The ACL stump is removed with a combination of the shaver and the electrocautery. In most cases no bone is removed, only the soft tissue from the wall of the notch. There is still considerable controversy over the extent of the notchplasty. Some surgeons do a notchplasty in only 10% of their cases. Others always do one. The author thinks that the answer lies somewhere in between. Each physician should do what needs to be done to accommodate an 8 to 10 mm graft. In cases with a very narrow A-frame notch, this will mean more extensive use of the burr to remove enough bone to visualize the back of the notch (Fig. 6.47 and Fig. 6.48). Measure the size of the notch with an instrument, such as a pituitary rongeur that opens to 10 mm. Make the notch large enough to accept this 10-mm instrument. The emphasis should be on the roof and the anterolateral corner. Change the A-shape at the top of the notch to a U-shape.
It is important to remove the soft tissue to visualize the back of the notch. Use a large curette to lift the soft tissue off and then a 5.5-mm Gater (Linvatec, Largo, FL) resector to clean the notch (Fig. 6.49). The critical area to see is the fringe of capsule at the back. The residents ridge does not have this fringe, so the physician should easily identify the correct area. Put the pump pressure up at this stage to distend the
fat behind the PCL so the drop-off can be clearly seen. Figure 6.50 shows the fringe at the back of the notch, which the physician must see to determine the over-the-top position for the guide. A 6-mm oval burr should be used to remove the bone. This does not jump around as much as the round burr. Linvatec makes a southpaw for left knees that also eliminates the jumping. The author makes a small divot with the burr at the position that the tunnel should be, that is, 7 mm in from the dropoff at 11 or 1 o'clock. The major mistake would be not to clear enough soft tissue to expose the posterior aspect of the notch. This can result in drilling the tibial tunnel too anterior. The result is late failure of the graft.
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