Lateral Extra-articular Tenodesis in ACL Reconstruction

Background: Following anterior cruciate ligament (ACL) reconstruction, rotational instability is thought to be a key contributor to the development of arthritis and may be one reason for decreased postoperative patient satisfaction. Multiple studies have shown that ACL reconstructions may leave patients with deficiencies in rotational stability when compared to the native knee. While the posterior lateral bundle of the ACL is considered the primary rotational stabilizer of the knee, the anterolateral complex also helps to impart additional rotatory stability and has drawn attention as a source for supplemental rotational stability after ACL injury via a lateral extra-articular tenodesis (LET). Indications: The anterolateral complex helps provide rotational stability to the knee, and LET should be considered following ACL injury for patients with a high-grade pivot shift, generalized ligamentous laxity, younger age with a desire to return to pivoting activities, or failed prior ACL reconstruction. Technique Description: Over the lateral aspect of the knee, Gerdy’s tubercle and the lateral epicondyle are identified. A 4-cm incision is created just posterior and proximal to the epicondyle to facilitate the graft harvest and the creation of a tunnel for the LET just proximal and posterior to the epicondyle to match the origin of the anterior lateral ligament (ALL). An iliotibial (IT) band graft is harvested, maintaining its distal insertion to Gerdy’s tubercle, and is passed medial to the fibular collateral ligament. A tunnel is drilled at the anatomic origin of the ALL with its trajectory aimed away from the femoral ACL tunnel, and the graft is secured with a suture anchor. Results: In the appropriate patient, ACL reconstruction with concomitant LET has been shown to confer a significantly lower clinical failure rate likely stemming from a reduced pivot shift and decreased forces on the ACL graft. Discussion: In vivo and in vitro studies have shown that ACL reconstruction reliably restores the knee’s anterior to posterior stability, but rotational stability remains significantly different between reconstructed and native ACLs. Rotational instability is thought to be a key contributor to the development of arthritis and may be one reason for decreased postoperative patient satisfaction. Performing LET in conjunction with ACL reconstruction decreases postoperative rotational instability and may decrease ACL failure in appropriately selected patients. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.