Abstract
Background:
Lateral extra-articular tenodesis (LET) is a reproducible and reliable technique to assist in control of rotational stability of the knee and decrease forces across an anterior cruciate ligament (ACL) graft in the setting of ACL reconstruction. Bone-tendon-bone (BTB) autograft is a common graft choice in revision ACL reconstruction. We present a technique for combining contralateral BTB autograft with LET in revision ACL reconstruction.
Indications:
This technique is indicated in patients undergoing ACL reconstruction who are at increased risk of graft failure, including revision cases, high-grade rotational instability, return to pivoting/cutting sports, ligamentous laxity, young age, meniscal deficiency, and hyperextension/recurvatum.
Technique Description:
The contralateral BTB autograft is harvested through standard fashion. We begin with the LET dissection prior to fluid infiltration in the soft tissues. A 1-cm strip of iliotibial (IT) band is harvested and whipstitched. The IT band strip is passed from anterior to posterior deep to the lateral collateral ligament (LCL). The LET socket is aimed 10° proximal and 10° anterior to limit tunnel convergence with the ACL. The LET is fixed with a tenodesis screw with the knee in neutral rotation and 30° of flexion. The ACL femoral socket is then placed, and care is taken to avoid convergence. A 10-mm tibial tunnel is drilled near the level of the posterior margin of the anterior horn of the lateral meniscus. The ACL is subsequently fixed with standard techniques.
Results:
The addition of LET to revision ACL has been shown to improve failure rate and outcomes. The use of contralateral patella tendon graft reduces morbidity on the operated leg. Notably, the position of the femoral LET tunnel is less important than the ACL tunnel position on the femur. If the LET is passed under the LCL, then the fixation point on femur becomes less relevant. The technique presented is a time-efficient way for combining tenodesis with revision ACL.
Discussion/Conclusion:
Performing a revision ACL reconstruction utilizing contralateral donor tissue with the addition of LET is a viable and reliable option for competitive athletes.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form.
This is a visual representation of the abstract.
Keywords
Video Transcript
We will be presenting a case and a technique for performing a revision anterior cruciate ligament (ACL) reconstruction utilizing contralateral bone-patellar tendon-bone autograft with an iliotibial (IT) band lateral extra-articular tenodesis with interference screw fixation.
The authors have no relevant disclosures. Here is the overview of our video presentation.
Reconstruction of the ACL helps provide stability to anterior translation of the tibia, but does not do as well in optimizing rotational stability. 1 Studies have demonstrated that up to one-third of patients continue to have a positive pivot shift phenomenon following ACL reconstruction. Lateral extra-articular tenodesis, or LET, may help control rotation. 9 Additionally, an LET offloads the forces experienced by the ACL graft, which may decrease the risk of failure. One cadaveric study demonstrated that an LET decreased stress on the ACL graft by 43%. 1
The native IT band serves as a primary dynamic restraint to internal rotation between 30° and 90° of knee flexion. Studies evaluating IT band sectioning, while maintaining an intact ACL, demonstrate a positive pivot shift phenomenon, giving credence to the fact that the lateral-sided structures are important contributors to rotational control. 1
Performing LET in combination with ACL reconstruction improves restraint to tibial internal rotation. It also decreases the pivot shift phenomenon without changing anterior translation relative to ACL reconstruction alone. Furthermore, current clinical studies do not demonstrate increased risk of lateral compartment degenerative changes.
In competitive athletes, our first-choice graft for a primary ACL reconstruction is ipsilateral bone-tendon-bone (BTB) autograft. However, in the revision setting following failed primary BTB autograft, for competitive athletes, we consider the use of contralateral BTB autograft along with LET, especially for those engaging in high-demand cutting sports.
Our patient is a 20-year-old female collegiate soccer player who underwent prior left-knee ACL reconstruction with ipsilateral BTB autograft several years ago. She sustained a contact injury playing soccer resulting in retear. Examination was notable for a grade 2B Lachman and 2+ pivot shift. She was stable to valgus and varus stress at 0° and 30° and had no meniscal signs.
Radiographs of the left knee demonstrated a prior ACL reconstruction with appropriately positioned tunnels. The contralateral right knee demonstrates prior ACL reconstruction with a screw and washer construct on the tibia. Magnetic resonance imaging (MRI) demonstrated a rupture of the ACL graft with appropriately positioned tunnels without widening. There were no meniscal tears.
Our treatment plan for this high-level athlete was to perform a revision ACL reconstruction with contralateral BTB autograft and concurrent LET. By utilizing a contralateral donor autograft, we limit a second hit to the ipsilateral extensor mechanism. 6 Other graft choices could include quadriceps and hamstring autograft. One systematic review demonstrated the most common indications for LET are patients with high-grade pivot shifts or revision cases where there is no obvious technical error from the primary surgery. 4
More broadly, indications for adding an LET may include revision cases, patients at high risk of failure, those with high-grade rotational laxity, younger patients, those with meniscal deficiency particularly on the medial side, those with elevated posterior tibial slope, patients with generalized laxity, those who have substantial hyperextension or recurvatum, and patients seeking to return to high-level competitive pivoting sports. 5 Relative contraindications include patients with posterolateral corner injuries and a lateral compartment degenerative disease.
Understanding of the native anatomy of the origins and insertions of the ligaments is paramount for optimal isometry and outcomes. Proper tunnel placement and proper tensioning or fixation position should decrease the risk of graft failure. We utilize topographical landmarks to guide tunnel positioning. The ACL originates from the femur on the lower third of the lateral femoral condyle when viewed at 90° of knee flexion. 10 In this position, the ACL originates below the lateral intercondylar ridge, and the bifurcate ridge separates the anteromedial and posterolateral bundles. Graft isometry is optimized by centering the femoral tunnel just below and posterior to the intersection of the lateral intercondylar and lateral bifurcate ridges.2,10
When performing this technique, careful planning should limit tunnel convergence. The ACL socket length should provide at least a 5-mm distance between the LET and ACL sockets. While drilling the LET socket on the femur, aim 10° anterior and proximal.
Here is our technique. A 1-cm strip of IT band is taken from approximately 5 mm anterior to the posterior border of the IT band. The knife sharply dissects the IT band, taking care to not dive deep into the underlying lateral collateral ligament (LCL). Metzenbaum scissors are used to free the deep surface of the IT band from the underlying tissues. The strip of IT band is then whipstitched. Varus stress is applied to the knee to assist in the identification of the LCL. A sharp incision is made anterior and posterior to the LCL. Blunt dissection is performed to create a passageway for the IT band. The IT band is channeled deep to the LCL from anterior to posterior utilizing Kelly clamps.
The lateral epicondyle is then identified, and a point just proximal and anterior to the lateral epicondyle is selected. A pin is driven at that location from lateral to medial across the femur, aiming 10° proximally and 10° anterior to avoid convergence with the femoral ACL socket.
Isometry is evaluated by wrapping the whipstitch sutures around the pin through knee range of motion. Once a satisfactorily isometric point is selected, the pin is over-reamed, with the reamer selected to the appropriate size for the interference screw—we typically utilize a 7-mm reamer. The beath pin is passed through the medial femoral cortex, and 1 of the 2 IT band suture strands is shuttled across to exit the medial-sided skin.
The remaining strand is placed into the tenodesis screw—we commonly utilize a 6.25-mm polyether ether ketone (or PEEK) screw. Tension is pulled on the strand passing through the medial side while the screw is placed, fixing the LET with the knee in neutral rotation and 30° of knee flexion. We then sew the nonabsorbable suture from the tenodesis screw to the local periosteum and proximal LCL for additional fixation. Construct stability is assessed. The lateral wound is closed in a layered fashion beginning with the IT band.
The femoral socket is reamed to a depth no greater than 25 to 30 mm. The BTB autograft is fixed with standard techniques. We tap and then place PEEK tenodesis screws on both the femoral and tibial sides.
Tips and tricks: In general, the surgeon should seek to identify any contributors to rotational instability. The IT band dissection should be performed prior to swelling in the soft tissues from arthroscopic fluid. Harvesting the posterior fibers of the IT band is beneficial to prevent graft truncation. It is helpful to pass the IT band graft deep to the LCL with a Kelly clamp. We start by evaluating our LET fixation just anterior and proximal to the lateral epicondyle based on our unpublished ongoing 3D finite element analysis study demonstrating greater isometry at that location, although it may vary by patient. We drill the LET socket first as the ACL femoral guidepin can be redirected more easily. We aim the LET socket 10° proximal and anterior; for the ACL socket, it may help to limit tunnel convergence by tilting the aiming guide horizontal. The LET should be fixed with the knee at 30° flexion and neutral rotation. Interference screw fixation may improve construct stability, which we reinforce with nonabsorbable suture into the periosteum and the proximal LCL.
The postoperative treatment and rehabilitation protocol is outlined here. Patients may be counseled to discontinue the hinged knee brace at postoperative week 4 and may return to running by approximately postoperative month 4.
Our patient is currently at over 3 years postoperatively and returned to sport uneventfully at 10 months at which point her outcome scores exceeded those of minimal clinically important difference and substantial clinical benefit.
The use of a contralateral BTB autograft does not have a negative impact on postoperative strength and outcomes. A study by Shelbourne et al8 found that overall quadriceps strength was higher in patients receiving contralateral donor graft. There was also less side-to-side difference between the donor and the ACL-reconstruction knee. Importantly, taking contralateral BTB autograft did not result in differences in International Knee Documentation Committee scores. 3
One propensity-matched cohort study evaluating specifically revision ACL reconstructions found that patients undergoing revision ACL reconstruction with LET outperformed those undergoing just revision ACL reconstruction alone in terms of patient-reported outcomes and time to return to sport. 8
A landmark study by Getgood et al5 from the STABILITY trial evaluated ACL reconstruction using hamstring autograft with or without LET. This multicenter randomized controlled trial included patients who met 2 of 3 criteria: (1) a high-grade pivot shift phenomenon, (2) returning to pivoting sports, and (3) generalized ligamentous laxity. 7 With almost 600 patients in total, there was a significant difference in graft failure between the groups. The isolated primary ACL group had an 11% graft rupture rate vs 4% in the combined ACL with LET group. This resulted in a number needed to treat of 14.3 patients with the addition of LET to prevent 1 graft rupture within the first 2 postoperative years. 7
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Footnotes
Submitted April 30, 2023; accepted September 8, 2023.
One or more of the authors has declared the following potential conflict of interest or source of funding: B.F. is a board or committee member for AOSSM; is on the editorial or governing board for the Video Journal of Sports Medicine; received research support from Arthrex, Inc, Smith + Nephew, and Stryker; is a paid consultant for Smith + Nephew and Stryker; receives publishing royalties, financial, or material support from Elsevier; has stock or stock options in iBrainTech, Options Jace Medical, and Sparta Biopharma; received education payments for resident education lab support from Medwest; and was a seed investor and was on the scientific advisory board for Jace Medical, which was acquired by Zimmer Biomet. Jace Medical developed and marketed sternal closure devices for cardiac surgery, and there is no orthopedic conflict of interest or relevance. E.F. received educational support from Medwest Associates. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
