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J. Biomedical Science and Engineering, 2010, 3, 359-360 JBiSE
doi:10.4236/jbise.2010.34049 Published Online April 2010 (http://www.SciRP.org/journal/jbise/).
Published Online April 2010 in SciRes. http://www.scirp.org/journal/jbise
Femoral notch cleaning in anterior cruciate ligament
reconstruction: a new instrument
Miroslav Z. Milankov1, Natasa Miljkovic2, Zoran Gojkovic1
1Department of Orthopaedic Surgery and Traumatology, Clinical Centre Vojvodina, Medical School, University of Novi Sad, Novi
2Plastic Surgery Research Laboratory, University of Pittsburgh, Pittsburgh, United State.
Email: email@example.com; firstname.lastname@example.org
Received 30 November 2009; revised 28 December 2009; accepted 2 January 2010.
This article describes using of this new, improvised
instrument that enables better removal of ACL rem-
nants, increased visibility of the intercondylar notch,
precise location of the femoral tunnel and by doing
this shor- tens the operative time. Also, the use of this
instrument is cost beneficial, because it decreases the
number of disposable shaver tips used and can de-
cr ea se the cost of the procedure which is impor tant for
countries with poor economies.
Keywords: Anterior Cruciate Reconstruction; Femoral
Notch Cleaning; Improvised Instrument
Optimal anatomical replacement of anterior cruciate liga-
ment (ACL) is essential for achieving knee stability. The
most frequent surgical error causing ACL reconstruction
failure is anterior and more vertical femoral tunnel place-
ment [1,2]. One po tential reason for this is failur e to a ccu -
rately identify the true over-the-back position on the
femur in the posterior aspect of the notch. Debridement
of soft tissue in the notch using radiofrequency energy,
shaver or different type of rasps is necessary in ACL
reconstruction of the knee. In order to simplify and
speed up the removal of the ACL remnants at the femo-
ral insertion, a new, improvised instrument for ligament
remnants removal has been developed.
2. TECHNICAL NOTE
An all-inside arthroscopical procedure for ACL recon-
struction was used. After the autograf t had been harv e st e d,
arthroscopic examination of the knee was performed. The
ACL remnants in close contact with the PCL were re-
moved using a shaver (Figure 1). Using a medial portal,
a special instrument for the removal of the ACL ligament
remnants at the femoral insertion, was introduced into
the knee. The instrument comprised of a 10 cm long,
headless, cancellous screw with 9-10th-reads at its distal
end and a proximal end fitted to a hold er (Figure 2). The
instrument was placed in close contact with the superior
and lateral part of the intercondylar roof and by moving
it from the anterior to posterior, the ACL remnants were
removed from the intercondylar roof and medial part of
the lateral femoral condyle. The small rest of the rem-
nants were removed using a shaver (Figure 3). After-
wards, the procedure was continued in the usual fashion.
Accurate and anatomic tunnel placements are essential
to the success of reconstruction of the anterior cruciate
ligament (ACL). On the femoral side, ideal tunnel place-
ment in the sagittal plane is in the posterior quartile .
In the coronal plane, the common goal is to place the
tunnel between the 1 and 2 o’clock position on the left
and between 10 and 11 o’clock position on the right .
Figure 1. Arthroscopic view of the right knee from the anter-
olateral portal, ACL remnants.
M. Z. Milankov et al. / J. Biomedical Science and Engineering 3 (2010) 359-360
Copyright © 2010 SciRes. JBiSE
Figure 2. New, improvised instrument for ACL remnants re-
moval. The instrument comprised of a 10 cm long, headless,
cancellous screw with 9-10 threads at its distal end and a
proximal end fitted to a holder.
Figure 3. Arthroscopic view of the right knee from the anter-
olateral portal after using instrument. ACL remnants were re-
moved from the intercondylar roof and medial part of the lat-
eral femoral condyle. The notch doesn’t have ACL remnants.
Tunnel placement based on lateral intercondylar ridge
and lateral bifurcate ridge, is a more reliable approach
[5-8]. The lateral intercondylar ridge is the superior bor-
der of the ACL with the knee in 90o of flexion, and the
anterior border of the ACL with the knee in full exten-
sion [6,7]. The lateral bifurcate ridge separates the
femoral attachment of the AM and PL bundles [6,7]. The
visualization of these landmarks requires meticulous rem-
nant removal. Failure to recognize these bone land marks,
leads to nonanatomic placement of the femoral tunnel
and, therefore, premature failure of reconstructions. In
older patients with poor bone quality, one has to be very
careful not to overdo with the ACL remnant removal,
since this can result in a sign ificant bone indentation. Up
till now, we have used this instrument in over 200 ar-
throscopic ACL reconstruction procedures without any
difficulty or complications.
The use of this new, improvised instrument enables bet-
ter removal of ACL remnants, increased visibility of the
intercondylar notch and precise location of the femoral
tunnel and by doing this shortens the operative time.
Also, the use of this instrument is cost beneficial, be-
cause it decreases the number of disposable shaver tips
used and can decrease the cost of the procedure which is
important for countries with poor economies.
 Carson, E.W., Simonian, P.T., Wickiewicz, T.L. and War-
ren, R.F. (1998) Revision anterior cruciate ligament re-
construction. Instructional Course Lectures, 47, 361-368.
 Sommer, C., Friederich, N.F. and Müller, W. (2000) Im-
properly placed anterior cruciate ligament grafts: Corre-
lation between radiological parameters and clinical re-
sults. The Journal of Knee Surgery, 8, 207-213.
 Bernard, M., Hertel, P., Hornung, H. and Cierpinski, Th.
(1997) Femoral insert ion of the A CL, r ad io gr aphic quadrant
method. American Journal of Knee Surgery, 10, 14-22.
 Loh, J.C., Fukuda, Y., Tsuda, E., Steadman, R.J., Fu, F.H.
and Woo, S.L.Y. (2003) Knee stability and graft function
following anterior cruciate ligament reconstruction: Com-
parison between 11 o’clock and 10 o’clock femoral tun-
nel placement. Arthroscopy, 19, 297-304.
 Farrow, L.D., Chen, M.R., Cooperman, D.R., Victoroff,
B.N. and Goodfellow, D.B. (2007) Morphology of the
femoral intercondylar notch. The Journal of Bone and
Joint Surgery (American), 89, 2150-2155.
 Ferretti, M., Ekdahl, M., Shen, W. and Fu, F.H. (2007)
Osseous landmarks of the femoral attachment of the an-
terior cruciate ligament: An anatomic study. Arthroscopy,
 Fu, F.H. and Jordan, S.S. (2007) The lateral intercondylar
ridge—a key to anatomic anterior cruciate ligament re-
construction. The Journal of Bone and Joint Surgery (Am-
erican), 89, 2103-2104.
 Hutchinson, M.R. and Ash, S.A. (2003) Resident’s ridge:
Assessing the cortical thickness of the lateral wall and
roof of the intercondylar notch. Arthroscopy, 19, 931-935.