Table 2.

Pearls and Pitfalls

Pearls

Use fluoroscopy to obtain contralateral knee perfect lateral images prior to draping.

Ensure that adequate exposure is possible by including the entire thigh in surgical field and using extensile incision.

Depending on retraction of the patella, releases can be performed sequentially, starting with release of adhesions around the quadriceps tendon and muscle, and then progressing to fractional lengthening of the quadriceps tendon, if necessary.

Keeping the patellar screw length slightly shorter than the length of the patella can help prevent cutting of the suture tape material proximally.

When creating the trough in the tibial tubercle for the calcaneal bone block, removal of the native tibial bone can be facilitated by cutting the bone into sections to be removed piecemeal and using an osteotome to lever them out of the trough.

A bolster under the heel to maintain full extension of the knee and traction sutures on the patellar tendon remnant can optimize patellar position, while the final construct is secured.

Pitfalls

Limited exposure can lead to difficulty in visualizing and mobilizing quadriceps tendon.

There is a risk of intraarticular penetration with patellar screws.

The tibial trough may need to be gradually expanded to allow the calcaneal bone block to fit flush with the anterior cortex of the tibia.

Prolonged postoperative immobilization can lead to knee flexion stiffness.

In some cases, quadriceps activation may be difficult to restore given chronicity of injury and may result in persistent extensor lag despite intact reconstruction and appropriate patellar height.