Table 1.

Pearls and Pitfalls

	Description
Pearls
Graft harvesting	The PL tendon lies posterior to the peroneus brevis at this location as described. Although the PL can be easily delivered out after incising the fascia, the peroneus brevis has muscle attached and this helps identify the correct tendon.
Graft preparation	The tendon graft must be sutured with a high-strength suture material only (e.g., No. 2 FiberWire). The interference screw fixation in the femur can cause graft laceration, and the presence of such suture material will provide protection from this complication.
Surgical approach	Making a liberal incision and raising a full-thickness fasciocutaneous flap prevent wound complications.
	Performing a common peroneal nerve neurolysis prior to drilling the tunnels is a sine qua non.
	Drilling the fibula can be tricky, but freehand passage of a 2.4-mm drill pin keeping the 50°/60° trajectory ensures the best bone.
	Intra-articular work such as femoral drilling for ACL reconstruction should be performed after the lateral dissection to avoid distortion of tissue planes due to fluid extravasation.
	The femoral drilling for an ACL reconstruction can be performed in an outside-in manner to prevent graft coalition.
Graft passage	The common PT/PFL segment must be marked at 25 mm, and only so much of the graft must be pulled into the tibial tunnel.
	The tunnel edges in the femur, tibia, and fibula must be chamfered with a rasp to prevent graft abrasion.
Graft fixation	The distal end of the PL tendon is tubular like the PT, and this must be used for PT reconstruction in the femur.
	The fixation of the PT and PFL must be achieved in 90° of knee flexion and 5° of internal rotation with a valgus force.
	Re-tensioning of the TightRope RT button at 80° to 90° of knee flexion will ensure that the PT and PFL segments in the tibia do not have any residual slack.
Pitfalls
Graft harvesting	The harvested PL tendon must be at least 25 cm in length. If this is not the case, as can be possible in very small individuals, the PL must not be used for this technique and a supplemental graft such as gracilis tendon graft must be used as well.
Graft preparation	Care should be taken to suture the 2 limbs in an unequal fashion with the short limb being 95 mm from 1 end.
	The ends of the tendon entering the sockets should be sutured for a length of at least 25 mm with high-strength suture. Lack of an appropriate length of suture or strength of suture may result in graft laceration.
Surgical approach	In the subacute scenario, care must be taken to isolate the common peroneal nerve carefully. In such situations, the nerve may look like scar tissue or tendon and tendon or scar tissue may look like the nerve.
	If careful attention is not paid to anatomic landmarks, the resulting reconstruction may not restore the stability.
Graft passage	The tibial tunnel graft passage is the most challenging because the graft has to be pulled in from posterior to anterior. If it becomes hung up on soft tissue, then the fixation point of the tibia will be insecure, leading to compromised stability of the reconstruction.
Graft fixation	The cortical button must be sitting flush on the bone. Failure to ensure this would lead to slackness in the PT and PFL reconstruction.

ACL, anterior cruciate ligament; PFL, popliteofibular ligament; PL, peroneus longus; PT, popliteus tendon.