Jeremy Burnham, MD, FAAOS | Anthony Drazick, MD | Savannah Knighton, ATC | Chloe Roy, BS | Adam Anz, MD, FAAOS| Justin Mitchell, MD, FAAOS | Rachel Frank, MD, FAAOS

This video demonstrates an anterior cruciate ligament reconstruction (ACLR) utilizing an quadriceps tendon autograft with all-suture button femoral fixation, combined with a lateral extra-articular tenodesis utilizing a loop-and-tack technique.

The case begins with quadriceps tendon harvest through a proximal patellar incision, emphasizing the advantages of an all-soft tissue graft. On the back table, the graft is prepared using a FiberTag construct with all-suture cortical buttons for both femoral and tibial fixation. Simultaneously, the LET is prepared through a lateral incision, with a strip of iliotibial band isolated and passed beneath the lateral collateral ligament using the Loop-and-Tack technique.

Femoral tunnel preparation is performed through an anteromedial portal in hyperflexion, followed by retrograde tibial tunnel creation with a FlipCutter device. The quadriceps graft is shuttled into the femoral tunnel, and the all-suture button is elongated to ensure smooth passage before being deployed and confirmed arthroscopically or fluoroscopically. Tibial passage is completed with proper button seating against the tibial cortex, followed by tensioning and graft cycling.

Following secure ACL fixation, the LET graft is tensioned and secured, avoiding tunnel collision while reinforcing anterolateral stability. Pearls and pitfalls of the technique are reviewed, including the importance of maintaining button elongation with passing sutures, confirming deployment prior to passing-suture removal, and tensioning the ACL before LET fixation.

The presentation concludes with a review of outcomes literature supporting the role of LET in high-risk patients and highlighting the advantages of all-suture button fixation, including elimination of hardware prominence, ability to re-flip, and reduced metal artifact on imaging.