1. Physeal-Sparing Technique for Femoral Tunnel Drilling in Pediatric Anterior Cruciate Ligament Reconstruction Using a Posteromedial Portal 
Stephen E. Lemos, M.D., Ph.D., Patrick M. Keating, B.S., Timothy P. Scott, M.P.A.S., P.A.-C., Ryan M. Siwiec, D.O. 
Arthroscopy Techniques 
Volume 2, Issue 4, Pages e483-e490 (November 2013)
DOI: /j.eats
Copyright © 2013 Arthroscopy Association of North America Terms and Conditions

2. Fig 1
When one is using a posteromedial portal to perform a physeal-sparing ACL reconstruction, the patient's knee is placed in 90° of flexion on a bump with the popliteal fossa free of any pressure. The landmarks are clearly marked, and the knee is free to allow access with a mini C-arm, arthroscope, and drilling equipment.
Arthroscopy Techniques 2013 2, e483-e490DOI: ( /j.eats )
Copyright © 2013 Arthroscopy Association of North America Terms and Conditions

3. Fig 2
(A) To establish a posteromedial portal, a cannulated obturator is placed over a switching stick into the posteromedial compartment. As shown, a switching stick is inserted through a cannula in the posteromedial portal to reach the ACL footprint on the lateral femoral condyle, viewed from the anterolateral portal, looking medial to the posterior cruciate ligament (PCL). (B) A lateral-view fluoroscopic image shows the switching stick inserted through the posteromedial portal to reach the ACL footprint. (C) The portal position is sufficient to reach the ACL footprint on the lateral femoral condyle with a switching stick placed through the posterior septum behind the PCL, viewed from the anterolateral portal looking lateral to the PCL. To reach the ACL footprint, a cannulated obturator inside the cannula is place over the switching stick to place the cannula directly on the ACL footprint. (D) An anteroposterior-view fluoroscopic image shows the switching stick reaching the ACL footprint on the lateral femoral condyle.
Arthroscopy Techniques 2013 2, e483-e490DOI: ( /j.eats )
Copyright © 2013 Arthroscopy Association of North America Terms and Conditions

4. Fig 3
The femoral guide pin is drilled from the posteromedial portal in all-epiphyseal fashion. (A) Arthroscopic view of the ACL footprint, marked on the lateral femoral condyle where the guide pin is drilled, seen from the posteromedial portal, looking through the cannula. (B) An anteroposterior-view fluoroscopic image of the knee with the femoral guide pin being drilled from the posteromedial portal confirms that the physis has not been violated. Orthogonal views of the distal femur were also obtained to ensure that the physis was not crossed. The knee is close to extension with the X-ray beam pointed posterior and slightly inferior to attempt to be parallel with the growth plate. (C) The femoral guide pin is drilled from the posteromedial portal with the patient's knee in 90° of flexion on a bump. In this case a second bump is used to raise the knee high enough to achieve sufficient clearance to drill. (D) A lateral-view fluoroscopic image of the patient's knee with the femoral guide pin being drilled from the posteromedial portal shows the location of the physis.
Arthroscopy Techniques 2013 2, e483-e490DOI: ( /j.eats )
Copyright © 2013 Arthroscopy Association of North America Terms and Conditions

5. Fig 4
An 8-mm acorn reamer is used to ream the femoral tunnel to a depth of 25 mm from the posteromedial portal, as visualized from the anterolateral portal.
Arthroscopy Techniques 2013 2, e483-e490DOI: ( /j.eats )
Copyright © 2013 Arthroscopy Association of North America Terms and Conditions

6. Fig 6
The tibial guide pin is drilled in an all-epiphyseal fashion, by use of fluoroscopy and arthroscopy for guidance. (A) A mini C-arm is used throughout the procedure to confirm appropriate guide pin placement and the location of the physis. (B) A lateral-view fluoroscopic image of the knee is used to avoid the physis while drilling the tibial guide pin. (C) The tibial guide pin is drilled from the soft-tissue graft harvest site into the joint space, as visualized from the anterolateral portal.
Arthroscopy Techniques 2013 2, e483-e490DOI: ( /j.eats )
Copyright © 2013 Arthroscopy Association of North America Terms and Conditions

7. Fig 5
(A) Passing suture is run from the posteromedial portal through the cannula and through the femoral tunnel, as visualized from the anterolateral portal. (B) The passing suture is visualized from the posteromedial portal, looking through the cannula, as it passes through the femoral tunnel and out the lateral femoral cortex. (C) The loop portion of the passing suture is retrieved from the joint space and pulled through the tibial tunnel. (D) After successful graft passage, the graft is seen in the femoral tunnel from the cannula in the posteromedial portal.
Arthroscopy Techniques 2013 2, e483-e490DOI: ( /j.eats )
Copyright © 2013 Arthroscopy Association of North America Terms and Conditions

8. Fig 7
(A) A lateral-view fluoroscopic image confirms placement of the EndoButton on the lateral femoral cortex, pictured with an approximate location for femoral tunnel placement. (B) An anteroposterior-view fluoroscopic image shows fixation of the EndoButton, secured on the lateral femoral cortex. (C) Tibial fixation is achieved with a post and spiked washer, as shown on an anteroposterior-view fluoroscopic image. (D) The post and spiked washer are seen through the skin incision on the tibia.
Arthroscopy Techniques 2013 2, e483-e490DOI: ( /j.eats )
Copyright © 2013 Arthroscopy Association of North America Terms and Conditions

9. Fig 8
Radiographs obtained 14 months postoperatively show femoral and tibial tunnel placement. (A) A lateral-view radiograph of the knee shows the tunnel locations and graft fixation devices. (B) An anteroposterior-view radiograph of the knee shows placement and angles of the tibial and femoral tunnels.
Arthroscopy Techniques 2013 2, e483-e490DOI: ( /j.eats )
Copyright © 2013 Arthroscopy Association of North America Terms and Conditions