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After the surgeon inspects the knee for damage to the cartilage or the
menisci, the remnants of the torn ACL are removed with a high-speed shaver.
This tool is a very specialized device that is used to remove torn ligaments
or torn pieces of cartilage from the knee. The surface of the intercondylar
notch where the ACL normally attaches to the femur is then prepared with
a high-speed burr so that the proper location for the tunnel for  femoral
fixation can be seen clearly.
Tunnels are then drilled through the bone in the femur and the tibia
so that the graft can be placed in the center of the knee in the same
position as the original ACL. A separate incision that is about 2 to 3
inches long also has to be made in order to harvest the graft from either
the patellar tendon or the hamstring tendons. After the graft has been
harvested, it is then prepared by placing several very strong surgical
sutures through the graft that are used to fix it in place.  Some
surgeons will also braid the graft before passing it through the tunnels.
After the graft is passed through the tunnels, it is then tensioned and
fixed in place. A variety of fixation techniques have been developed to
anchor the graft to the bone. Different techniques are used for different
types of grafts, and today, fixation failures, though possible, are very
rare.
Once the graft has been fixed in place and any additional damage has
been addressed, the incisions are closed and a sterile dressing is used
to cover the knee. This dressing will usually stay on for several days
while the wound begins to heal.
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