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Recent literature has identified a population of active adolescents aged 13 to 15 years who are at high risk for anterior cruciate ligament graft rupture. Addressing the anterolateral complex during primary anterior cruciate ligament reconstruction has recently re-emerged in the literature, with various techniques available. This paper aims to describe a lateral extra-articular tenodesis procedure using the iliotibial band with a modified Lemaire technique. This procedure is recommended for active adolescents at a high risk of graft re-tear as an enhancement to primary anterior cruciate ligament reconstruction with soft-tissue graft.
Technique Video
See video under supplementary data.
Anterior cruciate ligament (ACL) tears are a common injury in the pediatric population and are being recognized and treated with increasing frequency.
noted that nearly 1 in 4 young athletic patients who sustain an ACL injury and return to high-risk sports will go on to sustain another ACL injury at some point in their career. Surgical techniques to address ACL tears in growing children and adolescents have rapidly evolved to minimize the risk of growth disturbance and retear.
Addressing the anterolateral complex (ALC) during anterior cruciate ligament reconstruction (ACLR) has recently re-emerged in the literature. The ALC includes several structures: the iliotibial band (ITB), distal and proximal Kaplan's fibers, the anterolateral ligament (ALL), and the capsular attachment of the lateral meniscus. Noyes et al.
Rotational knee instability in ACL-deficient knees: Role of the anterolateral ligament and iliotibial band as defined by tibiofemoral compartment translations and rotations.
described the role of the ALL and ITB in knee rotational stability with cadaveric knee specimens. Their results showed that the ITB acts as a secondary restraint to tibial translation and internal rotation and that the ALL and ITB functioned in some knees as the primary restraint for internal rotation at high flexion angles.
Rotational knee instability in ACL-deficient knees: Role of the anterolateral ligament and iliotibial band as defined by tibiofemoral compartment translations and rotations.
These results suggest that an insufficient or injured ALC puts a significant force on an ACL, especially in sports involving cutting, jumping, and pivoting.
Research regarding ITB tenodesis as a supplemental procedure to ACLR is limited and primarily involves skeletally mature patients.
Long-term study of anterior cruciate ligament reconstruction for chronic instability using the central one-third patellar tendon and a lateral extraarticular tenodesis.
In an attempt to address the previously reported population of active adolescents at a high risk of graft re-tear, this paper aims to describe a lateral extra-articular tenodesis (LET) procedure using the ITB with a modified Lemaire technique to use as an enhancement to ACLR with soft-tissue graft in the high-risk athlete within the pediatric population.
Surgical Technique: Modified Lemaire ITB Tenodesis (With Video Illustration)
To begin, with the patient positioned supine and the knee in 90° of flexion, a lateral incision is performed beginning at the level of the femoral insertion of the lateral collateral ligament (LCL) and extended proximally for 5 cm. Dissection is taken through subcutaneous tissues to the ITB (Fig 1). A central 8-cm × 1-cm strip of ITB is harvested and left attached distally to Gerdy's tubercle (Fig 2). Care is taken to avoid the important Kaplan's fibers posteriorly. The ITB graft is then whipped stitched (Fig 3). After the LCL is identified, the graft is passed deep (medial) to the LCL. Intraoperative fluoroscopy (mini c-arm) is recommended to confirm positioning of a drill guide directed distal to the distal femoral physis with an anterior trajectory (to avoid convergence with the femoral socket of the ACLR) and just proximal and posterior to the femoral insertion of the LCL (Fig 4). In 30° of flexion and neutral rotation, the ITB graft is secured with an all-suture anchor (Fig 5). We currently prefer fixation with an all-suture anchor (1.3-mm DX FiberTak Suture Anchor; Arthrex, Naples, FL); however, PEEK (polyether ether ketone) or biocomposite suture anchors also may be used at the surgeon's discretion. The ITB graft is then passed lateral to the LCL and secured to itself using a nonabsorbable #2 suture to complete the tenodesis (Fig 6). The ITB donor defect is then closed using #2 nonabsorbable sutures in an interrupted simple fashion to complete the LET (Fig 7).
Fig 1Schematic of a lateral view of the right knee. The ITB (A) is exposed and left attached distally at Gerdy's Tubercle (B). (ITB, iliotibial band.)
Fig 2Schematic of a lateral view of the right knee. The ITB (A) is harvested proximally leaving the distal end attached to Gerdy's Tubercle (B) and producing an 8-cm × 1-cm graft from the central third of the ITB (C). (ITB, iliotibial band.)
Fig 4Anteroposterior intraoperative fluoroscopy with the knee in 30° flexion confirming the positioning of a drill guide (A) directed distal to the distal femoral physis (B) starting just proximal and posterior to the femoral insertion of the LCL. (LCL, lateral collateral ligament.)
Fig 5Schematic of a lateral view of the right knee. Shown is the ITB graft (A) passing deep to the lateral collateral ligament (C) and anchored (represented by the X) distal to the distal femoral growth plate (B) and just proximal and posterior to the LCL femoral insertion (D). (ITB, iliotibial band; LCL, lateral collateral ligament.)
Fig 6Schematic of a lateral view of the right knee. After the ITB graft is anchored (represented by the X), the proximal remnant of the graft is brought lateral to the LCL (A) and sutured onto itself (B) with #2 sutures. (ITB, iliotibial band; LCL, lateral collateral ligament.)
Fig 7Schematic of a lateral view of the right knee. The ITB donor site (A) is then closed over the tenodesed ITB graft with #2 sutures in an interrupted simple fashion. (ITB, iliotibial band.)
A video detailing the technique is shown in Video 1. Pearls and pitfalls and advantages and disadvantages of this adjunct technique are described in Tables 1 and 2, respectively.
Table 1Pearls and Pitfalls of a Modified Lemaire ITB Tenodesis
Harvest Incision can be Limited to 5 cm or less
Avoid Kaplan's fibers posteriorly when harvesting the ITB graft
Direct the tenodesis anchor drill distal to avoid the growth plate and anterior to avoid convergence with the distal femoral socket of ACLR
Consider the use of intraoperative fluoroscopy to ensure graft fixation does not compromise the femoral physis
Minimize the potential for overconstraint by maintaining the tibia in neutral rotation at the time of fixation and tensioning
Avoid overtensioning of the graft, as the goal of the procedure is to serve as a checkrein
Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: A prospective comparative study of 502 patients from the SANTI study group.
compared the graft rupture rate in 3 ACLR groups: 4-strand hamstring tendon (HT), bone–patellar tendon–bone (BPTB), and HT + ALL. The combined HT and ALL graft group experienced 2.5 and 3.1 times less graft rupture compared with BPTB and 4HT, respectively at minimum 2-year follow-up.
Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: A prospective comparative study of 502 patients from the SANTI study group.
Anterior cruciate ligament reconstruction associated with extra-articular tenodesis: A prospective clinical and radiographic evaluation with 10-to 13-year follow-up.
reported a 10- to 13-year follow-up on 54 patients who underwent ACLR with a similar technique. After 11 years, only 2 patients had >5 mm manual maximum side-to-side difference in laxity based on the KT-2000 arthrometer. The mean Lysholm score was 97.3, and the mean subjective score was 90.0%. Radiographic evaluation demonstrated progressive joint narrowing for 20 patients who had had concomitant medial meniscal surgery. In addition, there are 2 systematic reviews addressing the clinical outcomes of combined lateral extra-articular tenodesis and intra-articular ACLR.
Lateral extra-articular tenodesis reduces rotational laxity when combined with anterior cruciate ligament reconstruction: A systematic review of the literature.
Complications and revision surgeries in two extra-articular tenodesis techniques associated to anterior cruciate ligament reconstruction A case-control study.
The results at a mean of 13 months follow-up showed that the ACLR with ITB LET group had no extra risk of preoperative complication or reconstruction failure compared with the gracillis LET procedure group. Revision surgery was significantly more frequent in the gracilis LET group (31.7%) compared with the ITB LET group (7.3%). As growing literature supports anterolateral stabilization and its role in preventing graft rupture in adults, this article describes a technique that can be used in young athletes undergoing ACLR who are at high risk for graft rupture.
Return to sport and reoperation rates in patients under the age of 20 after primary anterior cruciate ligament reconstruction: Risk profile comparing 3 patient groups predicated upon skeletal age.
reported the 2-year return to sport and reoperation rates in 324 athletes younger than 20 years of age who underwent ACLR. Surgical technique was based on skeletal age and included an all-epiphyseal technique with hamstring autograft, partial transphyseal and complete transphyseal with hamstring autograft, and BPTB autograft. The rate of revision ACLR was significantly greater (20%) in the partial transphyseal/complete transphyseal with hamstring autograft group compared with the all-epiphyseal technique with HT autograft and BPTB groups (both 6%).
Return to sport and reoperation rates in patients under the age of 20 after primary anterior cruciate ligament reconstruction: Risk profile comparing 3 patient groups predicated upon skeletal age.
These results highlight a group of 8th- and 9th-grade adolescents who are at high risk for graft rupture. There are several potential explanations for this greater rate of revision, including surgical technique, graft choice, level of competition, and the physical and sports-specific development of the athlete. There are also, however, nonmodifiable physical risk factors that should be considered during surgical planning.
The indications for this modified Lemaire ITB tenodesis procedure have not been definitively established. We currently recommend considering this procedure to enhance the ALCR for patients in 8th and 9th grade (ages 13-15 years) who participate in high-risk competitive sports requiring cutting, pivoting, and jumping. High-risk sports in our practice include football, lacrosse, soccer, and basketball. These patients are also indicated if they present with a grade 3 pivot shift, anterior translation >7 mm side-to-side deference, lateral tibial slope >7°, recurvatum >10°, notch width index <0.22, large marrow edema patterns involving the lateral tibial plateau and lateral femoral condyle or hyperlaxity (Beighton >6).
Other important considerations are patients with chronic ACL insufficiency, contralateral ACLR, or revision ACLR.
The 2 most significant risks and limitations of this procedure include the potential for compromise of the distal femoral physis and convergence of the tenodesis suture anchor with the femoral socket of the ACLR. Long-term considerations include potential overconstraint and the subsequent development of degenerative arthritis. Although there are limited data, Devitt et al.
Combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis does not result in an increased rate of osteoarthritis: A systematic review and best evidence synthesis.
Knee Surg Sport Traumatol Arthrosc.2017; 25: 1149-1160
reported in a best-evidence study that no increased rate of osteoarthritis developed 11 years after isolated LET and primary ACLR augmented with a LET procedure.
Combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis does not result in an increased rate of osteoarthritis: A systematic review and best evidence synthesis.
Knee Surg Sport Traumatol Arthrosc.2017; 25: 1149-1160
Our experience with this technique has shown promising results thus far. To date, 51 patients younger than 20 years of age have undergone the modified Lemaire procedure alongside ACLR with quadriceps tendon autograft. None of the patients have experienced graft tear or other significant complications. Thirty-one patients have postoperative magnetic resonance imaging, which demonstrates an intact graft (Fig 8). With favorable short term preliminary results, we recommend this procedure as an enhancement to primary ACLR for active adolescents at a high risk of graft retear.
Fig 8Postoperative coronal magnetic resonance imaging of a 12-year-old girl 7.5 months following transphyseal anterior cruciate ligament reconstruction with quad autograft and lateral extra-articular tenodesis in the form of an iliotibial band tenodesis. Note how the lateral anchor (A) is just distal to the femoral physis (B).
With the patient in supine position and the knee in 90° of flexion, a 5-cm lateral incision is made proximal to Gerdy's tubercle and taken down through subcutaneous tissues to the level of the iliotibial band. After palpating the LCL, an 8-cm × 1-cm strip from the central third of the ITB is harvested and left attached distally to Gerdy's tubercle. The proximal ITB graft is then whipped stitched and protected. The graft is fixed just proximal and posterior to the femoral insertion of the LCL. As this is a skeletally immature patient, it is critical to ensure placement is also just distal to the distal femoral physis to avoid growth disturbance. Intraoperative fluoroscopy with a mini c-arm is recommended to confirm correct positioning of the drill guide with regards to the growth plate. Before securing the graft, the knee is brought to 30° of flexion and neutral rotation. The ITB graft is then secured with an all-suture anchor loaded with a nonabsorbable suture. The remnant graft tissue is then brought lateral to the LCL and secured to itself with heavy #2 sutures. Lastly, the ITB harvest site is closed with heavy #2 sutures in an interrupted simple fashion to complete the procedure. (ITB, iliotibial band; LCL, lateral collateral ligament).
Rotational knee instability in ACL-deficient knees: Role of the anterolateral ligament and iliotibial band as defined by tibiofemoral compartment translations and rotations.
Long-term study of anterior cruciate ligament reconstruction for chronic instability using the central one-third patellar tendon and a lateral extraarticular tenodesis.
Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: A prospective comparative study of 502 patients from the SANTI study group.
Anterior cruciate ligament reconstruction associated with extra-articular tenodesis: A prospective clinical and radiographic evaluation with 10-to 13-year follow-up.
Lateral extra-articular tenodesis reduces rotational laxity when combined with anterior cruciate ligament reconstruction: A systematic review of the literature.
Return to sport and reoperation rates in patients under the age of 20 after primary anterior cruciate ligament reconstruction: Risk profile comparing 3 patient groups predicated upon skeletal age.
Combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis does not result in an increased rate of osteoarthritis: A systematic review and best evidence synthesis.
Knee Surg Sport Traumatol Arthrosc.2017; 25: 1149-1160
The authors report the following potential conflict of interest or source of funding: D.W.G. reports personal fees from Arthrex, personal fees from Pega Medical, outside the submitted work. F.A.C. reports other from Arthrex, outside the submitted work; In addition, F.A.C. has a patent (Arthrex) with royalties paid, a patent (Wolters/Kluwer) with royalties paid, and a patent (Mosby/Sanders) with royalties paid and also reports Journal of Shoulder and Elbow Surgery board of trustees and American Shoulder and Elbow Surgeons executive board. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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