The knee is placed at 20° to 30° of flexion, pulling with 12 to 15lbs on the distal sutures. The smooth K-wire is pushed up the tunnel. Its position is confirmed arthroscopically. An 8 x 25-mm BioScrew is introduced along the K-wire and into the tunnel (Fig. 7.15). Steady tension is maintained on the sutures. Two sutures should be used in the tibial bone plug at slightly different angles. If one suture is cut by the screw insertion,
the surgeon will always have a backup. Guard against letting the screw push the bone plug up the tibial tunnel by pulling firmly on the distal sutures. The screw should remain at the external tibial cortex to have the best purchase on the bone plug. If the bone plug protrudes from the tibial tunnel, an interference fit screw cannot be used to fix it (Fig. 7.16).
If there is a graft mismatch, that is, if the bone plug protrudes out the tibial tunnel, the fixation may have to be changed. The options are to groove the anterior tibia and fix the graft with a staple or small frag-
ment screw in the groove or to tie the sutures over a screw post placed more distally in the tibia.
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