Modified Lemaire Lateral Extra-Articular Tenodesis Augmentation of Anterior Cruciate Ligament Reconstruction

Abstract

Background: A modified Lemaire lateral extra-articular tenodesis (LET) is a procedure that is designed to address anterolateral complex (ALC) deficiency. The procedure is performed as an augmentation to anterior cruciate ligament reconstruction (ACLR) to reduce anterolateral rotatory laxity. Studies have demonstrated improved rotational control and reduced failure rates of ACLR when LET is added. This is particularly helpful in young patients with high-grade rotatory laxity returning to contact pivoting sport, and in the revision ACLR scenario.

Description: A 6-cm skin incision is placed just posterior to the lateral epicondyle. The subcutaneous tissue is dissected down to the iliotibial band (ITB). A 1-cm-wide by 8-cm-long strip of the posterior half of the ITB is fashioned, leaving the distal attachment at Gerdy's tubercle intact. The free end is whipstitched with number-1 Vicryl suture, tunneled deep to the fibular collateral ligament (FCL), and attached to the metaphyseal flare of the lateral femoral condyle at the insertion of the distal Kaplan fibers of the ITB. Fixation is performed with a staple, with the graft tensioned to no more than 20 N (by simply holding it taut and not "tensioned"), with the knee held at 60° of flexion and neutral rotation of the tibia.

Alternatives: A number of procedures to address ALC deficiency have been described. The most common methods currently are variations of the ITB LET (Lemaire [ITB graft detached proximally, passed under the FCL, and attached to the femur] or Ellison [ITB graft detached distally, passed deep to the FCL, and reattached at Gerdy's tubercle]) or anterolateral ligament reconstructions. No clinical studies have been performed that demonstrate that one technique is superior to another.

Rationale: Current ACLR procedures focus on intra-articular graft placement to replace the ACL. Unfortunately, high rates of graft failure and persistent rotatory laxity (pivot shift) have been observed, particularly in young, high-demand individuals returning to contact pivoting sport. ALC deficiency has been shown to be a major cause of high-grade anterolateral rotatory laxity. The LET procedure is therefore designed to augment ACLR and reduce anterolateral rotation. The aim of adding LET to ACLR is to reduce the strain on the ACLR graft, reduce the prevalence of the pivot shift, and thereby potentially reduce the rate of ACLR graft failure.