Table 1.
Pearls and Pitfalls
| Pearls | Pitfalls |
|---|---|
| The anterior fat pad and ligamentum mucosum are cleared to obtain better visibility. | Excessive debridement of the fat pad can cause anterior knee pain and/or crepitus in the postoperative phase because of excessive scarring. |
| Debris near the ACL footprint is cleared. | The ACL remnant can be damaged in the process, thus decreasing the length of remnant. |
| The starting point of the femoral tunnel is marked with an angled awl from the AM portal so that the femoral tunnel will be anatomic. | Visibility is always a challenge; it is important to have proper vision to access the native footprint. |
| Minimal bony notchplasty of the medial wall of the lateral femoral condyle is performed. | Excessive bone takedown can lead to cartilage problems. |
| Suture passage into the ACL remnant is performed over a flexible cannula to prevent tissue bridges. | If a cannula is not used, tissue entanglement can occur. |
| Tibial tunnel drilling must be performed with care; the inner cortex should be hand reamed. | The remnant, as well as the sutures through it, can be damaged. |
| An antegrade self-retrieving suture-passing device is used. | Forcefully pushing the trigger of the device can lead the needle from the device to hit the notch and cause needle breakage in the joint. |
| The sutures from the shuttle suture and remnant should be pulled through the tibial tunnel in a single pass with a suture retriever. | |
| The remnant sutures are loaded into the button from below up and then into the shuttle suture. | Too many sutures can cause confusion intraoperatively. |
| Switching the viewing portal to the AM portal will allow an end-on view of the femoral tunnel during passage and flipping of the adjustable loop button. | |
| During pulling of graft intra-articularly, the sutures from the remnant should be simultaneously tensioned. | Over-tensioning can cause suture to cut through the remnant. |
| With the help of a knot pusher, 4-5 half-hitches are made over the button. | The knot must be tied over the button past the iliotibial band because knots over the iliotibial band can cause lateral-sided thigh pain. |
ACL, anterior cruciate ligament; AM, anteromedial.