Minimally Invasive Combined Anterior and Anterolateral Stabilization of the Knee Using Hamstring Tendons and Adjustable-Loop Suspensory Fixation Device: Surgical Technique

Abstract

Despite the numerous techniques described regarding isolated anterior cruciate ligament (ACL) reconstruction, many authors have reported that residual knee rotational instability is not always eliminated. The combination of lateral extra-articular knee tenodesis and ACL reconstruction is an alternative surgical approach with very promising clinical results. The purpose of this article is to describe a reliable and reproducible technique of combined ACL reconstruction and lateral extra-articular knee tenodesis using a continuous looped hamstring tendon autograft. A 4-strand graft inside the joint and a 2-strand graft for the tenodesis are attached to 2 adjustable-loop button suspensory fixation devices.

Fig 1

(A) Patient placed in the supine position with the left knee in 90° of flexion. The landmarks for the lateral extra-articular tenodesis are proximally and posteriorly to the lateral femoral epicondyle (E) and just posteriorly and proximally to the Gerdy tubercle (G) (arrows). (B) Outside-in technique for femoral tunnel creation aiming just posteriorly to the lateral epicondyle (arrow) (left knee). (C) Special guide. The asterisk shows the intra-articular offset, and the arrow shows the extra-articular part. (D) Confirmation of the drill guide position (arrow) from the anteromedial portal. (MW-LF, medial wall of lateral femoral condyle; PCL, posterior cruciate ligament.) (E) Final femoral tunnel created. The asterisk indicates the provisional arthroscopic portal cap. (MW-LF, medial wall of lateral femoral condyle). (F) Tibial drill guide placement for the anterior cruciate ligament reconstruction tunnel. The arrow indicates the medial side of the left knee. (G) Tibial drill guide placed with direction from medial to lateral (arrow), aiming just posteriorly and proximally to the Gerdy tubercle (G) for tibial tunnel creation for the lateral extra-articular tenodesis. (AL, anterolateral portal; AM, anteromedial portal; LFE, lateral femoral epicondyle; PH, peroneal head.) (H) Drill guide placed (arrow). (G, Gerdy tubercle; LFE, lateral femoral epicondyle; PH, peroneal head.) (I) Initial 4.5-mm full-length tunnel creation from medial to lateral (left knee). (G, Gerdy tubercle; LFE, lateral femoral epicondyle.) (J) Final 2-cm-deep socket drilling with a 6-mm drill from lateral to medial. Also shown are the femoral tunnel (FT) created and its relation to the lateral epicondyle (arrow). (G, Gerdy tubercle; LET, lateral extra-articular tenodesis.)

Fig 2

(A) The hamstring tendon common insertion is initially secured and sutured around the loop of the Pullup XL button (arrow 1). The tendons are marked according to the measured tunnels' length for the anterior cruciate ligament (ACL) reconstruction (arrow 2) and the lateral extra-articular tenodesis (LET) (arrow 3). (B) Initially, the 4-strand graft (3 strands from the semitendinosus [ST3] and 1 strand from the gracilis [GR1]) for the ACL reconstruction is prepared. The remaining gracilis (GR2) will be looped afterward for the LET graft. (C) Final graft prepared. The measurements correspond to the case presented in Video 1 (in which the ACL graft equals 8 cm and LET equals 8 cm). However, in all cases the surgeon should reserve 2 cm for the ACL graft incorporation into the tibia and 1 cm for the LET graft. The adjustable Pullup XL and normal Pullup buttons are attached at each side of the preparation table.

Fig 3

(A) Three different-color shuttling sutures are used. Blue arrow 1 indicates the suture for initial graft passage from the tibia to the femur; blue arrow 2, the suture for shuttling the lateral extra-articular tenodesis (LET) graft underneath the iliotibial band; and blue arrow 3, the suture for passing the LET graft through the tunnel to the medial side of the tibia. The white arrow shows the direction of the LET graft. (FT, femoral tunnel; G, Gerdy tubercle.) (B) The anterior cruciate ligament (ACL) graft (left knee) is pulled through the tibial and femoral tunnels until the nonabsorbable suture (co-braid in this case, arrow) appears in the joint (2 cm of graft is left in the tibial tunnel). (C) The graft is secured at the femur with an interference screw. The arrow indicates the LET graft. (FT, femoral tunnel.) (D) The LET graft (arrow) has been passed underneath the iliotibial band. The asterisk shows the remaining shuttling suture for the final retrieval of the normal button at the medial side of the tibia (left knee). (E) Final configuration of the technique. (F) Position of the 2 buttons at the medial side of the tibia (arrowheads) (left knee).