Table 1.

Pearls and Pitfalls

Tendon harvest

Pearls

Foot positioning is crucial for relaxing the FHL; this allows a very distal harvest.

Gentle traction on the stay suture further exposes the FHL.

Pitfalls

Failing to obtain enough length of the FHL tendon complicates manipulation.

The tibial nerve runs just medial to the FHL tendon; caution is to be observed.

Tunnel placement

Pearls

Suture-passing wire is used as a guide for tunnel placement, entering from the medial portal.

The wire forms an approximately 15° angle with the plantar aspect of the foot, and the plantar exit point should be lateral.

Pitfall

A straight tunnel puts the medial wall of the calcaneus at risk during drilling.

Fixation

Pearl

Adequate tension should be maintained on the FHL traction suture while advancing the screw; an assistant can hold the arthroscope while the surgeon controls the tension to provide fine-tuning.

Pitfall

Failure to provide adequate interference can result from buckling of the tunnel walls; in this case, the screw diameter can be increased.

FHL, flexor hallucis longus.