Intra-articular Anterior Cruciate Ligament Reconstruction With Extra-articular Lateral Tenodesis of the Iliotibial Band
João Luiz Ellera Gomes, M.D., Ph.D., Murilo Anderson Leie, M.D., Marcos Marczwski, M.D., George Sánchez, B.S., and Márcio Balbinotti Ferrari, M.D.
Arthroscopy Techniques, Vol -, No – (Month), 2017: pp e1-e8 (article in press)
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.
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.1, 2 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.3 Moreover, rotational instability in the setting of an ACLR may result in an inability to return to play at an athlete’s preinjury level.2
As a result, intra-articular ACLR has been previously done in conjunction with an extra-articular lateral tenodesis of the iliotibial band (ITB) for reinforcement of rotational stability.3 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).4 However, many remain skeptical concerning the exact definition of the structure and do not support the claim that it is a ligament.5 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.6 This position corresponds to the exact placement of the graft during a lateral tenodesis procedure.7, 8, 9, 10, 11, 12, 13 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.3, 14 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.
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.
|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|
ACL, anterior cruciate ligament; ITB, iliotibial band.
|Knee capsule must be preserved during harvest and preparation of strip of ITB.||Inaccurate identification of extra-articular landmark points will result in suboptimal postoperative outcome.|
|Femoral fixation of the strip of ITB and hamstring autograft must be done simultaneously.||Inappropriate position of the knee during tibial and femoral screw fixation will result in improper tensioning of the strip of ITB and hamstring autograft.|
|Femoral fixation of the strip of ITB and hamstring autograft should be done at 50°-60° of flexion and slight external rotation.||Muscular hernia and hematoma may result from improper closure of the fascia lata or lack of thorough hemostasis.|
|Tibial fixation of the hamstring autograft is done in 10°-30° of flexion; then the tibia is reduced.|
ITB, iliotibial band.
|Limited ipsilateral hip range of motion|
|Grade 3 pivot-shift test|
|ACL revision with rotational instability|
ACL, anterior cruciate ligament.
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.22 In fact, a tenodesis of the ITB reduces the tension placed on the graft in an ACLR by approximately 43%.23 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.24, 25, 26, 27 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.23
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.28 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.
- Ferretti, A., Monaco, E., and Vadalà, A. Rotatory instability of the knee after ACL tear and reconstruction. J Orthop Traumatol. 2014; 15: 75–79
- Rahnemai-Azar, A.A., Naendrup, J.-H., Soni, A., Olsen, A., Zlotnicki, J., and Musahl, V. Knee instability scores for ACL reconstruction. Curr Rev Musculoskelet Med. 2016; 9: 170–177
- Inderhaug, E., Stephen, J.M., Williams, A., and Amis, A.A. Biomechanical comparison of anterolateral procedures combined with anterior cruciate ligament reconstruction. Am J Sports Med. 2017; 45: 347–354
- Roessler, P.P., Schuttler, K.F., Heyse, T.J., Wirtz, D.C., and Efe, T. The anterolateral ligament (ALL) and its role in rotational extra-articular stability of the knee joint: A review of anatomy and surgical concepts. Arch Orthop Trauma Surg. 2016; 136: 305–313
- Musahl, V., Rahnemai-Azar, A.A., van Eck, C.F., Guenther, D., and Fu, F.H. Anterolateral ligament of the knee, fact or fiction?. Knee Surg Sports Traumatol Arthrosc. 2016; 24: 2–3
- Claes, S., Vereecke, E., Maes, M., Victor, J., Verdonk, P., and Bellemans, J. Anatomy of the anterolateral ligament of the knee. J Anat. 2013; 223: 321–328
- MacIntosh, D.L. and Darby, T.A. Lateral substitution reconstruction. J Bone Joint Surg Br. 1976; 58: 142
- Fox, J.M., Blazina, M.E., Del Pizzo, W., Ivey, F.M., and Broukhim, B. Extra-articular stabilization of the knee joint for anterior instability. Clin Orthop Relat Res. 1980; 147: 56–61
- Ferretti, A., Monaco, E., Ponzo, A. et al. Combined intra-articular and extra-articular reconstruction in anterior cruciate ligament-deficient knee: 25 years later. Arthroscopy. 2016; 32: 2039–2047
- Guzzini, M., Mazza, D., Fabbri, M. et al. Extra-articular tenodesis combined with an anterior cruciate ligament reconstruction in acute anterior cruciate ligament tear in elite female football players. Int Orthop. 2016; 40: 2091–2096
- Ellera Gomes, J.L. and Marczyk, L.R. Anterior cruciate ligament reconstruction with a loop or double thickness of semitendinosus tendon. Am J Sports Med. 1984; 12: 199–203
- Zarins, B. and Rowe, C.R. Combined anterior cruciate-ligament reconstruction using semitendinosus tendon and iliotibial tract. J Bone Joint Surg Am. 1986; 68: 160–177
- Lipscomb, A.B., Johnston, R.K., and Snyder, R.B. The technique of cruciate ligament reconstruction.Am J Sports Med. 1981; 9: 77–81
- Lording, T.D., Lustig, S., Servien, E., and Neyret, P. Lateral reinforcement in anterior cruciate ligament reconstruction. AP-SMART. 2014; 1: 3–10
- Kocher, M.S., Steadman, J.R., Briggs, K.K., Sterett, W.I., and Hawkins, R.J. Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med. 2004; 32: 629–634
- Luzo, M.V., Franciozi, C.E., Rezende, F.C., Gracitelli, G.C., Debieux, P., and Cohen, M. Anterior cruciate ligament—Updating article. Rev Bras Ortop. 2016; 51: 385–395
- Crawford, S.N., Waterman, B.R., and Lubowitz, J.H. Long-term failure of anterior cruciate ligament reconstruction. Arthroscopy. 2013; 29: 1566–1571
- Bonasia, D.E., D’Amelio, A., Pellegrino, P., Rosso, F., and Rossi, R. Anterolateral ligament of the knee: Back to the future in anterior cruciate ligament reconstruction. Orthop Rev. 2015; 7: 5773
- Zhang, H., Qiu, M., Zhou, A., Zhang, J., and Jiang, D. Anatomic anterolateral ligament reconstruction improves postoperative clinical outcomes combined with anatomic anterior cruciate ligament reconstruction. J Sports Sci Med. 2016; 15: 688–696
- Smith, J.O., Yasen, S.K., Lord, B., and Wilson, A.J. Combined anterolateral ligament and anatomic anterior cruciate ligament reconstruction of the knee. Knee Surg Sports Traumatol Arthrosc. 2015; 23:3151–3156
- Sonnery-Cottet, B., Daggett, M., Helito, C.P., Fayard, J.M., and Thaunat, M. Combined anterior cruciate ligament and anterolateral ligament reconstruction. Arthrosc Tech. 2016; 5: e1253–e1259
- Pernin, J., Verdonk, P., Si Selmi, T.A., Massin, P., and 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: 1094–1102
- Engebretsen, L., Lew, W.D., Lewis, J.L., and Hunter, R.E. The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion. Am J Sports Med. 1990; 18: 169–176
- Ellera Gomes, J.L., Palma, H.M., and Ruthner, R. Influence of hip restriction on noncontact ACL rerupture. Knee Surg Sports Traumatol Arthrosc. 2014; 22: 188–191
- Ellera Gomes, J.L., Palma, H.M., and Becker, R. Radiographic findings in restrained hip joints associated with ACL rupture. Knee Surg Sports Traumatol Arthrosc. 2010; 18: 1562–1567
- Lopes, O.V. Jr., Gomes, J.L., and de Freitas Spinelli, L. Range of motion and radiographic analysis of the hip in patients with contact and non-contact anterior cruciate ligament injury. Knee Surg Sports Traumatol Arthrosc. 2016; 24: 2868–2873
- Gomes, J.L., de Castro, J.V., and Becker, R. Decreased hip range of motion and noncontact injuries of the anterior cruciate ligament. Arthroscopy. 2008; 24: 1034–1037
- Austin, J.C., Phornphutkul, C., and Wojtys, E.M. Loss of knee extension after anterior cruciate ligament reconstruction: Effects of knee position and graft tensioning. J Bone Joint Surg Am. 2007; 89:1565–1574