Dti

Figure 51-11 A, Incision site for harvest of autogenous hamstring graft. B, Isolation of gracilis and semitendinosis tendons. A closed tendon stripper is then used to complete the individual tendon harvest.

harvest. A provisional pin is advanced into the ACL footprint using the guide. The aiming guide is then removed and the pin is overreamed with a cannulated reamer of appropriate size (Fig. 51-13A).

Any remaining bone fragments are then removed with the use of a motorized shaver. The femoral tunnel can then be

Figure 51-12 Quadruple hamstring graft being prepared for EndoButton (Smith & Nephew, Andover, MA) CL fixation.

HERMES*

Figure 51-13 A, Tibial guide pin positioned in the center of the anterior cruciate ligament footprint. B, Femoral tunnel in 2-o'clock position with approximately 1 to 2 mm of remaining posterior wall.

Figure 51-13 A, Tibial guide pin positioned in the center of the anterior cruciate ligament footprint. B, Femoral tunnel in 2-o'clock position with approximately 1 to 2 mm of remaining posterior wall.

addressed. The femoral tunnel can be drilled with the use of commercially available offset guides through a transtibial technique. Alternatively, a medial portal technique can be used, in which the femoral tunnel is drilled from the medial portal.34 An offset aimer guide, typically either 6 or 7 mm, is placed in the "over-the-top" position oriented toward the 10- to 11-o'clock (right knee) or 1- to 2-o'clock (left knee) position with the knee in 90 degrees of flexion. A guide pin is then advanced approximately 3 cm and overreamed with an acorn reamer of appropriate size to a depth of about 35 mm. A 1- to 2-mm cortical wall should remain posterior to the tunnel (Fig. 51-13B).

Femoral fixation is dependent on graft choice and surgeon preference. We generally use metal interference screw fixation for bone plugs and EndoButton (Smith & Nephew, Andover, MA) fixation for soft-tissue grafts. For bone plug fixation, a Beeth pin is advanced using a transtibial technique through the femoral tunnel and out the lateral aspect of the femur. It is retrieved laterally and used to pull the sutures on the graft through the femoral tunnel. The bone-patellar tendon-bone graft is then advanced through the tibial tunnel and into the femoral tunnel. A guide pin for the interference screw is then placed between the bone plug and the tunnel. A 7 X 25-mm can-nulated metal interference screw is then placed over the guidewire. With this technique, the cortical edge of the bone plug is placed posteriorly and the cancellous surface faces anteriorly.

In the case of soft-tissue grafts, after the femoral tunnel is drilled, the far cortex is breached with a 4.5-mm EndoButton drill and the depth gauge is used to assess the distance to the far cortex. Similarly, a Beeth pin is advanced through the EndoButton drill hole using a transtibial technique. It is retrieved laterally and used to pull the graft through the femoral tunnel. An appropriate length EndoButton loop is selected. Ideally between 30 and 35 mm of graft should ultimately reside within the tunnel. When EndoButton fixation is desired, the tunnel depth needs to be deep enough to accommodate the intended graft length plus an additional 8 mm for flipping the button. The quadruple-strand graft is placed in the closed loop EndoButton and sutured together using a no. 2-0 bioabsorbable stitch. Pulling sutures (using no. 2 nonabsorbable braided suture) are placed in

Figure 51-14 Final appearance of autogenous hamstring anterior cruciate ligament reconstruction.

the peripheral holes of the EndoButton, and these are advanced into the femoral tunnel using the Beeth pin. The graft is passed in a routine fashion, and the EndoButton loop is flipped to establish femoral fixation.

Once femoral fixation is achieved, the knee is cycled through a full range of motion and graft impingement is assessed. Tension is applied to the graft, and tibial fixation is performed in approximately 10 to 20 degrees of knee flexion. Bone-patellar tendon-bone grafts are secured with metal interference screw, whereas soft-tissue grafts can be secured with numerous fixation implants. Currently, we use interference fixation with a bioabsorbable screw or an Intrafix (Mitek, Innovasive Devices, Mitek, Westwood, MA) device on the tibial side for soft-tissue grafts

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Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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