An Alternative Technique to Avoid Injury to the Medial Femoral Condyle When Reaming the Femoral Tunnel During Anterior Cruciate Ligament Reconstruction  Kevin F. Bonner, M.D., Angelo Mannino, M.S.  Arthroscopy Techniques  Volume 6, Issue 1, Pages e149-e155 (February 2017) DOI: 10.1016/j.eats.2016.09.017 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 An arthroscopic view showing damage to the medial femoral condyle caused by reaming through the anteromedial portal during a prior anterior cruciate ligament reconstruction. Arthroscopy Techniques 2017 6, e149-e155DOI: (10.1016/j.eats.2016.09.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 An intraoperative view of a right knee at 90° of flexion. Marking of the starting point of the femoral tunnel on the lateral femoral condyle for anterior cruciate ligament reconstruction. Arthroscopy Techniques 2017 6, e149-e155DOI: (10.1016/j.eats.2016.09.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 With the knee in 90° of flexion, the acorn reamer enters the anteromedial portal passed the medial femoral condyle. Arthroscopy Techniques 2017 6, e149-e155DOI: (10.1016/j.eats.2016.09.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 With the knee in 90° of flexion, the guide pin is passed through the acorn reamer and engaged into the femoral starting point that was previously created on the lateral femoral condyle. Left: surgeon holding the acorn reamer in position. Right: intra-articular view of guide pin seated inside the femoral starting point within the acorn reamer. Arthroscopy Techniques 2017 6, e149-e155DOI: (10.1016/j.eats.2016.09.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 Once the guide pin is visualized engaging the starting position on the lateral femoral condyle, the knee is placed into hyperflexion, all while maintaining visualization and position of the guide pin. Arthroscopy Techniques 2017 6, e149-e155DOI: (10.1016/j.eats.2016.09.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 With the knee maintained in hyperflexion, power is attached to the guide pin and the guide pin is drilled into the femoral starting point and through the lateral femoral cortex, while the reamer is used as a guide. (For this, the surgeon maintains the position of the reamer while an assistant drills the guide pin.) Arthroscopy Techniques 2017 6, e149-e155DOI: (10.1016/j.eats.2016.09.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 With the knee maintained in hyperflexion, the power is now transferred from the guide pin to the reamer. The reamer is drilled to the desired depth to create the femoral tunnel. Arthroscopy Techniques 2017 6, e149-e155DOI: (10.1016/j.eats.2016.09.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 8 With the knee maintained in hyperflexion, the power is then transferred from the reamer to the guide pin and the guide pin is removed. The reamer remains in the femoral tunnel until the guide pin is removed. Arthroscopy Techniques 2017 6, e149-e155DOI: (10.1016/j.eats.2016.09.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 9 The reamer is removed from the femoral tunnel and placed into the intercondylar notch (not shown). The knee is relaxed to 70° to 90° of flexion, allowing easier mobility around the medial femoral condyle (MFC). The reamer is navigated around the MFC and exits the anteromedial portal. Arthroscopy Techniques 2017 6, e149-e155DOI: (10.1016/j.eats.2016.09.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 10 A model demonstrating the basic technique of passing the guidewire through the acorn reamer into the desired starting position once the straight acorn reamer is delivered into the notch (acorn reamer placed into the notch adjacent to the lateral wall of the lateral femoral condyle [LFC] so that it can be used as a guide for the guide pin). Arthroscopy Techniques 2017 6, e149-e155DOI: (10.1016/j.eats.2016.09.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions