Arthroscopic-Assisted Lateral Extra-Articular Tenodesis With Knotless Anchor Fixation

Abstract

Recent studies have reported the biomechanical and clinical advantages of lateral extraarticular augmentation procedures including the modified lateral extra-articular tenodesis (LET) in the setting of anterior cruciate ligament reconstruction. LET has been shown to significantly decrease re-rupture rates in high-risk patients and decrease anterior cruciate ligament graft forces during pivoting loads and instrumented anterior laxity testing. Many variations of the modified LET approaches have been described. However, concerns including lateral hematoma, wound-healing complications, and increased operative time exist. This minimally invasive, arthroscopic-assisted approach using a knotless, all-suture anchor allows for direct visualization through a 2-cm incision and inherently decreases the morbidity associated with traditional LET techniques.

Fig 1

Landmarks and incision. Shown is the right knee in 90° flexion and neutral rotation on a supine patient. Before primary anterior cruciate ligament repair, anatomy is defined, landmarks are marked, and a small 2-cm skin incision (proximal and distal edges indicated by arrows) is created proximally from the lateral epicondyle. The surgeon is demonstrating the posterior and anterior borders of the iliotibial band with the first and second digits of his left hand respectively. (D, distal side; FCL, fibular collateral ligament; FH, fibular head; LE, lateral epicondyle; P, proximal side.)

Fig 2

Arthroscopic view of the ITB. Shown is the arthroscopic view of the right ITB of a supine patient with knee in 90° flexion and neutral rotation. After subcutaneous dissection, an arthroscope is directed proximally and placed through the lateral skin incision into the potential space just superficial to the ITB. This allows the surgeon to directly visualize the anterior and posterior borders of the ITB and identify any superficial vessels. (AB ITB, anterior border of iliotibial band; D, distal side; ITB, iliotibial band; P, proximal side; PB ITB, posterior border of iliotibial band.)

Fig 3

Parallel blade harvesting tendon. Shown is the right knee in 90° flexion and neutral rotation on a supine patient. A mark (red dot) is placed 5 cm proximal to the lateral epicondyle. A 10-mm Parallel Graft Knife Blade (Arthrex) is used to incise the ITB posterior to its midline for approximately 5 cm along the trajectory marked by the dotted line directly in line with the ITB fibers. The superior blade of the knife should be at or slightly posterior to the level of mid-point of the LE. (D, distal side; ITB, iliotibial band; LE, lateral epicondyle; P, proximal side.)

Fig 4

Arthroscopic view of the incised ITB. Shown is the arthroscopic view of the right ITB of a supine patient with knee in 90° flexion and neutral rotation. The anterior and posterior borders of the incised ITB are directly visualized. (AB G, anterior border of graft; D, distal aspect; ITB, iliotibial band; P, proximal aspect; PB G, posterior border of graft.)

Fig 5

Portal for proximal graft harvest. Shown is the right knee in 90° flexion and neutral rotation on a supine patient. After a small incision is made just anterior to the proximal extent of the harvest, arthroscopic scissors can be placed anteriorly to posteriorly in preparation to complete the tendon harvest. (A, arthroscope; AS, arthroscopic scissors; D, distal aspect; FCL, fibular collateral ligament; FH, fibular head; LE, lateral epicondyle; P, proximal aspect.)

Fig 6

Arthroscopic view of scissors incising proximal edge of graft. Shown is the right ITB as viewed through the arthroscope in 90° flexion and neutral rotation on a supine patient. The arthroscopic scissors are used to incise the proximal end of the ITB strip under direct visualization. (AB G, anterior border of graft; AS, arthroscopic scissors; D, distal aspect; ITB, iliotibial band; P, proximal aspect; PB G, posterior border of graft.)

Fig 7

FCL is defined. Shown is the right knee in 90° flexion and neutral rotation on a supine patient. The ITB graft is pulled distally allowing the surgeon to visualize the underlying FCL and define its anterior and posterior borders. Curved-tip forceps are then placed to create a passage deep to the FCL from anterior to posterior and used to pull a passing suture through this passage. (D, distal aspect; FCL, fibular collateral ligament; FH, fibular head; ITB, iliotibial band; P, proximal aspect.)

Fig 8

Graft shuttled deep to FCL. Shown is the right knee in 90° flexion and neutral rotation on a supine patient. The prepared ITB graft has been shuttled proximally deep to the FCL. At this point, the graft can be wrapped in vancomycin-soaked gauze and stored in the wound. The femoral tunnel for anterior cruciate ligament reconstruction is then drilled. (D, distal aspect; FCL, fibular collateral ligament; ITB, iliotibial band; LE, lateral epicondyle; P, proximal aspect.)

Fig 9

Anchor placement. (A) Depicts the right knee in 90° flexion and neutral rotation on a supine patient. The ACL femoral tunnel has been completed, but the ACL graft has not been pulled into the tunnel. A single-loaded Arthrex FiberTak knotless all-suture anchor is placed at the metaphyseal flare, 10 mm proximal to the lateral epicondyle and 5 mm posterior. A passing suture exiting from the ACL femoral tunnel is used to identify the location of the tunnel and avoid collision with the suture anchor. (B) The location of ideal placement of graft fixation is indicated by the white box. After the anchor is placed and set, the ACLR is completed. (ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament; rehabilitation; D, distal side; FT A, FiberTak anchor; ITB G, iliotibial band graft; LE, lateral epicondyle; P, proximal side.)

Fig 10

Reducing graft proximally after ACLR is complete. Shown is the right knee in <90° flexion and neutral rotation on a supine patient. After completion of the ACLR, the repair suture from the anchor is held over the anterior thigh, the looped “pull” suture is held posteriorly, and the tag suture is held distally. An arthroscopic grasper is placed through the previously created proximal incision and used to grasp the tag suture and pull it proximally, reducing the graft. (ACLR, anterior cruciate ligament; rehabilitation; AG, arthroscopic grasper; D, distal side; FH, fibular head; ITB, iliotibial band; LE, lateral epicondyle; P, proximal side; PS, pull suture; RS, repair suture; TS, tag suture.)

Fig 11

Reduced graft. Shown is the right knee in 90° flexion and neutral rotation on a supine patient. The graft is now reduced over the desired fixation point with its trajectory outlined (dotted lines). Gentle proximal traction is applied to the tag suture being careful to avoid over tensioning of the ITB graft. The repair suture is still over anterior thigh and the looped “pull” suture is still posterior to thigh. (D, distal side; FH, fibular head; ITB, iliotibial band; LE, lateral epicondyle; P, proximal side; PS, pull suture; RS, repair suture; TS, tag suture.)

Fig 12

Fixed ITB graft with sutures removed. Shown is the right knee in 30° flexion and neutral rotation on a supine patient. After using the looped pull suture to bring the repair suture over the top of the tendon, the knee is brought to 30° flexion and neutral rotation. The construct is then fully tightened resulting in a reconstructed ALC. (AD, distal side; ALC, anterolateral complex; FH, fibular head; LE, lateral epicondyle; P, proximal side; T, tenodesis.)

Fig 13

Closed incisions. Shown is the right knee in 30° flexion and neutral rotation on a supine patient. The 2-cm incision is closed. (D, distal side; FH, fibular head; LE, lateral epicondyle; P, proximal side.)