Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra‐articular Tenodesis With Augmented Continuous Iliotibial Band Autograft

Abstract

The purpose of this technical note is to describe a reproducible surgical technique for anterior cruciate ligament reconstruction combined with a lateral tenodesis using a continuous iliotibial band autograft that allows self‐augmentation of graft diameter without the need for additional tendon harvesting. The key modification involves creating an augmented intra‐articular graft by inverting a detached distal iliotibial band strip over the central portion of the graft, thereby increasing its diameter while preserving native continuity.

Combined anterior cruciate ligament (ACL) and anterolateral stabilization of the knee using the iliotibial band (ITB) has been increasingly described and refined in recent years. ¹ , ² A notable critique of this technique concerns the relatively smaller graft diameter compared with alternative approaches utilizing hamstring tendons.

To address this limitation, some surgical teams ³ , ⁴ proposed a modified technique involving graft augmentation with the gracilis tendon. Those authors confirmed this option as reliable in terms of rerupture, even if the use of a second graft may be debatable.

To address this point, our purpose was to describe a surgical technique that allowed an ITB augmentation graft with the ITB itself, without having to harvest another graft.

SURGICAL TECHNIQUE

This technical note (Video 1) is based on a previous description of the combined ACL and anterolateral knee stabilization using a continuous ITB autograft. ¹ Tables 1 and 2, respectively, summarize the advantages and disadvantages of this technique, as well as its pearls and pitfalls.

VIDEO 1.

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A skin incision is made 2 cm behind Gerdy's tubercle and is usually between 8 and 10 cm long. The subcutaneous tissue is opened and detached up to the fascia lata using a surgical blade. Gerdy's tubercle is exposed using a Farabeuf retractor. The posterior part of the graft is incised, starting at Gerdy's tubercle. The anterior part is incised 1 cm more anteriorly. The proximal subcutaneous tissue is then detached with a surgical blade to continue harvesting the graft, ensuring that the anterior incision flares out by approximately 2.5 cm. The anterior and posterior incisions are joined. The graft is freed while remaining pedicled on Gerdy's tubercle. The lateral collateral ligament is identified and followed upward to its insertion on the lateral femoral epicondyle, which allows the entrance to the femoral tunnel to be marked with an electroscalpel 5 mm above and 5 mm behind the lateral epicondyle. The intra‐articular diameter of the graft is increased by separating a 6‐ to 8‐cm‐long strip from the anterior and distal portion of the fascia and folding it onto its proximal portion. The strip is fixed with absorbable sutures, taking care to maintain continuous tension on it during this step using forceps. The graft is shaped as a tube with the strip hidden inside it. Care must be taken to ensure that the nonabsorbable green traction suture is threaded sufficiently upward over the augmentation strip to provide effective traction when the new anterior cruciate ligament is finally tensioned with the interference screw. The arthroscopic step allows the femoral guide to be positioned to drill the femoral tunnel in an outside‐in fashion, using the mark previously made with the electroscalpel. The green traction suture is inserted into the femoral tunnel to be retrieved into the joint space and then passed through the tibial tunnel; this step was not filmed. Note that the fibers of the native anterior cruciate ligament have been preserved. The graft is fixed with the leg in extension and neutral rotation using a single biocompression tibial screw. The tension of the Lateral Tenodesis should increase during internal rotation of the leg when the knee is at 90° of flexion and should also increase when the leg is brought into full extension. The fascia lata is closed without excessive tension by sectioning the intermuscular septum. Fascia closure must be performed thoroughly to prevent muscle herniation. An anesthetic is injected into the lateral part of the thigh and into the joint space. Video content can be viewed at https://doi.org/10.1002/atn2.70222.

TABLE 1.

Advantages and Disadvantages

Advantages
Increased intra‐articular graft diameter
No additional graft harvest site
Single ITB graft used for ACL reconstruction and extra‐articular tenodesis
Single screw fixation
Reproducible technique with improved visualization of optimal femoral extra‐articular placement

Disadvantages
Difficulty with fascia lata closure because of over‐resection
Larger skin incision
Careful dissection of a straight 5‐mm ITB so as not to weaken the graft

ACL, anterior cruciate ligament; ITB, iliotibial band.

TABLE 2.

Pearls and Pitfalls of the Technique

Surgical Steps	Pearls	Pitfalls
Identifying the bony landmarks	Identification of the femoral LCL insertion site and genicular vessels will help in determining the best femoral extra‐articular position	Difficulty in identifying these individual points in bulky patients
Distal graft delineation	Exposition of the GT with a Farabeuf facilitates to realize the three parallel incisions, detaching the 5‐mm‐wide anterior ITB strip carefully with a No. 23 scalpel, preserving its proximal continuity	Precise harvesting of a straight 5‐mm ITB graft requires careful dissection to maintain uniform width without over‐resection; respecting the lateral femoral epicondyle landmark and using Metzenbaum scissors for precise anterior ITB graft contouring are critical to achieve proper self‐augmentation of the intra‐articular graft segment
Length of the graft	Exposition of the GT distally with a Farabeuf and proximally with a large retractor to check the length of the graft (15 cm)	Risk of inadequate graft length
Graft harvest	While harvesting the ITB, care should be taken not to cut the vessels posterior to the lateral condyle	Postop hemorrhage because of excessive bleeding from the severed vessels
Graft fixation	Maintaining the knee between 30° flexion, full extension and neutral rotation while fixing the graft to the tibia	Inappropriate knee position while fixing the graft may lead to a nonisometric reconstruction
ITB closure	Tight closure of the fascia lata with a No. 2 suture at the end of the surgical procedure	Closure of the fascia lata using the Jaeger artifice may be helpful in cases of bulky vastus lateralis

GT, Gerdy's tubercle; ITB, iliotibial band; LCL, lateral collateral ligament.

ITB Harvesting

The skin incision begins 2 cm proximal to Gerdy's tubercle (GT) and extends longitudinally 7 to 10 cm proximally. The ITB is exposed beginning at GT using a Farabeuf retractor (Landanger, Chaumont, France) for soft tissue retraction. The posterior margin of the ITB at GT is incised with a No. 23 scalpel, extending this incision proximally along the posterior ITB over 5 to 6 cm.

A parallel anterior incision is made 1.5 cm anterior to the initial posterior incision, creating a 1.5‐cm‐wide graft at its distal attachment point.

A third incision is then performed 5 mm posterior parallel to the anterior incision, originating at GT and ending 1 cm proximal to the premarked lateral epicondyle (Figure 1).

FIGURE 1.

Distal ITB harvesting (right knee): 1.5 cm wide graft from the GT insertion, with 10 mm wide for the lateral tenodesis and 5 mm anterior wide for the self‐augmentation (red circle, GT; green circle, lateral epicondyle). (GT, Gerdy's tubercle; ITB, iliotibial band.)

The proximal part of the ITB is exposed using a large retractor (B Braun Aesculap, Tuttlingen, Germany) to optimize visualization. The posterior incision is extended proximally using a No. 11 long‐handled scalpel, parallel to the longitudinal fibers of the ITB, maintaining strict alignment with the anatomical axis of the thigh. This specific orientation is deliberately chosen to preserve the posterior ITB fibers, which biomechanical studies have shown to contribute to anterolateral knee stability by tightening during tibial internal rotation. ⁵ , ⁶

Then, an anterior incision is carefully made to progressively create a 3‐cm‐wide proximal graft segment, while maintaining the distal attachment point to GT.

The distal ITB is meticulously separated from its deep fibers using a No. 23 scalpel, preserving its native insertion on GT.

The total length of the graft is approximately 15 cm and comprises 4 distinct segments: a 4‐cm‐long extra‐articular segment from GT to the femoral tunnel entrance, a 3‐cm‐long femoral tunnel segment, a 4‐cm‐long intra‐articular segment, and a 4‐cm‐long tibial tunnel segment.

Graft Preparation and Augmentation

The 5‐mm‐wide anterior ITB strip is carefully detached from GT using a No. 23 scalpel, while preserving its proximal continuity, folded in a proximal direction, and placed in the central portion of the graft (Figure 2). Tubulization is done using 2‐0 Vicryl sutures (Ethicon, Somerville, NJ) with 4‐point fixation. The terminal fixation suture serves also as a marker suture, strategically positioned at the free end of the inverted ITB segment.

FIGURE 2.

Graft inversion (right knee): (1) ITB harvesting with a 5‐mm anterior ITB strip, proximally detached. (2) The 5‐mm anterior ITB strip is detached on GT (red dotted arrow), whereas the rest of the ITB remains attached distally to the GT. (3) Graft inversion: the proximally detached ITB graft is flipped (blue dotted arrow) while maintaining its distal attachment to the GT, and the 5‐mm anterior ITB strip is also flipped distally. (4) Graft preparation, with the 5‐mm anterior ITB strip distally flipped and incorporated within the ITB graft, before “tubulization” technique preparation. (GT, Gerdy's tubercle; ITB, iliotibial band.)

This positioning provides visual confirmation during arthroscopy, ensuring that the folded graft segment is properly incorporated within the intra‐articular portion.

Finally, a No. 3 Mersuture traction suture (Ethicon, Somerville, NJ) is placed through the ITB's free end to facilitate controlled graft passage (Figure 3).

FIGURE 3.

Final aspect of the graft (right knee). Black dotted arrow, LEAP; red dotted arrow, self‐augmented ITB. (ITB, iliotibial band; LEAP, lateral extra‐articular procedure.)

Extra‐articular Landmark of the Femoral Tunnel

The extra‐articular femoral tunnel landmark is anatomically positioned 5 mm proximal and posterior to the lateral femoral epicondyle, at the lateral collateral ligament (LCL) insertion, immediately superficial to the genicular vessels. This point, which serves as the femoral attachment for the anterolateral ligament reconstruction, is marked with electrocautery.

Tunnels

The femoral guide (Arthrex, Naples, FL) is introduced through the medial portal and precisely positioned to direct the guide pin into the ACL intra‐articular insertion area. The guide is then secured against the previously marked extra‐articular femoral landmark to perform an 8‐ or 9‐mm femoral tunnel diameter (Orthomed SAS, St Jeannet, France).

Intra‐articular tibial guide (Arthrex, Naples, FL) positioning is carefully achieved by placing the guide tip just medial to the lateral tibial spine and anterior to the posterior cruciate ligament, centered within the ACL remnant for anatomical placement. Tunnel drilling is performed on the medial tibial cortex through a minimal skin incision using an adapted reamer (Orthomed SAS, St Jeannet, France), whose diameter is based on preoperative graft size measurements.

Graft Passage

The traction suture is passed through the femoral tunnel in an outside‐in fashion and then retrieved through the medial portal with an arthroscopic grasper. It is then placed near the intra‐articular entrance of the tibial tunnel and subsequently pulled out of the tibial tunnel with an arthroscopic grasper. Final arthroscopic verification confirms anatomical placement of both the intra‐articular ACL reconstruction, with visualization of the sutures placed over the additional anterior ITB and the lateral tenodesis.

Graft Fixation

Prior to final fixation, graft isometry is assessed by cycling the knee through a range of motion from 120° of flexion to full extension. The graft is secured with the knee positioned in extension and neutral rotation to optimize tensioning under functional loading conditions. A guide pin is introduced into the tibial tunnel for an 8‐ or 9‐mm bioabsorbable interference screw (Arthrex, Naples, FL) for tibial fixation. The tension of the graft is checked both at 90° flexion and in extension, ensuring optimal tension in extension with slight slack at 90° to avoid excessive stress in medial rotation.

Wound Closure

After deflation of the tourniquet, meticulous hemostasis is obtained, with particular attention directed toward controlling bleeding from the deep vascularization of the ITB, particularly in the region posterior to the lateral femoral condyle. The ITB is closed using No. 2 Vicryl absorbable sutures (Ethicon, Somerville, NJ). The subcutaneous and skin layers are closed with absorbable sutures.

DISCUSSION

Biomechanical and clinical evidence consistently shows an inverse relation between graft diameter and rerupture rates in ACL reconstruction. ⁷ , ⁸ Current literature indicates a significant reduction in the risk of failure with an increase in graft size, with studies reporting a reduction of approximately 0.86 with a 0.5 mm increase in graft diameter within the clinically relevant range of 7 to 10 mm. ⁹ This diameter‐dependent effect is attributed to enhanced load‐bearing capacity and improved graft maturation, as smaller grafts (≤8 mm) show 7% higher failure rates compared with larger grafts in midterm follow‐ups. ¹⁰

The present technique represents a significant evolution from previously described ITB‐based combined stabilization procedures, ¹ primarily through its optimization of graft tissue utilization. Unlike conventional methods that often yield ITB‐based graft diameters ≤6 mm for the intra‐articular ACL segment, this modified approach consistently provides augmented diameters of 7 mm or greater, correlated with reduced failure rates in a large meta‐analysis. ¹¹ Contrary to prevailing diameter‐outcome paradigms, without any precision on the association of ACL reconstruction with a lateral extra‐articular procedure (LEAP), a recent study by Helito et al. revealed that combined ACL‐ALL reconstruction with sub‐7 mm ACL grafts achieved comparable clinical outcomes and failure rates to isolated ACL reconstruction using >7 mm grafts at 24‐month follow‐up. ¹²

Current literature supports the reliability of ITB autografts for ACL reconstruction, showing satisfactory graft incorporation, mechanical stability, and survival rates comparable to other autograft options. ¹³ Contemporary surgical practice has seen growing adoption of hybrid techniques combining anatomic ACL reconstruction with LEAP, driven by evolving biomechanical understanding of the ALL complex. ¹⁴ , ¹⁵ Recent kinematic studies reveal the ALL's critical role in controlling rotational stability, ¹⁶ particularly during pivot‐shift maneuvers, whereas clinical outcome research suggests reduced graft failure rates ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ and improved return‐to‐sport metrics when extra‐articular procedures are added.

Among the technical points commonly discussed in LEAP, the passage of the graft either beneath or over the LCL remains debated. Passing the graft beneath the LCL creates a pulley effect that reduces graft tension during knee flexion and therefore decreases the risk of restricting internal rotation of the tibia. ²¹ The absence of femoral fixation described in this article ²² allows stress to be distributed evenly between the intra‐ and extra‐articular parts of the graft during the flexion‐extension range of motion, thereby unloading tension on the graft during the flexion motion. As fixation is performed in full extension, with maximum tension in this position, the position of the femoral tunnel, posterior and proximal to the femoral epicondyle, will reduce graft tension during flexion and maintain a favorable anisometry without overloading the lateral compartment of the knee.

Finally, in an article on the technical details of lateral tenodesis with the ITB, Laudet et al. ²³ quotes authors who believe that passing the graft under the LCL could interfere with the anatomy and function of this ligament. No femoral fixation is required in this continuous technique because the intra‐ and extra‐articular parts of the graft are fixed in maximum extension with the tibial screw, allowing optimal and simultaneous tension of both parts of the graft. ²⁴ During flexion, the graft's tension will decrease without any modification of its length. Furthermore, a screw in the femoral tunnel could push the graft medially, increasing the tension of the lateral tenodesis.

To perform ACL reconstruction with LEAP while preserving the ITB and increasing its diameter, some surgical teams proposed modified techniques. Dos Santos et al. ³ as well as Aubret et al. ⁴ described an innovative technique combining ITB reconstruction with gracilis tendon augmentation for graft reinforcement. This approach requires an additional graft harvest site (gracilis) and may compromise future revision options, particularly given that the prior harvesting of both the ITB and gracilis tendons significantly reduces available autologous tissue for subsequent procedures. The utilization of the ITB in lateral tenodesis offers distinct advantages by preserving the integrity of the extensor mechanism ²⁵ while maintaining the native insertion point of the ITB on GT. This technique provides superior cost‐efficacy and reproducibility, requiring only a single biological screw for fixation.

The disadvantages of this technique are (1) the length of the lateral scar which is usually longer than for the other types of graft harvesting sites, (2) challenging closure of the fascia lata at the end of the procedure particularly when the vastus lateralis muscle is highly developed, and (3) careful dissection of a straight 5‐mm ITB graft to maintain uniform width without over‐resection. Self‐augmented ACL reconstruction with a continuous ITB autograft provides a reproducible technique that increases graft diameter while preserving native tissue continuity and avoiding secondary tendon harvest. This method combines the advantages of ACL reconstruction and lateral tenodesis in a single construct, with the potential to reduce the rate of rerupture and optimize functional outcomes. Ongoing clinical evaluation will determine its long‐term efficacy.

DISCLOSURES

The author (C.L.) declares the following financial interests/personal relationships which may be considered as potential competing interests: C.L. reports receiving payment from Arthrex and Zimmer Biomet for lectures, presentations, speaker engagements, manuscript writing, and educational events; received support from Zimmer Biomet for attending meetings and/or travel; Unpaid as a Member of the board of the French Association of Arthroscopy: Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid. The other authors (G.Z., D.E., P.I.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.