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1.
A linear oblique skin incision in line with the direction of the semitendinosus tendon (STT) fibers could decrease the incidence of nerve injury, can be extended either way for further access of surgical field, and provides good exposure to harvest the periosteum flap.
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2.
STTs usually have 3 to 5 vincula and on palpation are felt distal to the popliteal crease.
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3.
To confirm that all the soft-tissue adhesions are released from the STT:
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a.
Feel for musculoskeletal junction of the STT
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b.
All vincula should be released
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c.
At least 15 cm of the tendon stripper can be inserted along the tendon without any resistance.
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d.
When all the soft-tissue adhesions are released, the STT can be pulled across the proximal tibia and it should reach the head of fibula easily. Only then the STT in continuous with periosteum should be harvested.
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4.
The free flap of periosteum of size 2 cm × 2 cm can be harvested from below the STT attachment or above the GT attachment.
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5.
The diameter of the femoral end of the graft may be increased by 0.5-1 mm after the free flap of flipped periosteum is sutured.
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6.
Use 3-0 MONOCRYL to suture the periosteum to the graft to decrease the incidence of infection.
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7.
Graft is marked at either end so that the periosteum is at the level of femoral tunnel entry and at the intra-articular point of tibial tunnel
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8.
Far cortex suspensory fixation is preferred to interference screw fixation on the femur side to avoid crushing of the periosteum sleeve.
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9.
The length of the interference screw in the tibial should be just long enough to avoid crushing of the periosteum sleeve, which lies close to the intra-articular margin.
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10.
Supplementary transosseous fixation will provide extra stability to the graft.
