Anterior Cruciate and Anterior Oblique Ligament Reconstruction Using Hamstrings and Peroneus Longus' Anterior Half Grafts

Abstract

Anterior cruciate ligament injuries are common in high school and college with an estimated 120,000 cases per year in the United States. Most sports injuries occur without direct contact, and knee valgus with external rotation of the foot is the most common movement. This movement may be related to the injury of the anterior oblique ligament located in the anteromedial quadrant of the knee. This technical note presents anterior cruciate ligament reconstruction with extraarticular anteromedial reinforcement using hamstring and the anterior half of the peroneus longus grafts.

Fig 1

This photo shows the right ankle being prepared for removal of the peroneus longus tendon graft. A line delimiting the lateral malleolus was drawn. An incision was made starting 3 cm proximal to the most distal point of the lateral malleolus. Note the tendon of the peroneus longus muscle.

Fig 2

This photo shows the right ankle after the lateral ankle incision was made to remove the peroneus longus tendon graft. A line delimiting the lateral malleolus was drawn. An incision was made starting 3 cm proximal to the most distal point of the lateral malleolus. At this moment, the tendons of the peroneus longus and peroneus brevis muscles are identified. The two tendons are individualized so that the correct union is performed with suture.

Fig 3

This photo shows the right ankle after the lateral incision was made to remove the peroneus longus tendon graft. A line delimiting the lateral malleolus was drawn. An incision was made starting 3 cm proximal to the most distal point of the lateral malleolus. After identifying the peroneus longus and peroneus brevis tendons, the two tendons are sutured in the most distal region of the incision using simple stitches with 1.0 Vicryl thread (Ethicon, Somerville, NJ).

Fig 4

This photo shows the right ankle after the lateral incision was made to remove the peroneus longus tendon graft and the suture between the peroneus longus and peroneus brevis tendons. A line delimiting the lateral malleolus was drawn. After identifying the peroneus longus and peroneus brevis tendons and suturing them in the most distal region of the incision using simple stitches with Vicryl 1.0 thread (Ethicon, Somerville, NJ), a longitudinal incision is made, splitting the peroneus longus tendon into two halves. The anterior half is repaired with a continuous stitch performed with 1.0 Vicryl thread (Ethicon, Somerville, NJ).

Fig 5

On the back table the grafts are observed. The anterior half of the peroneus longus (AHPL) was prepared with continuous sutures at both ends performed with 1.0 Vicryl thread (Ethicon, Somerville, NJ). The hamstrings (G and ST) were also prepared with continuous sutures at both ends and folded in half forming a traditionally used quadruple graft.

Fig 6

On the back table, the anterior half of the peroneus longus (AHPL) was prepared with continuous sutures at both ends performed with 1.0 Vicryl thread (Ethicon, Somerville, NJ). The hamstrings (G and ST) were also prepared with continuous sutures at both ends and folded in half forming a traditionally used quadruple graft. The AHPL is then incorporated into the quadruple graft forming a quintuple graft in the most proximal region and a single graft in the distal region.

Fig 7

This photo shows the right knee after the graft has been fixed in the tunnels prepared for the anterior cruciate ligament with interference screws (Biosure; Smith & Nephew, Andover MA). It is possible to see the incision through which the hamstring grafts were removed and where the tibial tunnel was drilled. The distal part of the graft is then directed through the subcutaneous tissue from the medial region to the point of attachment on the femur.

Fig 8

This photo shows the right knee after the graft has been fixed in the tunnels prepared for the anterior cruciate ligament with interference screws (Biosure; Smith & Nephew, Andover MA). The distal part of the graft is then directed through the subcutaneous tissue from the medial region to the point of attachment on the femur. The ideal point of fixation on the femur is guided by fluoroscopy, and the single graft is fixed under traction, neutral rotation, and extension with an interference screw (Biosure).