The leg is exsanguinated at the beginning of the case, and the tourniquet is inflated if one is used. Graft harvest can be executed before or after standard diagnostic arthroscopy, though this may be influenced by suspicion of additional surgical pathology to address. The size of the graft can be tailored to anatomical considerations of native ACL femoral and tibial insertion site size and notch widths when performed after diagnostic arthroscopy should the surgeon desire. If the knee is insufflated and arthroscopy is performed prior to harvest, all fluid should be thoroughly drained from the knee, as capsular distention decreases surgeon control of graft thickness. Arthroscopic portals are marked, including the anterolateral portal at the junction of the lateral and inferior patellar borders (made in extension to enter superior to the infrapatellar fat pad), an anteromedial portal placed just medial to the medial border of the patellar tendon, and accessory far medial portal (both made in 90° of flexion). The graft harvest site is marked with a 1.5 to 2 cm horizontal mark just proximal to the superior pole of the patella, favoring laterally to avoid the vastus medialis obliquus (VMO) (in 90° of flexion) (Figure 2).

The ideal graft length is between 6 and 7 cm in length.⁹ The average ACL is between 2.5 and 3 cm in length. Thus, that leaves 2 cm of graft for each bone tunnel.

With the knee positioned at 90° of flexion, a 15-blade scalpel is used to make the 1.5 to 2 cm transverse skin incision over the superior patellar pole. Alternatively, a longitudinal incision is acceptable if the surgeon requires additional exposure. The authors prefer a horizontal incision compared with a vertical incision secondary to ease of distal graft visualization and better cosmesis along Langer lines. It is critical to widely excise subcutaneous, pretendinous fat (Figure 3, A). This allows for adequate exposure and QT access through a small incision (Figure 3, B). The paratenon is excised. A RayTech sponge is passed into the incision with forceps to débride soft tissue from the tendon. A key elevator is then passed up the tendon and distally over the superior third of the patella to remove off any residual soft tissue. An Army-Navy retractor is used to elevate the pretendinous skin, and the dry arthroscope is introduced and directed subcutaneously and proximally to visualize the quadriceps tendon. All pretendinous vessels are coagulated with a radiofrequency (RF) ablator or electrocautery device to avoid harvest site hematoma. The triangular junction of the VMO, vastus lateralis, and distal rectus femoris musculotendinous is visualized (Figure 4). The arthroscope is advanced to the junction, and the light source is turned 180° to transilluminate and mark the skin centered over the junction. The distance from the proximal pole of the patella to the mark is measured, representing the
maximum achievable length with an all soft-tissue graft, which is usually at least 7 cm. By keeping grafts below 7 cm in length, the harvest stays distal to the myotendinous junction and diminishes the risk of postoperative hematoma and postoperative quadriceps deformity.

The Arthrex (Naples, FL) double-blade harvest knife is introduced while the knee is firmly held by an assistant in 90° of flexion (Figure 5). The knife is able to cut antegrade (ie, proximal to distal) and retrograde (ie, distal to proximal) and has an innate depth limiter. Retrograde cutting is more reproducible, starting just proximal to the proximal pole of the patella, and aiming toward the junction’s skin mark. The knife handle has markings for measurement of the length of the QT harvest, which should be incised to a length of 6 to 7 cm from the incision. A 15-blade is used to extend the tendon
incision to the superior patellar surface. The longitudinal incisions are connected perpendicularly at the distal quadriceps insertion to the superior pole of the patella. Alternatively, a 1.0 to 1.5 cm bone plug can be harvested if preferred.¹⁰ Should a bone plug be harvested, we recommend a smaller depth to avoid the proximal patella articular surface that extends proximally on the patella to avoid chondral iatrogenic injury. We prefer an all soft-tissue graft. Dissection is then continued proximally with dissecting scissors, while maintaining tension on the distal QT graft with an Allis clamp. A decision can be made to harvest a full- or partial-thickness graft. If QT thickness is ≤7 mm on the preoperative sagittal MRI, then a full-thickness tendon is selected to obtain a graft diameter at least 8 mm¹¹ (Figure 6). If pre-op measurement is ≥8 mm, a partial-thickness graft is taken. If fat is encountered deep to the tendon, avoid deeper dissection to prevent capsulotomy (if aiming for a partial thickness harvest).