Mini-LET: A Technique Note

Abstract

Lateral extra-articular tenodesis (LET) has shown an upswing in popularity since the role of antero-lateral rotatory instability (ALRI) in ACL tears has become better understood. Its primary aim is to restore antero-lateral rotatory stability and hence reduce stresses placed on the ACL graft in high-risk individuals which should reduce graft failure rates. Many techniques have been described for LET using a variety of fixation methods (screws, anchors, etc.). Most of these techniques rely on a large incision laterally. We describe a novel technique ('mini-LET') which uses a 3-4 cm incision, to improve cosmesis.

Keywords: Lateral extra-articular tenodesis (LET); Surgical technique; Technique.

Fig. 1

Surface marking done by identifying two bony landmarks; Lateral epicondyle (L.E) and Gerdy's tubercle (G.T)

Fig. 2

A 3 cm incision is made from just distal to the lateral epicondyle of femur proximally to Gerdy's tubercle distally

Fig. 3

Shiny white fibers of Iliotibial band (*) can be clearly seen after rubbing off the residual fat beneath the subcutaneous fascia layer

Fig. 4

Utilizing the push–pull technique for retraction facilitates the procedure despite having limited exposure

Fig. 5

Flap elevated from proximal to distal up to Gerdy's tubercle (A) and whipstitched for graft passage (B)

Fig. 6

LCL appears as a taut shiny structure after thorough superficial dissection (black asterisk)

Fig. 7

Small artery forceps slid through the two tiny stab incisions made on either sides of LCL for the delivery of the graft

Fig. 8

Graft is shuttled beneath the LCL by pulling the whipstitch threads attached to the graft

Fig. 9

Anatomical attachment point of the graft fixation marked by cautery pencil (black asterisk) is proximal and posterior to the tip of lateral epicondyle (shown by the tip of the mosquito forceps)

Fig. 10

Anchor Omega (Stryker^©, USA)

Fig. 11

Anchor insertion trajectory is precisely kept parallel to the femoral tunnel for ACL reconstruction (White Arrow) to avoid convergence

Fig. 12

Necessary slack (black asterisk) is given to the anchor threads to prevent overtightening at the time of final insertion

Fig. 13

Final graft fixation checked and confirmed in adequate tension

Fig. 14

Final closure of skin and subcutaneous tissue displaying effectively shorter length of incision