Hello, my name is Bill Ciccone from Denver, Colorado, and we'll talk about ACL reconstruction with the use of the antermedial portal for femoral tunnel placement. There are different options for creating your femoral tunnel. You can use a trans-tibial approach, you can use the antermedial portal, or you can do a two-incision or outside-in approach. We're going to be talking about the antermedial approach today. For this technique, you do your standard knee arthroscopy. You can create your medial and lateral portals. You want to do your inter-articular work with ACL debridement and lateral wall exposure and clear out the fat pad medially. You then flex the knee to around 120 degrees to create your accessory antermedial portal, and it's usually right in that location there. The advantages of this portal is that it allows independent placement of your femoral and tibial tunnels. As you're not working through your tibial tunnel, there's not a lot of fluid leakage, so you can get good visualization. It allows for anatomic placement of the femoral tunnel and limits your fixation divergence if you're using interference fixation. And it's an excellent technique for placement of the femoral tunnel in revision surgery. The disadvantages are, with the knee inflection, it can restrict your visualization a bit. But the main issue is particular damage that can occur to the articular cartilage along the medial femoral condyle while passing the reamer. This technique will address this problem. I like to use a knee holder when I'm doing ACL surgery. It allows for stable positioning of the knee, especially inflection, that allows me to more focus on the arthroscopic parts of the procedure and not worrying about holding the knee in the correct position. So in this technique, we again flex the knee to around 120 degrees. We create the portal first with a spinal needle to get the appropriate location. The correct offset guide is then utilized. We then mark the site of the femoral wall with the beeth pin. We then remove the beeth pin. The main way that the medial femoral condyle articular cartilage is injured is by trying to squeeze the reamer along the guide wire around the medial femoral condyle. There's just not a lot of room there. So in this technique, we remove the beeth pin so that the reamer can be inserted well anterior to the medial femoral condyle so that there's no damage to the articular cartilage. We then replace the beeth pin through the reamer in the correct position into the bone. And then we can ream our femoral tunnel. You then remove the beeth pin. So again, you can remove the reamer around the medial femoral condyle. So this is the technique. This is a left knee, where we're visualizing the spinal needle coming in in the position for the low anterior medial portal with good access. We'll go ahead and create the tunnel under direct visualization. The offset guide is then placed, and we're going to mark the femoral tunnel now with the beeth pin. We'll drill that in about a centimeter and then pull that out so we have a good mark. We're then going to bring in the reamer without being constrained by the guide wire. We'll bring that right in and line that back up with the previously made hole. We'll reinsert the guide wire and then drill that through like you would do normally, and then create our femoral tunnel. We'll then just pull back the reamer into the notch, and then we'll remove the guide wire again. So again, I can pull the reamer around the medial femoral condyle. This portal allows for good placement for a correctly positioned femoral tunnel.

ACL reconstruction

Anteromedial Portal

femoral tunnel

knee arthroscopy

Denver Colorado

anterior-medial portal

femoral tunnel placement

cartilage damage