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Minimally Invasive Combined Anterior and Anterolateral Stabilization of the Knee Using Hamstring Tendons and Adjustable-Loop Suspensory Fixation Device: Surgical Technique

Open AccessPublished:April 10, 2017DOI:https://doi.org/10.1016/j.eats.2016.10.019

      Abstract

      Despite the numerous techniques described regarding isolated anterior cruciate ligament (ACL) reconstruction, many authors have reported that residual knee rotational instability is not always eliminated. The combination of lateral extra-articular knee tenodesis and ACL reconstruction is an alternative surgical approach with very promising clinical results. The purpose of this article is to describe a reliable and reproducible technique of combined ACL reconstruction and lateral extra-articular knee tenodesis using a continuous looped hamstring tendon autograft. A 4-strand graft inside the joint and a 2-strand graft for the tenodesis are attached to 2 adjustable-loop button suspensory fixation devices.

      Technique Video

      See video under supplementary data.

      Despite the numerous surgical techniques described, isolated anterior cruciate ligament reconstruction (ACLR) has not succeeded in all cases to eliminate residual knee rotational instability.
      • Chalmers P.N.
      • Mall N.A.
      • Moric M.
      • et al.
      Does ACL reconstruction alter natural history?: A systematic literature review of long-term outcomes.
      Newer review studies reported that the mean overall clinical and anatomic graft failure rates after ACLR were estimated at 11.2% (range, 3.2%-27%).
      • Crawford S.N.
      • Waterman M.B.R.
      • Lubowitz J.H.
      Long-term failure of anterior cruciate ligament reconstruction.
      The scientific interest in the correlation between rotational stability and ligamentous procedures at the lateral aspect of the knee is not new.
      • Duthon V.B.
      • Magnussen R.A.
      • Servien E.
      • Neyret P.
      ACL reconstruction and extra-articular tenodesis.
      However, despite the older techniques that have improved rotational instability, their clinical results were significantly variable, possibly because of the untreated anterior cruciate ligament (ACL) lesions.
      • Duthon V.B.
      • Magnussen R.A.
      • Servien E.
      • Neyret P.
      ACL reconstruction and extra-articular tenodesis.
      Focusing on the control of persistent pivot shift, some surgeons have proposed combined ACLR and lateral knee tenodesis with promising clinical results.
      • Duthon V.B.
      • Magnussen R.A.
      • Servien E.
      • Neyret P.
      ACL reconstruction and extra-articular tenodesis.
      • Colombet P.D.
      Navigated intra-articular ACL reconstruction with additional extra-articular tenodesis using the same hamstring graft.
      • Song G.
      • Hong L.
      • Zhang H.
      • Zhang J.
      • Li Y.
      • Feng H.
      Clinical outcomes of combined lateral extra-articular tenodesis and intra-articular anterior cruciate ligament reconstruction in addressing high-grade pivot-shift phenomenon.
      Despite that this lateral knee augmentation is an accepted surgical approach and may benefit some patients, its absolute indications have not been clarified yet.
      • Lubowitz J.H.
      • Provencher M.T.
      • Rossi M.J.
      • Brand J.C.
      News you can use: The knee anterolateral ligament and the ISAKOS journal.
      On the basis of the aforementioned data, the purpose of this article is to provide a reproducible technique of combined ACLR and lateral extra-articular tenodesis (LET) using a continuous looped hamstring tendon autograft attached to 2 adjustable button suspensory fixation devices.

      Surgical Technique

      Preoperative Evaluation and Possible Indications

      All the patients undergo careful clinical and appropriate radiologic examinations. Possible indications for performing combined ACLR and LET are great rotational knee laxity with a marked pivot-shift test, athletes participating in pivoting contact sports, revision cases, chronic ACL-deficient knees, and severe anterior laxity (side-to-side difference >10 mm).

      Patient Setup and Bony Landmarks

      The patient is positioned supine with a lateral post placed at the level of the thigh tourniquet and a distal foot stop, retaining 90° of knee flexion. By this manner, the limb remains stable during the procedure and the surgeon is able to perform varus or valgus stress maneuvers and achieve full passive range of motion without difficulty. The following bony landmarks are marked: lateral and medial joint lines, lateral femoral epicondyle, peroneal head, and Gerdy tubercle (Fig 1A).
      Fig 1
      Fig 1(A) Patient placed in the supine position with the left knee in 90° of flexion. The landmarks for the lateral extra-articular tenodesis are proximally and posteriorly to the lateral femoral epicondyle (E) and just posteriorly and proximally to the Gerdy tubercle (G) (arrows). (B) Outside-in technique for femoral tunnel creation aiming just posteriorly to the lateral epicondyle (arrow) (left knee). (C) Special guide. The asterisk shows the intra-articular offset, and the arrow shows the extra-articular part. (D) Confirmation of the drill guide position (arrow) from the anteromedial portal. (MW-LF, medial wall of lateral femoral condyle; PCL, posterior cruciate ligament.) (E) Final femoral tunnel created. The asterisk indicates the provisional arthroscopic portal cap. (MW-LF, medial wall of lateral femoral condyle). (F) Tibial drill guide placement for the anterior cruciate ligament reconstruction tunnel. The arrow indicates the medial side of the left knee. (G) Tibial drill guide placed with direction from medial to lateral (arrow), aiming just posteriorly and proximally to the Gerdy tubercle (G) for tibial tunnel creation for the lateral extra-articular tenodesis. (AL, anterolateral portal; AM, anteromedial portal; LFE, lateral femoral epicondyle; PH, peroneal head.) (H) Drill guide placed (arrow). (G, Gerdy tubercle; LFE, lateral femoral epicondyle; PH, peroneal head.) (I) Initial 4.5-mm full-length tunnel creation from medial to lateral (left knee). (G, Gerdy tubercle; LFE, lateral femoral epicondyle.) (J) Final 2-cm-deep socket drilling with a 6-mm drill from lateral to medial. Also shown are the femoral tunnel (FT) created and its relation to the lateral epicondyle (arrow). (G, Gerdy tubercle; LET, lateral extra-articular tenodesis.)

      Graft Harvesting

      The hamstring tendon grafts are harvested with an open tendon stripper and detached from their tibial insertion with a small periosteal sleeve to obtain the maximum length. All tendon-muscle attachments are removed by use of flat scissors before their detachment from the tibia.

      Knee Arthroscopy and Tunnel Preparation

      Through standard anteromedial and anterolateral portals, the knee joint is evaluated and other associated lesions are initially assessed and addressed. The ACL rupture is confirmed, and by use of a motorized shaver, the medial side of the lateral femoral condyle and the tibia are prepared with an effort to preserve all ACL remnant tissue (if present).
      The outside-in ACL femoral drill guide (SBM, Lourdes, France) is introduced from the anteromedial portal and placed at the site of the normal ACL femoral footprint. Outside the joint, the direction of the guide is adjusted and the accompanying drill sleeve is placed just proximally and posteriorly to the lateral femoral epicondyle. After guide pin placement and confirmation of its accurate intra-articular position (with the arthroscope in the anteromedial portal, Fig 1D), a full-length 6-mm-wide femoral tunnel is created (Fig 1B).
      The respective ACL tibial drill guide (SBM) is inserted from the anteromedial portal and positioned in the center of the ACL tibial insertion. Under visual control and with low-speed drilling, an additional 6-mm tibial tunnel is created, always staying inside the ACL stump (Fig 1F).
      To create the tibial tunnel for the LET, the tibial drill guide is set at 65° and its tip is aimed just posteriorly and proximally to the Gerdy tubercle, where a stamp incision is made. Then the cannulated sleeve of the guide is placed at the medial side of the tibia (approximately 2 cm anterior to the ACL tunnel, avoiding undesirable tunnel connection). Thereafter, a pin is passed from the medial to the lateral side of the tibia and a consecutive 4.5-mm tunnel is created (Fig 1G).

      Length Measurement and Graft Preparation

      By use of a No. 2 white Vicryl suture (Johnson & Johnson) passed through the femoral and tibial tunnels, the whole ACL length is calculated. However, for the tibial tunnel, we consider only 2 cm for tendon incorporation. Thereafter, the desired length for the ACLR is 2 cm in the tibial tunnel, approximately 3 cm for the intra-articular part,
      • Colombet P.
      • Graveleau N.
      An anterior cruciate ligament reconstruction technique with 4-strand semitendinosus grafts, using outside-in tibial tunnel drilling and suspensory fixation devices.
      and finally, the length of the femoral tunnel. Regarding the LET, the necessary length is represented by the distance between the lateral end of the femoral tunnel and the tunnel exiting posteriorly to the Gerdy tubercle plus 1 cm for graft incorporation into the tibia (Fig 2C, Table 1).
      Fig 2
      Fig 2(A) The hamstring tendon common insertion is initially secured and sutured around the loop of the Pullup XL button (arrow 1). The tendons are marked according to the measured tunnels' length for the anterior cruciate ligament (ACL) reconstruction (arrow 2) and the lateral extra-articular tenodesis (LET) (arrow 3). (B) Initially, the 4-strand graft (3 strands from the semitendinosus [ST3] and 1 strand from the gracilis [GR1]) for the ACL reconstruction is prepared. The remaining gracilis (GR2) will be looped afterward for the LET graft. (C) Final graft prepared. The measurements correspond to the case presented in (in which the ACL graft equals 8 cm and LET equals 8 cm). However, in all cases the surgeon should reserve 2 cm for the ACL graft incorporation into the tibia and 1 cm for the LET graft. The adjustable Pullup XL and normal Pullup buttons are attached at each side of the preparation table.
      Table 1Surgical Steps, Tips, Pearls, and Pitfalls of Described Technique
      Surgical StepsTips and PearlsPitfalls
      1. Bony landmarks• The most isometric points are located (1) at the femur proximally and posteriorly to the lateral epicondyle and (2) at the tibia posteriorly and proximally to the Gerdy tubercle.• There may be difficulty in recognizing these landmarks in overweight or muscular patients.
      • Care should be taken at the fibrous tissue close to the femoral epicondyle in revision cases.
      2. Graft harvesting• With an open-type tendon stripper and a small periosteal sleeve, the maximum length of both hamstring tendons is obtained.• The use of a closed-type stripper should be avoided.
      • All tendon-muscle attachments should be cleaned before final harvesting.
      3. Initial femoral and tibial tunnel preparation• By use of outside-in femoral and tibial drill guides, the guide pins are placed at the appropriate position.• In revision cases, the arthroscope should always be introduced into the tunnels to verify their inner wall integrity.
      • The sleeve of the femoral guide should aim proximally and posteriorly to the lateral femoral epicondyle.
      • The surgeon should initially prepare full-length 6-mm-wide tunnels.
      4. Tibial tunnel for LET• With the tibial drill guide, a 4.5-mm tunnel is created, starting medially (2 cm anteriorly to the ACL tunnel) and exiting laterally (just posteriorly to the Gerdy tubercle).• The surgeon should avoid connecting the ACL and LET tunnels on the medial side of the tibia.
      • The tibial LET tunnel passes underneath the tibial tubercle. The surgeon should check the depth of the initial guide pin and avoid being very superficial.
      5. Length measurement and graft preparation• By use of a white Vicryl suture, the surgeon measures the whole length of the femoral and tibial tunnels and the intra-articular part of the ACL.• The initial hamstring tendon length should be at least 21-22 cm. This prerequisite mainly concerns the gracilis that should be “looped” at 15 cm at least.
      • The length of the whole graft (according to our usual measurements) is approximately calculated as follows: 2 cm for ACL tibial tunnel + 3 cm for ACL intra-articular part + 3-4 cm for femoral tunnel + 6-7 cm for LET part + 1 cm for LET final tibial tunnel = 15-17 cm.• In cases in which the gracilis tendon is very thin, continuous looped or Krackow stitches can be used during the 2-strand graft preparation for the LET.
      6. Final tunnel preparation• Both the initial 6-mm tibial and femoral ACL tunnels are finally prepared with a cannulated drill that matches the graft diameter.• The surgeon should always use a guide pin into the initial tibial or femoral tunnel and place the final cannulated drill, which matches the graft diameter, over the guide pin.
      • A final tibial 2-cm socket for the LET (1 cm for graft incorporation and 1 cm for button flip) is prepared from laterally to medially.• After drilling, the arthroscope should be introduced into the tunnels to verify their inner wall integrity.
      7. Graft passage• Three different-color shuttling sutures are used for the ACL tunnel, for 2-strand graft passage underneath the ITB, and for the tibial LET tunnel.• Attention is required during tensioning the ACL part of the graft to ensure that 2 cm of it remains in the tibial tunnel (until the No. 2 blue or co-braid PowerTex suture of the 4-strand graft at the tibial side appears in the joint).
      • The graft is shuttled through the tibial and femoral ACL tunnels starting from the side of the 2-strand graft (normal Pullup) until the nonabsorbable suture (at the tibial side of the ACL graft) appears in the joint.• The surgeon should ensure that the shuttle suture and, consequently, the LET graft are passed underneath only the ITB and not the LCL.
      • The ACL is initially fixed in 20° of flexion (the femoral part with an interference screw and the tibial by securing the Pullup XL).• When the overall tibial tunnel for the LET is long, the surgeon can elongate the adjustable loop of the normal Pullup button to pass and flip at the medial side of the tibia.
      • The LET graft is shuttled underneath the ITB and through its tibial tunnel and fixed by securing the adjustable-loop button (normal Pullup) in 20° of knee flexion and neutral rotation.
      ACL, anterior cruciate ligament; ITB, iliotibial band; LCL, lateral collateral ligament; LET, lateral extra-articular tenodesis.
      Preparation of the graft is performed on the GraftTech table (SBM). Initially, an extra-large adjustable-loop button suspensory fixation device (Pullup XL; SBM) is attached at one side of the GraftTech table (Fig 2A). The common insertion of the hamstring tendon is preserved and secured around the loop of the Pullup XL with figure-of-8 stitches.
      • Colombet P.
      • Graveleau N.
      An anterior cruciate ligament reconstruction technique with 4-strand semitendinosus grafts, using outside-in tibial tunnel drilling and suspensory fixation devices.
      Thereafter, the previously measured necessary lengths for the ACLR and LET are marked on the hamstring tendons (Fig 2A).
      Initially, the other limb of the GraftTech table is adjusted to the desired length for the ACL. Thereafter, a looped nonabsorbable No. 3 Mersuture (Ethicon SAS [Johnson & Johnson], Issy-les-Moulineaux, France) is attached to it and both hamstrings are passed through it. By keeping the No. 3 Mersuture and the gracilis tendon under tension, the semitendinosus is looped 3 to 4 times (depending on its length) through the Pullup XL and the suture loop and secured provisionally with a clamp (Fig 2B). With this operation, a 4-strand graft for the ACLR is accomplished. By use of a No. 2 blue or co-braid ultrahigh-molecular-weight polyethylene fiber (PowerTex; SBM), each side of the 4-strand graft is secured with 2 figure-of-8 stitches.
      • Colombet P.
      • Graveleau N.
      An anterior cruciate ligament reconstruction technique with 4-strand semitendinosus grafts, using outside-in tibial tunnel drilling and suspensory fixation devices.
      It is important that the distance between the Pullup XL's loop and the second stitch is approximately 2 cm and represents the part of the tendon in the tibial tunnel. To avoid nonabsorbable sutures in the joint, the middle of the graft is also secured with 2 or 3 figure-of-8 stitches with No. 2-0 Vicryl (Johnson & Johnson) (Fig 2C).
      Now that the graft for the ACLR is prepared, the adjustable limb of the GraftTech table is placed at the desired length for the further LET preparation (ACL plus LET length). A normal-size Pullup fixation device (SBM) is attached at this side of the GraftTech table. The remaining gracilis tendon is looped through the Pullup and the 4-strand ACL graft. A 2-strand graft for the LET is obtained and secured again with figure-of-8 stitches that are placed at the entire length of it to avoid slippage during the adjustable-loop fixation (Fig 2C). Finally, by use of a special graduated calibration device, the width of the 4-strand graft for the ACLR and the width of the 2-strand graft for the LET are measured.

      Final Tunnel Preparation and Graft Passage

      According to the prepared graft size, the already made 6-mm femoral and tibial tunnels are drilled at their entire length to the desired width. In most cases the 4-strand graft has a thickness of 9 to 10 mm. Regarding the tibial tunnel for the LET, in no case does the 2-strand LET graft exceed 6 mm, and only a 2-cm-deep socket is created laterally to medially. Three different-color shuttling sutures are used for passing the graft: (1) from the tibia to the femur, (2) from the lateral end of the femoral tunnel underneath the iliotibial band (ITB) to the lateral end of the tibial tunnel for the LET, and (3) through the tibial tunnel for the LET to the medial side of the tibia (Fig 3A).
      Fig 3
      Fig 3(A) Three different-color shuttling sutures are used. Blue arrow 1 indicates the suture for initial graft passage from the tibia to the femur; blue arrow 2, the suture for shuttling the lateral extra-articular tenodesis (LET) graft underneath the iliotibial band; and blue arrow 3, the suture for passing the LET graft through the tunnel to the medial side of the tibia. The white arrow shows the direction of the LET graft. (FT, femoral tunnel; G, Gerdy tubercle.) (B) The anterior cruciate ligament (ACL) graft (left knee) is pulled through the tibial and femoral tunnels until the nonabsorbable suture (co-braid in this case, arrow) appears in the joint (2 cm of graft is left in the tibial tunnel). (C) The graft is secured at the femur with an interference screw. The arrow indicates the LET graft. (FT, femoral tunnel.) (D) The LET graft (arrow) has been passed underneath the iliotibial band. The asterisk shows the remaining shuttling suture for the final retrieval of the normal button at the medial side of the tibia (left knee). (E) Final configuration of the technique. (F) Position of the 2 buttons at the medial side of the tibia (arrowheads) (left knee).
      By use of the first shuttling suture, the side of the graft with the normal Pullup button is pulled through the tibial and femoral tunnels until the No. 2 blue or co-braid PowerTex suture of the 4-strand graft at the tibial side appears in the joint (2-cm length left in the tibia) (Fig 3B). At 20° of knee flexion and under arthroscopic control, the femoral side is initially secured with an absorbable interference screw (Fig 3C) and then the tibial side is secured with the adjustable Pullup XL button. After the tension of the ACL graft is verified, the remaining double-stranded gracilis is passed under the ITB and through the small tibial tunnel (Fig 3D). Finally, the graft for the LET is tensioned by pulling the normal Pullup button from the medial side of the tibia in 20° of flexion and neutral knee rotation
      • Imbert P.
      • Lutz C.
      • Daggett M.
      • et al.
      Isometric characteristics of the anterolateral ligament of the knee: A cadaveric navigation study.
      (Video 1, Fig 3E).

      Discussion

      Our technique was inspired by the initial LET technique described by Lemaire and by its latest modification with combined ACLR proposed by the “French school philosophy.”
      • Duthon V.B.
      • Magnussen R.A.
      • Servien E.
      • Neyret P.
      ACL reconstruction and extra-articular tenodesis.
      We also believe that the lateral femorotibial tenodesis functions as a lever arm of the knee's center of rotation, controlling the excessive tibial internal rotation in ACL-deficient knees, and protects the ACL graft, providing up to 40% reduction of intra-articular stresses.
      • Duthon V.B.
      • Magnussen R.A.
      • Servien E.
      • Neyret P.
      ACL reconstruction and extra-articular tenodesis.
      However, our purpose was to overpass the difficulties of the principal technique by using the same type of autograft for both ACLR and LET, combined with a strong fixation method. In detail, only 1 tunnel in the femur was created and a continuous hamstring graft that did not pass under the lateral collateral ligament formed a “frame loop” around the knee joint.
      Furthermore, to avoid postoperative stiffness and overconstraint of the lateral compartment, the optimal isometric positioning and graft tensioning during LET are very important. Therefore, the tunnel's placement proximally and posteriorly to the femoral epicondyle and just posteriorly to the Gerdy tubercle offers the most isometric structure without undesirable interruptions with normal knee motion.
      • Imbert P.
      • Lutz C.
      • Daggett M.
      • et al.
      Isometric characteristics of the anterolateral ligament of the knee: A cadaveric navigation study.
      In addition, we performed the LET in 20° of knee flexion and neutral rotation to reverse the lateral tibial plateau translation during the pivot-shift phenomenon as described in vitro by Bull et al.
      • Bull A.M.
      • Andersen H.N.
      • Basso O.
      • Targett J.
      • Amis A.A.
      Incidence and mechanism of the pivot shift. An in vitro study.
      and in vivo by Tardy et al.
      • Tardy N.
      • Marchand P.
      • Kouyoumdjian P.
      • Blin D.
      • Demattei C.
      • Asencio G.
      A preliminary in vivo assessment of anterior cruciate ligament–deficient knee kinematics with the KneeM device.
      Recently, considering the importance of ligamentous procedures at the lateral aspect of the knee, investigators have attempted to establish the anatomic existence and the precise bony insertions of an anterolateral ligament.
      • Caterine S.
      • Litchfield R.
      • Johnson M.
      • Chronik B.
      • Getgood A.
      A cadaveric study of the anterolateral ligament: Re-introducing the lateral capsular ligament.
      • Claes S.
      • Vereecke E.
      • Maes M.
      • Victor J.
      • Verdonk P.
      • Bellemans J.
      Anatomy of the anterolateral ligament of the knee.
      • Dodds A.L.
      • Halewood C.
      • Gupte C.M.
      • Williams A.
      • Amis A.A.
      The anterolateral ligament: Anatomy, length changes and association with the Segond fracture.
      • Helito C.P.
      • Demange M.K.
      • Bonadio M.B.
      • et al.
      Anatomy and histology of the knee anterolateral ligament.
      • Sonnery-Cottet B.
      • Archbold P.
      • Rezende F.C.
      • Neto A.M.
      • Fayard J.-M.
      • Thaunat M.
      Arthroscopic identification of the anterolateral ligament of the knee.
      Despite the numerous cadaveric explorations, the accurate anatomic location and the isometry of this structure remain yet debatable.
      • Caterine S.
      • Litchfield R.
      • Johnson M.
      • Chronik B.
      • Getgood A.
      A cadaveric study of the anterolateral ligament: Re-introducing the lateral capsular ligament.
      • Claes S.
      • Vereecke E.
      • Maes M.
      • Victor J.
      • Verdonk P.
      • Bellemans J.
      Anatomy of the anterolateral ligament of the knee.
      • Dodds A.L.
      • Halewood C.
      • Gupte C.M.
      • Williams A.
      • Amis A.A.
      The anterolateral ligament: Anatomy, length changes and association with the Segond fracture.
      • Helito C.P.
      • Demange M.K.
      • Bonadio M.B.
      • et al.
      Anatomy and histology of the knee anterolateral ligament.
      • Sonnery-Cottet B.
      • Archbold P.
      • Rezende F.C.
      • Neto A.M.
      • Fayard J.-M.
      • Thaunat M.
      Arthroscopic identification of the anterolateral ligament of the knee.
      However, whether the anterolateral ligament exists or not, the newest biomechanical studies have shown that its “quasi-isometric” behavior is achieved when fixed just proximally and posteriorly to the lateral femoral epicondyle as we also propose.
      • Imbert P.
      • Lutz C.
      • Daggett M.
      • et al.
      Isometric characteristics of the anterolateral ligament of the knee: A cadaveric navigation study.
      • Kittl C.
      • Halewood C.
      • Stephen J.M.
      • et al.
      Length change patterns in the lateral extra-articular structures of the knee and related reconstructions.
      Some authors have also proposed LET with hamstring autograft. However, it was stabilized only with interference screws and the length of the tendons was a serious limitation.
      • Colombet P.D.
      Navigated intra-articular ACL reconstruction with additional extra-articular tenodesis using the same hamstring graft.
      In addition, details regarding the isometry and the fixation angles were not provided.
      • Colombet P.D.
      Navigated intra-articular ACL reconstruction with additional extra-articular tenodesis using the same hamstring graft.
      By using a double adjustable-loop button device, the graft's length restrictions could be overpassed and a satisfactory size of ACL graft accomplished (Table 2). Further advantages of this technique are the creation of one femoral tunnel, the preservation of the ITB, the better isometry according to the international literature, and the possibility of preserving all intra-articular ACL remnants.
      Table 2Advantages, Risks, and Limitations of Combined ACLR and Lateral Extra-articular Knee Tenodesis
      Advantages
       With adjustable-loop button devices, a satisfactory size of ACL graft can be accomplished and the hamstring tendons' length restrictions can be overpassed.
       Isometric points of LET fixation (according to the international literature) are used (proximally and posteriorly to the lateral femoral epicondyle and just posteriorly and proximally to the Gerdy tubercle).
       The technique is minimally invasive and reproducible with a cosmetic scar.
       There is a possibility of preserving the ACL remnants (if present).
       Possible complications after ITB stripping (e.g., hematoma or muscular hernia formation) are avoided.
      Risks
       Breakage of the cortical bridge between the 2 tibial tunnels may occur. This bridge is crucial for the cortical button fixation device.
       Creation of the tunnel at non-isometric points may occur; this could result in knee stiffness (in all cases the appropriate bony landmarks must be designed preoperatively).
       Leaving the femoral interference screw prominent could cause painful friction symptoms with the ITB.
      Limitations
       A tendon length <20 cm may be encountered (mainly the gracilis that is used for the LET). In such cases the common insertion of the hamstrings could be cut and the gracilis sutured at the middle of the ACL 3- or 4-strand graft. Otherwise, the technique should be abandoned and the ITB used for the LET.
       The diameter of the prepared 3- or 4-strand graft for the ACLR should be at least 8 mm. The common insertion of the hamstrings could be cut and the tendons sutured appropriately to achieve an 8-mm graft diameter. Otherwise, both the hamstrings are used for the ACLR and the ITB is used for the LET.
       As in all combined lateral knee augmentation techniques, the absolute indications are not widely established yet.
      ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; ITB, iliotibial band; LET, lateral extra-articular tenodesis.
      Although this study is only a Technical Note presentation, it should be noted that it has several limitations. Despite the theoretical advantage, no long-term outcomes are available and a blinded comparison with other LET techniques is probably needed. Furthermore, it is widely accepted that although an additional LET could be a reliable solution for a large number of patients,
      • Song G.
      • Hong L.
      • Zhang H.
      • Zhang J.
      • Li Y.
      • Feng H.
      Clinical outcomes of combined lateral extra-articular tenodesis and intra-articular anterior cruciate ligament reconstruction in addressing high-grade pivot-shift phenomenon.
      • Hewison C.E.
      • Tran M.N.
      • Kaniki N.
      • Remtulla A.
      • Bryant D.
      • Getgood A.M.
      Lateral extra-articular tenodesis reduces rotational laxity when combined with anterior cruciate ligament reconstruction: A systematic review of the literature.
      its absolute indications have not yet been clarified.
      • Duthon V.B.
      • Magnussen R.A.
      • Servien E.
      • Neyret P.
      ACL reconstruction and extra-articular tenodesis.
      With the described technique, any ACLR could be combined with LET using the already harvested hamstring autograft and without affecting the normal anatomy of the area. Moreover, by using 2 adjustable-loop suspensory fixation devices, possible tendon length problems are mainly overpassed.

      Acknowledgment

      The senior author (J.B.) acknowledges Dr. Philippe Colombet for his initial combined “anterior cruciate ligament and lateral knee tenodesis technique” that inspired the authors to further develop their proposed operational approach. The authors thank Mrs. Christina Eleftheriadou, graphic designer, for the design of the professional-quality drawings.

      Supplementary Data

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