A Surgical Technique for Posterolateral Placement of Interference Screw Accurately in Tibial Tunnel in Single-Bundle Anterior Cruciate Ligament Reconstruction  Prashant Parate, D.N.B., Bancha Chernchujit, M.D.  Arthroscopy Techniques  Volume 5, Issue 6, Pages e1481-e1486 (December 2016) DOI: 10.1016/j.eats.2016.08.026 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 The patient is placed in the supine position with the opposite leg on a lithotomy positioner and the operative limb in the hanging position. The right knee is being operated on. (A) The arthroscope is in the anterolateral portal. The Ethibond suture is pulled into the tibial tunnel through the femoral tunnel for graft passage. (B) The arthroscope is in the anterolateral portal. The guidewire is passed in the tibial tunnel from distal to proximal and held with straight artery forceps inside the joint. As the straight artery forceps come from the anterolateral (AL) portal, it becomes easy to hold the guidewire laterally to place the screw posterolateral in the tibial tunnel. (C) The arthroscope is placed in the anteromedial (AM) portal. Straight artery forceps are placed through the anterolateral (AL) portal to hold the guidewire in position (outside view). (D) The arthroscope is in the anteromedial portal. The guidewire is adjusted posterior to the Ethibond suture in the tunnel. Using a suture retriever may be helpful sometimes to bring the Ethibond suture into the appropriate position. (E) The arthroscope is in the anteromedial portal. Graft-pulling threads are pulled through the femoral tunnel. These threads come anterior to the guidewire because of the adjustment made in the previous step. (F) The arthroscope is in the anteromedial portal. The graft automatically comes anteromedial to the guidewire because of meticulous positioning of the guidewire. (G) The arthroscope is in the anteromedial portal. In its final position, the guidewire is placed posterolateral to the graft before screw insertion. This position is ideal, and the guidewire needs to be held appropriately because sometimes it becomes difficult to see it. (H) The arthroscope is in the anteromedial portal. The final orientation of the graft is well aligned with the medial tibial spine after the screw is inserted up to the joint line. Arthroscopy Techniques 2016 5, e1481-e1486DOI: (10.1016/j.eats.2016.08.026) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 The patient is placed in the supine position with the opposite leg on a lithotomy positioner and the operative limb in the hanging position. The right knee is being operated on. (A) The arthroscope is in the anterolateral portal. The Ethibond suture is pulled into the tibial tunnel through the femoral tunnel for graft passage. (B) The arthroscope is in the anterolateral portal. The guidewire is passed in the tibial tunnel from distal to proximal and held with straight artery forceps inside the joint. As the straight artery forceps come from the anterolateral (AL) portal, it becomes easy to hold the guidewire laterally to place the screw posterolateral in the tibial tunnel. (C) The arthroscope is placed in the anteromedial (AM) portal. Straight artery forceps are placed through the anterolateral (AL) portal to hold the guidewire in position (outside view). (D) The arthroscope is in the anteromedial portal. The guidewire is adjusted posterior to the Ethibond suture in the tunnel. Using a suture retriever may be helpful sometimes to bring the Ethibond suture into the appropriate position. (E) The arthroscope is in the anteromedial portal. Graft-pulling threads are pulled through the femoral tunnel. These threads come anterior to the guidewire because of the adjustment made in the previous step. (F) The arthroscope is in the anteromedial portal. The graft automatically comes anteromedial to the guidewire because of meticulous positioning of the guidewire. (G) The arthroscope is in the anteromedial portal. In its final position, the guidewire is placed posterolateral to the graft before screw insertion. This position is ideal, and the guidewire needs to be held appropriately because sometimes it becomes difficult to see it. (H) The arthroscope is in the anteromedial portal. The final orientation of the graft is well aligned with the medial tibial spine after the screw is inserted up to the joint line. Arthroscopy Techniques 2016 5, e1481-e1486DOI: (10.1016/j.eats.2016.08.026) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 Screw position by rear end of drill and empty space that will be occupied by graft. The patient is placed in the supine position with the opposite leg on a lithotomy positioner and the operative limb in the hanging position. The right knee is being operated on, and the arthroscope is in the anteromedial portal. (A) If the screw is posterolateral in the tunnel, the graft will be able to cover the anterior part of the tunnel from the anterior margin of the footprint and fall over posterolaterally. (B) If the screw is in the anteromedial part of the tunnel, the graft will come from the posterolateral aspect of the tunnel, not covering the anteromedial tunnel, where the normal C-shaped attachment should start. Arthroscopy Techniques 2016 5, e1481-e1486DOI: (10.1016/j.eats.2016.08.026) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 The patient is placed in the supine position with the opposite leg on a lithotomy positioner and the operative limb in the hanging position. A right knee is being operated on. (A) The arthroscope is in the anteromedial portal. The guidewire is inserted anterior to the graft; the screw will occupy the anterior portion in the tunnel, and the graft will be pushed posteriorly. (B) The arthroscope is in the anteromedial portal. With our technique, the screw remains posterolateral. (C) The arthroscope is in the anterolateral portal. The final position of the guidewire is posterolateral so that the screw will occupy the posterolateral portion of the tunnel and the graft falls naturally anteromedially to posterolaterally, covering the whole tunnel. Arthroscopy Techniques 2016 5, e1481-e1486DOI: (10.1016/j.eats.2016.08.026) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions