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Bone Patellar Bone Repair: Graft Insertion



- Technique:
    - at this point, No 2 Ethibond stay sutures will have already been passed thru drill holes made in each bone plug;
           - proposed tibial bone plug should have an additional stay suture passed thru the bone-tendon interval (as a safety feature should the 
                 interference screws cut through the bone plug stay sutures);
    - prior to graft passage mark each graft ends w/ a skin marker:
           - mark the proximal osseous tendinous junction is marked;
           - mark the cortical surface of the distal end of the proposed tibial graft;
    - shut off inflow as saline will cause the graft to expand;
    - prior to graft passage, use a pituitary grabber to remove soft tissue surrounding the outer femoral tunnel (to facilitate graft passage);
    - the smaller of the bone plugs will enter the tunnel first;
    - ensure that the cortical side of the proximal bone plug faces posteriorly;
    - the cortical surface of the distal (tibial) bone plug may either face anterior or posteriorly, depending on whether the tibial tunnel has been 
           placed too anteriorly or too posteriorly;
           - if unsure, the cortical surface should face posteriorly;
    - one incision technique:
           - previously a Harris Beath guide wire has been passed thru the femoral tunnel site, which subsequently has been driven out of the 
                  skin on the anterolateral aspect of the thigh;
           - one or two No 2 ethibond sutures are passsed thru drill holes at one end of the graft, which are then passed thru the "eye" of the 
                  distal end of the guide wire;
           - the proximal end of the guide wire is then pulled proximally, drawing the graft into the tibial and femoral tunnels;
    - two incision technique:
          - pass the tibial bone plug stay sutures down the femoral tunnel and into the intercondylar notch;
          - pass a grabber up the tibial tunnel and grab the stay sutures, pulling the sutures out of the tibial tunnel;
          - this is visualized under air arthroscopy;
          - a probed placed thru anteromedial portal assists w/ passage;
          - plugs are visualized at each end;
    - look for the blue mark at the edge of the bone plug to ensure that the entire plug resides with in the tunnel;
    - the distal bone plug can be rotated 90 deg laterally