Table 1.

Pearls and Pitfalls

Pearls
Preoperative
Emotional maturity is important to assess as adherence to postoperative activity limitations and active participation in the intensive rehabilitation regimen are critical for favorable outcomes.
Transepicondylar distance can be used to calculate the length of the iliotibial band required.31
Intraoperative
The free end of the graft should be “bulleted” during tubularization to help facilitate passage of the graft through the posterolateral capsule.
The free end of the graft should be folded into thirds, wrapped in a moist sponge, and tucked under the skin to prevent desiccation during arthroscopy.
An inferolateral sling of ACL should be left to decrease the likelihood of the graft subluxating into the lateral compartment.
Tibial fixation should be performed medial to the tibial tubercle apophysis to avoid iatrogenic injury.
Postoperative
A slower return to sports is protective against subsequent ACL injury.32 Inability to return to full activity, including cutting and pivoting sports, is always a risk and is more likely when the initial surgical indication is a multiligamentous injury or a congenital insufficient or absent ACL.
Emotional maturity is important to assess

Pitfalls
Intraoperative
Insufficient harvesting of the iliotibial band fascia can result in a graft that is too short to effectively secure to the tibia. It is recommended to attempt to harvest a 15-cm-long graft.
Overly aggressive dissection around the posterolateral aspect of the femoral condyle or overly vigorous posterior notchplasty can cause injury to the perichondral ring and possible deformity.

ACL, anterior cruciate ligament.