Femoral Footprint Reconstruction With a Direct Viewing of the Posterior Insertion Using a Trans-Septal Portal in the Outside-In Anterior Cruciate Ligament Reconstruction  Ashraf Elazab, M.D., M.Sc., Yong Seuk Lee, M.D., Ph.D., Seo Goo Kang, M.D.  Arthroscopy Techniques  Volume 5, Issue 1, Pages e49-e54 (February 2016) DOI: 10.1016/j.eats.2015.10.001 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 Viewing from the posteromedial portal using a 30° arthroscope through the posterior trans-septal portal, the medial side of the lateral femoral condyle is exposed and showing the native anterior cruciate ligament (ACL) remnant. (PCL, posterior cruciate ligament.) Arthroscopy Techniques 2016 5, e49-e54DOI: (10.1016/j.eats.2015.10.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 Viewing from the posteromedial portal using a 30° arthroscope through the posterior trans-septal portal, the tip of the guide hook is pointed toward the posterosuperior corner of the anterior cruciate ligament remnant and its center is usually corresponding with the posterior cartilage edge in the anteroposterior direction. (PCL, posterior cruciate ligament.) Arthroscopy Techniques 2016 5, e49-e54DOI: (10.1016/j.eats.2015.10.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 Under direct vision by a 30° scope through the trans-septal portal, the FlipCutter is passed through the sleeve from the outside-in direction toward the joint. Once the FlipCutter is positioned at the inside of the joint, the blade of the FlipCutter is folded until it is perpendicular to the shaft. (PCL, posterior cruciate ligament.) Arthroscopy Techniques 2016 5, e49-e54DOI: (10.1016/j.eats.2015.10.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 A looped wire introduced through the sleeve passing the tunnel toward the joint to be used for the later graft passage. Arthroscopy Techniques 2016 5, e49-e54DOI: (10.1016/j.eats.2015.10.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 Direct viewing from the anterolateral portal to superolateral pouch, the correct location of the guidewire could be identified. The arthroscopic shaver is inserted via a skin incision for the FlipCutter or beath pin, and debridement of soft tissue around the guidewire is performed along the guidewire. Then, the tunnel exit is exposed for the complete seating without the impingement of soft tissue (arrow: exit point of the FlipCutter). Arthroscopy Techniques 2016 5, e49-e54DOI: (10.1016/j.eats.2015.10.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 Tip of the tibial guide hook is inserted at the anteromedial corner of the tibial footprint, and then a suitable reamer size corresponding to the graft size introduced over a guide pin toward the joint. (ACL, anterior cruciate ligament.) Arthroscopy Techniques 2016 5, e49-e54DOI: (10.1016/j.eats.2015.10.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 A looped wire introduced through the sleeve passing the tunnel toward the joint is pulled through the tibial tunnel for the graft passage. Arthroscopy Techniques 2016 5, e49-e54DOI: (10.1016/j.eats.2015.10.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 8 TightRope RT button is pulled through the femur until it exits the lateral cortex and the graft is advanced by tensioning on the TightRope RT (arrow: exit point of the FlipCutter). Arthroscopy Techniques 2016 5, e49-e54DOI: (10.1016/j.eats.2015.10.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 9 Viewing from the anterolateral portal, the reconstructed anterior cruciate ligament (ACL) is surrounded by the native ACL remnant (left). Viewing from the posteromedial portal, the reconstructed ACL is surrounded by the native ACL remnant (right). The dark arrow shows the native ACL remnant; the open arrow shows the reconstructed ACL. Arthroscopy Techniques 2016 5, e49-e54DOI: (10.1016/j.eats.2015.10.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 10 Postoperative 3-D computed tomography scan shows the site of the femoral tunnel corresponding with the center of the posterior cartilage edge in the anteroposterior direction. Arthroscopy Techniques 2016 5, e49-e54DOI: (10.1016/j.eats.2015.10.001) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions