Table 1.

Pearls and Pitfalls

1.Prepare the graft like an anterior cruciate ligament, single or double stranded, to allow adequate size for its function. Remember that graft–tunnel size match is crucial for graft passage.

2.Note that the femoral tunnel exit point is difficult to see, even with good range of motion, often because of remnants of the LT. Preplan and trust the radiographs obtained in both planes, but make sure that they are true anteroposterior and lateral films.

3.Use curved long graspers and instruments; their use is crucial.

4.Preplan good main anchor positioning; curved guides are helpful for this.

5.Carefully clear the entry at the greater trochanter of soft tissue to avoid difficulty passing the graft; the graft pull vector is not in line as in anterior cruciate ligament surgery, necessitating more attention to detail before shuttling the graft.

6.Do not trust the drilling diameter. Use dilators to ensure proper tunnel width.

7.Use a burr to clear enough space for the LT in the cotyloid fossa. Leave enough medial pelvis cortex to allow good anchor security. Make sure the space available for the LT is large enough to accommodate graft tissue in the neutral position when the LT is relaxed.

8.Before drilling the acetabular anchors, alert the anesthesia team to watch for changes in the patient’s vital signs.

9.When drilling, advance slowly to avoid plunging. When the anchors are being seated, remember that they too can simply be tapped just beyond the drill hole. Always be aware of the location of the vascular structures of the pelvis.

10.When shuttling the graft, note that careful attention to suture management is critical; the line of pull should be as straight as possible.

11.Use 1 suture of the double-loaded anchor to shuttle the graft and tie a knot; use the second suture to further secure the graft. The knot pusher can assist in a push-pull fashion. Do not past point with the knot pusher.

12.Before shuttling the graft, mark it so that you are aware of the amount of graft in the tunnel at all times during the shuttling procedure.

13.Once the graft is seated and secure, place 1 or 2 more anchors around the periphery of graft to increase the contact patch of the graft for healing. The SpeedStitch device can be very helpful for passing the stitches through the graft at this point.

14.Check the graft position and tension through range of motion.