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An increasing concern has been given to the rotation stability of the knee in the setting of an anterior cruciate ligament (ACL) reconstruction. This growing interest stems from a better understanding of the rotational stability of the knee afforded by the identification of the anterolateral ligament. Previously, a residual abnormal pivot-shift test had been found after an anatomic single-band reconstruction of the ACL because of a lack of rotational stability, which may lead to the development of osteoarthritis. Residual instability affects function, especially in high-demand athletes who perform many flexion-rotation movements during sporting activity. The purpose of this Technical Note is to describe our preferred method of intra-articular ACL reconstruction using a hamstring tendon autograft in combination with an extra-articular iliotibial band tenodesis for reinforcement of rotational stability.
See video under supplementary data.
Full restoration to preinjury function and quality of life after an anterior cruciate ligament (ACL) reconstruction (ACLR) has been shown to be jeopardized because of a lack of rotational stability confirmed through a residual positive pivot shift test at postoperative physical examination.
Although operative treatment, regardless of technique, provides acceptable anterior knee stability in the majority of the cases after ACLR, residual rotational instability in some cases demonstrates the lack of an isolated ACLR to definitively reproduce preinjury knee stability.
However, the prevalence of this coupled technique has declined in the recent past given the steep learning curve, length of the incision/scar, and challenging postoperative rehabilitation associated with the technique. Currently, studies suggest that rotational instability after an ACLR may be due to the injury of a newly discovered structure known as the anterolateral ligament (ALL).
The ALL is located on the prominence of the lateral femoral epicondyle, slightly anterior to the origin of the lateral collateral ligament (LCL), and assumes an oblique course into the proximal anterolateral aspect of the tibia.
Ultimately, lateral tenodesis of the ITB can provide a better leverage arm in very rotationally unstable knees, thereby severely limiting anterolateral mobility unlike an isolated intra-articular ACLR.
The purpose of this Technical Note is to describe our preferred method of intra-articular ACLR using a hamstring tendon autograft in combination with an extra-articular ITB tenodesis for reinforcement of rotational stability.
The patient is placed supine on the surgical table (Video 1). After induction of general anesthesia, a thigh tourniquet is placed on the proximal aspect of the operative limb. The knee is then prepared and draped in a sterile fashion. After this, the surgical limb is exsanguinated, and then the tourniquet is inflated to 250 to 350 mmHg.
Harvesting and Preparing the Hamstring Tendon
An oblique 5-cm incision is performed at the anteromedial portion of the proximal tibia, directly over the pes anserinus. The subcutaneous tissue is then bluntly dissected using Metzenbaum scissors, thereby exposing the tendon insertion. The semitendinosus and gracilis tendons are then carefully isolated and all adhesions are removed. A tendon stripper (Smith & Nephew, Andover, MA) is used to harvest the 2 tendons individually. After this, the 2 harvested portions of the tendon are transferred to the back table and prepared through use of a tendon workstation (Arthrex, Naples, FL). A quadruple-band, 12-cm-long and 8- to 10-mm-thick autograft is prepared through use of absorbable Vicryl suture (Ethicon, Somerville, NJ) at the proximal portion and no. 2.0 nonabsorbable Ethibond suture (Ethicon) at the distal portion of the graft. After this, the autograft is pretensioned for approximately 5 minutes and then kept in physiological saline solution until its eventual use.
Harvest and Preparation of the ITB Strip
After the harvest of the hamstring autograft, attention is turned to the exposure of the ITB to complete the lateral tenodesis. A curved incision is performed, starting from 2 cm proximal to the Gerdy tubercle (GT) and extending 10 cm proximally and slightly posterior to the femoral axis (Fig 1). The subcutaneous tissue is then bluntly dissected and the ITB is thoroughly exposed. Using a coagulator, a strip of ITB to be removed, measuring 10 cm long and 1 cm wide, is outlined (Fig 2), with its corresponding incision done from posterior to anterior. The proximal tip is then carefully detached from the rest of the ITB whereas the distal insertion on GT remains intact. After this, no. 5.0 nonabsorbable Ethibond suture (Ethicon) is whip-stitched through the final 30 mm of the proximal portion of the strip. The strip of ITB is then kept in the subcutaneous tissue layer to minimize contact with the skin layer and risk of graft dehydration. The lateral epicondyle and LCL are then carefully dissected with Metzenbaum scissors to identify the location where the strip of ITB shall be positioned. We suggest that the strip of ITB be placed at the prominence of the lateral epicondyle, slightly posterior and proximal to the origin of the LCL (Fig 3). Care must be taken to avoid potential damage of the knee capsule given that a disturbance in the capsule will result in fluid leakage during ACLR completed through arthroscopy.
Femoral Tunnel Preparation
Once the strip of ITB has been secured to the prominence of the lateral epicondyle, ACLR may be completed. First, an anterolateral portal is created in standard fashion. A 30° arthroscope (Smith & Nephew) is then inserted. After this, an anteromedial portal is created under direct visualization. A diagnostic arthroscopy is initially performed throughout all compartments. If any previously unidentified injury is recognized, it is addressed at this point. Afterward, the femoral footprint is exposed and identified. An outside-in femoral guide (Arthrex) is then introduced through the anterolateral portal with its tip placed exactly on the anatomic insertion of the ACL at the medial wall of the lateral femoral condyle. The insertion is located 5 mm anterior to the posterior femoral cortex and 5 mm inferior to the intercondylar roof at the 1- to 2-o'clock position on the left knee. The external portion of the guide is then positioned slightly posterior and proximal to the LCL proximal attachment. After this, the guide is placed in an oblique position approximately 15° to 20° anterior in the axial plane and 90° in the coronal plane to avoid damage to the posterior cortex of the femur. Once the knee is flexed more than 120°, a 2.0-mm guidewire is drilled in an outside-in direction through use of the guide. The intra-articular position of the guidewire is then further shaped through arthroscopy (Fig 4). A cannulated femoral drill with the same diameter as the hamstring autograft to be inserted (Arthrex) is then used to prepare the femoral tunnel. Any remaining bony debris around and inside the femoral tunnel is then removed through use of a soft tissue shaver (Dyonics; Smith & Nephew). Once the femoral tunnel is finalized, the lateral posterior femoral condyle wall is inspected to ensure that it is intact.
Tibial Tunnel Preparation
A C-shaped tibial guide (Arthrex) set at 50° to 55° is introduced through the anteromedial portal and placed on the ACL footprint of the tibia. Any ACL remnant around the tibial insertion is preserved to stimulate graft consolidation. The external portion of the guide is then positioned over the previous incision on the anteromedial aspect of the tibia for harvest of the autograft. The guide is positioned 45° in relation to the tibial axis in the coronal plane and parallel to the femoral axis. The knee is maintained at 90° of flexion while the guide pin is drilled. Once the optimal position is confirmed, based on the surgeon's judgment, the tibial drill (Arthrex) is used to prepare the tunnel (Fig 5).
Passage of the Hamstring Autograft and Strip of ITB
A passing suture is first passed in an outside-in direction through the femoral tunnel and retrieved through the anteromedial portal using an arthroscopic grasper. Once retrieved, the passing suture is passed through the tibial tunnel using a grasper (Fig 6). Then, a second passing suture is introduced in an outside-in direction through the femoral tunnel and then retrieved through the anteromedial portal using the arthroscopic grasper (Fig 7).
First, the hamstring autograft is passed through use of the first passing suture. Under arthroscopic visualization, the graft is placed inside the femoral tunnel. After this, the location of the proximal 30 mm of the graft within the tunnel is verified. At this point, the arthroscopic portion of the procedure is briefly interrupted to create a soft tunnel underneath the LCL using a Penfield dissector and/or osteotomes. The second passing suture is then passed through this newly created tunnel to allow for the passage of the strip of ITB. Once this is complete, the strip of ITB is passed directly underneath the LCL and introduced inside the femoral tunnel (Fig 8). As the hamstring autograft is held in place to ensure its optimal position, the assistant retrieves the second passing suture through the anteromedial portal to deliver the strip of ITB through the femoral tunnel. Prior to definitive fixation, the positioning of the grafts is verified.
Fixation of the Hamstring Autograft and Strip of ITB
Once positioning is verified, the knee is placed in 50° to 60° of flexion and slight external rotation. The strip of ITB is first secured to the LCL using a no. 5.0 nonabsorbable Ethibond suture (Ethicon) to verify optimal anterolateral tensioning prior to screw fixation. A guide pin is then introduced in the femoral tunnel while the surgical assistant maintains the autograft and strip of ITB under tension. As the knee is kept in this position, an 8 × 25-mm bioabsorbable interference screw (Arthrex) corresponding to the 8-mm previously formed femoral tunnel is introduced with a matching screwdriver (Fig 9). Inside the femoral tunnel, the screw simultaneously secures the strip of ITB as well as the femoral portion of the hamstring autograft. After this, the knee is placed in 10° to 30° of flexion and the tibia is reduced. While maintaining the knee in this position, the hamstring autograft is fixed into the tibial tunnel using a 9 × 25-mm bioabsorbable interference screw (Arthrex) (Fig 10). Once fixation at the femoral and tibial tunnels is complete, the knee is taken through a full range of motion, while the Lachmann and Pivot-Shift tests are performed to verify proper reconstruction.
After copious irrigation with saline solution, ropivacaine 7.5 mg/mL (20 mL) and epinephrine (2 mL) are injected in the subcutaneous layer over the lateral incision to maximize hemostasis. Afterward, the tourniquet is released. Absorbable no. 1.0 Vicryl suture (Ethicon) is then used to close the proximal portion of the ITB while the distal portion over the lateral epicondyle remains as is. Finally, the subcutaneous layer is closed using no. 2.0 Vicryl suture (Ethicon) and the skin layer is closed through use of no. 4.0 Mononylon suture (Ethicon).
After the procedure, early knee range of motion is encouraged as soon as the first postoperative day. The patient is allowed to bear weight as tolerated. However, we recommend the use of crutches during the first 2 weeks postoperatively. Physiotherapy should begin as soon as possible, varying in length according to the patient's discretion. The patient's reported knee pain and noted swelling of the knee is used to guide the progression of rehabilitation exercises. During the initial 2 postoperative months, rehabilitation should focus on re-establishing proper knee range of motion in combination with exercises for quadriceps activation as well as restoration of patella and patellar tendon mobility. After these initial 3 months, cycling exercise should begin with a gradual progression of resistance according to the patient's individual progress. In combination with cycling exercise, walking exercise on a treadmill is initiated with gradual progression to 7° of inclination from the horizontal plane. A full return to sports and exercise without limitations is individualized according to the progress of the patient, but usually is not reached until 6 months after surgery. Tables 1 and 2 list the advantages and disadvantages as well as the pearls and pitfalls associated with the described technique. Our indications for this technique are listed in Table 3.
Table 1Advantages and Limitations
Additional anterolateral stability of the knee in comparison to an isolated ACL reconstruction
Large incision resulting in a notable postoperative scar
Direct visualization of bone and soft-tissue landmarks
Risk of hematoma in the lateral thigh compartment
Lateral tenodesis is completed simultaneously with intra-articular ACL reconstruction
Risk of a hernia of the vastus lateralis due to harvesting site of the ITB
Minimal extraoperative time necessary
Risk of overconstraining the knee, which may result in cartilage damage
Minimal morbidity of harvesting site of ITB with added rotational knee stability
reported that the pivot shift examination after ACLR may be a better, more clinically relevant measure than the Lachman test to evaluate knee stability given that the pivot-shift test shows a better association with subjective variables, including patient satisfaction, return to sport, and difficulty in cutting and twisting exercises. The search for a solution that sufficiently addresses and corrects residual rotational instability seen in up to 20% of all isolated ACLRs has stimulated the return of the lateral tenodesis technique done in combination with ACLR to reinforce rotational stability.
Moreover, the newly discovered structure, ALL, found on the anterolateral aspect of the knee has gained considerable attention in recent years, although there remains a lack of consensus regarding the ALL's exact anatomic properties.
A lateral tenodesis of the ITB is an effective surgical method that not only restores but also reinforces anterolateral stability and allows for sufficient rotational stability in the setting of an ACLR. Ultimately, a hamstring autograft in an isolated ACLR may be more predisposed to deformation and elongation than an ACLR done in combination with an extra-articular procedure due to supplementary stability afforded by the extra-articular graft.
Another important consideration regarding a tenodesis of the ITB that should be highlighted is that a site more posterior and proximal to the LCL for the attachment point of the strip of ITB results in the basic reproduction of ALL anatomy.
Aside from the lack of rotational stability that may be seen in some cases of ACLR, a better understanding concerning the relation between hip bony abnormalities as well as irregularity in hip range of motion and risk of ACL injuries has also been reported in the literature.
In addition to cases of knee rotatory instability confirmed clinically as a high-grade pivot shift, we also perform and recommend our technique of lateral tenodesis in patients with restricted hip range of motion because tension placed on the graft will be severely limited as a result.
Furthermore, we would like to highlight that the strip of ITB must be fixed in flexion to arrive at optimal tensioning and restrict internal rotation of the knee to 35° of flexion at most. However, in contrast, the hamstring autograft must be fixed in almost full extension for proper restoration of anterior stability while ensuring extension of the knee is not limited.
Although excess operative time may be a perceived disadvantage of the described technique, the overall time for the procedure does not greatly exceed an arthroscopic isolated single-bundle ACLR even with the additional steps associated with the extra-articular tenodesis. Moreover, despite the added risk for hematoma and muscular hernia with the described technique, we have not recognized any incidence of hematoma or muscular hernia in our case series. Therefore, these risks should not be considered, especially if thorough hemostasis and closure of the fascia lata is carefully performed.
In conclusion, we acknowledge that our technique is not indicated in all cases of an ACL tear. Instead, the described technique may only be considered after a thorough physical examination that allows for comprehensive patient selection. Ultimately, the described technique should be particularly considered in the case of a high-grade pivot-shift (grades 2-3), a challenging ACL primary case with bony abnormality of the hip or restricted hip range of motion, and selected revision cases of ACLR with noted rotational instability of the affected knee.
A curved incision is performed in the left knee, starting 2 cm proximal to the Gerdy tubercle (GT) and extending 10 cm proximally and slightly posterior to the femoral axis. Afterward, the subcutaneous tissue is dissected until the Iliotibial band (ITB) is visualized. Using a coagulator, an ITB strip measuring 10 cm in length and 1 cm in width is harvested from posterior to anterior. However, the distal attachment of the ITB remains intact on GT. The ITB strip is then kept in the subcutaneous tissue layer until femoral tunnel fixation. After this, the lateral epicondyle and lateral collateral ligament (LCL) are carefully dissected with Metzembaum scissors to identify the point of proximal fixation of the extra-articular tenodesis. We recommended that proximal fixation be done at the prominence of the lateral epicondyle, slightly posterior and proximal to the origin of the LCL. After this, attention is turned to the arthroscopic portion of the procedure. The femoral and tibia tunnels are created at the discretion of the surgeon through use of an outside-in femoral guide (Arthrex) and C-shaped tibial guide (Arthrex). Once the tunnels have been properly formed, a passing suture is passed in an outside-in direction through the femoral tunnel and then retrieved through the anteromedial portal. Once retrieved, the passing suture is passed through the tibial tunnel using a grasper. Afterward, a second passing suture is introduced in an outside-in direction through the femoral tunnel and then retrieved through the anteromedial portal using the arthroscopic grasper. The hamstring autograft is then passed into the femoral and tibial tunnels using the first passing suture. Once this is complete, attention is turned back to the extra-articular portion of the procedure. A soft tunnel is carefully created directly underneath the LCL, and then the second passing suture is passed through the soft tunnel. The ITB strip is then passed through the soft tissue tunnel underneath the LCL and introduced inside the femoral tunnel. The knee is then positioned in 50° to 60° of flexion and slight external rotation. As the hamstring autograft and ITB strip are kept under tension, an 8 × 25-mm bioabsorbable interference screw is introduced into the femoral tunnel for simultaneous fixation of the hamstring autograft and ITB strip. After this, the knee position is moved to 10° to 30° of flexion. A 9 × 25-mm bioabsorbable interference screw is then introduced into the tibial tunnel. Once fixation is complete, any excess graft is removed. To avoid a potential hernia of the vastus lateralis, the fascia lata is sutured with no. 2.0 non-absorbable Ethibond suture (Ethicon, Somerville, NJ). The subcutaneous and skin layers are then closed in standard fashion and the procedure is complete.
The investigation was performed at the Hospital de Clínicas de Porto Alegre, Brazil.
The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.