Modified Lemaire Lateral Tenodesis Associated With an Intra-articular Reconstruction Technique With Bone-Tendon-Bone Graft Using an Adjustable Fixation Mechanism

Combined All-Inside Anterior Cruciate Ligament Reconstruction With Semitendinosus Plus Anterolateral Ligament Reconstruction With Intact Gracilis Tibial Insertion and Transtibial Passage

The indications for combining anterior cruciate ligament reconstruction with anterolateral ligament reconstruction have increased considerably in recent years since several anatomical, clinical, and biomechanical studies have proven the importance of the anterolateral periphery in knee rotational stability. Much is still being discussed on how to combine these techniques in terms of which grafts and fixation options to use, as well as avoiding tunnel convergence. This study aims to describe anterior cruciate ligament reconstruction with a triple-bundle semitendinosus tendon graft all-inside technique combined with an anterolateral ligament reconstruction maintaining the gracilis tendon insertion on the tibia, using independent anatomical tunnels. With this, we were able to reconstruct both using only hamstring autografts, reducing morbidity in other possible donor areas, in addition to allowing stable fixation of both grafts without tunnel convergence.

Single Femoral Tunnel for Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Graft and Lemaire's Extra-Articular Tenodesis as a Good Alternative for Combined Anterior Cruciate Ligament and Anterolateral Ligament Revision Surgeries

The literature has shown a significant decrease in failure rates when the anterior cruciate ligament (ACL) reconstruction was associated with an extra-articular reinforcement technique such as the anterolateral ligament (ALL) or the iliotibial band tenodesis (ITBT) using the modified Lemaire technique. As much as there is a progressive decrease in the failure rates of ACL reconstructions when the ALL reconstruction technique is associated, there are still and will be cases that will result in graft rupture. These cases will require more alternatives for revision, which are always challenging for the surgeon, where the lateral approaches represent complicating factors, especially because of the distortion of the lateral anatomy (by the previous approach for ALL reconstruction), previous reconstruction tunnels, and the presence of fixation materials. We present here a safe technique that offers great stability to the fixation of the graft and is easy to perform, using a single tunnel for the passage of the ACL and ITBT grafts, allowing a single fixation for both. In this way, we performed a lower-cost surgery, with a lower risk of lateral condyle fracture and tunnel confluence. This technique is indicated to be used in cases of revision after failure of combined ACL reconstruction with ALL.

An eponymous history of the anterolateral ligament complex of the knee

BACKGROUND

Recent interest has surged in the anterolateral ligament (ALL) and complex (ALC) of the knee. Its existence and role in rotary stability of the knee, particularly in the setting of anterior cruciate ligament (ACL) reconstruction, remains a contentious and controversial topic.

UNDERSTANDING THE ALC

We must review our history and recognize the pioneers who pushed our understanding of the ALL forward before it was popularly recognized as a discrete structure. Additionally, given that many eponyms remain in common use related to the ALC, we must standardize our nomenclature to prevent misuse or misunderstanding of terms in the literature. In this review, modern understanding of the anterolateral ligament complex (ALC) is traced to 1829 by exploring eponymous terms first in anatomy and then in surgical technique. Understanding our history and terminology will allow us to better understand the ALC itself.

CONCLUSION

This review aims to provide historical context, define terminology, and provide insight into the clinical relevance of the ALC.

Imaging Findings of Complications After Lateral Extra-Articular Tenodesis of the Knee: A Current Concepts Review

Background

Despite successful anterior cruciate ligament (ACL) reconstruction, many patients continue to experience persistent anterolateral rotatory instability. Lateral extra-articular tenodesis (LET) is used to address this instability by harvesting a portion of the iliotibial band, passing it underneath the fibular collateral ligament, and attaching it just proximal and posterior to the lateral femoral epicondyle. Based on the most recent clinical evidence, the addition of LET to ACL reconstruction improves clinical outcomes, which has led to an increase in the use of this technique.

Purpose

To provide an overview of the postoperative complications of the LET procedure and their associated imaging findings, with a focus on magnetic resonance imaging (MRI).

Study Design

Narrative review.

Methods

In this scoping review, the authors reviewed available radiographic, computed tomography, and MRI scans of patients who experienced postoperative complications after ACL reconstruction with LET, in which the complication was determined to be from the LET procedure. Images were reviewed and subsequently described by an on-staff musculoskeletal radiologist.

Results

The authors found 9 different complications associated with LET: graft failure, hematoma, infection, chronic pain, tunnel convergence, fixation device migration, muscular hernia, peroneal nerve palsy, and knee stiffness. They supplemented these findings with radiographic evidence from 6 patients.

Conclusion

As extra-articular reconstruction techniques including LET become more popular among orthopaedic surgeons, it is important that radiologists and surgeons be adept at recognizing the normal imaging findings of LET and associated complications.

Isolated lateral extra-articular tenodesis enhance better rotatory knee joint stability post-primary ACL repair: Four cases report and literature review

INTRODUCTION AND IMPORTANCE

Residual rotatory instability has been reported to occur after primary anterior cruciate ligament reconstruction. The anterolateral ligament complex of the knee has gained attention for its role in rotational instability of the knee, especially in association with anterior cruciate ligament injuries. The role of an isolated lateral extra-articular tenodesis procedure among those patients presenting with residual rotatory instability after primary anterior cruciate ligament reconstruction has not been reported on.

CASE PRESENTATION

Four patients (Tegner level 4) presenting with residual rotatory instability after primary anterior cruciate ligament reconstruction without signs of graft failure, underwent an isolated lateral extra-articular tenodesis with modified Lemaire procedure. Pre- and postoperative outcome scores were assessed. At one-year follow-up, all patients reported functional knee stability. Pivot shift tests were negative and postoperative Lysholm scores were increased with a mean of 19.75 points. Tegner scores equaled the preinjury level.

CLINICAL DISCUSSION

This case report showed that our four patients where successfully treated with an isolated secondary modified Lemaire procedure for residual anterolateral rotatory instability after primary anterior cruciate ligament reconstruction.

CONCLUSION

An isolated secondary lateral extra-articular tenodesis procedure can be a valuable treatment option for moderate active patients with residual rotatory instability after a primary anterior cruciate ligament reconstruction without signs of graft failure.

The deep lateral femoral notch sign: a reliable diagnostic tool in identifying a concomitant anterior cruciate and anterolateral ligament injury

PURPOSE

The aim of the present study was to investigate the validity and reliability of the deep lateral femoral notch sign (DLFNS) in identifying a concomitant anterior cruciate ligament (ACL)/anterolateral ligament (ALL) rupture and predicting the clinical outcomes following an anatomical single-bundle ACL reconstruction. It was hypothesized that patients with a concomitant ACL/ALL rupture would have an increased DLFNS compared to patients without a concomitant ACL/ALL rupture.

METHODS

The lateral preoperative radiographs and MRI images of 100 patients with an ACL rupture and 100 control subjects were evaluated for the presence of a DLFNS and ACL/ALL rupture, respectively. The patients were evaluated clinically preoperatively and at a minimum 1 year following the ACL reconstruction. A receiver operator curve (ROC) analysis was performed to define the optimal cut-off value of the DLFNS for identifying a concomitant ACL/ALL injury. The relative risk (RR) was also calculated to determine whether the presence of the DLFNS was a risk factor for residual instability or ACL graft rupture following an ACL reconstruction.

RESULTS

The prevalence of DLFNS was 52% in the ACL-ruptured patients and 15% in the control group. At a minimum 1-year follow-up, 35% (6/17) of the patients with DLFNS > 1.8 mm complained of persistent instability, and an MRI evaluation demonstrated a graft re-rupture rate of 12% (2/17). In patients with a DLFNS < 1.8 mm, 8% (7/83) reported a residual instability, and the graft rupture rate was 2.4% (2/83). A DLFNS > 1.8 mm demonstrated a sensitivity of 89%, a specificity of 95%, a negative predictive value of 98%, and a positive predictive value of 89% in identifying a concomitant ACL/ALL rupture. Patients with a DLFNS > 1.8 mm had 4.2 times increased risk for residual instability and graft rupture compared to patients with a DLFNS ≤ 1.8 mm.

CONCLUSIONS

A DLFNS > 1.8 mm could be a clinically relevant diagnostic tool for identifying a concomitant ACL/ALL rupture with high sensitivity and PPV. Patients with a DLFNS > 1.8 mm should be carefully evaluated for clinical and radiological signs of a concomitant ACL/ALL rupture and treated when needed with a combined intra-articular ACL reconstruction and extra-articular tenodesis to avoid a residual rotational instability and ACL graft rupture.

LEVEL OF EVIDENCE

III.

Combined Anterior and Anterolateral Stabilization of the Knee With the Hamstring Tendons

Anterior cruciate ligament reconstruction allows good control of sagittal laxity but insufficient rotary laxity control. Our objective is to describe an original lateral extra-articular tenodesis using gracilis in addition to an intra-articular reconstruction using the semitendinosus in a short 4-strand graft. The principles are as follows: The femoral tunnel for intra-articular and extra-articular reconstruction is unique, the femoral attachment is posterior and proximal to the lateral epicondyle, the graft is under the lateral collateral ligament, and the tibial insertion is isometric from 0° to 60° between the Gerdy tubercle and the fibular head.

Minimally Invasive Modified Lemaire Tenodesis

Increasing emphasis in the literature is recently being put on controlling rotational stability in patients with an anterior cruciate ligament rupture by addressing the anterolateral complex during anterior cruciate ligament reconstruction. Many different techniques for lateral extra-articular tenodesis have been described, with the (modified) Lemaire technique being widely favored. Recent literature does report that lateral extra-articular tenodesis leads to a reduction in persistent rotatory laxity and graft rupture rate, but also may be associated with increased pain, reduced quadriceps strength, reduced subjective functional recovery, and cosmetic complaints. Thus this article aims to describe our minimally invasive technique for a modified Lemaire tenodesis.

Computed tomography (CT), X-ray, and MRI evaluation of two anterolateral knee reconstruction techniques: lateral extra-articular tenodesis (LET) and the anterolateral ligament (ALL) reconstruction

The anterolateral ligament (ALL) and capsule of the knee are anatomical structures involved in rotational stability and pivot-shift control. As such, it has been demonstrated that the extra-articular anterolateral procedures improve clinical outcome when performed as an augmentation of the anterior cruciate ligament (ACL) reconstruction in specific groups of patients. This review describes the postoperative imaging findings of two techniques used to perform these procedures, using magnetic resonance imaging (MRI), computed tomography (CT), and radiography. The first technique described is the lateral extra-articular tenodesis (LET), which uses a strip of the iliotibial band that is harvested, passed underneath the lateral collateral ligament (LCL) and fixed posterior, and proximal to the lateral femoral epicondyle (LFE), preserving ITB insertion on Gerdy's tubercle. The second technique described is the ALL reconstruction, a procedure that attempts to recreate the anatomy of the ALL, using most often a gracilis autograft. In this procedure, femoral fixation is performed proximal and posterior to the LFE, and tibial fixation is slightly distal to the joint line, halfway from Gerdy's tubercle to the fibular head. The main objective of this review is to provide an overview of the postoperative imaging aspects of these two procedures with MRI, CT, and radiography and to describe possible complications. As they become more common, it is important for the radiologist and the orthopedic surgeon to understand their particularities in combination with the already well-known ACL reconstruction.

Lateral Tenodesis Associated With an Intra-articular Anterior Cruciate Ligament Reconstruction Without Proximal Disinsertion of Iliotibial Band

The persistence of rotational instability after anterior cruciate ligament (ACL) reconstruction has been studied by several authors in the past 10 years. Although ACL lesions are currently treated arthroscopically, in the recent past, they were treated with isolated extra-articular tenodesis alone. Understanding the role and importance of anterolateral structures in the pathophysiology of rotational knee instability has increased since the rediscovery of the anterolateral ligament, and combined intra- and extra-articular reconstructions have been increasingly investigated. We sought to describe an option of lateral tenodesis associated with the ACL reconstruction through an iliotibial band tenodesis, without the need for large incisions or extra fixation devices, in a simple, fast, and reproducible manner.