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.

Over the past decades, there has been a major development in surgical techniques, evolving from open, extra-articular, and non-anatomical techniques to arthroscopic, intra-articular, and anatomical techniques, including procedures such as double³ or triple bundle⁴ reconstructions or repairs with or without biological enhancement^5,6. However, a significant percentage of patients (around 10-15% according to the literature⁷) reported unsatisfactory outcomes, with persistent tibial anterior translation and rotational instability. This can represent one of the causes of a reduced proportion of patients returning to the sport as well as an increased risk of re-rupture or subsequent meniscal or cartilage injuries^8,9.

Antero-lateral rotatory instability (ALRI) is often associated with ACL injury, both acutely as a concomitant injury to the anterolateral complex, and in chronic cases as the result of a progressive lengthening of the anterolateral structures due to the altered kinematics of the ACL-deficient knee¹⁰. In fact, different studies show that after isolated reconstruction of the ACL, the phenomenon of pivot shift is present in 25-38% of the patients¹¹, and this percentage drops significantly when an anterolateral procedure is associated¹².

Over the years, different techniques have been described to address the anterolateral complex. These techniques include using a strip of the iliotibial band (ITB) to be passed under the lateral collateral ligament (LCL) in different configurations and fixed at the lateral femoral condyle^{13,14,15,16,17} or sutured to itself¹⁸, reconstruction of the anterolateral ligament (ALL)¹⁹, or more complex techniques that allow concomitant reconstruction of ACL and ALL (i.e., as described by Marcacci et al.²⁰, Yamaguchi et al.²¹ and Saragaglia et al.²²). The addition of a lateral extraarticular tenodesis could reduce the residual tibial anterior translation and the residual pivot shift, allowing an earlier return to sports and providing better subjective outcomes. One of the most commonly used techniques is the modified Lemaire lateral extra-articular tenodesis. In this technique, a 1 cm wide and 7-8 cm long strip of the ITB is harvested from its central portion preserving the distal insertion on the Gerdy's tubercle. Then it is passed below the LCL and fixed on the femur anterior and proximal to the lateral head of the gastrocnemius with staples, anchors or transosseous tunnels²³. However, all these techniques are not free from complications, including the risk of over constraining the lateral compartment²⁴ or convergence between ALL/LET femoral fixation and ACL femoral tunnel²⁵. This second complication should definitely be avoided when using extracortical fixation devices for ACL femoral fixation, since the device can be damaged by suture anchors, staples or femoral tunnel used for the anterolateral procedures.

In this paper, the authors describe a modified Lemaire technique, without additional fixation devices or femoral tunnels with the goal of minimizing the risk of over constraint and avoiding convergence with ACL femoral tunnel.

The technique described in the present paper can be performed when extracortical fixation devices are used for ACL femoral fixation (mostly when using hamstrings or quadriceps tendon as a graft for ACLR). The authors' indications for LET reflect the recent literature²⁶ and this technique is then performed if one or more of the following circumstances are present: 1) revision ACLR, 2) high-grade rotational laxity (grade-2 or 3 pivot shift), 3) generalized hyperlaxity or genu recurvatum of > 10°, 4) young patient (<20 years old), 5) patient aiming to return to pivoting sports. Other secondary criteria that may be taken into account to determine the patient's eligibility for this procedure are: presence of a Segond fracture, DLFNS (deep lateral femoral notch sign), obesity, total/subtotal lateral meniscectomy. There are no specific contraindications; however, caution should be observed in patients with posterolateral corner injury and initial lateral compartment osteoarthritis²³.

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 order to achieve an anatomical transportal femoral drilling.
3. Under anesthesia, evaluate the stability of the knee in all planes to confirm the ACL tear and to rule out any other ligamentous injuries. Test antero-posterior stability with Lachman test (positive if anterior tibial translation > 5mm), anterior and posterior drawer test (positive if tibial translation > 5 mm anteriorly or posteriorly from a neutral starting position)²⁷, rotational stability with pivot shift test (positive if a glide or a clunk is observed)²⁷, collateral ligaments integrity with varus-valgus stress maneuvers at 0° and 30° of flexion (normal values: no opening at 0° and < 5° opening at 30° for both tests)²⁸.
4. Place the patient in supine position on the operating table. Place a tourniquet on the proximal thigh.
5. Sterilize the leg with chlorhexidine and drape with a sterile drape.
6. With a number 11 surgical blade create standard anteromedial (AM) and anterolateral (AL) arthroscopic portals by making 2 vertical incisions about 1-2 cm long and about 1 cm away from the lower pole of the patella.
7. Perform an initial arthroscopic evaluation in order to identify any cartilage lesions. To do so follow the steps below.
   1. Test the tension of the posterior cruciate ligament by pulling it anteriorly with the help of a probe inserted through one of the arthroscopic portals.
   2. With the knee in extension and under valgus stress, test the medial meniscus mobility and integrity of roots insertion by palpating and pulling it with a probe.
   3. In the same manner, test the lateral meniscus mobility and integrity with the knee in figure-of-four position and under varus stress. Then test the medial meniscus with the knee in extension and under valgus stress.
   4. Test the lateral meniscus with the knee in figure-of-four position and under varus stress.
8. Perform tenodesis after ACL reconstruction.

2. ACL reconstruction

1. Graft choice
   1. With a surgical blade number 20, perform a longitudinal incision (3-5 cm) starting from the proximal pole of the patella and centered on the quadriceps tendon.
   2. With a surgical blade number 20, make two parallel incisions at the level of the middle portion of the quadriceps tendon, and with the help of scissors harvest a 10 mm wide and 60-70 mm long strip of quadriceps tendon (full or partial thickness) without bone block.
      NOTE: The authors generally perform the technique described in association with soft tissue grafts (hamstrings or full-thickness quadriceps tendon). While hamstrings are used in older and less active patients, quadriceps tendon is preferred in young and active patients with higher risk of re-rupture.
   3. Bring the graft to the back table for preparation. Prepare the quadriceps tendon with dedicated adjustable loop extracortical fixation devices on both femoral and tibial sides.
      NOTE: In the case of hamstrings graft, arm it in a 6-strands fashion and prepare the femoral end with an adjustable loop extracortical fixation device.
   4. Pre-soak the graft in Vancomycin (500 mg /100 ml) for 10 min before implantation.
   5. Reapproximate the tendon margins with simple interrupted sutures and close the subcutaneous and superficial layers in the same manner.
2. Femoral tunnel drilling
   1. Remove the ACL residual stump with a shaver and carefully debride the medial wall of the lateral femoral condyle with the help of a small curette.
   2. By using femoral offset guides (in order to preserve at least 2 mm of posterior wall), place a guidewire through the anteromedial portal aiming toward the anatomical femoral footprint. Drill over the guidewire a 4.5 mm full femoral tunnel first and then a 15-20 mm long half socket of the same diameter of the graft.
3. Tibial tunnel drilling
   1. Insert an angled ACL guide (55°- 65°) into the joint through the AM portal. Position the guide on the lateral wall of the medial tibial spine, in the center of the tibial stump.
   2. At the level of the anteromedial surface of the tibia, make a small cutaneous incision with a number 20 surgical blade and drill a 2.4 mm pin into the proximal tibia from a point located halfway between the tibial tubercle and the posteromedial corner of the tibia.
   3. Carefully evaluate the intraarticular position of the pin after that drill a full tunnel of the same diameter of the graft over the guidewire.
4. Graft insertion and fixation
   1. With the help of a shuttle suture, pass the graft into the tibial tunnel first and then into the femoral tunnel by gentle traction and flip the button outside the lateral femoral cortex. Confirm secure fixation by pulling on the graft distally, and fully seat the neo-ligament inside the femoral tunnel by tightening the sutures of the adjustable loop.
   2. Cycle the knee several times while pulling the distal sutures of the graft, checking full range of motion, and ruling out graft impingement.
   3. Perform fixation in full extension with a 20 mm diameter round button attached to the adjustable loop and secure it with at least three simple knots.
      NOTE: For hamstrings, perform final tibial fixation at 20° of flexion with a bioabsorbable interference screw (diameter of the screw 1 mm larger than the tibial tunnel).
   4. Place the knee again through a passive full range of motion and check the correct tension of the graft under arthroscopic visualization with the help of a probe.

3. Lateral tenodesis

1. Landmark and skin incision
   1. With the knee at 90° of flexion, identify by palpation and mark the fibular head, lateral epicondyle and Gerdy's tubercle.
   2. Perform a straight 5 cm longitudinal incision centered on the lateral femoral epicondyle. (Figure 1).
2. ITB harvesting and preparation
   1. Dissect the subcutaneous fat with blunt scissors down to the iliotibial band (ITB). Harvest an 8-cm-long, 1-cm-wide strip of the ITB preserving the distal attachment. Center the incisions of the ITB for harvesting the strip on the lateral femoral epicondyle both anterior-posterior and proximal-distal directions.
   2. Place a whipstitch with a number-2 multifilament adsorbable suture in the proximal free end of the strip for 3 cm (Figure 2).
3. ITB strip positioning
   1. Identify the lateral collateral ligament (LCL) by palpation (by placing the knee in a figure-of-4 position) (Figure 3A) and incise the soft tissues posterior to the LCL parallel to the it (~1 cm long) (Figure 3B).
   2. Advance a 90° suture passer deep to the LCL and direct it anteriorly until it can be palpated. Make a second 1 cm sharp incision parallel to the LCL at the tip of the suture passer. Use the suture passer to retrieve the polyglactin arming sutures deep to the LCL through the proximal incision (Figure 4A).
   3. By gently pulling on the arming sutures and by cycling the knee, drive the ITB strip through the same path (Figure 4B).
4. Final fixation
   1. Retrieve the high resistance sutures of the adjustable loop through the ITB incision by inserting a finger or a probe under the ITB, while keeping some tension on the adjustable loop sutures. (Figure 5A).
   2. Use a free needle to pass the high resistance sutures through the proximal part of the ITB strip (Figure 5B) and place two to three simple interrupted sutures secured with at least three knots. Perform the final fixation with the knee at 30° of flexion and the foot in neutral rotation (Figure 5C).
   3. After wound irrigation and final hemostasis, close the iliotibial band completely with a number-2 polyglactin continuous locking suture. Position a surgical drainage intraarticularly with exit through one of the arthroscopic portals.

4. Post-operative evaluation and follow-up

1. Evaluate the patient at day 30, 3, 6 and 9 months after surgery by performing clinical tests (Lachman test, pivot shift test, KT-1000) and collecting PROMs like IKDC score, Lysholm knee score, Tegner activity score and Knee injury and Osteoarthritis Outcome Score (KOOS).

Results

The operating time is approximately 50-70 min, with the tourniquet being released just before the skin closure for a final check for bleeding. The patient is generally discharged the following day after removal of the surgical drainage and post-operative X-ray (Figure 7). Post-operatively full weight bearing as tolerated and immediate ROM and muscle strengthening exercises are generally permitted, while in case of additional cartilage or meniscal surgery the weightbearing is delayed when mea...

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)