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1.
Biceps femoris (BF) tendon can be easily identified and palpated while keeping the knee in flexion on the operating table.
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2.
With a 2.5-cm oblique or vertical incision, starting at 1-2 cm, just posterior to the posterior border of the fibular head, is recommended. If better exposure is required, extending the incision in the proximal and distal direction could be done.
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3.
The demarcation between BF tendon and muscle can be easy to identify and could be used as an important landmark to harvest the graft.
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4.
If the harvested graft is too large to insert in an open-end tendon stripper. Insert the tendon stripper at the more proximal part of the BF tendon, which is commonly thinner.
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5.
In case a larger and longer BF autograft is required, harvest the BF tendon at the middle one-third area, while keeping the posterior one-third of the BF tendon intact to protect the peroneal nerve.
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6.
Keeping the knee in flexion while harvesting the graft and preserving the posterior part of the BF tendon could lower the risk of peroneal nerve injury.
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7.
If the remnant of the lateral collateral ligament (LCL) stump is seen, suture the distal BF graft together with the LCL stump to strengthen the distal insertion.
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8.
While releasing the distal stump, if a longer graft is required, releasing more at the posterior part of the graft could facilitate inverting the graft upside-down during retrieving the graft to LFE.
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9.
To prevent graft obstruction under iliotibial band (ITB), always dilate the graft retrieval passage under the ITB before passing the graft.
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10.
In case LCL injury is reparable; repair LCL before reconstruction is recommended.
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11.
The required graft length for LCL reconstruction could be estimated by measuring the distance from the tip of the proximal fibula to the LFE plus 2 cm.
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12.
For incomplete BF rupture or peeling off from the insertion, stitching the injured tendon with the LCL stump or augmenting with a suture anchor is recommended.
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13.
If peroneal nerve neurolysis or exploration is required, convert the incision to a standard lateral approach, and harvest the BF graft by open-end tendon stripper.
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14.
The internal brace can be used to protect the graft after reconstruction.
