Anterior Cruciate and Anterior Oblique Ligament Reconstruction Using Hamstrings and Peroneus Longus’ Anterior Half Grafts
Authors: Jorge PB , Oliveira DE , Horita MM , Helito CP , Canuto SMG , Morales GJS 
Published: November 2024

Objective: To describe the surgical technique for anterior cruciate ligament (ACL) and anterior oblique ligament (AOL) reconstruction using hamstring tendons and the anterior half of the peroneus longus tendon. Methods: The surgical technique involves the following key steps: 1. Tendon Harvesting: The semitendinosus and gracilis (STG) tendons are harvested from the injured limb or the contralateral limb in cases of prior ACL reconstruction. Additionally, a 3 cm longitudinal incision is made in the posterolateral region of the fibula to harvest the anterior half of the peroneus longus (PL) tendon, ensuring the fibular nerve is not injured. The harvested tendons form a quintuple graft, with the STG folded four times and the PL used as a fifth component. 2. Graft Preparation: The STG graft is folded to create a quadruple graft, and the PL is integrated into this without folding, forming a quintuple graft proximally. The distal portion remains single, extending the PL length. 3. Tunnel Positioning for ACL: The reconstruction involves precise anatomic positioning of the femoral and tibial tunnels. The femoral tunnel is created in the Anatomical Functional Position, as described by Jorge et al., using an outside-in technique with the Acufex Pinpoint guide (Smith & Nephew). The tibial tunnel is positioned on the anteromedial surface of the tibia, ensuring optimal alignment with the femoral tunnel. 4. Femoral Tunnel for AOL: The femoral tunnel for the AOL is positioned at the medial epicondyle. Fluoroscopy is used to identify the medial epicondyle in the lateral view. A guidewire is passed through the anterior portion of the medial epicondyle, creating a tunnel under radiographic visualization to ensure correct anatomical placement of the AOL. 5. Graft Passage and Fixation: The graft is passed through the tibial and femoral tunnels using a No. 5.0 Ethibond suture. The quintuple graft occupies both tunnels, and the single PL portion remains outside the tibial tunnel until fixation. Femoral fixation is achieved with an interference screw (Biosure; Smith & Nephew). After pretensioning, tibial fixation is completed with the knee in full extension. The remaining PL is passed subcutaneously on the medial side and fixed in the AOL tunnel with the knee in neutral rotation and 45 degrees of flexion. This technique ensures optimal biomechanical restoration and stability in the anterolateral and anteromedial knee compartments. Results: This technique aims to improve knee stability by addressing anterolateral and anteromedial instability, which is critical in some instances of ACL injury. Using the anterior half of the peroneus longus tendon in conjunction with hamstring tendons provides a viable, biomechanically sound option for reconstruction. Conclusion: Combined ACL and AOL reconstruction using hamstring and peroneus longus tendons is a promising technique for improving knee stability in patients with ACL injuries, particularly those with anteromedial instability. This approach may be a valuable alternative to exclusive anterolateral reinforcement in select cases.