Abstract
The main goal in anterior cruciate ligament reconstruction (ACLR) should be to restore normal knee biomechanics so the chances of failure decrease. The persistence of knee instability after ACLR goes from 0.7% to 20%. Several factors have been identified and studied, but there are some selected cases in which it seems that without adding lateral extra-articular tenodesis (LET) it is not possible to control rotational instability. Data exist supporting that LET could reduce pivot shift (PS), without losing flexion/extension range of motion nor adding risk of osteoarthritis. Recently, LET has been used in addition to ACLR to add restriction to internal tibial rotation forces, and different authors have shown their techniques to achieve this task. Also, biomechanical studies have compared different techniques for LET procedures. This article aims to describe our technique performing a modified Macintosh LET as an addition to ACLR in selected patients who require extra internal tibial rotation control. This is a reproducible, easy to learn, and inexpensive procedure in terms that only a high resistance suture is needed and not any other implant, such as a stapler, anchors, or screws, reducing the risk of tunnel coalition.
The main goal in anterior cruciate ligament reconstruction (ACLR) should be to restore normal knee biomechanics so the chances of failure decrease. The persistence of knee instability after ACLR ranges from 0.7% to 20%.1 Several factors have been identified and studied, but there are some selected cases in which it seems that without adding lateral extra-articular tenodesis (LET), it is not possible to control rotational instability.2 There are data supporting that LET could reduce pivot shift (PS) without losing flexion/extension range of motion3 nor adding the risk of osteoarthritis.4
Recently, LET has been used in addition to ACLR to add restriction to internal tibial rotation forces,4 and different authors have shown their techniques to achieve this task.5, 6, 7, 8, 9 Also, biomechanical studies have compared different techniques for LET procedures.10
This article aims to describe our technique performing a modified Macintosh LET as an addition to ACLR in selected patients who require extra internal tibial rotation control.
Surgical Technique (With Video Illustration)
A video of this technique is available (Video 1). Pearls and pitfalls are shown on Table 1.
Table 1.
Pearls and Pitfalls
| Pearls | Pitfalls |
|---|---|
| Always look for other potential rotation instability contributors and solve them. LET is not the solution to everything. | Overconstrained or non-neutral rotation may lead to altered biomechanics with bad results. |
| It is not necessary to obtain big incisions; with your assistant having good separation techniques, a 7-cm skin incision should be enough. | Going too anterior or too posterior in ITB dissection will make it difficult to close and might have an excess of tension when doing it. |
| Have special careful in tibial rotation when performing an LET. Always do it in neutral rotation.(spaces between senteces are not symetric , in this table and in table number 2 ) | When suturing the free portion of the ITB make sure it gets thin enough to pass deep the FCL and the intermuscular septum. |
| Remember to close the ITB. It will prevent muscular herniation. Using a continuous knotless suture makes it easier to close the most proximal aspect |
FCL, fibular collateral ligament; ITB, iliotibial band; LET, lateral extra-articular tenodesis.
Patient Positioning, Examination With and Without Anesthesia
The patient is placed in supine position on the surgery table. Before anesthesia is administered, a bilateral knee examination is performed to evaluate any instability. With inertial sensors installed in the middle point between the patient's Gerdy's tubercle and the tibial tuberosity, the surgeon performs a PS test to have an accurate digital result of the internal rotation of the tibia (Fig 1). When the examination is completed, general or spinal anesthesia is performed and when motor block is ready and confirmed the examination is repeated, to address the real PS without muscle reaction and pain. An explosive grade III PS shown with the inertial sensors alerts of the need to reinforce the ACLR with a LET. A padded high tourniquet is installed on the operating side thigh and placed in a semicircular leg holder so the knee gets to 90° of flexion.
Fig 1.
Patient is in the supine position. Lateral view of a right knee. With inertial sensors installed in the middle point between the patient's Gerdy's tubercle and the tibial tuberosity, the surgeon performs a pivot shift test to have an accurate digital result of the internal rotation of the tibia.
Surgical Approach
Before starting with the LET procedure, arthroscopy is performed. It is crucial to assess all injuries that could contribute to rotational instability, such as meniscus or meniscal root tears. We prefer to do the ACLR reconstruction before the LET procedure because it gives the surgeon an idea about how the joint is going to behave with the ACLR. Another important measure that encourages adding an LET is the closure of the lateral tibiofemoral joint space after ACLR. If the space after ACLR is more than 5 mm, we perform the LET (Fig 2). We are looking forward to publishing this measure.
Fig 2.
Arthroscopic view of the lateral tibiofemoral space. Another important measure that encourages adding an LET is the closure of the lateral tibiofemoral joint space after ACLR. If the space after ACLR is more than 5 mm, we perform the LET. (ACLR, anterior cruciate ligament reconstruction; LET, lateral extra-articular tenodesis.)
A 6- to 8-cm skin incision is made in the lateral aspect of the thigh, proximal to Gerdy's tubercle (Fig 3). Dissection is performed to expose the iliotibial band (ITB). It is important to recognize the posterior and anterior limits of the ITB. To obtain a 1-cm wide ITB strand, an incision is made in the middle third to begin harvesting keeping the distal attachment on Gerdy's tubercle (Fig 4). The harvest is extended proximal to complete 8-12 cm in length (Fig 5). We recommend starting the incision with a scalpel and continuing with Metzenbaum scissors, taking care not to damage deep structures such as fibular collateral ligament (FCL). As you get to the more proximal aspect, skin separation is needed to have a complete view of the ITB. If you need to tension the skin in excess, then it is preferred to extend the skin incision.
Fig 3.
Patient is in the supine position, knee at 90° of flexion. Lateral view of a right knee. A 6- to 8-cm skin incision is made in the lateral aspect of the thigh, proximal to Gerdy's tubercle. (FCL, fibular collateral ligament.)
Fig 4.
Patient in supine, knee at 90° of flexion. Lateral view of a right knee. To obtain a 1-cm wide ITB strand, an incision is made in the middle third to begin harvesting keeping the distal attachment on Gerdy's tubercle. (ITB, iliotibial band.)
Fig 5.
Patient is in the supine position, knee at 90° of flexion. Proximally detached ITB strand seen form lateral. The ITB harvest is extended proximal to a complete 8- to 12-cm length. (ITB, iliotibial band.)
After you obtain a clean 8- to 12-cm length and 1-cm wide strand of ITB with its distal attachment in Gerdy's tubercle, a no. 2.0 VICRYL suture (Ethicon-Johnson & Johnson, Somerville, NJ) is passed in the free end with a Krakow-like fashion for 1 cm approximately (Fig 6).
Fig 6.
Patient is in the supine position, knee at 90° of flexion. Free end of ITB harvest seen laterally. After you obtain a clean 8- to 12-cm length and 1-cm wide strand of ITB with its distal attachment in Gerdy's tubercle, a no. 2.0 VICRYL suture is passed in the free end with a Krakow-like fashion for 1 cm approximately. (ITB, iliotibial band.)
With the free end prepared, the ITB strand is passed from distal to proximal and the most important aspect to get the biomechanics as expected, is to pass deep to the FCL (Fig 7). Having passed it under the FCL the intermuscular septum is identified and the sutures are passed deep to it (Fig 8). This is easier to do with a vascular clamp. When the ITB strand is passed deep the septum, make a loop so you return heading distal again (Fig 9). Now you are ready to suture the band onto itself. For this, 30° of flexion is recommended and neutral rotation of the tibia is a must. Fixation is done with 5 independent high-resistance stitches (FiberWire; Arthrex, Naples, FL) of the band onto itself (Fig 10). A key point here is not to overconstrain, so it is important not to apply too much tension and to always check that full range of motion is permitted Before closure, careful hemostasia is performed so the eventual risk of lateral hematoma is decreased. For closure, anterior and posterior lips of the ITB are sutured with continuous knotless suture (STRATAFIX; Johnson & Johnson) to make it easier and to avoid the risk of muscular herniation (Fig 11). The subcutaneous layer is closed using no 3.0 VICRYL suture (Ethicon-Johnson & Johnson), and the skin closure is up to surgeon's preferences; staples or intradermic sutures can be used.
Fig 7.
Patient is in the supine position, knee at 90° of flexion. Lateral view of a right thigh, distal portion. With the free end prepared, the ITB strand is passed from distal to proximal and the most important aspect to get the biomechanics as expected, is to pass deep to the FCL. (FCL, fibular collateral ligament; ITB, iliotibial band.)
Fig 8.
Patient is in the supine position, knee at 90° of flexion. Lateral view of a right thigh, distal portion. Having passed it under the fibular collateral ligament, the intermuscular septum is identified and the sutures are passed deep to it. (FCL, fibular collateral ligament.)
Fig 9.
Patient is in the supine position, knee at 90° of flexion. Lateral view of a right thigh, distal portion. When the ITB strand is passed deep into the septum, make a loop so you return heading distal again. (FCL, fibular collateral ligament; ITB, iliotibial band.)
Fig 10.
Patient is in the supine position, knee at 30° of flexion. Lateral view of a right thigh, distal portion. Suture the band onto itself. For this, 30° of flexion is recommended and neutral rotation of the tibia is a must. Fixation is performed with 5 independent high-resistance stitches.
Fig 11.
Patient is in the supine position, knee at 30° of flexion. Lateral view of a right thigh, distal portion. For closure, anterior and posterior lips of the ITB are sutured with continuous knotless suture to make it easier and to avoid the risk of muscular herniation. (ITB, iliotibial band.)
Discussion
With the aim of improving rotational stability, anatomic and nonanatomic lateral procedures have been developed. To our understanding and based on the literature, LET is a better choice over anterolateral ligament reconstruction.11 It is a technique that has shown to decrease not only anterior translation when combined with ACLR but also to reduce internal tibial rotation that produces anterolateral instability that may lead to ACL graft failure.10
Our group has been performing this procedure since 2014, and different techniques have been applied. Now, we use a modification of the aforementioned original Macintosh procedure because of its advantages and low risks (Table 2); it is a reproducible, easy to learn, and inexpensive procedure in terms that only a high-resistance suture is needed and not any other implant, such as stapler, anchors, or screws, reducing the risk of tunnel coalition.
Table 2.
Advantages and Disadvantages
| Advantages | Disadvantages/Risks |
|---|---|
| Reproducible, easy-to-learn technique. | May add pain to postoperative rehabilitation. (spaces between senteces are not symetric) |
| Inexpensive procedure: only a high-resistance suture is needed | Special attention to quadriceps inhibition. |
| No risk of tunnel coalition when performed with an ACLR. | Muscle herniation if ITB closure is not performed in proper way. |
ACLR, anterior cruciate ligament reconstruction; ITB, iliotibial band.
In terms of indicating this additional procedure to ACLR, we recommend to assess it case by case, and supported by the published literature,12,13 we can say that suggested indications may be ACLR rerupture, younger age, lateral tibial slope >12°, hyperlaxity, medial meniscus posterior horn suture or deficiency, elite players in cutting or pivoting sports, and history of contralateral ACLR.
To assess its biomechanical value, we have been performing a landing and pivoting study with 3-dimensional kinematic movement analysis (Vicon, Oxford, UK) that has shown a reduction in pivot shifting compared with the contralateral limb, without affecting flexion and extension range of motion. We are looking forward to publishing our results. Although this technique and preliminary results have been presented in several meetings by the senior author, this is the very first time we have published it. Based on the biomechanical effects and the literature supporting LET, we recommend this procedure in addition to ACL in selected cases. Further investigation should focus on long-term and clinical outcomes.
Footnotes
The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
Lateral extra-articular tenodesis: a technique with ITB strand without implants. A 6- to 8-cm skin incision is made in the lateral aspect of the thigh, proximal to Gerdy's tubercle, and dissection is performed to expose the ITB. It is important to recognize the posterior and anterior limits of the ITB. To obtain a 1-cm wide strand, 2 points are marked in the middle third of ITB. An incision is made in the middle third to begin harvesting keeping the distal attachment on Gerdy's tubercle. The harvest is extended proximal to complete 8-12 cm. length. A no. 2.0 VICRYL suture (Ethicon) is passed in the free end with a Krakow-like fashion for 1 cm approximately. FCL identification. Using a vascular, the ITB strand is passed from distal to proximal, deep to the FCL. Intermuscular septum is identified and the sutures are passed deep to it. Fixation with 5 independent, high-resistance stitches of the band onto itself. 30° of flexion is recommended, and neutral rotation of the tibia is a must. To avoid muscular herniation, anterior and posterior lips of the ITB are sutured with continuous knotless suture. The subcutaneous layer is closed using no. 3.0 VICRYL suture, and the skin closure is up to surgeon's preference; staples or intradermic suture can be used. (FCL, fibular collateral ligament; ITB, iliotibial band.)
References
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Associated Data
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Supplementary Materials
Lateral extra-articular tenodesis: a technique with ITB strand without implants. A 6- to 8-cm skin incision is made in the lateral aspect of the thigh, proximal to Gerdy's tubercle, and dissection is performed to expose the ITB. It is important to recognize the posterior and anterior limits of the ITB. To obtain a 1-cm wide strand, 2 points are marked in the middle third of ITB. An incision is made in the middle third to begin harvesting keeping the distal attachment on Gerdy's tubercle. The harvest is extended proximal to complete 8-12 cm. length. A no. 2.0 VICRYL suture (Ethicon) is passed in the free end with a Krakow-like fashion for 1 cm approximately. FCL identification. Using a vascular, the ITB strand is passed from distal to proximal, deep to the FCL. Intermuscular septum is identified and the sutures are passed deep to it. Fixation with 5 independent, high-resistance stitches of the band onto itself. 30° of flexion is recommended, and neutral rotation of the tibia is a must. To avoid muscular herniation, anterior and posterior lips of the ITB are sutured with continuous knotless suture. The subcutaneous layer is closed using no. 3.0 VICRYL suture, and the skin closure is up to surgeon's preference; staples or intradermic suture can be used. (FCL, fibular collateral ligament; ITB, iliotibial band.)