. So when I hold my hand, my eye is looking straight right, and I've got my hand parallel to the floor, and I'm looking at the whole notch. I should see this going at about the 1.30 to 2 o'clock position, or 11.30, 10.30 to 10 o'clock position on the opposite side. So I'm pretty happy with that. I think this will do great, and thank you all.

ACL surgery

ligament reconstruction

graft positioning

tibial tunnel

surgical precision