The lateral wall and roof have to be opened up to accommodate a 10-mm graft. There is still considerable controversy over the notch-plasty. 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 must be done to accommodate the graft.
In cases with a very narrow A-frame notch, this will be more extensive (Fig. 6.47). Measure the size of the notch with an instrument, such as a pituitary rongeur that opens to 10mm. 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. I use a large curette to lift the soft tissue off and then a 5.5 mm resector to clean the notch. 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 at this stage to distend the fat behind the PCL so the drop-off of the femoral condyle can be clearly seen. The back of the lateral femoral condyle has been cleared to see the fringe of tissue that marks the over-the-top position (Fig. 6.50).
A 6-mm oval burr should be used to remove the bone (Fig 6.48). 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, 7mm in from the drop-off, 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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