Table 2.
Surgical Steps, Pearls, and Pitfalls
| Surgical Step | Pearls | Pitfalls |
|---|---|---|
| Tourniquet | A tourniquet is applied to both sides, but the surgeon should elevate the tourniquet on the normal limb first for graft harvest. Then, after draping and complete instrumentation, the surgeon should elevate the tourniquet on the affected limb. | If the tourniquet is elevated on the affected limb first, this will lead to increased tourniquet time and the need for its release and then elevation, increasing surgery time. |
| ACL graft | A closed or open tendon stripper can be used to free the graft. A closed stripper is preferred. | The use of an open tendon stripper may be associated with premature cutting of the graft and a short graft. |
| Tripled hamstrings allow suspension at either end; suspension is achieved by sutures at the proximal end and by gracilis graft at the distal end. | Doubled hamstrings allow suspension at only 1 end and do not allow gracilis graft or passing-suture suspension. | |
| Tripled hamstrings allow adequate graft length. The ACL tibial tunnel is longer than usual because the distal end is made at least 6 cm below the joint line. | A quadrupled hamstring leads to a shorter ACL graft. A more proximal entry of the ACL tibial tunnel is associated with a nonanatomic MCL-POL graft position. | |
| MCL-POL graft | After medial surgical exposure, the gracilis tendon is harvested and the semitendinosus tendon is preserved. | If performed before medial surgical exposure, the semitendinosus tendon may be harvested accidentally. |
| Subfascial tunnels | The surgeon should start from proximal to distal. | The reverse is difficult. |
| Tunnels are created with the knee flexed 30°. | This is in line with the knee position during graft fixation. | |
| The anterior subfascial tunnel is passed under and posterior to the preserved semitendinosus. | A subfascial tunnel that is anterior or proximal to the preserved semitendinosus is nonanatomic. | |
| The anterior subfascial tunnel is created in 2 steps to give 2 tibial attachments. | If created in 1 step, this ignores the proximal tibial attachments. | |
| The posterior subfascial tunnel is created in 2 steps to give 2 tibial attachments. The proximal one is fixed by a metal staple after creation of a row bed at the tibial cortex. | If a row bed at the tibial cortex at the proximal tibial attachment is not created, graft-to-bone healing is delayed. | |
| Subfascial tunnels are passed deeply near the knee joint line. | This gives a more stable and anatomic reconstruction. | |
| The anterior subfascial tunnel forms, with the posterior tunnel, a triangle. Its apex is at the isometric point on the medial femoral condyle. | This gives a more stable and nearly anatomic MCL reconstruction. | |
| Passing sutures are made to mark the subfascial tunnels. | This allows easy graft passage at the MCL-POL reconstruction. | |
| ACL tibial tunnel | The entry point of the tibial tunnel should be 6 cm from the joint line posterior to the semitendinosus. | An entry point <6 cm below the joint line or anterior to the semitendinosus is nonanatomic. |
| The surgeon should use a curette through the anteromedial portal for protection during reaming. | If not used, PCL and/or articular cartilage injury may occur. | |
| The tibial guide pin is inserted while the knee is in 90° of flexion for proper visualization. | Knee flexion >90° will draw the infrapatellar fat pad into the field, making visualization difficult. | |
| Intermittent use of a plastic stopper in the tibial tunnel prevents loss of fluid and allows washout of bone debris through the tunnel. | Fluid loss will lead to loss of joint distension and accumulation of bone debris with poor visualization. | |
| Graft passage and fixation | The ACL graft is passed; then, the MCL-POL graft is suspended on the ACL graft at the medial cortex of the tibia. | If the ACL graft is passed after MCL-POL graft suspension, the graft may be impacted at the tibial tunnel. |
| The ACL graft is fixed at the femoral tunnel after MCL-POL graft suspension. | If the reverse is performed, MCL-POL graft suspension may be difficult. | |
| The ACL graft is fixed first at the femoral tunnel and then at the tibial tunnel. | If the reverse is performed, this may lead to loss graft tension. | |
| The entry point of the tibial tunnel is enlarged by a reamer to allow settling of the graft at the point of suspension. | If the entry point of the tibial tunnel is not enlarged, a painful prominent graft on the medial tibia and delayed suspended graft incorporation may occur. | |
| An interference screw of the same graft thickness with a length of 25-30 mm is used. The surgeon should ensure settling of the screw in the tunnel. | If the interference screw is not settled well, it may protrude under the medial fascia, causing its irritation. | |
| The interference screw is inserted in the anterior or distal half of the tibial tunnel. This is performed according to the orientation of the suspended graft; if the 2 graft limbs are oriented vertically after their suspension, the screw is inserted in the anterior half of the tibial tunnel, whereas if the 2 graft limbs are oriented horizontally after their suspension, the screw is inserted in the distal half of the tibial tunnel. | Insertion of the interference screw into the posterior or proximal half of the tibial tunnel will lead to graft impingement on the screw and will shorten the graft and cause its prominence. | |
| MCL graft | Passage is performed in a femoral tunnel at the isometric point and is directed anteriorly and upward. | This is done to avoid injury to the trochlear surface or intercondylar notch. |
| Arthroscopic evaluation | Arthroscopy at the end is performed to check the ACL reconstruction, ACL graft tension, and medial-compartment joint space and to show the intra-articular MCL graft limbs. |
ACL, anterior cruciate ligament; MCL, medial collateral ligament; POL, posterior oblique ligament.