Table 1.

Pearls and Pitfalls

Pearls	Pitfalls
Aim for a graft diameter that matches the size and activity demands of the patient. Harvest the ST first and measure its quadrupled diameter. If needed, the GT can then be harvested and added.	Do not make the graft longer than 70 mm. Trim the harvested ST tendon to 27 cm. A longer graft may become proud on the tibial end making it necessary to change from adjustable suspensory fixation to a post. It is more common to have a graft that is too long than one that is too short.
Cerclage sutures at both ends of the graft increase strength, and allow for improved tubularization and graft passage.	Trim the GT graft to 15 cm if you are using it 2 stranded (most of the cases) to avoid proud grafts coming off the tibial tunnel and interfering with suspensory fixation in the tibia.
Compression tubes can be used for enhanced tubularization and graft downsizing for easier passage. In the absence of formal compression tubes, the sizing blocks or tubes can be used for this purpose.
When using the full tibial tunnel technique the TightRope RT loop can be initially lengthened to allow passage and flipping of the RT button on the femur before engagement of the graft in the tibial tunnel. This allows for a more controlled perception of button passage and seating on the femoral cortex and minimizes the risk of interposed soft tissue beneath the button.
Perform final tensioning in full extension. With a larger graft and the cortical fixation the construct is very rigid. Tensioning in any degree of flexion is more likely to result in fixed flexion. Any retensioning after cycling the knee should only be performed in full extension.

GT, gracilis tendon; ST, semitendinosus tendon.