Lateral Extra-articular Tenodesis: A Technique With an Iliotibial Band Strand Without Implants

Abstract

The main goal in anterior cruciate ligament reconstruction (ACLR) should be to restore normal knee biomechanics so the chances of failure decrease. The persistence of knee instability after ACLR goes from 0.7% to 20%. Several factors have been identified and studied, but there are some selected cases in which it seems that without adding lateral extra-articular tenodesis (LET) it is not possible to control rotational instability. Data exist supporting that LET could reduce pivot shift (PS), without losing flexion/extension range of motion nor adding risk of osteoarthritis. Recently, LET has been used in addition to ACLR to add restriction to internal tibial rotation forces, and different authors have shown their techniques to achieve this task. Also, biomechanical studies have compared different techniques for LET procedures. This article aims to describe our technique performing a modified Macintosh LET as an addition to ACLR in selected patients who require extra internal tibial rotation control. This is a reproducible, easy to learn, and inexpensive procedure in terms that only a high resistance suture is needed and not any other implant, such as a stapler, anchors, or screws, reducing the risk of tunnel coalition.

Fig 1

Patient is in the supine position. Lateral view of a right knee. With inertial sensors installed in the middle point between the patient's Gerdy's tubercle and the tibial tuberosity, the surgeon performs a pivot shift test to have an accurate digital result of the internal rotation of the tibia.

Fig 2

Arthroscopic view of the lateral tibiofemoral space. Another important measure that encourages adding an LET is the closure of the lateral tibiofemoral joint space after ACLR. If the space after ACLR is more than 5 mm, we perform the LET. (ACLR, anterior cruciate ligament reconstruction; LET, lateral extra-articular tenodesis.)

Fig 3

Patient is in the supine position, knee at 90° of flexion. Lateral view of a right knee. A 6- to 8-cm skin incision is made in the lateral aspect of the thigh, proximal to Gerdy's tubercle. (FCL, fibular collateral ligament.)

Fig 4

Patient in supine, knee at 90° of flexion. Lateral view of a right knee. To obtain a 1-cm wide ITB strand, an incision is made in the middle third to begin harvesting keeping the distal attachment on Gerdy's tubercle. (ITB, iliotibial band.)

Fig 5

Patient is in the supine position, knee at 90° of flexion. Proximally detached ITB strand seen form lateral. The ITB harvest is extended proximal to a complete 8- to 12-cm length. (ITB, iliotibial band.)

Fig 6

Patient is in the supine position, knee at 90° of flexion. Free end of ITB harvest seen laterally. After you obtain a clean 8- to 12-cm length and 1-cm wide strand of ITB with its distal attachment in Gerdy's tubercle, a no. 2.0 VICRYL suture is passed in the free end with a Krakow-like fashion for 1 cm approximately. (ITB, iliotibial band.)

Fig 7

Patient is in the supine position, knee at 90° of flexion. Lateral view of a right thigh, distal portion. With the free end prepared, the ITB strand is passed from distal to proximal and the most important aspect to get the biomechanics as expected, is to pass deep to the FCL. (FCL, fibular collateral ligament; ITB, iliotibial band.)

Fig 8

Patient is in the supine position, knee at 90° of flexion. Lateral view of a right thigh, distal portion. Having passed it under the fibular collateral ligament, the intermuscular septum is identified and the sutures are passed deep to it. (FCL, fibular collateral ligament.)

Fig 9

Patient is in the supine position, knee at 90° of flexion. Lateral view of a right thigh, distal portion. When the ITB strand is passed deep into the septum, make a loop so you return heading distal again. (FCL, fibular collateral ligament; ITB, iliotibial band.)

Fig 10

Patient is in the supine position, knee at 30° of flexion. Lateral view of a right thigh, distal portion. Suture the band onto itself. For this, 30° of flexion is recommended and neutral rotation of the tibia is a must. Fixation is performed with 5 independent high-resistance stitches.

Fig 11

Patient is in the supine position, knee at 30° of flexion. Lateral view of a right thigh, distal portion. For closure, anterior and posterior lips of the ITB are sutured with continuous knotless suture to make it easier and to avoid the risk of muscular herniation. (ITB, iliotibial band.)