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Lateral Extra-articular Tenodesis for Anterior Cruciate Ligament Injuries

March 01, 2020

Contributors: Arien Lee Cherones; Mia Smucny, MD; Christopher Y Kweon, MD, FAAOS; Robert G Marx, MD, FAAOS; Albert Ooguen Gee, MD, FAAOS

Residual knee rotatory laxity after anterior cruciate ligament (ACL) reconstruction is considered a substantial risk factor for surgical failure, inability to return to sport, and poor patient-reported outcomes. Considerable research has been conducted on the anterolateral complex as an overlooked component of knee stability after ACL injury, and interest has increased with regard to the use of lateral extra-articular tenodesis (LET) procedures to augment standard ACL reconstruction. Various surgical techniques and tissue sources have been described for LET, with no one technique being clinically superior to another. Data is mainly limited to clinical case series; however, early results from a large multicenter randomized clinical trial show that LET in combination with ACL reconstruction dramatically decreased the rate of failure in high-risk patients undergoing primary ACL reconstruction. This video demonstrates our technique for LET with the use of a 10-mm – 8-cm-long strip of the iliotibial band, which is left attached to the Gerdy tubercle. After whipstitching the free end of the graft, the graft is routed under the lateral collateral ligament, passed into a bone tunnel created just proximal and slightly anterior to the lateral femoral epicondyle, and fixed with the use of an interference screw with the knee in full extension. Postoperative rehabilitation follows standard ACL reconstruction postoperative rehabilitation protocols. We begin early range of motion and allow patients to bear weight as tolerated based on meniscal repair status. Crutches are used until appropriate quadriceps muscle control returns to allow for a normal gait pattern. Strengthening exercises are begun after full motion is achieved. Return to sport progression is allowed at 9 months postoperatively based on functional assessment testing. In our series of 35 patients (27 revision ACL reconstruction; 8 primary ACL reconstruction), we found that LET in combination with ACL reconstruction was successful, resulting in only one failed procedure and one postoperative infection at a mean follow-up of approximately 3 years. We believe our technique is a safe, effective, and reproducible method for lateral extra-articular tenodesis.

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