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I'm Munjed Al Muderis, orthopaedic surgeon from sydney australia i am performing today an anterior cruciate ligament reconstruction using all inside technique and utilizing aloe vera the patient is positioned to find on the table right support and a bolster under the hook and the knee is positioned 60 to 80 degrees of flexion i don't inflate the tourniquet until i prepare the graph for the ground preparation i need two tight ropes one on each end of the rough preparation station this is an allograft most likely tibialis posterior tendon that i use is a straight needle fiber loop but you can use any kind of suture you also need three or monochrome marking pen and few other instruments to hold the brush after filling the glass i trim it to the desirable size for the implantation ideally the graph size should be 10 to 11 millimeters in diameter in a male i remove one third of the proximal part of the graph and that should give us the desirable side positioning the graph in the top row is very important the tight fork is prepared where i can lengthen the arms of the title from inside each arm should be separated it's very important not to make a mistake where we put the title in this position as this will prevent attention you need to be careful when you are fired this is the correct position the aloe vera tendon is passed from top to bottom and on average i leave six and a half to seven centimeter of length and i flip it from the bottom upward and then from the top downward again the two internal parts meet each other in the middle i use an artery clamp to hold it together i utilize a wet fiberless suture to suture it together i measure a distance of around two and a half centimeter from the tip where i insert my five blue suture i do the internal two at the beginning i pass the thread in the middle and i proceed from out in with one go by doing this we secure the internal parts of the suture together this is the third goal i then tension the station for the desirable length now make sure that all the parts are tensioned to the desirable length equally i then divide the five a little future in half this is the desirable tension that i wanted i exit through the external part from one end in the middle and put tension on that piece and i exit on the other side with the other arm i tied these two ends together this point the apex of the graph i tie it to the station and then tension the overall station you can see the graph is uniform i then utilize you can go to the proximal half and then you can return back from the other side you don't need to go all the way down to the bottom we finished the three hour monocle at the same end that we started you can see this graph preparation technique involves covering the tendon completely without any abrasive suture showing only the monochrome is on view and it's very smooth i mark a graph length and it's measuring 75 so i take into consideration the depth of my tunnel i measure two and a half on one end and two and a half from the other end sizing the ground this looks like around 10

this is very good size we finished preparing the graph and we leave it with antibiotic impregnated airline glow i elevate and inflate the tonic we start by performing the arthroscopies my landmarks are the imperial fall of the patella and the lateral border of the patellar tendon i use an eleventh blade to enter the joint utilize a blunt choker go into the joint i first use suction to suck the joints considering this is an acute injury i use standard apostrophe looking at the supracatalog pure surface i then insert my entry medial photo that's performed in the video i know the size of the graph is 10 millimeters so we need to make sides enough to fit that thrust and you can see the pusher ligament is completely warm this is and we need to remove that to prevent appearance after clearing the anterior part of the tibial component of the stump i need the femoral component and i clear the remnant of the acl from the femur air must be taken not to persuade the prosperous captain as the neovascular structure is lying behind the capsule after thinking clearing the primal side of the stomach i care and the tibial tongue this is the pco ligament beware of the infamous i insert it through the lateral portal and it should sit exactly at the femoral stump of the acl i make a lateral cut at the femoral side i just inserted the femur in the hip flipkart there is a black marker to identify the step of my drawing the flip cutter after i unplug it and then i insert a wire this is a passing wire going from out to the inside i remove the chalker i change my portal again to i clean the debris from the joint so they don't form heterotrophic ossification or loose bodies i repeat the wire through the medial portal you can use it the next step is to do the tibial tunnel the tibial tunnel has to be an atomic recognition i use the same size lip cutter as you can see the flip chat is coming out exactly at the start of the aco i use the same o-ring to identify the half a centimeter but you can use any kind of suture material to retrieve the graft from the tibial tunnel i then use another suture to retrieve the side of the glass just pull the the wire so you have one suture coming from the femur one suture coming from the tibia and this will retrieve the graft through the medial or the anterior portal the final step before inserting the graph is to make sure that the interior photon is large enough to take the graph the markers show where it should sit in the femoral tunnel tibial tunnel for the sake of pulling the channel through the bra portals i use the advantage of having this suture as accessory to the title this side will be the thermal side so we pull all the sutures together this is the core suture of the inner part of the graph and that's what i tend to pull initially the blue suture will take the button in and you can see the graph is coming through the joint this process needs to be done gently and gradually now the graph is seated by tension the position of the graph in the socket at the femur side then we move on to the tibial side i pass the sutures through the loop then i deliver sutures through the tibial panel i pull on the blue switcher first and you can see the button has come out and the graft is seated perfectly in the real tunnel i tension the grout on the similar side first considering that i bottomed the thermal side already i don't push the button down to the bottom yet i make sure that the graph is tensioned on the finger side then i perform a software reflection extension to make sure that the graph is not impinging on the knee ideally you can tension the graph as much as you want in extension i then tension the terminal side and make sure that the button is seated in the joint without impingement on the capsule or so i can tell that the patient can achieve full extension now we flex the knee the final step is checking the position of the guard and the tension the position is very good and i check the tension which is very good and then i extend the knee and make the final tensioning of the ground in extension so this is tensioning the breath in extension making sure that the knee has full extension utilizing an image intensifier we identify the position of the graft you can see it's very horizontal exactly where we want it to be and on the tibia central on the ap view and on the lateral it's exactly where it should be i'm very pleased with this position thank you very much

Source: Youtube

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