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Lemaire lateral extra-articular tenodesis for anterolateral rotational knee instability

    Overview

    Learn the Lemaire lateral extra-articular tenodesis for anterolateral rotational knee instability surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Lemaire lateral extra-articular tenodesis for anterolateral rotational knee instability surgical procedure.
    The Anterolateral ligament(ALL) is described as a triangular structure in the anterolateral aspect of the knee and found deep to the iliotibial tract. It measures between 34 and 59 mm in length and is approximately 2mm thick in men and 1mm in women. Its origin is near the lateral epicondyle in the femur and its insertion is located between Gerdy’s tubercle and the fibula, with an extension toward the lateral meniscus.
    Biomechanical studies have shown that the ALL is an important stabilizer during anterolateral tibial rotation and effects pivot shift in cases of ACL failure. The description of the anterolateral ligament (ALL) and its effect on controlling internal rotation has led to the development of ALL reconstruction. However, there is continued debate regarding the anatomy of the ALL and in particular the ideal femoral origin. This has led to some confusion over the best technique of reconstruction and consequently the generalisation of the results of the different techniques reported in the literature.
    Historically, multiple extra-articular procedures were developed to reduce anterolateral rotational instability (ALRI), collectively referred to as lateral extra-articular tenodesis (LET) procedures. However, concerns regarding the nonanatomic nature of LET procedures and the potential for over-constraint led to a decrease in their popularity. Biomechanical studies have also shown that the IT band does play an important role in rotational stability of the knee and the donor morbidity of these procedures is unknown.
    Cadaveric biomechanical studies have shown that the lateral Lemarie tenodesis in association with ACL reconstruction better restores the rotational stability to the knee compared to ACL reconstruction combined with ALL reconstruction. The Lemaire reconstruction is my preferred technique to address ALRI of the knee in addition to ACL reconstruction.

    Indications

    INDICATIONS
    The indication for the procedure are still relatively ill-defined, however the addition of a lateral tenodesis to a standard ACL reconstruction is currently recommended in patient groups who are at high risk of graft failure. The main indications are:
    Evidence of a high-grade pivot shift on examination.
    Revision ACL reconstruction.
    General hypermobility or excessive hyperextension of the knee
    Other potential indications
    • Participation in pivoting sports or a high-demand athlete.
    • A Segond fracture.
    SYMPTOMS & EXAMINATION
    The history and examination is focused around the ACL deficiency and the identification of the above risk factors that indicate the need for the addition of an extra-articular tenodesis.
    INVESTIGATIONS
    There is no specific imaging required prior to undertaking this procedure, a segond fracture may be identified on plain X-rays or MRI . Prior to undertaking a primary or revision ACL reconstruction, consideration should be given to obtaining alignment films and or a CT scan in addition to an MRI in order to fully delineate the bony anatomy and tunnel positions. Injury to the LCL and IT band should be excluded on the imaging as well as on examination.
    ALTERNATIVE OPERATIVE TREATMENT
    The Alternative to a lateral tenodesis, is a formal reconstruction of the ALL usually with an autologous hamstring tendon.
    CONTRAINDICATIONS
    Significant lateral compartment degeneration/chondral damage – due to the risk of potential over constraint
    LCL incompetence or injury.

    Setup

    Patient is positioned as per normal set-up for ACL reconstruction with the knee bent between 60-90o with the use of an Alvarado foot positioner and side post.

    Operation

    The revision ACL reconstruction has already been carried out using a bone patella bone autograft. A lateral based incision is then drawn for the proposed lateral extra-articular tenodesis. The traction sutures from the patella tendon graft can be seen exciting the lateral thigh.
    An approximate 10cm incision is centred over the lateral epicondyle extending 3cm distally towards Gerdy’s tubercle (the insertion point of the IT band, which is easily palpated lateral to the tibial tubercle) and 7cm proximally.

    The skin and fat are incised down to the iliotibial band and full thickness flaps are developed so that the IT band is fully exposed. There are no structures at risk during this approach.

    The inferior portion of the iliotibial band is used for the transfer which is defined by those fibres which run towards Gerdy’s tubercle. An imaginary line from Gerdy’s tubercle to the exposed IT band will help identify these fibres which tend to be more inferior but above the muscular septum.

    A 1cm width strip of IT band is required, and this is measured by using a ruler. The IT band is initially incised using a 15 blade. 2 small starter incisions are created, big enough to get a pair of scissors through and allow extension of the the splits proximally and distally.

    The scissors are then used to continue the initial split made with the knife. The scissors are opened a small amount, placed within the split and then pushed proximally.Initially the scissors are placed within the inferior split. There are no structures at risk during this procedure, however care should be taken not to injure the vastus lateralis muscle.

    The scissors are then placed in the superior split and this is again extended proximally. The IT band is released proximally as far as possible within the limits of the skin incision, a Langenbeck retractor is used to improve exposure and clearly identify the proximal limit. A split length of approximately 10cm proximal to the epicondyle is desirable.

    The incisions in the IT band are then extended distally towards Gerdy’s tubercle. A swab is placed proximally within the wound in order to control bleeding in the proximal split, particularly in cases such as this where the tourniquet has already been released. The ribbon is kept within the wound to ensure the swab is not accidentally left within the patient.

    Depending on the method of fixation the length of IT band required is variable. When using staples one needs a longer length of IT band than if one was using a bone anchor. With greater experience, a better understanding of the required length of IT band is obtained.
    Initially is better to harvest more than is required in order to ensure adequate fixation. The length can then be reduced. Initially a minimum of 10cm proximal to the epicondyle is recommended. The IT band is divided proximally and then freed up distally removing any septal connections.

    The strip of IT band is then whip stitched using a number 2 firewire in order to allow traction to be placed on the strip.

    Any remaining adhesions are then divided, whilst traction is placed in the strip of IT band proximally and distally.

    The lateral collateral ligament is then identified. This can usually be palpated from the tip of the fibula head extending to the epicondyle. The tip of the dissecting scissors are used to dissect out the anterior and posterior boarders of the LCL. Direct palpation guides the dissection and is checked frequently. Time should be taken to clearly identify the LCL to ensure that the IT band is placed below it and not below a facial band. During this dissection the joint is usually entered and the residual intra articular fluid is released. Due to the intra articular perforation the lateral tenodesis is always left to the end of the procedure, once the arthroscopy and ACL has been completed.

    The lateral collateral ligament needs to be clearly identified and the under surface released so that the strip of IT band can be passed underneath it.

    A small curved clip is placed underneath the lateral collateral to retrieve the traction suture on the IT band and this is then pulled through.

    The strip of IT band is pulled through ensuring there is no kinking or snagging.

    The inferior border of the vastus lateralis (VL) is then identified in the proximal portion of the wound and lifted up with a langenbeck retractor. Diathermy is used to divide adhesions beneath it in order to allow access to the metaphysical area of the lateral femur.

    A Hohmann retractor is then placed underneath the VL and onto the anterior aspect of the femur. The VL can then be retracted superiorly. When using suspensory fixation for the associated ACL reconstruction, retracting VLO in this fashion usually reveals the button on the metaphyseal cortex, as fixation of the IT band is performed roughly in the same location. One can take the opportunity to ensure that the button has flipped fully at this point and remove the lead sutures.
    The point of fixation of the lateral tenodesis is of some debate. It has been suggested that as the graft is passed underneath the lateral collateral it controls the function of the lateral tenodesis and therefore its fixation point is not particularly critical. Some people argue that the lateral tenodesis should be fixed 1cm posterior and proximal to the lateral collateral insertion. My preferred technique is to use 2 staples to fix the IT band strip underneath the VLO in the metaphysical region. This provides strong fixation and a large fixation footprint.

    The periosteum is lifted in the area under VL at the site of the proposed fixation and the surface of the bone scuffed using an osteotome. Two 8mm ligament staples (Arthrex) are then used to fix the IT band in a belt buckle fashion.
    The position of the knee at this point is one of neutral rotation and approximately 60 degrees of flexion. This position is an attempt to
    The first staple should be placed proximally bearing in mind that a second staple is going to be placed distally. This is a tenodesis and therefore excessive traction should not be placed on the IT band and only gentle tension is therefore recommended.

    Once the first staple has been inserted over the IT band strip, it is then folded distally back over the first staple and a second staple inserted more distally over both strips of IT band. Care must be taken to ensure that the tension on the folded portion of the IT band is not so high that it causes tearing of the strip itself on the corner of the first staple.

    Placing the first staple as proximal as possible will allow the second staple to be inserted ideally 2-3mm away distal from the first, preventing the second staple cutting the `IT band on the first staple. The excess portion of IT band is then cut distal to the second staple.

    The VLO is then placed over the fixation point and the defect within the IT band closed from proximal to distal. If this can be closed completely without tension then it is done so, however the distal defect is left open if the tension is felt to be too large. One tries to close the defect as proximal as possible in order to prevent a muscle hernia.

    The fat and skin are then closed in the usual manner

    Post Operative

    The rehabilitation is dictated by the associated procedures. This procedure is carried out in association with a primary or revision ACL reconstruction and therefore the rehabilitation is dictated by the treatment of associated meniscal or cartilage procedures. There is no specific rehabilitation relating to the extra articular procedure.

    Recommended Reading

    Guan-yang Song et al in a recent reviewed severn studies involving 326 patients (326 knees) with high-grade pivot shift who underwent combined LET and intra-articular ACLR with a mean follow-up period of 46.2 months (range, 24 to 76 months). There were 274 patients (84.1%) with grade 0, 42 (12.9%) with grade I, and 10 (3.0%) with grade II pivot shift at the final follow-up. Among the 5 comparative studies, the prevalence of residual pivot shift was significantly lower (P < .05) in patients with LET plus ACLR (13.3%, 30 of 226) than those with isolated ACLR (27.2%, 67 of 246). However, the distribution of objective IKDC scores and anterior knee stability showed no significant differences between groups.
    Guan-yang Song et al in a recent reviewed severn studies involving 326 patients (326 knees) with high-grade pivot shift who underwent combined LET and intra-articular ACLR with a mean follow-up period of 46.2 months (range, 24 to 76 months). There were 274 patients (84.1%) with grade 0, 42 (12.9%) with grade I, and 10 (3.0%) with grade II pivot shift at the final follow-up. Among the 5 comparative studies, the prevalence of residual pivot shift was significantly lower (P < .05) in patients with LET plus ACLR (13.3%, 30 of 226) than those with isolated ACLR (27.2%, 67 of 246). However, the distribution of objective IKDC scores and anterior knee stability showed no significant differences between groups.

    References
    Clinical Outcomes of Combined Lateral Extra-articular Tenodesis and Intra-articular Anterior Cruciate Ligament Reconstruction in Addressing High-Grade Pivot-Shift Phenomenon. Guan-yang Song, Lei Hong, Hui Zhang, Jin Zhang, Yue Li, Hua Feng Arthroscopy: The Journal of Arthroscopic & Related Surgery, Volume 32, Issue 5, 2016, pp. 898-905.
    Anterolateral Knee Extra-articular Stabilizers: A Robotic Study Comparing Anterolateral Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis. Am J Sports Med. 2018 Mar;46(3):607-616. Geeslin AG, Moatshe G, Chahla J, Kruckeberg BM, Muckenhirn KJ, Dornan GJ, Coggins A, Brady AW, Getgood AM, Godin JA, LaPrade RF. Am J Sports Med. 2018 Mar;46(3):607-616.
    The scientific rationale for lateral tenodesis augmentation of intra-articular ACL reconstruction using a modified ‘Lemaire’ procedure. Williams A, Ball S, Stephen J, White N, Jones M, Amis A. Knee Surg Sports Traumatol Arthrosc. 2017 Apr;25(4):1339-1344
    Anterolateral Ligament Reconstruction or Extra-Articular Tenodesis: Why and When? Mathew M, Dhollander A, Getgood A. Clin Sports Med. 2018 Jan;37(1):75-86. doi: 10.1016/j.csm.2017.07.011.

    Reference

    • orthoracle.com

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