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Clinical Results of Lateral Extra-Articular Tenodesis.

ABSTRACT: In the anterior cruciate ligament (ACL) deficient knee, excellent outcomes are achieved in many patients with an isolated, intra-articular ACL reconstruction. Some patients, however, have ongoing instability or suffer graft rupture. Failure after ACL reconstruction is multifactorial, but residual anterolateral rotatory laxity is 1 potential contributing factor. Lateral extra-articular procedures are a heterogenous group of operations that were initially described as isolated treatments for the ACL deficient knee, and subsequently used in combination with intra-articular reconstructions. Initial observational studies were encouraging, however, comparative studies were less flattering and lead to a general abandonment of these procedures. With improved understanding of the anatomy and biomechanics of the anterolateral capsuloligamentous complex there has been a renewed interest in these procedures. Recent systematic reviews suggest efficacy of these procedures in improving rotational control, though data showing improved patient reported outcomes or reduced graft rupture rates are lacking. Preliminary results from ongoing clinical trials are supportive for lateral extra-articular tenodesis when used as an augment to modern, intra-articular ACL reconstructions in targeted, high-risk patients.

SUBMITTER: Batty L

PROVIDER: S-EPMC6250277 | biostudies-other | 2018 Dec

REPOSITORIES: biostudies-other

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Clinical Results of Lateral Extra-Articular Tenodesis.

Batty Lachlan L Lording Timothy T

Techniques in orthopaedics (Rockville, Md.) 20171225 4

In the anterior cruciate ligament (ACL) deficient knee, excellent outcomes are achieved in many patients with an isolated, intra-articular ACL reconstruction. Some patients, however, have ongoing instability or suffer graft rupture. Failure after ACL reconstruction is multifactorial, but residual anterolateral rotatory laxity is 1 potential contributing factor. Lateral extra-articular procedures are a heterogenous group of operations that were initially described as isolated treatments for the A ...[more]

PMID: 30542222

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Project description:Tibial anterolateral rotary instability associated with anterior cruciate ligament (ACL) tears is a well-documented and difficult problem with a long history of solutions. The lateral extra-articular tenodesis (LET) has undergone multiple refinements in technique, largely focusing on the femoral site insertion using either an interference screw versus a staple for adequate fixation. In this article, we present an improved technique using a suture anchor as an alternative to a staple or an interference screw with secure fixation to insert the LET graft onto the femur. This technique diminishes the chance of ACL tunnel–LET drilling convergence, minimizes the footprint required for adequate graft fixation, and allows the surgeon to dial in the correct tension necessary for adequate augmentation of an ACL reconstruction. Technique Video Video 1 Onlay technique of lateral extra-articular tenodesis (LET). The lateral aspect of a right knee is shown, with the patient positioned supine. The surgeon performs an approach to the iliotibial band, removing all subcutaneous tissue for adequate exposure starting approximately at the Gerdy tubercle and extending proximally about 8 cm. A distally based strip of the iliotibial band is harvested, approximately 1 cm in width, by use of separate incisions. A double-loaded 2.3-mm Iconix all-suture suture anchor is used for LET graft insertion. The graft is whipstitched with an arm of the suture anchor that is first passed underneath the lateral collateral ligament, followed by a simple suture pass through the graft by the other end of the same arm of the suture attached to the suture anchor. The fixation with 1 arm of the double-loaded Iconix suture anchor was enough to secure the graft appropriately, and the other suture within the double-loaded 2.3-mm Iconix suture anchor was removed prior to definitive fixation of the LET graft. Once the LET graft was appropriately stitched, the graft was passed underneath the lateral collateral ligament again, from distal to proximal, and then secured to the Iconix suture anchor.

Project description:PurposeTo identify the risk of anterior cruciate ligament (ACL) femoral tunnel penetration with the use of a staple for lateral extra-articular tenodesis (LET) graft fixation and to determine whether this varied between 2 different techniques for ACL femoral tunnel drilling.MethodsTwenty paired, fresh-frozen, cadaver knees underwent ACL reconstruction with a LET. Left and right knees were randomized to ACL reconstruction with femoral tunnel creation by use of either a rigid guide pin and reamer through the accessory anteromedial portal or by the use of a flexible guide pin and reamer through the anteromedial portal. Immediately after tunnel creation, the LET was performed and fixated with a small Richard's staple. Fluoroscopy was used to obtain a lateral view of the knee to determine staple position, and visualization of the ACL femoral tunnel was performed with the arthroscope to investigate penetration of the staple into the femoral tunnel. The Fisher exact test was conducted to determine whether there was any difference in tunnel penetration between tunnel creation techniques.ResultsThe staple was noted to penetrate the ACL femoral tunnel in 8 of 20 (40%) extremities. When stratified by tunnel creation technique, the Richards staple violated 5 of 10 (50%) of the tunnels made via the rigid reaming technique compared with 3 of 10 (30%) of those created with a flexible guide pin and reamer (P = .65).ConclusionsA high incidence of femoral tunnel violation is seen with lateral extra-articular tenodesis staple fixation.Level of evidenceLevel IV, controlled laboratory study.Clinical relevanceThe risk of penetrating the ACL femoral tunnel with a staple for LET graft fixation is not well understood. Yet, the integrity of the femoral tunnel is important for the success of ACL reconstruction. Surgeons can use the information in this study to consider adjustments to operative technique, sequence, or fixation devices used when performing ACL reconstruction with concomitant LET to avoid the potential for disruption of ACL graft fixation.

Dataset Information

Clinical Results of Lateral Extra-Articular Tenodesis.

Publications

Clinical Results of Lateral Extra-Articular Tenodesis.

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