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, 8 (5), 379-384

Technical Note: Anterior Cruciate Ligament Reconstruction in the Presence of an Intramedullary Femoral Nail Using Anteromedial Drilling


Technical Note: Anterior Cruciate Ligament Reconstruction in the Presence of an Intramedullary Femoral Nail Using Anteromedial Drilling

Matthew Lacey et al. World J Orthop.


Aim: To describe an approach to anterior cruciate ligament (ACL) reconstruction using autologous hamstring by drilling via the anteromedial portal in the presence of an intramedullary (IM) femoral nail.

Methods: Once preoperative imagining has characterized the proposed location of the femoral tunnel preparations are made to remove all of the hardware (locking bolts and IM nail). A diagnostic arthroscopy is performed in the usual fashion addressing all intra-articular pathology. The ACL remnant and lateral wall soft tissues are removed from the intercondylar, to provide adequate visualization of the ACL footprint. Femoral tunnel placement is performed using a transportal ACL guide with desired offset and the knee flexed to 2.09 rad. The Beath pin is placed through the guide starting at the ACL's anatomic footprint using arthroscopic visualization and/or fluoroscopic guidance. If resistance is met while placing the Beath pin, the arthroscopy should be discontinued and the obstructing hardware should be removed under fluoroscopic guidance. When the Beath pin is successfully placed through the lateral femur, it is overdrilled with a 4.5 mm Endobutton drill. If the Endobutton drill is obstructed, the obstructing hardware should be removed under fluoroscopic guidance. In this case, the obstruction is more likely during Endobutton drilling due to its larger diameter and increased rigidity compared to the Beath pin. The femoral tunnel is then drilled using a best approximation of the graft's outer diameter. We recommend at least 7 mm diameter to minimize the risk of graft failure. Autologous hamstring grafts are generally between 6.8 and 8.6 mm in diameter. After reaming, the knee is flexed to 1.57 rad, the arthroscope placed through the anteromedial portal to confirm the femoral tunnel position, referencing the posterior wall and lateral cortex. For a quadrupled hamstring graft, the gracilis and semitendinosus tendons are then harvested in the standard fashion. The tendons are whip stitched, quadrupled and shaped to match the diameter of the prepared femoral tunnel. If the diameter of the patient's autologous hamstring graft is insufficient to fill the prepared femoral tunnel, the autograft may be supplemented with an allograft. The remainder of the reconstruction is performed according to surgeon preference.

Results: The presence of retained hardware presents a challenge for surgeons treating patients with knee instability. In cruciate ligament reconstruction, distal femoral and proximal tibial implants hardware may confound tunnel placement, making removal of hardware necessary, unless techniques are adopted to allow for anatomic placement of the graft.

Conclusion: This report demonstrates how the femoral tunnel can be created using the anteromedial portal instead of a transtibial approach for reconstruction of the ACL.

Keywords: Anterior cruciate ligament reconstruction; Anteromedial drilling; Intramedullary femoral nail; Retained hardware.

Conflict of interest statement

Conflict-of-interest statement: All the authors have no conflict of interest related to the manuscript.


Figure 1
Figure 1
Preoperative imaging of femoral nail. A 380 mm × 11 mm Synthes trochanteric femoral nail was in place from prior and now well-healed femoral neck fracture. Two 5 mm diameter distal locking screws were used. The distal-most locking screw was placed in the distal femur approximately 20 mm superior to the trochlear notch and oriented from posterolateral to anteromedial, in close proximity to the posterlateral femoral cortex and planned femoral tunnel. A: Sagittal; B: Axial CT images; C: Intraoperative fluoroscopic radiograph. CT: Computed tomography.
Figure 2
Figure 2
Algorithm for anterior cruciate ligament reconstruction with anteromedial portal femoral drilling and distal femoral hardware. Preoperative planning should guide femoral tunnel trajectory and size. Each step of femoral tunnel preparation may be performed under fluoroscopic guidance to avoid contact with existing hardware. Hardware obstruction is most likely to occur during Endobutton drilling. ACL: Anterior cruciate ligament.
Figure 3
Figure 3
Preoperative and postoperative imaging of distal femoral hardware. Anterior cruciate ligament (ACL) reconstruction required removal of existing distal femoral locking screw located approximately 2 cm superior to the intercondylar notch adjacent to posterior femoral cortex and oriented from posterolateral to anteromedial. A: Preoperative Coronal X-ray; B: Postoperative Coronal X-ray; C: Preoperative Sagittal X-ray; D: Postoperative Sagittal X-ray.

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