Anterior Cruciate and Anterolateral Ligament Reconstruction Using Hamstring and Peroneus Longus Tendons: Surgical Technique Description

Abstract

The main objective of this study is to describe a surgical technique that combines intra- and extra-articular techniques using the semitendinosus, gracilis, and peroneus longus to perform reconstruction of the anterior cruciate ligament and anterolateral ligament. This technique offers a more stable, fast, low-cost, and widely accessible procedure and consists of drilling 3 tunnels-1 femoral and 2 tibial tunnels-in which the grafts are fixed with interference screws. The fact that the peroneus longus graft is long and thick allows for robust reconstruction of the aforementioned ligaments.

Fig 1

The right ankle is shown. The lateral malleolus and the incision site are traced. An incision in the skin is made 3 cm from the most distal point of the lateral malleolus.

Fig 2

The right ankle is shown. A 3-cm incision is made proximal to the lateral malleolus. The peroneus longus and peroneus brevis tendons are identified and individualized.

Fig 3

The right ankle is shown. Both peroneal tendons are brought together in the most distal region of the incision using single sutures with No. 1-0 Vicryl thread.

Fig 4

The right ankle is shown. After being combined with the peroneus brevis, the peroneus longus is incised and removed with the aid of a tenotome.

Fig 5

The grafts are shown: The hamstrings (gracilis [G] and semitendinosus [ST]) form a quadruple graft. (PL, peroneus longus.)

Fig 6

The peroneus longus (PL) graft is incorporated into the hamstring grafts without folding, forming a quintuple graft in the most distal region and a single, more proximal graft comprising the remainder of the length of the PL. (G, gracilis; ST, semitendinosus.)

Fig 7

The right knee is shown. Anatomic landmarks are traced: fibular head, Gerdy tubercle, and articular line. A guidewire (Smith & Nephew) is passed halfway between the Gerdy tubercle and the fibular head through the tibia in the anterior direction, and a bone tunnel is constructed under radioscopic visualization. ∗Point where the tunnel to fix the ALL ligament will be performed.

Fig 8

To fix the grafts, we perform the following sequence: The single portion of the graft is passed freely through the tibial and femoral tunnels until the quintuple portion occupies both tunnels. Then, the graft is pulled, and an interference screw is fixed to the femur. The next step is to fix the lower end of the quintuple graft to the tibia after pre-tensioning. Fixation is performed with the graft tensioned and the knee in full extension and after performing the posterior drawer maneuver. After tibial fixation, the remaining peroneus longus is passed through the subcutaneous and ALL tunnels. The ligament is fixed under traction, mild valgus stress, and 30° of flexion. (PLT, peroneus longus tendon; DCM, designer's signature; G, gracilis; ST, semitendinosus.)