Achilles tendon grafts have two unique features to address during graft preparation: the collagen insertion into the bone plug is angular and the tendinous portion is fan shaped. Although Achilles tendon grafts come with ample bone blocks, the nature of the tendinous insertion is such that the bone plug length is always short. Therefore, bone should not be removed from the distal end of the bone block unless necessary during final preparation (Fig. 17-1). A prominent pump bump at the posterior aspect of the plug may need to be trimmed along with a small amount of tendinous tissue (Fig. 17-2). The bone plug should be fashioned to fit easily through the sizing tube. We typically use a 10-mm bone plug. Next, shorten the graft to a length of approximately 120 mm and trim excess collagen from the sides (Fig. 17-3A). A No. 2 nylon passing suture is placed through the bone plug. Next, suture the distal portion of the graft by placing a No. 2 Ethibond suture 40 to 50 mm distal to the bone block. Distal interference screws seem to get better purchase on the graft if they are placed adjacent to a sutured graft; suturing can begin more distally if interference fixation is not used. The first suture placed should be used to tubularize the graft (see Fig. 17-3B). A second arm of the suture is run down opposite this and then a second suture is placed rotated 90 degrees to the initial suture. With each strand of the suture place one or two locked passes and then run distally.

Although soft tissue allows a tighter fit in the sizing tubes compared with bone plugs, avoid the tendency to make a collagen graft that is too large. A 10-mm bundle of collagen may not fit well in the knee of a petite gymnast.