Anatomic Anterior Cruciate Ligament Reconstruction: An Anteromedial Approach Without Hyperflexion

The primary goal of anterior cruciate ligament reconstruction surgery is to recreate the patient's native ligament. We describe an anteromedial drilling technique using a flexible reamer to place an anatomic femoral tunnel without the need for hyperflexion. Identifying the anterior cruciate ligament insertion sites can be accurately performed using measurements from known anatomy. The central femoral insertion is 8.5 mm superior and 2.0 mm deep to the low point on the lateral wall of the notch with the knee in 90° flexion. Anteromedial drilling using a flexible reaming system requires flexion of at most 110° during guide pin placement, and subsequently, tunnel preparation can be performed at less knee flexion. A standard tibial guide is used to place the tibial tunnel based on the constraints of the intercondylar notch. The tibial tunnel is placed slightly anterior and medial to the desired position, as the graft will exit to the posterior and lateral aspect of the tibial tunnel. Femoral fixation is performed with an interference screw placed without hyperflexion. Tibial fixation with an interference screw is performed with the knee in full extension to provide normal anterior translation without overconstraining the knee.