Minimally Invasive Lateral Extra-Articular Tenodesis Using a Hybrid All-Suture Anchor of the Knee

Abstract

Anterior cruciate ligament reconstruction is a common knee procedure, yet postoperative graft failure remains a challenge, particularly in high-risk populations and revision cases. Lateral extra-articular tenodesis has been introduced as an adjunct to improve rotational stability and reduce graft failure risk. This Technical Note describes a minimally invasive lateral extra-articular tenodesis using the modified Lemaire technique with a hybrid all-suture anchor construct.

Anterior cruciate ligament reconstruction (ACLR) is among the most frequently performed knee procedures worldwide, with an estimated annual incidence exceeding 100,000 cases in the United States alone.^1,2 Despite advancements in surgical techniques and graft selection, studies indicate that 5% to 20% of patients experience postoperative instability, underscoring the need for adjunct procedures to enhance outcomes.3, 4, 5

Lateral extra-articular tenodesis (LET) has emerged as a valuable addition to ACLR, particularly for patients with a high-grade pivot shift, generalized ligamentous laxity, or previous graft failure.^6,7 By redistributing forces on the ACL graft during pivoting movements, the LET reduces anterior tibial translation and limits excessive internal rotation, thereby mitigating the risk of graft retear.^8,9 Although multiple techniques for LET exist, there remains variability in fixation methods.¹⁰

This Technical Note details a minimally invasive LET approach using the modified Lemaire technique, incorporating the Hybrid Knee FiberTak Anchor (Arthrex, Naples, FL) for fixation. This construct utilizes two specialized repair sutures: a knotless, preconverted 1.3-mm SutureTape loop and a sliding 1.3-mm SutureTape with swaged-on needles. By leveraging modern fixation strategies and a minimally invasive technique, this approach aims to enhance procedural efficiency and improve graft stability in patients undergoing ACLR.

Surgical Technique

Preoperative Workup

Preoperative evaluation includes a comprehensive history and physical examination, with particular attention to anterolateral rotatory laxity assessed via pivot shift testing, baseline ligamentous laxity quantified by the Beighton score, knee hyperextension, and any previous ACLR. Although indications for LET remain variable, the senior author advocates for its use as an adjunct to ACLR in high-risk populations, particularly female athletes, patients with a Beighton score >4, high-grade pivot shift, significant knee hyperextension, or those undergoing revision ACLR.

Surgical Positioning

The patient is positioned supine with all bony prominences well-padded. After an examination under anesthesia, a high-thigh tourniquet is applied, and the leg is prepped and draped. Key surgical landmarks including the fibular head, the Gerdy tubercle, lateral collateral ligament (LCL), and the planned minimally invasive incision proximal to the lateral femoral epicondyle are marked (Fig 1).

Fig 1.

Intraoperative view of a left knee in 90° of flexion, demonstrating key anatomic landmarks used for minimally invasive iliotibial band (ITB) harvest. The Gerdy tubercle (black arrow), fibular head (blue arrow), and lateral collateral ligament (green arrow) are identified to guide graft orientation and safe dissection. A ruler is shown to approximate the planned incision length and location along the lateral aspect of the knee.

Iliotibial Band Harvest

The iliotibial band (ITB) can be harvested at any point during the procedure. The senior author prefers harvesting the ITB before the arthroscopy, after harvesting the ACL graft (in this case, a full-thickness all-soft tissue quadriceps tendon autograft). LET anchor placement is performed after ACL femoral tunnel drilling, and LET fixation is performed after ACL graft tensioning (Video 1).

A 2- to 3-cm longitudinal incision is made over the lateral distal femur, in line with the ITB. Full-thickness skin flaps are elevated, exposing the ITB. Overlying tissue is cleared with a Cobb elevator, extending proximally and distally to the Gerdy tubercle.

A fresh marking pen is used to demarcate the intended anterior and posterior aspects of the ITB dissection, which will be approximately 10 mm in width (from anterior to posterior) along the middle-to-posterior third of the ITB. Using a No. 10 scalpel, 2 parallel longitudinal incisions are made in the ITB in line with its fibers, again spaced about 10 mm apart, and the incisions are carried proximally. Using the scalpel, the proximal ITB is released approximately 60 to 0 mm from the Gerdy tubercle to ensure adequate graft length. An Allis clamp is placed on to the free end, and dissection is continued distally using the scalpel along the ITB toward the Gerdy tubercle, to create a 10-mm × 80-mm strip (anterior-posterior × distal-proximal) (Fig 2). The ITB remains attached distally to the Gerdy tubercle. Care is taken to preserve 5 to 10 mm of ITB posteriorly to facilitate closure and to avoid excessively deep dissection, which could risk injury to the LCL (Table 1).

Fig 2.

Intraoperative view of a left knee after harvest of the iliotibial band (black arrow). The graft is released proximally while remaining distally attached to the Gerdy tubercle, preserving its anatomic insertion. This configuration facilitates subsequent passage and fixation during lateral extra-articular tenodesis.

Table 1.

Pearls and Pitfalls of LET Using a Hybrid All-Suture Anchor

Pearls	Pitfalls
When passing the ITB graft around the LCL, it is helpful to place a gentle varus force on the knee or place leg in the figure-of-four position to help identify the LCL.	When harvesting the ITB graft, it is possible to injure the LCL by cutting too deeply while releasing the proximal side of the graft.
To prevent convergence of the anchor with the femoral ACL tunnel, use the arthroscope in the anteromedial portal to look up into the femoral tunnel while drilling.	If the pilot hole for the anchor placement converges with the femoral ACL tunnel, it is possible to damage the ACL graft and/or its fixation.
While tensioning the ITB graft, ensure that the knee is held in 30-60° of flexion and neutral rotation to prevent overconstraint.	If the knee is allowed to externally rotate or is held in greater than 60° of flexion while tensioning the ITB graft, it can overtighten the lateral structures, limiting flexibility and physiologic laxity.

ACL, anterior cruciate ligament; ITB, iliotibial band; LCL, lateral collateral ligament; LET, lateral extra-articular tenodesis.

Once the ITB is harvested, a FiberLoop SutureTape (Arthrex) is passed through the free end of the graft for 2 to 3 circumferential whipstitches. The ITB graft is wrapped in a vancomycin-soaked RAY-TEC sponge while the LCL is identified. Typically, the LCL can be easily palpated as a cord-like structure running from the lateral femoral epicondyle down to the fibular head. To improve LCL identification, a gentle varus force can be applied or the knee positioned in a figure-of-four configuration (Table 1).

A scalpel or Bovie electrocautery device is used to incise tissue just anterior and posterior to the LCL. A curved hemostat is passed beneath the LCL, superficial to the joint capsule, to create a pathway for the ITB graft. A passing suture is placed deep to the LCL to facilitate future ITB graft passage. We do not pass the graft at this time, to avoid any risk of injuring the graft with pin placement during future ACL femoral tunnel drilling. (Fig 3 A and B).

Fig 3.

Intraoperative view of a left knee in flexion during lateral extra-articular tenodesis. (A) A curved hemostat (black arrow) is passed deep to the lateral collateral ligament (LCL) but superficial to the joint capsule to create the graft passage plane. (B) A TigerLink passing suture (blue arrow) is shuttled beneath the LCL using the hemostat, enabling secure and anatomic graft positioning.

Diagnostic Arthroscopy and Tunnel Drilling

After harvesting the ACL and ITB grafts, a diagnostic arthroscopy is performed through standard anteromedial and anterolateral portals to assess and address intra-articular pathology. Once the femoral tunnel for ACLR is drilled, attention is turned to anchor placement for ITB fixation.

Anchor Placement

The lateral femoral epicondyle is palpated. Next, the drill guide for the Hybrid Knee FiberTak Anchor (Arthrex) is positioned posterior and just proximal to the epicondyle. A 2.6-mm drill pin, aimed anteriorly and proximally, is used to drill a pilot hole. To prevent convergence of the anchor with the femoral ACLR tunnel while drilling, we recommend performing a “tunneloscopy” by placing the arthroscope in the anteromedial portal to visualize the femoral tunnel (Table 1). If convergence occurs, the guide should be adjusted slightly more proximal. Next, a 2.6-mm Hybrid Knee FiberTak Anchor is tapped using a mallet until it reaches the guide handle. The inserter and guide handle are removed, and the suture limbs are pulled to set the anchor and ensure secure fixation.

ITB Passage and Fixation

After ACLR graft tensioning and fixation (Video 1), the ITB is passed deep to the LCL using the previously placed passing suture, shuttling the graft deep to the LCL from distal to proximal (Fig 4 A-C). Next, the white retention suture is removed from the knotless preconverted SutureTape loop (blue) of the hybrid suture anchor, and the ITB is shuttled through this preconverted SutureTape loop (Fig 5A).

Fig 4.

Intraoperative view of a left knee highlighting the steps to shuttle the iliotibial band (ITB) under the lateral collateral ligament (LCL). (A) The FiberLoop SutureTape used to whipstitch the free end of the ITB is loaded into the TigerLink passing suture (black arrow) and shuttled deep to the LCL. (B) The FiberLoop (blue arrow) is then used to pull the ITB (C) so that the ITB is shuttled under the LCL from distal to proximal (green arrow).

Fig 5.

Intraoperative view of a left knee demonstrating key steps in securing the hybrid all-suture anchor construct during lateral extra-articular tenodesis. (A) The iliotibial band (ITB) graft is shuttled from distal to proximal through the preconverted blue knotless SutureTape loop (black arrow). (B) Tensioning is achieved by pulling the blue suture limb (blue arrow), allowing the ITB to be securely approximated. The graft is then reflected distally, and the black sliding SutureTape is used to reinforce fixation by suturing the graft to itself. (C) The suture limbs and excess ITB graft are trimmed, revealing the completed construct (green arrow) secured over the femoral cortex.

The SutureTape loop is provisionally tensioned with the knee in 30 to 60° of flexion and neutral rotation (Fig 5B). Once the desired constraint is confirmed by cycling the knee (Table 1), the loop is fully tensioned to secure the ITB against the femoral cortex. The ITB is then reflected over itself distally, and the sliding SutureTape (black) limbs are used to suture the graft to itself in mattress fashion (Table 1). The limbs of the sliding SutureTape and any excess ITB are trimmed, completing the Hybrid Knee FiberTak Anchor construct (Fig 5C).

Closure

The LET wound is irrigated, and the ITB is reapproximated with interrupted 0-VICRYL sutures (Ethicon). All incisions are irrigated and closed in layers (Fig 6). A self-retrieving suture passing device can be used to close the most proximal aspect of the harvest, particularly when a small skin incision is used. Sterile dressings are applied, and the patient is placed in a hinged knee brace locked in full extension.

Fig 6.

Intraoperative view of a left knee demonstrating that lateral extra-articular tenodesis can be performed through a small 2- to 3 -cm incision (ruler), as marked by the green arrow. This minimally invasive approach allows for iliotibial band harvest and graft passage with limited soft tissue disruption, potentially improving cosmesis and reducing postoperative discomfort.

Rehabilitation Protocol

Postoperative rehabilitation depends on the procedure performed. Patients with poor-quality or radial meniscus tears requiring repair are limited to toe-touch weight-bearing for 4 weeks, then 50% weight-bearing until week 6. Others are weight-bearing as tolerated in a hinged knee brace locked in extension until they achieve a straight leg raise without lag. Early range of motion is encouraged. Gradual return to athletics, guided by a physical therapist, typically begins at 6 months after a functional sports assessment, with full return expected at 9 months.

Discussion

LET has proven beneficial in ACLR, particularly in revisions and high-risk cases.^2,11, 12, 13 Randomized trials show it improves stability and lowers graft re-rupture rates.14, 15, 16 In a study of 455 elite athletes, LET reduced revision risk by 2.8-fold.¹⁷ Given this evidence, LET should be considered for graft protection in high-risk populations.

The use of a hybrid all-suture anchor offers several advantages. The soft anchor mechanism and low-profile construct theoretically minimize implant-related irritation, while the knotless design facilitates controlled tensioning and may allow for a more accelerated rehabilitation protocol, potentially leading to improved postoperative outcomes. Compared with a double knotless anchor, the hybrid version incorporates swaged-on needles, enabling secure fixation of the excess ITB graft onto itself. This feature prevents graft slippage and provides additional reinforcement. In addition, the minimally invasive harvest technique may help limit soft tissue disruption, with potential benefits such as reduced postoperative discomfort and improved cosmesis (Table 2).

Table 2.

Advantages and Disadvantages of LET Using a Hybrid All-Suture Anchor

Advantages	Disadvantages
LET improves stability and reduces rates of graft retear.	Minimally invasive approach may be considered technically challenging
In cases of revision ACLR, patients that undergo LET report a greater return to pre-injury level of sport.	Implant cost
Low-profile design prevents implant irritation	Patients may experience prolonged lateral-sided knee pain due to ITB donor-site morbidity
The ability to re-tension the construct after cycling the knee allows for a dialed repair and helps prevents overconstraint.	It is possible to overconstrain the knee which can lead to reduced range of motion.
Compared with the double knotless design, using a hybrid anchor prevents the possibility of the excess ITB graft sliding out from the second suture loop.	There is a risk of tunnel convergence that can cause damage to the ACL graft and/or its fixation if a “tunneloscopy” is not used.
The minimally invasive technique reduces soft tissue trauma, risk of infection, and postoperative pain.

ACLR, anterior cruciate ligament reconstruction; ITB, iliotibial band; LCL, lateral collateral ligament; LET, lateral extra-articular tenodesis.

Despite the advantages of the hybrid all-suture LET technique, certain challenges remain (Table 2). The minimally invasive approach, while advantageous, may present a technical learning curve. Additionally, the use of an autologous graft introduces the risk of donor-site morbidity, which may contribute to prolonged lateral-sided pain. Proper graft tensioning is critical, as excessive constraint can result in reduced range of motion, stiffness, and decreased patient satisfaction. Although meta-analyses and clinical studies suggest that LET does not accelerate osteoarthritis progression, improper tensioning may still alter joint mechanics and affect long-term outcomes.¹⁸

Ultimately, minimally invasive LET using a hybrid all-suture anchor represents a promising adjunct to ACLR, particularly in high-risk patients. As interest in LET continues to grow, standardized techniques and further research will help refine its role in optimizing ACLR outcomes.

Disclosures

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: R.M.F. reports board membership with American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, Arthroscopy Association of North America, International Cartilage Regeneration & Joint Preservation Society, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Journal of Shoulder and Elbow Surgery, and Orthopedics Today; consulting or advisory and speaking and lecture fees from AlloSource and JRF Ortho; consulting or advisory, funding grants, and speaking and lecture fees from Arthrex; and speaking and lecture fees from Ossur. All other authors (E.H.R., D.J.S., B.M.M., M.G.M., P.A.S.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

This video demonstrates a minimally invasive lateral extra-articular tenodesis using a hybrid all-suture anchor technique, offering a reproducible method with minimal soft-tissue disruption.