Authors

Dr Keran Sundaraj MBBS, MSc (Trauma), FRACS, FAOA

ACL injuries have remained a challenge, particularly in the young athletic population. Higher demands in returning to pivoting sports place greater strain on the ACL graft. This can stretch the graft, leading to instability (giving way) or graft rupture.

In order to combat these "failures" (stretching or rupture), surgeons have looked at ways to help augment (reinforce) the reconstructions performed. Methods may include the size or type of graft used, internal braces (strong sutures running with the graft), or a lateral extra-articular tenodesis.

Lateral extra-articular tenodesis (LET) procedures have a long history in the setting of ACL reconstruction. We have seen a revitalised interest in the anterolateral structures on the knee and their contribution to anterolateral rotatory stability. Indeed, there has been media attention on the anterolateral ligament (ALL), leading to patient and health providers' interest.

The History of the LET Procedure

Of historical note, Marcel Lemaire was the first to describe a lateral tenodesis in 1967 (1). At the time, intra-articular (inside the joint) procedures did not exist. Lemaire described a procedure to use the iliotibial band (ITB) to loop around the lateral collateral ligament (LCL), thus providing rotator stability. Since then, numerous iterations of the "LET procedure" have taken shape. These include:

• The modified Lemaire

• The MacIntosh

• The Ellison

• The modified Ellison procedure

• The Andrews procedure

• The Losee procedure

Current Evidence for the LET Procedure

In recent times, more robust literature has supported the use of the LET procedure. The STABILITY Study (2) has provided compelling evidence to use the LET procedure in high-risk patients. Factors that Dr Sundaraj considers when deciding if you are appropriate for a LET procedure include;

• Revision surgery

• Professional athletes or high-risk sports

• Clinical examination demonstrating high-grade instability - grade III pivot-shift test

• Younger age

• High posterior tibial slope

• Previous ACL injury

• Increased hyperextension

• Positive family history

The current research strongly points towards decreased ACL graft rupture or strain when a LET procedure is used. In the 1990s, LET procedures fell out of favour over potential over constraint (decreased movement leading to increased force on cartilage) in the knee's lateral (outside) compartment. This has subsequently been shown not to be the case (3) (4).

Technique used by Dr Sundaraj

In selected cases, Dr Sundaraj performs a modified Ellison procedure, in which a strip of the iliotibial band (ITB) is passed beneath the lateral collateral ligament (LCL) and fixed to the tibia using a bone anchor and sutures. This device sits entirely within the bone and is not palpable. As with most ACL reconstructions performed by Dr Sundaraj, no post-operative brace is required.

In other cases, an anterolateral ligament (ALL) reconstruction is preferred. This involves a small incisions through which a donor graft is tunnelled beneath the skin and secured with bone anchors. This approach is generally associated with less post-operative discomfort, though it provides marginally less rotational constraint than the modified Ellison technique.

In either case, the standard rehabilitation protocol applies without modification.

What to Discuss with Dr Sundaraj

• What type of operation will I require?

• Do I need a LET procedure?

• What is the likely outcome of this treatment?

• What are the potential complications of a LET procedure?

• Does having a LET procedure change my rehabilitation protocol?

• How long can I expect off work?

• When can I start driving?

• When can I start physiotherapy?

• When do I need to come back?

References

(1) Lemaire M. Old ruptures of the anterior cruciate ligament of the knee. J Chir 1967; 93:311-320.

(2) Getgood AMJ, et al. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med. 2020 Feb;48(2):285-297. doi: 10.1177/0363546519896333. Epub 2020 Jan 15. PMID: 31940222.

(3)  Devitt BM, Bouguennec N, Barfod KW, 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 Sports Traumatol Arthrosc. 2017;25(4):1149-1160.

(4) Pernin J, Verdonk P, Si Selmi TA, Massin P, Neyret P. Long-term follow-up of 24.5 years after intra-articular anterior cruciate ligament reconstruction with lateral extra-articular augmentation. Am J Sports Med. 2010;38(6):1094-1102