While the graft is being prepared, preparation of the knee continues. Prior to arthroscopy, an incision is created on the anterolateral knee extending from just proximal to the lateral epicondyle to the level of Gerdy’s tubercle (GT). One then divides the iliotibial band (ITB) in line with its fibers from the level of Gerdy’s tubercle proximally to the end of the incision, taking care not to damage the underlying lateral collateral ligament (LCL) (Fig. 15.2). The LCL is identified by palpation with the knee in Fig. 15.4 position. Soft tissue is cleared to provide good visualization of the ligament, but dissection under the ligament is avoided prior to arthroscopy to prevent extravasation of arthroscopic fluid.

Gerdy’s tubercle is then identified in the distal portion of the incision and a small amount of the origin of the tibialis anterior is elevated to improve visualization. A bone tunnel from superomedial to inferolateral is created with an awl and dilated sufficiently to allow passage of a doubled gracilis graft (Fig. 15.3).

At this point the arthroscope is placed into the knee and notch preparation proceeds as with an isolated intra-articular reconstruction. Tunnel placement may be complicated in revision cases. Decisions must be made regarding tunnel reuse vs. the creation of new tunnels. The femoral tunnel is generally drilled to 10 mm and the tibial tunnel to 9 mm. If significant bone loss is present from a prior femoral tunnel, the tibial bone block size can be increased at harvest to fill this defect and still obtain a good press fit.

The graft is passed in an antegrade direction (from femur to tibia) and the patellar bone block is directed into the tibial tunnel. Femoral fixation is achieved with a press-fit technique, simultaneously fixing the lateral extra-articular graft into the femur (Fig. 15.4). Tibial fixation of the intra-articular graft is then performed with an interference screw.

The two free ends of the gracilis graft are then passed toward the tibia for fixation into Gerdy’s tubercle. The more posterior limb is passed under the LCL, superficial to the popliteus tendon, and through the tunnel in Gerdy’s tubercle in a superomedial to inferolateral direction. The other limb is passed under the LCL, superficial to the popliteus tendon, under the posterior portion of the ITB, and through the same tunnel in Gerdy’s tubercle in an inferolateral to superomedial direction. The graft is tensioned with the knee in approximately 30° of flexion and neutral rotation and the two limbs of the graft are sutured to each other in a side-to-side manner, completing the reconstruction (Fig. 15.5).

In the rare case of well-placed and intact intra-articular graft that fails to adequately control rotation, one can consider the addition of a lateral extra-articular reconstruction. We prefer to utilize the central third of the ITB for such reconstructions as described by Lemaire [24, 25].