ACL Reconstruction and Modified Lemaire Tenodesis Utilizing Common Suspensory Femoral Fixation

Abstract

Persistent rotatory instability after anterior cruciate ligament (ACL) reconstruction has been well studied and recognized as the cause of unsatisfactory clinical results. Various anterolateral techniques have been described as an adjunct to the ACL reconstruction to improve clinical outcomes. Modified deep Lemaire lateral extra-articular tenodesis has been tested both biomechanically and clinically and proved an efficient solution in controlling tibia internal rotation, when performed in conjunction with ACL reconstruction. We describe a simple, versatile, effective, and reproducible technique of lateral extra-articular tenodesis, using common suspensory femoral fixation, with no additional cost and surgical risk.

Fig 1

Left knee. Supine position with the knee flexed at 90°. (A) Anterior view. For the quadriceps tendon graft harvesting, the superior, medial, and lateral borders of the patella are marked. The skin incision is placed 1 cm proximal and in line with the center of the superior border of the patella. (B) Lateral view. For the lateral extra-articular tenodesis, the peroneal head, lateral femoral epicondyle, and Gedy’s tubercle are marked. The skin incision is placed under the lateral femoral epicondyle and in line with the iliotibial band (ITB) fibers.

Fig 2

Left knee. Supine position with the knee flexed at 90°. Endoscopic view of the quadriceps tendon. For quadriceps tendon harvesting, the proximal, medial, and lateral borders of the tendon should be identified. The yellow dotted lines represent the endoscopic view of the quadriceps tendon borders with the vastus medialis and vastus lateralis.

Fig 3

For the all-inside anterior cruciate ligament reconstruction technique, the quadriceps tendon graft is prepared with suspendory adjustable loop fixation implants at both ends. The length of the graft should be 6 to 7 cm.

Fig 4

Left knee. Supine position with the knee flexed at 90°. Lateral view. The iliotibial band graft should be 9 to 10 cm in length and 9 to 10 mm thick.

Fig 5

Left knee. Supine position with the knee flexed at 90°. Lateral view. The lateral collateral ligament (LCL) is identified and the area proximal and posterior to the lateral femoral epicondyle is cleaned with the electrocautery tip (yellow arrow).

Fig 6

Left knee. Supine position with the knee flexed at 90°. Anterior view. The anterior cruciate ligament, outside-in femoral guide is introduced through the anterolateral portal and positioned in the desired position (arthroscopic view), while the drill sleeve is positioned proximal and posterior to lateral femoral epicondyle, at the area that was previously marked. The scope is in the anteromedial portal.

Fig 7

Left knee. Supine position with the knee flexed at 90°. Anterior view. The anterior cruciate ligament graft passage has been completed, and the graft is in place (arthroscopic view) but not fixed. The yellow circles point to the tibial and femoral adjustable loop suspensory implants with both loops loose.

Fig 8

Left knee. Supine position with the knee flexed at 90°. Lateral view. The iliotibial band (ITB) graft, lateral collateral ligament (LCL), and the loop (yellow arrow) of the suspensory fixation implant are identified.

Fig 9

Left knee. Supine position with the knee flexed at 90°. Lateral view. The iliotibial band (ITB) graft is passed under the lateral collateral ligament (LCL).

Fig 10

Left knee. Supine position with the knee flexed at 90°. Lateral view. The iliotibial band is passed (yellow arrow) through the adjustable loop of the suspensory fixation implant.

Fig 11

Left knee. Supine position. Lateral view. The iliotibial band graft is fixed with the suspensory fixation implant (yellow arrow) with the knee in 10° of flexion, thus fixating the anterior cruciate ligament graft as well. The picture is taken in 90° of knee flexion (after the fixation has been completed) for demonstration purposes.

Fig 12

Left knee. Supine position with the knee flexed at 90°. Lateral view. After the graft fixation, the free end of the iliotibial band graft is brought over the suspensory fixation implant.

Fig 13

Left knee. Supine position with the knee flexed at 90°. Lateral view. The free end of the iliotibial graft is sutured to itself for additional security.

Fig 14

Left knee. Supine position with the knee flexed at 90°. Lateral view. Final result of the modified Lemaire tenodesis with the iliotibial band (ITB) graft passing under the lateral collateral ligament (LCL), fixed by the suspensory femoral fixation of the anterior cruciate ligament graft (button, yellow arrow) and tied to itself.

Fig 16

Drawing of the technique. Right knee. Lateral and anterior view. (ITB, iliotibial band; LCL, lateral collateral ligament; QT, quadriceps tendon.)

Fig 15

Left knee. Arthroscopic view of the anterior cruciate ligament graft through the anterolateral portal.