Fig 1.

Graft preparation. (A) A hamstring tendon is harvested from the pes anserinus and a 1- to 2-strand graft is prepared. An allograft tendon is an alternative. Required length is estimated on preoperative magnetic resonance imaging and radiographs. Because the ATTL should be at least 25 mm long, the harvested tendon must be longer than 55 mm to contain a 1-strand bundle or 110 mm to contain a 2-strand bundle. The 2 ends form a 15-mm-long bundle or loop to facilitate attachment of the thread for graft delivery. The recommended graft diameter is 4.5 to 5.5 mm. (B) A semitendinosus tendon graft is shown that contains a 1-strand bundle for the ATTL graft. The talar side end of the ATTL graft is sutured using the Krackow method. (Patient 1 is shown.) (ATTL, anterior tibiotalar ligament.)