Prior Creation of the Lateral Extra‐articular Tenodesis Tunnel to Minimize Tunnel Convergence During Combined Anterior Cruciate Ligament Reconstruction

Abstract Lateral extra‐articular procedures are increasingly combined with anterior cruciate ligament (ACL) reconstruction in revision and high‐risk primary cases; however, femoral tunnel convergence between ACL and lateral extra‐articular tenodesis (LET) tunnels remains a cause of iatrogenic graft compromise. We describe a simple technique to minimize tunnel interference when performing LET according to the modified Lemaire technique with bone tunnel fixation. The key concept is to create the LET femoral tunnel first and leave the passing pin in situ while creating the ACL femoral tunnel under fluoroscopic guidance, allowing real‐time adjustment of the guide pin trajectory. After arthroscopic confirmation that the passing pin is not visible within the ACL tunnel, it is removed while retaining a shuttle suture for graft passage. ACL reconstruction is completed in the standard manner, followed by LET graft preparation, passage posterior to the lateral collateral ligament, and fixation with a SwiveLock anchor with the lower leg in internal rotation. This sequence requires no specialized instruments and can be applied to other lateral extra‐articular procedures, including anterolateral ligament reconstruction. This technique provides a practical option to reduce femoral tunnel interference and protect the ACL graft during combined procedures.