Direct Visualization of Existing Footprint and Outside-In Drilling of the Femoral Tunnel in Anterior Cruciate Ligament Reconstruction in the Knee  E. Grant Sutter, M.D., M.S., John A. Anderson, M.D., M.Sc., William E. Garrett, M.D., Ph.D.  Arthroscopy Techniques  Volume 4, Issue 2, Pages e107-e113 (April 2015) DOI: 10.1016/j.eats.2014.11.017 Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 1 Arthroscopic view showing the remainder of the ruptured anterior cruciate ligament (ACL) stump on the lateral wall of the femur adjacent to the synovium overlying the posterior cruciate ligament (PCL) (viewed through anteromedial portal, with lateral [L] on left and medial [M] on right). Arthroscopy Techniques 2015 4, e107-e113DOI: (10.1016/j.eats.2014.11.017) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 2 Arthroscopic view of the posterior border of the anterior cruciate ligament (ACL) footprint at the junction of the reflection of the synovium and the proximal border of the articular cartilage (viewed through anteromedial portal, with lateral [L] on left and medial [M] on right). The center of the ACL lies straight distal to this point, and it acts as the starting point of the swath. Arthroscopy Techniques 2015 4, e107-e113DOI: (10.1016/j.eats.2014.11.017) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 3 Arthroscopic view of the lateral femoral condyle with identification of the anterior cruciate ligament remnant on the lateral intercondylar wall (oval) after debridement, distal to the point identified in Figure 2 in line with the axis of the femur (viewed through anteromedial portal, with lateral [L] on left and medial [M] on right). Arthroscopy Techniques 2015 4, e107-e113DOI: (10.1016/j.eats.2014.11.017) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 4 Arthroscopic view of the swath through the center of the anterior cruciate ligament (ACL) footprint created by the radiofrequency probe, with equal parts of the footprint above and below (arrows) (viewed through anteromedial portal, with lateral [L] on left and medial [M] on right). Only a swath is created because these remaining fibers aid in targeting the center of the ACL. Arthroscopy Techniques 2015 4, e107-e113DOI: (10.1016/j.eats.2014.11.017) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 5 Sagittal view of the intercondylar surface of the lateral femoral condyle. The black dashed lines represent the path of the swath, distal to the proximal border of the articular cartilage and parallel to the axis of the femur. The swath passes through the anterior cruciate ligament (ACL) footprint (yellow area) and the center of the footprint (red circle). Portions of the footprint remain above and below the swath. The white line represents the lateral intercondylar ridge, a reference for the anterior border of the footprint. Arthroscopy Techniques 2015 4, e107-e113DOI: (10.1016/j.eats.2014.11.017) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 6 Arthroscopic view of the lateral intercondylar ridge (also called the resident's ridge), which can be used as a landmark to identify the anterior border of the anterior cruciate ligament (ACL) footprint (as described in Fig 5) (viewed through anteromedial portal, with lateral [L] on left and medial [M] on right). Arthroscopy Techniques 2015 4, e107-e113DOI: (10.1016/j.eats.2014.11.017) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 7 Arthroscopic view of the femoral guide marking hook placed over the center of the anterior cruciate ligament (ACL) footprint (viewed through anteromedial portal, with lateral [L] on left and medial [M] on right). This guide is inserted through the anterolateral portal. Arthroscopy Techniques 2015 4, e107-e113DOI: (10.1016/j.eats.2014.11.017) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 8 Arthroscopic view of the 3.5-mm FlipCutter reamer drilled through the anterior cruciate ligament footprint, opening to drill the femoral socket in a retrograde manner (viewed through anteromedial portal, with lateral [L] on left and medial [M] on right). Arthroscopy Techniques 2015 4, e107-e113DOI: (10.1016/j.eats.2014.11.017) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 9 Arthroscopic view of the femoral socket drilled in retrograde fashion to the desired depth by the FlipCutter reamer (viewed through anteromedial portal, with lateral [L] on left and medial [M] on right). A passing suture is then placed. Arthroscopy Techniques 2015 4, e107-e113DOI: (10.1016/j.eats.2014.11.017) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 10 Arthroscopic view of the tibial tunnel guide placed within the tibial anterior cruciate ligament footprint near the posterior margin to avoid impingement (viewed through anteromedial portal, with lateral [L] on left and medial [M] on right). The stylet at the other end of the guide is placed on the tibia through the graft harvest incision (not shown). Arthroscopy Techniques 2015 4, e107-e113DOI: (10.1016/j.eats.2014.11.017) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 11 Arthroscopic view of the 4-stranded hamstring graft tensioned into the femoral socket by the TightRope RT construct until fixation is achieved (viewed through anteromedial portal, with lateral [L] on left and medial [M] on right). The graft is anatomically positioned at the posterior aspect of the lateral wall, there is no posterior cruciate ligament impingement, and there are no graft fibers at the apex of the intercondylar notch. Arthroscopy Techniques 2015 4, e107-e113DOI: (10.1016/j.eats.2014.11.017) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions