Table 2.

Pearls and Pitfalls of Multiligament Reconstruction

Pearls	Pitfalls
These lesions should be treated in the acute setting whenever possible.	To avoid the increased risk of failure the MCL graft tibial insertion should be posteriorized to better resemble the anatomy of the sMCL.
A comprehensive physical examination, stress radiographs, and MRI are key to fully diagnose associated lesions.	Nonanatomic placement of the tunnels can jeopardize the reconstruction; thus only ream the tunnels after verifying that the guide pins are in the correct place. Medial-sided tunnels should be created aiming anteriorly and proximally in the femur.
Leaving passing sutures after drilling each tunnel facilitates later graft passage.	Not using a screw protector during screw placement on the femur for cruciate ligament grafts can lead to graft damage.
If feasible, address all the pathology during a single surgery.	If the tunnels are not properly cleared of all soft tissue, passage of the grafts can be difficult.
In chronic cases, assess the limb alignment so it can be addressed before or concurrent with the reconstruction.	Too long of a graft for the sMCL can result in a lax graft because the graft fills the tunnel prematurely.

MCL, medial colateral ligament; MRI, magnetic resonance imaging.