Simultaneous Backup Femoral-sided Anterior Cruciate Ligament Graft Fixation and Lateral Extra-Articular Tenodesis With Iliotibial Band Anchoring With Single-Suture Anchor

Abstract

The modified Lemaire lateral extra-articular tenodesis (LET) has gained increasing adoption as an augmentation technique for high-risk primary and revision anterior cruciate ligament (ACL) reconstructions. Recent studies show lower rates of ACL graft failure and rotatory laxity when LET is combined with ACL reconstruction. In revision ACL surgery, optimal graft fixation becomes especially critical because compromised bone stock from previous surgeries increases the risk of fixation failure attributable to device failure, bone osteopenia, suboptimal tunnel placement, or inadequate tendon-bone interface. To address these challenges, backup femoral fixation methods using suture anchors are employed to reinforce primary fixation. This Technical Note presents a technique for backup fixation of ACL graft combined with LET anchoring through a single suture anchor. This approach offers several advantages including dual fixation capability through a single anchor, compatibility with various primary fixation methods, and enhanced stability in cases with decreased bone quality or suboptimal tunnel positioning.

The modified Lemaire lateral extra-articular tenodesis (LET) procedure has gained increasing adoption as an augmentation technique to address rotational instability in high-risk primary and revision anterior cruciate ligament (ACL) reconstructions and repairs. Multiple recent studies, including randomized controlled trials, have found lower rates of ACL graft failure and rotatory laxity when the LET is combined with ACL reconstruction.^1,2 The increasing use of LET in progressively more complex revision cases presents additional challenges when bone stock has been compromised by previous surgeries.

Optimal graft fixation is one of the key principles of ACL reconstruction, especially in the revision setting, in which worse outcomes have been reported.³ Fixation failure can occur as the result of device failure, host bone osteopenia, increased interference screw-tunnel divergence angle, and inadequate socket length and tendon-bone interface for healing.³ In the context of revision, tunnel positioning and bone quality are especially important for maintaining good fixation.

To supplement primary fixation, various methods of backup femoral fixation are commonly used, including suture anchors and screws.⁴ The suture anchor can both reinforce graft fixation and serve as the anchor point for the fixation of the LET through a twisting of the anchor. This opportunity can be especially valuable in the revision setting when bone stock is suboptimal, the risk for poor fixation is increased, and the LET is indicated. In this Technical Note and associated video (Video 1), we describe our preferred technique for enhancing femoral ACL graft fixation using a suture anchor that simultaneously provides fixation for the LET.

Surgical Technique

Indications and Preoperative Planning

Relative indications for LET in the setting of ACL reconstruction or repair include revision ACL surgery, high-grade pivot shift or Lachman tests, generalized hypermobility, Segond fracture or anterolateral corner injury, high-risk athletic participation, posterior tibial slope >12°, knee hyperextension >10°, or use of hamstring autograft. Standard preoperative imaging includes anteroposterior, Rosenberg, lateral, Merchant, and standing alignment radiographs (Fig 1), along with magnetic resonance imaging to confirm ACL rupture and evaluate concomitant pathology. The advantages and disadvantages of this technique are shown in Table 1.

Fig 1.

Lateral approach to the left knee. A skin incision has been made, and subcutaneous tissue is retracted to expose the iliotibial band for grafting.

Table 1.

Advantages and Disadvantages of Combined Fixation

Advantages	Disadvantages
Single-suture anchor functions as both backup fixation for the femoral side of the ACL reconstruction as well as an anchor point for the LET	Possible IT band pain postoperatively
The surgical approach for LET provides access to the lateral femur, which is often essential in revision procedures that may require hardware removal or management of bone loss	Potential for LET femoral tunnel convergence with the ACL femoral tunnel
Compatible with multiple methods of primary fixation	Potential for overconstraint of the lateral compartment

ACL, anterior cruciate ligament; IT, iliotibial; LET, lateral extra-articular tenodesis.

Preoperative Anesthesia

Patients receive general anesthesia with optional regional anesthesia for intraoperative and postoperative analgesia. Regional options include single-shot adductor canal block with or without iPACK (infiltration between the popliteal artery and posterior knee capsule) block.

Patient Positioning, Skin Preparation, and Surgical Draping

The patient is positioned supine with an ipsilateral thigh post placed distally to aid in applying valgus force for medial compartment visualization. A nonsterile tourniquet is positioned proximally on the thigh to ensure adequate exposure for unobstructed graft harvest. After application of a 1,000 drape distal to the tourniquet, chlorhexidine skin preparation is performed, followed by standard extremity draping and placement of an impervious stockinette over the lower leg and foot.

Knee Arthroscopy With Concomitant ACL Reconstruction

First, examination under anesthesia is performed to confirm rotational instability. The surgical technique begins with standard anteromedial and anterolateral portal creation, followed by diagnostic arthroscopy and any necessary meniscal work. Attention then turns to the injured ACL. Graft harvest or allograft preparation and bone tunnel/socket creation proceed, with graft preparation on the back table while tunnels are drilled on the basis of the chosen graft type. The femoral socket is created using an outside-in technique through a small lateral thigh incision, with a shuttling suture passed through this portal. This same incision will later be used to secure the femoral-sided graft sutures after graft passage.

LET and Backup Femoral Fixation of the ACL

The lateral distal thigh incision is expanded 3 cm proximally and distally using a No. 10 blade for the skin incision only. Deep dissection proceeds to the iliotibial (IT) band, where a lap sponge is used to clear superficial fatty and fibrous tissue (Fig 1). The IT band split created by the exiting femoral graft sutures is identified. The entire IT band width is inspected to determine whether this split should serve as the superior or inferior margin of the LET graft, with the goal of harvesting a centrally located graft with fibers inserting onto the Gerdy tubercle. A 1-cm by 9- to 10-cm IT band graft is then harvested, dividing it proximally from the remaining IT band while preserving its distal attachment at the Gerdy tubercle (Fig 2). The fibular collateral ligament is identified, and a 90° hemostat is used to pass the graft deep to this structure.

Fig 2.

Lateral view of the left knee after harvest of the iliotibial band graft. A segment of the band has been mobilized for lateral extra-articular tenodesis, with its distal attachment at the Gerdy tubercle preserved.

With the knee flexed to 90°, an Army Navy or appendiceal retractor is positioned superiorly by an assistant to retract the vastus musculature and superior IT band. The femoral ACL sutures are freed to the femoral level, followed by careful dissection to clear the distal lateral metaphyseal flare near the distal Kaplan fibers. The sutures are loaded into the eyelet of a 4.75-mm double-suture tape loaded twist-in suture anchor (Anika Therapeutics, Bedford, MA). At the region just superior to the distal Kaplan fibers, posterior and proximal to the lateral epicondyle, a 4.75-mm pilot hole is drilled and tapped with a 5.2-mm tap. After careful tensioning of each suture limb, the anchor is inserted to complete femoral-sided ACL backup fixation. The knee is then positioned in 20 to 30° of flexion with neutral rotation using a bump for support. An Allis clamp grasps the IT band graft and reduces it to the anchor, with this location then marked on the graft. One limb from each of the 2 preloaded suture tape sets is passed in running locked fashion from distal to proximal and back distally, exiting at the marked site, while the corresponding limbs are passed in simple fashion. Using a tension-slide technique, the graft is reduced to the anchor and secured with 7 alternating half hitches using a knot pusher.

The knee is gently cycled through full flexion and extension to ensure no graft capture. Any redundant IT band graft is then sutured back upon itself using No. 0 braided absorbable suture (Fig 3). Final Lachman and pivot shift testing confirms translational and rotational stability. Pearls and pitfalls of this procedure are summarized in Table 2.

Fig 3.

Lateral view of the left knee with final LET fixation. Redundant LET graft has been sutured back upon itself using No. 0 braided absorbable suture. LET, lateral extra-articular tenodesis.

Table 2.

Pearls and Pitfalls

Pearls	Pitfalls
Use large split in the iliotibial band for the harvest of the graft to better identify the appropriate insertion site near the distal Kaplan fibers	Ensure the tourniquet is released before closure of the iliotibial band to ensure the lateral geniculate artery is cauterized if injured in the suture anchor placement
Ensure 9-10 cm of iliotibial band is harvested for graft placement as shorter can lead to insufficient graft	Watertight closure of the iliotibial band defect should be completed as residual defects in the iliotibial band can lead to muscle herniation and pain
Place the suture anchor with the ACL graft sutures in the eyelet of the anchor at 90° of knee flexion, allowing for better retraction of the vastus lateralis and better visualization of the distal femur	Placement of the suture anchor at 30° will close the window that allows for better visualization of the distal femur. Once placed at 90°, the graft of the LET should be fixed in 20-30° of knee flexion with neutral rotation

ACL, anterior cruciate ligament; LET, lateral extra-articular tenodesis.

Closure

Before closure, meticulous hemostasis is achieved followed by copious normal saline irrigation. One gram of vancomycin powder is placed into the wound for infection prophylaxis. Then, the IT band is closed in watertight fashion using No. 1 absorbable braided suture, which is critical to prevent vastus lateralis muscle herniation. Layered closure continues with 2-0 absorbable monofilament suture for the deep dermal layer and running subcuticular 3-0 absorbable monofilament for the skin. Dermabond is applied over the incision, followed by a silver-impregnated waterproofing dressing. The patient is placed in a hinged knee brace locked in extension.

Rehabilitation

Postoperative restrictions depend on concomitant procedures. In cases with meniscus repair, patients remain non−weight-bearing with knee flexion limited to 90° for 2 to 6 weeks. Without meniscal work, patients are allowed weight-bearing as tolerated and unrestricted range of motion. Physical therapy begins 1 to 3 days postoperatively.

Discussion

Performing ACL reconstruction, especially in the case of revision, combined with LET has been associated with improved rotational stability and lower failure rates.⁵ On the basis of the authors’ clinical experience, combining backup femoral-sided ACL graft fixation with LET fixation is beneficial for patients undergoing ACL revision surgery, especially those who have compromised bone stock. This technique allows for enhanced fixation when tunnel positioning is slightly suboptimal or in cases with poor bone quality. Importantly, this method can be used with various primary fixation methods, including interference screw fixation for bone–patellar tendon–bone grafts or suspensory fixation for soft-tissue grafts. In addition, this technique is efficient and minimizes hardware by using a single anchor to serve dual fixation purposes.

Potential disadvantages of utilizing the LET in ACL reconstruction include overconstraint of the lateral compartment, IT band pain, and LET tunnel convergence with the ACL femoral tunnel.⁶ These consequences should be considered when using the described technique.

Disclosures

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: J.J.R. reports consulting or advisory with Smith & Nephew. All other authors (O.M.J., E.K.A., D.A.B., J.H.K.) 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

A step-by-step video illustration demonstrating lateral extra-articular tenodesis (LET) with anterior cruciate ligament (ACL) reconstruction. This video demonstrates the technique for performing a LET in conjunction with ACL reconstruction using a single suture anchor for both backup fixation for the femoral side of the ACL as well as for the LET to address combined rotational and translational instability. The surgical technique was used for the case of a 23-year-old female patient, an avid skier who reinjured her left knee after a previous ACL reconstruction with hamstring autograft 2 years prior. Findings of her examination were notable for a positive Lachman test, a high-grade pivot shift, and a Beighton score of 4/9. Standard preoperative imaging includes anteroposterior, Rosenberg, lateral, Merchant, and standing alignment radiographs, along with magnetic resonance imaging to confirm ACL injury and evaluate concomitant pathology. A sagittal magnetic resonance imaging of the left knee is shown, indicating ACL rupture. This case was notable for neutral coronal alignment and a tibial slope of 11°. Our preferred technique involves general anesthesia with an adjunctive adductor canal and iPACK blocks for postoperative pain control. The patient is positioned supine with an ipsilateral thigh post to facilitate valgus stress during arthroscopy. The procedure begins with diagnostic arthroscopy to confirm ACL rupture and evaluate for concomitant meniscal pathology. The ACL reconstruction using patella tendon autograft is then completed and fixed using titanium interference screws. Attention is then turned to the LET procedure. The lateral incision is extended 3 cm proximally and distally to expose the iliotibial (IT) band. The exiting femoral ACL graft sutures are identified. The entire IT band width is inspected to determine whether this split should serve as the superior or inferior margin of the LET graft harvest, with the goal of harvesting a centrally located graft with fibers inserting onto Gerdy’s tubercle. A 1-cm × 9-cm strip of IT band is harvested, preserving its distal attachment at the Gerdy tubercle. The graft is passed deep to the fibular collateral ligament with a 90° hemostat. With the knee flexed to 90°, the ACL graft sutures are secured for backup fixation using a 4.75-mm twist in suture anchor placed posterosuperior to the lateral epicondyle at the level of the distal Kaplan fibers. The IT band graft is then tensioned at 20 to 30° of knee flexion and, while held in neutral rotation, is secured to the same anchor’s double-loaded retention tape sutures using a combination of running locked and simple sutures, followed by a tension-slide knotting technique. The knee is gently cycled through full flexion and extension to ensure full motion. Final Lachman and pivot shift testing confirms translational and rotational stability. Any redundant IT band graft is sutured back upon itself using #0 braided absorbable suture. The IT band defect is closed in a watertight fashion using a braided absorbable suture to prevent vastus lateralis herniation. Layered wound closure is performed. The patient is placed in a hinged knee brace locked in extension postoperatively, with rehabilitation protocols tailored based on concomitant procedures.