Minimally Invasive Modified Lemaire Tenodesis

Abstract

Increasing emphasis in the literature is recently being put on controlling rotational stability in patients with an anterior cruciate ligament rupture by addressing the anterolateral complex during anterior cruciate ligament reconstruction. Many different techniques for lateral extra-articular tenodesis have been described, with the (modified) Lemaire technique being widely favored. Recent literature does report that lateral extra-articular tenodesis leads to a reduction in persistent rotatory laxity and graft rupture rate, but also may be associated with increased pain, reduced quadriceps strength, reduced subjective functional recovery, and cosmetic complaints. Thus this article aims to describe our minimally invasive technique for a modified Lemaire tenodesis.

Fig 1

The patient is in supine position with the left knee in >90° flexion and neutral rotation. Before primary anterior cruciate ligament repair, important landmarks and the intended skin incision for the minimally invasive modified Lemaire tenodesis are marked. The arrow marks the intended incision site, measuring ∼3 cm in length. The incision will be made with a stab incision scalpel, starting from the lateral epicondyle and extended proximally along the intended incision marking. The skin and iliotibial band are incised simultaneously, aiming centrally in the iliotibial band. Abbreviations: AB ITB, anterior border iliotibial band; D, distal side; FH, fibular head; G, Gerdy's tubercle; LE, lateral epicondyle (femur); P, proximal side; PB ITB, posterior border iliotibial band.

Fig 2

The patient is in supine position with the left knee in >90° flexion and neutral rotation. Depending on placement of the initial stab incision, the second iliotibial band (ITB) incision is placed either anteriorly or posteriorly (posteriorly in this figure), so that an 8- to 12-mm-wide strip can be harvested from the central one third of the ITB. The arrows mark the anterior and posterior incision in the ITB, with the intended harvested ITB strip measuring 8 to 12 mm. Abbreviations: AB ITB, anterior border iliotibial band; D, distal side; FH, fibular head; LE, lateral epicondyle (femur); P, proximal side; PB ITB, posterior border iliotibial band.

Fig 3

Smillie knife. The minimally invasive modified Lemaire tenodesis allows only a short skin incision of maximum 4 cm. By using a Smillie knife, the iliotibial band incision can be extended down to Gerdy's tubercle without further incising the skin.

Fig 4

The patient is in supine position with the left knee in >90° flexion and neutral rotation. With the Smillie knife in the right hand, the iliotibial band (ITB) incisions (arrows) are extended distally, aiming posteriorly and toward the thumb of the left hand, which is placed directly on Gerdy's tubercle. The intended trajectories of both the extended ITB incisions are marked by the dotted line. Abbreviations: D, distal side; FAB ITB, anterior border iliotibial band; H, fibular head; G, Gerdy's tubercle; P, proximal side; PB ITB, posterior border iliotibial band.

Fig 5

The patient is in supine position with the left knee in >90° flexion and neutral rotation. With both the posterior and anterior iliotibial band incisions distally extended to Gerdy's tubercle, the proximal end of the graft is detached using Metzenbaum scissors (arrow). The distal attachment is left intact. Using this technique, an iliotibial band graft with a total length of 10 to 12 cm and width of 8 to 12 mm is harvested. Abbreviations: AB ITB, anterior border iliotibial band; D, distal side; FH, fibular head; G, Gerdy's tubercle; LE, lateral epicondyle (femur); P, proximal side; PB ITB, posterior border iliotibial band.

Fig 6

The patient is in supine position with the left knee in >90° flexion and neutral rotation. Using an Allis tissue forceps, the proximal end of the graft is grasped and manipulated. Soft tissues and fat are dissected away from the graft. While an assistant holds the iliotibial band (ITB) graft toward the distal corner of the skin incision, the femoral attachment of the fibular collateral ligament (FCL) is identified. A soft tissue tunnel is then created medially from the FCL using Metzenbaum scissors. A curved-tip forceps is placed from anterior to posterior through this tunnel. The arrow marks the tip of the curved-tip forceps. Abbreviations: AB ITB, anterior border iliotibial band; D, distal side; FH, fibular head; G, Gerdy's tubercle; P, proximal side; PB ITB, posterior border iliotibial band.

Fig 7

The patient is in supine position with the left knee in >90° flexion and neutral rotation. A looped wire is placed in the tip of the curved-tip forceps and pulled through the tunnel. By gently moving the looped wire proximally with the right hand and distally with the left hand (directions marked by arrows), the tunnel is widened. Abbreviations: AB ITB, anterior border iliotibial band; D, distal side; Dist, directed distally; FCL, fibular collateral ligament; G, Gerdy's tubercle; ITB graft, iliotibial graft; P, proximal side; PB ITB, posterior border iliotibial band; Prox, directed proximally.

Fig 8

The patient is in supine position with the left knee in >90° flexion and neutral rotation. After the tunnel is sufficiently widened, the looped wire is placed around the iliotibial band (ITB) graft and pulled through the tunnel medially from the fibular collateral ligament (FCL). The dotted line marks the trajectory of the FCL, crossing over the ITB graft after the graft is pulled through the tunnel. Abbreviations: AB ITB, anterior border iliotibial band; D, distal side; FH, fibular head; G, Gerdy's tubercle; P, proximal side; PB ITB, posterior border iliotibial band.

Fig 9

The patient is in supine position with the left knee in >90° flexion and neutral rotation. The femoral fixation site of the lateral extra-articular tenodesis (circle) should be just anterior to the insertion of the distal Kaplan's fibers and proximal to the femoral suspensory button of the anterior cruciate ligament graft (arrow). The soft tissues at the femoral fixation site are dissected away, and the bony surface is stimulated with a debridement rasp. A 2.8-mm titanium suture anchor (FASTak; Arthrex) is placed. Abbreviations: D, distal side; ITB, iliotibial; LE, lateral epicondyle (femur); P, proximal side.

Fig 10

The patient is in supine position with the left knee in >90° flexion and neutral rotation. Two wires originate from the placed suture anchor (circle). Wire 1 (W1) is held toward the anterior border of the skin incision by an assistant and is later used to hoist the iliotibial band (ITB) graft toward the femur. Wire 2 (W2) is attached to a suture needle and is used to whipstitch the ITB graft (marked by arrow). Abbreviations: D, distal side; LE, lateral epicondyle (femur); P, proximal side.

Fig 11

The patient is in supine position with the left knee brought from >90° to >30° flexion and neutral rotation. After whipstitching the iliotibial band (ITB) graft with wire 2 (W2), wire 1 (W1) is used to hoist the ITB graft toward the suture anchor placed on the femur (circle). With sufficient tension on the graft, the wires are tied together, securing the graft onto the femur. Abbreviations: AB ITB, anterior border iliotibial band; D, distal side; FH, fibular head; LE, lateral epicondyle (femur); P, proximal side; PB ITB, posterior border iliotibial band.

Fig 12

The patient is in supine position with the left knee in >30° flexion and neutral rotation. After evaluating adequate tensioning patterns (the lateral extra-articular tenodesis should tension with internal rotation), the iliotibial band donor defect is closed using a barbed suture (Stratafix; Johnson & Johnson) (circle). Abbreviations: AB ITB, anterior border iliotibial band; D, distal side; FH, fibular head; G, Gerdy's tubercle; LE, lateral epicondyle (femur); P, proximal side; PB ITB, posterior border iliotibial band.

Fig 13

The patient is in supine position with the left knee in >30° flexion and neutral rotation. The wound, measuring ∼3 cm in length, is closed, and the minimally invasive modified Lemaire procedure is complete. Abbreviations: AB ITB, anterior border iliotibial band; D, distal side; FH, fibular head; G, Gerdy's tubercle; LE, lateral epicondyle (femur); P, proximal side; PB ITB, posterior border iliotibial band.

Fig 14

Radiographic imaging of the left knee after all-inside anterior cruciate ligament reconstruction combined with minimally invasive modified Lemaire tenodesis. (A) Anteroposterior image. (B) Lateral image. The red arrow marks the titanium suture anchor (FASTak; Arthrex).