Abstract
Tibial anterolateral rotary instability associated with anterior cruciate ligament (ACL) tears is a well-documented and difficult problem with a long history of solutions. The lateral extra-articular tenodesis (LET) has undergone multiple refinements in technique, largely focusing on the femoral site insertion using either an interference screw versus a staple for adequate fixation. In this article, we present an improved technique using a suture anchor as an alternative to a staple or an interference screw with secure fixation to insert the LET graft onto the femur. This technique diminishes the chance of ACL tunnel–LET drilling convergence, minimizes the footprint required for adequate graft fixation, and allows the surgeon to dial in the correct tension necessary for adequate augmentation of an ACL reconstruction.
Technique Video
Onlay technique of lateral extra-articular tenodesis (LET). The lateral aspect of a right knee is shown, with the patient positioned supine. The surgeon performs an approach to the iliotibial band, removing all subcutaneous tissue for adequate exposure starting approximately at the Gerdy tubercle and extending proximally about 8 cm. A distally based strip of the iliotibial band is harvested, approximately 1 cm in width, by use of separate incisions. A double-loaded 2.3-mm Iconix all-suture suture anchor is used for LET graft insertion. The graft is whipstitched with an arm of the suture anchor that is first passed underneath the lateral collateral ligament, followed by a simple suture pass through the graft by the other end of the same arm of the suture attached to the suture anchor. The fixation with 1 arm of the double-loaded Iconix suture anchor was enough to secure the graft appropriately, and the other suture within the double-loaded 2.3-mm Iconix suture anchor was removed prior to definitive fixation of the LET graft. Once the LET graft was appropriately stitched, the graft was passed underneath the lateral collateral ligament again, from distal to proximal, and then secured to the Iconix suture anchor.
The problem of tibial anterolateral rotary instability (ALRI) associated with anterior cruciate ligament (ACL) tears is well documented and difficult to resolve, with multiple proposed solutions. Lemaire1 in 1967 proposed the original lateral extra-articular tenodesis (LET) as a transfer of a distally attached strip of the iliotibial band (ITB) to address ALRI associated with ACL tears. This procedure was largely abandoned in America after a team of knee experts at the American Orthopaedic Society for Sports Medicine (AOSSM) meeting in Snowmass, Colorado, in 1989 concluded that it was largely unnecessary and added unnecessary comorbidity to an ACL reconstruction.2 The priority shifted to a properly performed intra-articular ACL reconstruction. However, addressing ALRI with lateral extra-articular procedures as an augmentation to ACL reconstruction has regained interest in recent years to provide optimal ACL reconstruction results.2 Therefore, various refined operative techniques for the LET have centered largely on the femoral insertional site.3 Biomechanical studies have illustrated the isometric insertional sites that extend along an imaginary line from the modified Lemaire insertional site to the Macintosh insertional site, as shown in Figure 1.4, 5, 6, 7, 8, 9 The strategies to anchor the ITB to the lateral femoral condyle most commonly are interference screws or staples. Unfortunately, these modalities require a large footprint to perform with a longer length of ITB harvest, account for higher rates of hardware irritation and/or removal postoperatively, and lead to a common complication of tunnel convergence owing to the close proximity of the lateral femoral tunnel for an ACL reconstruction and the point of insertion for an LET. The onlay technique with a suture anchor for femoral site insertion provides an improved solution to achieve stability for the LET graft while minimizing graft–ACL tunnel convergence, ITB harvest length, and soft-tissue dissection to the lateral femoral condyle. This technique is illustrated in Video 1.
Fig 1.
Lateral aspect of knee showing several anchorage points for lateral extra-articular tenodesis. The femoral anchor points from distal to proximal are the modified Lemaire, Krackow F9,7 and Macintosh anchor points. (LCL, lateral collateral ligament.)
Surgical Technique
ACL reconstruction is performed in standard fashion. We typically use an all-inside drilling technique with retro-reamers using quadriceps autograft. We prefer to perform the LET procedure after the tibial and femoral tunnels are drilled but before the ACL graft is passed. The following landmarks are palpated and labeled, as illustrated in Figure 2: lateral femoral epicondyle (LFE), fibular head, Gerdy tubercle, and lateral collateral ligament (LCL). An approximately 8-cm incision is made, starting just proximal to the Gerdy tubercle in line with the ITB, aiming 1 cm inferior to the LFE, as illustrated in Figure 2. The ITB is exposed thoroughly to completely visualize the entire ITB. Through the exposure, the LFE, fibular head, LCL, and Gerdy tubercle are properly palpated, as shown in Figure 3. If the LCL is difficult to palpate, the extremity can be placed in the figure-of-4 position to tighten the ligament.
Fig 2.
Lateral aspect of right knee, with patient positioned supine, showing significant landmarks drawn for appropriate orientation and localization of incision. The incision for the lateral extra-articular tenodesis (dotted arrow) is localized approximately 2 cm proximal to the Gerdy tubercle (solid arrow), aiming approximately 1 cm inferior to the lateral femoral epicondyle (black asterisk), and is approximately 8 cm in length. The fibular head is marked with the white star, and the lateral collateral ligament is marked as the structure connecting the lateral femoral epicondyle and the fibular head.
Fig 3.
Lateral aspect of right knee, with patient positioned supine. Adequate exposure of the iliotibial band is achieved with satisfactory dissected subcutaneous tissue, enabling adequate palpation of the protuberant landmarks of the lateral femoral epicondyle, Gerdy tubercle, fibular head, and lateral collateral ligament. The distal extremity is marked with the black asterisk, and the superior-dorsal extremity is marked with the white star.
Graft Harvest
The graft is harvested along the posterior two-thirds of the ITB beginning 3 cm proximal to the LCL and ending just proximal to the Gerdy tubercle, with parallel incisions made approximately 10 mm apart. The most posterior element of the ITB is left intact to leave a sleeve to close at the end. The surgeon should make the initial parallel incisions proximally and insert a hemostat within the incisions and underneath the harvested LET graft to bluntly separate the ITB from the underlying LCL and capsule. The hemostat should be used to lift the LET graft and ITB away from the underlying structures to minimize the risk of damaging the LCL, as shown in Figures 4 and 5. Once the dual, parallel incisions have been initiated, the hemostat is used to bluntly separate any adhesions between the LCL and capsule and the LET graft, as shown in Figure 6. Once the adhesions have been separated, amputation of the proximal attachment of the LET graft is performed, creating a distally based graft approximately 8 cm × 10 mm in size. A tagging stitch is placed on the end of the graft to assist in handling and passing of the graft. Dissection is performed underneath the proximal LCL, under the LFE origin, without breaking through the capsule of the knee. The surgeon uses a blunt hemostat to widen the tunnel deep to the LCL as much as possible, ensuring the mobility of the final LET graft will be unimpeded when the knee is cycled during activities.
Fig 4.
Lateral aspect of right knee, with patient positioned supine, with exposed iliotibial band (ITB) and initial parallel proximal incisions, separated by 10 mm in width, with hemostat inserted within incision to isolate element of ITB used for lateral extra-articular tenodesis graft. The hemostat is used to lift the ITB away from the underlying structures while the lateral extra-articular tenodesis graft is harvested to avoid damaging underlying important stabilizing structures of the knee. The distal aspect of the extremity is marked with the black asterisk, and the superior-dorsal aspect is marked with the white star.
Fig 5.
Lateral aspect of right knee, with patient positioned supine, with exposed iliotibial band and active harvesting of lateral extra-articular tenodesis graft. A hemostat has been inserted between the 2 parallel incisions proximally, separated by 10 mm in width, and lifts the graft away from the underlying structures while the distal elements of the graft are being harvested. This technique helps to minimize damage to underlying important stabilizing structures of the knee while harvesting the lateral extra-articular tenodesis graft. The distal aspect of the extremity is marked with the black asterisk, and the superior-dorsal aspect of the extremity is marked with the white star.
Fig 6.
Lateral aspect of right knee, with patient positioned supine, with exposed iliotibial band and harvested lateral extra-articular tenodesis graft with proximal attachment remaining intact. The hemostat is used to strip underlying soft-tissue adhesions or attachments from the deep underlying structures of the knee prior to amputation of the proximal attachment. The distal extremity is marked with the black asterisk, and the superior-dorsal extremity is marked with the white star.
Docking of LET Graft
Next, the LET graft femoral insertional site is localized, and a Cobb elevator or rongeur is used to clean off any soft tissue obscuring the area. The surgeon must be cautious to avoid the superolateral genicular artery. Meticulous hemostasis should be ensured to avoid postoperative hematomas. The previously drilled ACL femoral tunnel is visualized, and the location of the LET femoral insertion site—generally posterior and proximal to the LFE in the modified Lemaire femoral insertional site—is localized (Fig 1). Once the site is localized, the LET graft is grasped with a hemostat and the graft is held over the site of insertion with about 20 N of tension while full range of motion of the knee is performed to quickly assess isometry. Once the surgeon is satisfied with the area of isometry, the spot is marked with a Bovie device (Bovie Medical, Clearwater, FL). Next, the surgeon uses a 2.3-mm drilling guide, aiming proximal and anterior, to place a double-loaded 2.3-mm × 18-mm Iconix suture anchor (Stryker, Kalamazoo, MI) in standard fashion at the marked area, as shown in Figure 7. Simultaneously, an assistant should intra-articularly visualize the ACL femoral tunnel via the arthroscope to ensure that the suture anchor drilling does not communicate with the ACL femoral tunnel. If communication occurs, drilling is ceased immediately and the drill trajectory is changed. After suture anchor placement, the knee is positioned in 60° of flexion with the foot in neutral rotation. The graft is stretched toward the suture anchor with about 20 N of force with the graft in the proper orientation (deep side of graft facing bone). Preliminary simple passes of sutures of the same color are placed at the level of the graft over the suture anchor. The surgeon slides the graft along the sutures all the way to the bone and begins ranging the knee to assess the isometry of the femoral insertion site. He or she should pay attention to the position of the knee at which the graft becomes tightest. Ideally, the graft will hold the same tension throughout the entire range of motion. However, if the graft becomes too tight at the extremes of range of motion, the sutures can be removed and re-placed at a more proximal position on the LET graft to account for the laxity at full extension or flexion. If necessary, another suture anchor can be placed at a more ideal position if the placement of the first suture anchor is unsatisfactory. Once satisfied with suture anchor placement, the surgeon removes the preliminary passing stitches from the LET graft and marks the area with a marking pin. The sutures are passed underneath the LCL, and one suture tail is stitched through the graft in the orientation shown in Figure 8 at the level of the marking. The other corresponding suture tail utilized as a sliding stitch with a simple pass at the same marking. A knot is tied to indicate the sliding stitch. If the suture anchor is double-loaded with an extra pair of suture tails, the previous steps are performed again to achieve extra fixation but on the opposite side of the graft. The graft, along with its sutures, is passed under the LCL from distal to proximal toward the suture anchor. The graft is then cinched to the suture anchor by pulling on the sliding stitches. The corresponding sutures are tied together directly over the suture anchor with the knee at 60° of flexion in neutral rotation. The surgeon should range the knee 1 last time to have 1 final visualization. Once satisfied with the position and tension of the graft, we typically then reflect the redundant LET graft onto itself and suture it to the LET distally over the LCL. The surgeon can also just cut the redundant graft if preferable.
Fig 7.
(A, B) Placement of suture anchor at localized area of femoral insertion for lateral extra-articular tenodesis graft. (A) Lateral aspect of right knee, with patient positioned supine, after harvesting of lateral extra-articular tenodesis graft with proximal attachment transected and distal attachment remaining. The surgeon is demonstrating the proximal-anterior trajectory of the angled guide during placement of the suture anchor to minimize the chance of impingement on the previously drilled anterior cruciate ligament femoral tunnel. The distal aspect of the extremity is marked with the white asterisk, and the superior-dorsal aspect of the extremity is marked with the white star. (B) Simultaneous visualization of femoral tunnel, intra-articularly, from anteromedial portal to ensure drill guide does not connect with anterior cruciate ligament femoral tunnel.
Fig 8.
Suture-passing technique to secure lateral extra-articular tenodesis graft to suture anchor with 3 whipstitches, starting at marked area on proximal end of graft and progressing distally with 3 throws. The technique is finished with a transverse locking stitch underneath the graft and then a final throw behind the locking stitch that exits at the marked area next to the initial entry throw. The sliding stitch is a simple throw at the marked area. A simple pass of the other corresponding suture tail is placed at the marked area to act as a sliding stitch.
Closure
The ITB is closed with Vicryl sutures (Ethicon, Somerville, NJ), as shown in Figure 9. The most posterior element of the ITB should be intact, being the primary resistance of the ITB to ALRI of the tibia.10,11 Meticulous hemostasis should again be ensured to avoid postoperative hematomas. The subcutaneous tissue and skin are closed in standard fashion.
Fig 9.
Lateral aspect of right knee, with patient positioned supine, showing closure of iliotibial band with Vicryl stitches once lateral extra-articular tenodesis graft has been anchored appropriately. The most posterior element of the iliotibial band has been left intact to ensure appropriate closure and provide optimal tibial anterolateral stability to the knee. The distal aspect of the extremity is marked with the black asterisk, and the superior-dorsal aspect of the extremity is marked with the white star.
Postoperative Recovery
Postoperative rehabilitation typically begins with toe-touch weight bearing for 2 weeks with the knee locked in extension. Subsequently, the patient can begin full range of motion and progression of weight bearing as tolerated, with advancement through an ACL rehabilitation protocol in standard fashion.
Discussion
The LET onlay technique provides a simple, efficient, and reliable technique to secure the LET graft to the lateral femoral condyle while minimizing tunnel convergence, minimizing graft length, and providing an easy and reproducible way to optimally tension the LET graft (Table 1). Tunnel convergence with penetration from an LET insertional site and lateral femoral ACL tunnel is a recognized complication.12, 13, 14 The primary benefit of the onlay technique involves minimizing the footprint necessary with a suture anchor while maintaining excellent fixation, enabling a lesser risk of tunnel convergence. Other proposed techniques have tried to mitigate these concerns by incorporating the LET graft into the suture button used to secure the ACL graft in the lateral femoral tunnel.15 Although this approach solves the concern of tunnel convergence, changing the ACL femoral tunnel trajectory or placing the LET graft in a non-isometric position becomes more problematic long-term. Our technique allows independent decisions on both graft placements in the optimal positions without affecting placement of either. Techniques using staples, as well as interference screws, perhaps provide confident fixation of the graft on the lateral femur, but the footprint necessary for fixation creates a high risk of impingement of the tunnels, as well as the need for a long graft to maximize the fixation with suturing the graft back onto itself.16 Getgood et al showed a high rate of LET staple irritation, with 13 patients reporting staple irritation and 10 of 13 electing to undergo staple removal within 24 months of ACL reconstruction.4 Our technique allows less graft to be harvested with a low-profile suture anchor that provides compression as well as fixation that is efficiently used for the desired outcome.
Table 1.
Advantages and Disadvantages of LET Onlay Technique
| Advantages |
| Ability to check and trial preliminary site of insertion for LET graft on femur, with option to optimize position if not satisfactory |
| Optimization of tensioning of LET graft |
| Small footprint used for LET graft |
| Fixation achieved with stitches on graft |
| Minimal ITB harvest necessary for adequate fixation |
| Low-profile nature of device |
| Disadvantages |
| Fixation achieved through bone-anchor interface |
| Added cost of suture anchor compared with staple |
| Reliance of construct on properly tied suture knot holding graft to 2.3-mm Iconix suture anchor |
ITB, iliotibial band; LET, lateral extra-articular tenodesis.
The onlay technique is also beneficial to ensure appropriate tensioning and isometric positioning of the LET graft with multiple checks and balances prior to definitive fixation. Inderhaug et al.5 assessed the amount of tension necessary to optimally stabilize the lateral side of the knee while avoiding over-constraint and found that 20 N of tension force is optimal without increasing intra-articular pressure and/or tibial external rotation. The described technique allows optimal assessment and fine-tuning of the area of fixation of the LET graft in real time during the case.
A perceived disadvantage of the onlay technique could be reliance of the suture-anchor fixation at the bone-anchor interface as opposed to the interference screw or staple (Table 2). However, it is possible that lower pullout strength is achieved than with a staple or interference screw. In addition, the quality of the knot holding the LET graft to the base of the suture anchor is crucial to the overall stability and fixation of the construct. A poorly tied knot—or an air knot—would be fatal to the integrity of the procedure. Pending an adequately performed procedure with 20 N of tension in an isometric position, the suture anchor stability should provide plenty of reassurance with stability for an LET procedure.
Table 2.
Pearls and Pitfalls of LET Onlay Technique
| The surgeon should avoid cutting any underlying structures beneath the ITB when harvesting the LET graft. This is minimized while using the hemostat to lift the ITB away from the underlying structures as described in the “Surgical Technique” section. |
| The surgeon should ensure excellent visualization of the lateral femur to the posterior cortex of the distal femur on the lateral femoral condyle for adequate placement of the LET graft insertion. |
| For trialing of the LET graft, the surgeon should pass the sutures through the graft at the level of the 2.3-mm Iconix suture anchor with the graft at 20 N of tension while ensuring the extremity is in neutral rotation and knee is at 60° of flexion. This sets the tension of the graft. Then, the surgeon should range the knee to assess the isometry of the insertion. The primary concern is a graft that becomes too tight in extension, hindering the patient from obtaining full knee extension during postoperative rehabilitation. |
| When whipstitching the LET graft as illustrated in Figure 8, the surgeon should pass the first throw and the sliding stitch at the level of the marked area to replicate the tension of the LET graft after trialing. |
| The surgeon should ensure that the LET graft is in the correct orientation when passing sutures, with the deep side of the graft facing the bone and the superficial side of the graft facing out. |
| The surgeon should ensure that the knee is in neutral rotation when tying the graft to the 2.3-mm Iconix suture anchor. Over-tightening in external rotation should be avoided, especially if a posterolateral corner injury is present. |
ITB, iliotibial band; LET, lateral extra-articular tenodesis.
In conclusion, the onlay technique with LET graft augmentation for ACL reconstruction provides a simple, efficient, and stable fixation alternative to other techniques with a minimal footprint necessary to achieve the desired outcome and minimal risk of impingement.
Footnotes
The authors report the following potential conflicts of interest or sources of funding: S.W.M. is a paid consultant for Stryker, outside the submitted work. J.W.G. receives intellectual property royalties from Stryker, is a paid consultant for Stryker and Pivot, is a paid presenter or speaker for Stryker, and receives research support from Stryker, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
Onlay technique of lateral extra-articular tenodesis (LET). The lateral aspect of a right knee is shown, with the patient positioned supine. The surgeon performs an approach to the iliotibial band, removing all subcutaneous tissue for adequate exposure starting approximately at the Gerdy tubercle and extending proximally about 8 cm. A distally based strip of the iliotibial band is harvested, approximately 1 cm in width, by use of separate incisions. A double-loaded 2.3-mm Iconix all-suture suture anchor is used for LET graft insertion. The graft is whipstitched with an arm of the suture anchor that is first passed underneath the lateral collateral ligament, followed by a simple suture pass through the graft by the other end of the same arm of the suture attached to the suture anchor. The fixation with 1 arm of the double-loaded Iconix suture anchor was enough to secure the graft appropriately, and the other suture within the double-loaded 2.3-mm Iconix suture anchor was removed prior to definitive fixation of the LET graft. Once the LET graft was appropriately stitched, the graft was passed underneath the lateral collateral ligament again, from distal to proximal, and then secured to the Iconix suture anchor.
References
- 1.Lemaire M. Rupture anciennes du ligament croisé antérieur. Frequence-clinique traitement. J Bone Joint Surg Br. 1967;58:142. [in French] [Google Scholar]
- 2.Ferretti A. Extra-articular reconstruction in the anterior cruciate ligament deficient knee: A commentary. Joints. 2014;2:41–47. [PMC free article] [PubMed] [Google Scholar]
- 3.Slette E.L., Mikula J.D., Schon J.M., et al. Biomechanical results of lateral extra-articular tenodesis procedures of the knee: A systematic review. Arthroscopy. 2016;32:2592–2611. doi: 10.1016/j.arthro.2016.04.028. [DOI] [PubMed] [Google Scholar]
- 4.Getgood A., Moatshe G. Lateral extra-articular tenodesis in anterior cruciate ligament reconstruction. Sports Med Arthrosc. 2020;28:71–78. doi: 10.1097/JSA.0000000000000278. [DOI] [PubMed] [Google Scholar]
- 5.Inderhaug E., Stephen J.M., Williams A., Amis A.A. Biomechanical comparison of anterolateral procedures combined with anterior cruciate ligament reconstruction. Am J Sports Med. 2017;45:347–354. doi: 10.1177/0363546516681555. [DOI] [PubMed] [Google Scholar]
- 6.Inderhaug E., Stephen J.M., Williams A., Amis A.A. Anterolateral tenodesis or anterolateral ligament complex reconstruction: Effect of flexion angle at graft fixation when combined with ACL reconstruction. Am J Sports Med. 2017;45:3089–3097. doi: 10.1177/0363546517724422. [DOI] [PubMed] [Google Scholar]
- 7.Krackow K.A., Brooks R.L. Optimization of knee ligament position for lateral extraarticular reconstruction. Am J Sports Med. 1983;11:293–302. doi: 10.1177/036354658301100503. [DOI] [PubMed] [Google Scholar]
- 8.Kittl C., Halewood C., Stephen J.M., et al. Length change patterns in the lateral extra-articular structures of the knee and related reconstructions. Am J Sports Med. 2015;43:354–362. doi: 10.1177/0363546514560993. [DOI] [PubMed] [Google Scholar]
- 9.Macintosh D., Darby T. Lateral substitution reconstruction. J Bone Joint Surg Br. 1976;58:142. doi: 10.1302/0301-620X.70B4.3403611. [DOI] [PubMed] [Google Scholar]
- 10.Kittl C., Inderhaug E., Williams A., Amis A.A. Biomechanics of the anterolateral structures of the knee. Clin Sports Med. 2018;37:21–31. doi: 10.1016/j.csm.2017.07.004. [DOI] [PubMed] [Google Scholar]
- 11.Dodds A.L., Halewood C., Gupte C.M., Williams A., Amis A.A. The anterolateral ligament: Anatomy, length changes and association with the Segond fracture. Bone Joint J. 2014;96-B:325–331. doi: 10.1302/0301-620X.96B3.33033. [DOI] [PubMed] [Google Scholar]
- 12.Smeets K., Bellemans J., Lamers G., et al. High risk of tunnel convergence during combined anterior cruciate ligament and anterolateral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019;27:611–617. doi: 10.1007/s00167-018-5200-3. [DOI] [PubMed] [Google Scholar]
- 13.Jaecker V., Ibe P., Endler C.H., Pfeiffer T.R., Herbort M., Shafizadeh S. High risk of tunnel convergence in combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis. Am J Sports Med. 2019;47:2110–2115. doi: 10.1177/0363546519854220. [DOI] [PubMed] [Google Scholar]
- 14.Gali J.C., de Paula Bernardes A., dos Santos L.C., Ferreira T.C., Almagro M.A.P., da Silva P.A.C. Tunnel collision during simultaneous anterior cruciate ligament and posterolateral corner reconstruction. Knee Surg Sports Traumatol Arthrosc. 2016;24:195–200. doi: 10.1007/s00167-014-3363-0. [DOI] [PubMed] [Google Scholar]
- 15.Koukoulias N.E., Dimitriadis T., Vasiliadis A.V., Germanou E., Boutovinos A.-P. ACL Reconstruction and modified Lemaire tenodesis utilizing common suspensory femoral fixation. Arthrosc Tech. 2022;11:e2185–e2193. doi: 10.1016/j.eats.2022.08.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Jesani S., Getgood A. Modified Lemaire lateral extra-articular tenodesis augmentation of anterior cruciate ligament reconstruction. JBJS Essent Surg Tech. 2019;9:e41. doi: 10.2106/JBJS.ST.19.00017. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Onlay technique of lateral extra-articular tenodesis (LET). The lateral aspect of a right knee is shown, with the patient positioned supine. The surgeon performs an approach to the iliotibial band, removing all subcutaneous tissue for adequate exposure starting approximately at the Gerdy tubercle and extending proximally about 8 cm. A distally based strip of the iliotibial band is harvested, approximately 1 cm in width, by use of separate incisions. A double-loaded 2.3-mm Iconix all-suture suture anchor is used for LET graft insertion. The graft is whipstitched with an arm of the suture anchor that is first passed underneath the lateral collateral ligament, followed by a simple suture pass through the graft by the other end of the same arm of the suture attached to the suture anchor. The fixation with 1 arm of the double-loaded Iconix suture anchor was enough to secure the graft appropriately, and the other suture within the double-loaded 2.3-mm Iconix suture anchor was removed prior to definitive fixation of the LET graft. Once the LET graft was appropriately stitched, the graft was passed underneath the lateral collateral ligament again, from distal to proximal, and then secured to the Iconix suture anchor.
Onlay technique of lateral extra-articular tenodesis (LET). The lateral aspect of a right knee is shown, with the patient positioned supine. The surgeon performs an approach to the iliotibial band, removing all subcutaneous tissue for adequate exposure starting approximately at the Gerdy tubercle and extending proximally about 8 cm. A distally based strip of the iliotibial band is harvested, approximately 1 cm in width, by use of separate incisions. A double-loaded 2.3-mm Iconix all-suture suture anchor is used for LET graft insertion. The graft is whipstitched with an arm of the suture anchor that is first passed underneath the lateral collateral ligament, followed by a simple suture pass through the graft by the other end of the same arm of the suture attached to the suture anchor. The fixation with 1 arm of the double-loaded Iconix suture anchor was enough to secure the graft appropriately, and the other suture within the double-loaded 2.3-mm Iconix suture anchor was removed prior to definitive fixation of the LET graft. Once the LET graft was appropriately stitched, the graft was passed underneath the lateral collateral ligament again, from distal to proximal, and then secured to the Iconix suture anchor.