Modified Lemaire Lateral Extraarticular Tenodesis Using an Anterior Cruciate Ligament Reconstruction Suspensory Device

Summary

This article describes a modified Lemaire technique that helps achieve a stable and functional anterolateral plasty during ACL reconstruction without additional femoral tunnels or fixation devices.

Abstract

The anterior cruciate ligament (ACL) tears often occur along with damage to the structures of the anterolateral extra-articular complex, leading to increased anterior tibial translation and rotational instability requiring surgical treatment. Anatomic ACL reconstruction improves knee stability, but a few patients experience some degrees of instability. Recently, several techniques have been described in the literature to treat rotatory instability. Among these, the modified Lemaire procedure is performed as an augmentation to the anterior cruciate ligament reconstruction (ACLR) to reduce the anterolateral rotatory laxity. Studies have demonstrated improved rotational control and reduced failure rates of ACLR when lateral extra-articular tenodesis (LET) is added. This is particularly helpful in young patients returning to high demand pivoting sports, revision ACLR, pre-operative high-grade pivot shift test, Segond fracture, and congenital hyperlaxity. In the modified Lemaire LET, a strip of the iliotibial band (ITB) is harvested from its middle while leaving the distal insertion on the Gerdy's tubercle intact. The strip is then passed underneath the lateral collateral ligament and fixed on the lateral aspect of the distal femur with various fixation devices (such as suture anchors, bone tunnels with extracortical fixation, and staples). Along with the risk of tunnel convergence in combined ACL and LET surgeries, these types of fixations include a risk of over-tensioning the ITB graft, which could result in over-constraint of the lateral compartment and regional pain. To minimize these complications, in this paper, we describe a simple, reproducible, and cost-effective technique for modified Lemaire LET, with proximal fixation using the sutures of the ACLR femoral extracortical fixation device,thereby nullifying the risk of tunnel convergence and possible lateral irritative pain related to the presence of any additional hardware, and maximizing the cost-effectiveness of the procedure.

Introduction

Anterior cruciate ligament (ACL) injury is one of the most common sports-related injuries, affecting about 3% of amateur athletes each year, with percentages increasing by about 5 times when professional athletes are considered¹. Studies have also shown that the incidence of this injury has increased over the years², and as a result, ACL reconstruction is widely performed. It is widely accepted in the literature that a surgical approach is required for young and active patients to restore normal knee kinematics, to preserve the cartilage and menisci, as well as to increase the probability of returning to sports.

Protocol

This protocol follows the guidelines of our institution's human research ethics committee (Mauriziano Umberto I Hospital, Turin, Italy). Pre-operative images are shown (Figure 1).

1. Patient positioning and pre-operative evaluation

1. Performing spinal or general anesthesia.
2. Place a lateral support at the level of the proximal third of the thigh. Ensure that the positioning allows hyperflexion of the knee up to 120° in .......

Discussion

The persistence of rotational instability after ACL reconstruction can be as high as 25% of cases, resulting in poor outcomes and an increased risk of re-rupture^29,30. The modified Lemaire LET has recently been shown to reduce antero-lateral rotatory laxity in the ACL-reconstructed knee^12,31 and, as described by Geeslin et al.³², the association of ACL reconstruction with an ALL re.......

Materials

Name	Company	Catalog Number	Comments
ACL Fibertag Tightrope implant	Arthrex	AR-1588RTT	ACL reconstruction with quadriceps tendon, femoral fixation. Not mentioned in the paper because  not related to the technique described
ACL Fibertag ABS implant	Arthrex	AR-1588TNT	ACL reconstruction with quadriceps tendon, tibia fixation.  Not mentioned in the paper because  not related to the technique described
TightRope ABS Button, Round, Concave 20 mm	Arthrex	AR-1588TB-5	ACL reconstruction with quadriceps tendon, tibia fixation.  Not mentioned in the paper because  not related to the technique described
Vycril 2 Suture	Ethicon	J849G	ITB strip distal end reinforcement, cited in the manuscript (protocol section 7 Lateral tenodesis, subsection 2)