ACL Reconstruction and Extra-articular Tenodesis

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<ul><li><p>ACL Reconstruction andExtra-articular Tenodesis</p><p>Victoria B. Duthon, MDa,*, Robert A. Magnussen, MDb,Elvire Servien, MD, PhDc, Philippe Neyret, MDc</p><p>extra-articular reconstructions provided only moderate control of anterior laxity. Theprocedure was largely abandoned when single-bundle intra-articular ACL reconstruc-tion emerged as the gold standard surgical treatment of ACL tear. Some patients,however, experience persistent rotatory laxity after such reconstructions. Double-bundle ACL reconstruction was developed in part to allow improved control of rota-tional laxity through independent reconstruction and tensioning of the posterolateral(PL) bundle of the ACL. Although this procedure has been shown to produce excellentresults in the hands of experienced surgeons, it is technically challenging, particularlyin patients with smaller ACL footprints. Excessive rotatory laxity can also be controlled</p><p>Funding sources: Nil.Conflict of interest: Nil.</p><p>tology, Universitynd; b Department050 Kenny Road,</p><p>Suite 3100, Columbus, OH 43221, USA; c Department of Orthopaedic Surgery, Hopital de la</p><p>KEYWORDS</p><p> ACL reconstruction Extra-articular tenodesis ACL revisionCroix-Rousse, Centre Albert Trillat, 103 Grande rue de la Croix-Rousse, Lyon 69004, France* Corresponding author.E-mail address: victoria.duthon@hcuge.ch</p><p>Clin Sports Med 32 (2013) 141153a Department of Orthopaedic Surgery, Orthopaedic Surgery and TraumaHospital of Geneva, Rue Gabrielle-Perret-Gentil 14, Gene`ve 1205, Switzerlaof Orthopaedic Surgery, The Ohio State University College of Medicine, 2Historically, anterior laxity in ACL-deficient knees was treated surgically by isolatedextra-articular tenodesis, as described by Lemaire or MacIntosh.1,2 This procedureINTRODUCTION</p><p>effectively limited rotation of the tibial plateau relative to the femur; however, isolated</p><p>KEY POINTS</p><p> Historically, anterior laxity in anterior cruciate ligament (ACL)-deficient knees was treatedsurgically by isolated extra-articular tenodesis, as described by Lemaire or MacIntosh.</p><p> Thisprocedureeffectively limited rotationof the tibial plateau relative to the femur; however,isolated extra-articular reconstructions provided only moderate control of anterior laxity.</p><p> The procedure was largely abandoned when single-bundle intra-articular ACL reconstruc-tion emerged as the gold standard surgical treatment of ACL tear.http://dx.doi.org/10.1016/j.csm.2012.08.013 sportsmed.theclinics.com0278-5919/13/$ see front matter 2013 Elsevier Inc. All rights reserved.</p></li><li><p>Duthon et al142by the addition of an extra-articular lateral tenodesis to a single-bundle intra-articularACL reconstruction. Recent studies report comparable results of double-bundle ACLreconstruction and single-bundle reconstruction augmented with lateral extra-articular tenodesis. The aims of this article are to review the clinical indications,surgical techniques, and reported results of augmentation of intra-articular ACL recon-struction with lateral extra-articular tenodesis.</p><p>BACKGROUNDSingle-Bundle ACL Reconstruction</p><p>Single-bundle ACL reconstruction is performed to restore control of anterior and rota-tional knee laxity that is lost with rupture of the native ACL. Stabilizing the knee aims toprevent further injury to articular cartilage and the menisci and to maximize patientfunction. This technique provides good to excellent results in most cases and reliablyrestores function in activities of daily living and athletic activities in most cases. Ameta-analysis of 48 studies (5770 participants) on return to sport after ACL recon-struction showed that 90% of participants achieved normal or nearly normal kneefunction; 82% of participants had returned to some kind of sports participation,63% had returned to their preinjury level of participation; and 44% had returned tocompetitive sport at final follow-up.3 Recurrent or persistent instability after ACLreconstruction, however, several studies report 11% to 30% of recurrent and persis-tent instability after ACL reconstruction.46</p><p>Failure of ACL Reconstruction</p><p>Reasons for instability after ACL reconstruction are varied7 and include technical error(frequently tunnel malposition or failure to address associated injuries), inadequategraft material or fixation, traumatic reinjuries, and biologic failure.8 Recurrent or persis-tent laxity, in particular rotational laxity associated with a positive pivot shift test, hasbeen associated with poorer patient-reported outcomes after ACL reconstruction.4</p><p>This rotatory laxity has been reported even without failure of the ACL graft, suggestingthat in some patients a single-bundle intra-articular reconstruction is not sufficient tocompletely restore rotational knee stability.9</p><p>Double-Bundle ACL Reconstruction</p><p>Several approaches have been developed in recent years to improve rotational controlafter ACL reconstruction. First, the concept of anatomic ACL reconstruction has beenadvanced as a possible solution to persistent rotational laxity. The native ACL iscomposed of 2 bundles: the anteromedial (AM) bundle and the PL bundle. Traditionalsingle-bundle ACL reconstructions often resulted in nonanatomic vertical graft place-ment or at best only recreated the AM bundle.10 Vertical graft placement fails torecreate the PL bundle (which functions to resist tibial internal rotation near full-knee extension), possibly contributing to persistent rotatory laxity in some patientsundergoing this procedure. More anatomically placed single-bundle reconstructionsas well as anatomic double-bundle ACL reconstructions have been developed tobetter restore the function of the PL bundle. Biomechanical studies have demon-strated better rotational control with anatomic double-bundle reconstructions, leadingto the increased popularity of these techniques.10,11 Clinical superiority of this tech-nique, however, has not been definitively demonstrated.12</p><p>Lateral Extra-Articular Tenodesis</p><p>Another approach to improve rotational control after ACL reconstruction is based on</p><p>the concept that anterolateral capsular injury is frequently associated with ACL tears.</p></li><li><p>ACL Reconstruction and Extra-articular Tenodesis 143The capsular avulsion is termed a Segond fracture13,14 when associated with bonyavulsion of the lateral tibial plateau but does not always include an osseous fragment.This lesion has been shown to be present in the vast majority of acute ACL injuries andits presence is associated with significantly increased rotational knee laxity. Further-more, when chronic anterior laxity is left untreated, rotatory laxity can develop dueto a progressive stretching of secondary restrains in the lateral aspect of theknee.15 This stretching can further increase anterior laxity. To address the contribu-tions of anterolateral capsule injury to rotational knee laxity, some investigatorshave proposed the addition of a lateral extra-articular tenodesis to the standardintra-articular ACL reconstruction.16 Several techniques classically used for isolatedlateral tenodesis have been modified and used as an adjunct to intra-articular ACLreconstruction in this manner. These combined procedures are advantageous forseveral reasons. First, the longer lever arm of the lateral reconstruction allowed for effi-cient control of tibial rotation. Second, the lateral tenodesis may effectively controlrotational laxity even in the face of failure of the intra-articular graft, provided a backupfor the intra-articular graft in such cases.17 Finally, the addition of a lateral tenodesishas been shown to decrease the stress seen by the associated intra-articular recon-struction by more than 40%.18 These advantages are especially useful in cases of revi-sion ACL reconstruction. One contraindication to lateral extra-articular tenodesis isthe presence of a PL corner injury. In such cases, the tenodesis may tether the tibiain a PL subluxated position.</p><p>SURGICAL TECHNIQUES</p><p>Many lateral extra-articular tenodesis techniques have been described in the litera-ture. The most common are summarized according to the type of graft used. Thecommon goal of these different procedures is to diminish tibial internal rotation andanterior translation of the lateral tibia.</p><p>Iliotibial Band</p><p>Lemaire procedureThe Lemaire procedure was first described in 1967.1 This extra-articular tenodesisuses a strip of iliotibial band measuring 18 cm long and 1 cm wide that is left attachedto the Gerdy tubercle. Two osseous tunnels are prepared to anchor this graft: the firstis in the femur, just above the lateral epicondyle and proximal to the lateral collateralligament (LCL) insertion; the other is through the Gerdy tubercle on the proximal lateraltibia. Once the strip of iliotibial band is harvested and the bony tunnels are prepared,the graft is passed under the LCL, through the femoral bone tunnel, and back underthe LCL and finally inserted into Gerdy tubercle via the second bone tunnel. Graft fixa-tion is done at 30 of knee flexion, with neutral rotation (Fig. 1). When this technique isperformed in association with a standard ACL reconstruction, a technical problem canbe encountered in the lateral distal femur when the femoral tunnel made for the ACLgraft interferes with the femoral tunnel made to anchor the iliotibial band graft. Toavoid this problem, the bone-tendon-bone ACL graft can be prepared with a hole inthe tibial bone block that is fixed in the femoral tunnel. The iliotibial band graft(Fig. 2A) can be passed through this bone block and is thus automatically anchoredin the femur when the ACL graft is fixed in the femur (see Fig. 2B).</p><p>Modified Lemaire procedureChristel and Djian19 described a modified Lemaire procedure in order to simplify theclassic Lemaire technique. First, the length of the iliotibial band graft is diminished</p><p>in order to decrease the required skin incision and subcutaneous dissection on the</p></li><li><p>Duthon et al144lateral thigh. Christel and Djian described a graft measuring 75 mm long and 12 mmwide, again left attached distally on the Gerdy tubercle. The proximal portion of thegraft is then passed to an isometric point on the lateral femoral condyle determined</p><p>Fig. 1. Isolated lateral extra-articular tenodesis procedure as described by Lemaire.by a compass and secured in a femoral tunnel with an interference screw. To avoidpossible devascularization of the LCL, the graft is not passed under the ligament.The graft is twisted 180 because this method has been shown by Draganish andcolleagues17 to yield more homogenous graft forces and better isometry.</p><p>MacIntosh procedureThe first described MacIntosh procedure2 (MacIntosh 1) was similar to the Lemaireprocedure; however, femoral fixation was achieved not via a bone tunnel but throughsuture fixation to the lateral intermuscular septum. This procedure was modified</p><p>Fig. 2. Bone-tendon-bone ACL reconstruction and lateral extra-articular tenodesis with ilio-tibial band. (A) A strip of iliotibial band measuring 18 cm long and 1 cm wide is harvestedand left attached to the Gerdy tubercle. (B) The strip of iliotibial band is passed through thebone block of the ACL graft before the bone block is press-fit into the femoral tunnel,securing it to the femur.</p></li><li><p>ACL Reconstruction and Extra-articular Tenodesis 145(MacIntosh 2) to include passage of the graft into the joint via the over-the-top posi-tion, through the notch, and into a tibial tunnel. In 1979, theMarshall-MacIntosh proce-dure20 (MacIntosh 3) was described. The central third of the entire extensormechanism is harvested with a wider portion taken from the prepatellar aponeurotictissue. This graft was used to reconstruct the intra-articular ACL via a tibial tunneland passage over the top of the lateral femoral condyle, and to complete the extra-articular tenodesis by fixing it in Gerdy tubercule. This same concept of using one graftto reconstruct both the ACL and perform the extra-articular tenodesis is used nowwithhamstring tendons (discussed later), although current techniques use a femoral tunnelrather than passing the tendons over the top.</p><p>Hamstrings</p><p>Hamstrings can be used to perform the extra-articular tenodesis alone or associatedwith an intra-articular reconstruction performed with other tissue or can be used forboth the ACL reconstruction and the extra-articular tenodesis. Both techniques aredescribed.</p><p>Hamstrings for both ACL reconstruction and extra-articular tenodesisColombet,21 in 2011, described a mini-invasive technique using the same hamstringgraft for intra-articular reconstruction and extra-articular tenodesis. The gracilis andsemitendinosus tendons are harvested and stripped of muscle fibers. Then, the graftis prepared in 1 of 2 possible configurations according to the length or the tendons:4 1 2 or 2 1 2. The overall length graft should measure at least 21 cm. When thegracilis and semitendinosus tendons are long enough to form a 9-cm segment con-taining 4 strands (which are used to reconstruct the ACL) and a 12-cm segment con-taining 2 strands (which are used to do the extra-articular tenodesis), the 4 1 2configuration is used. If not, the 2 1 2 configuration is used. The tibial and femoraltunnel tunnels are drilled via an outside-in approach and absorbable interferencescrews are used in both tunnels to secure the graft. The remaining extra-articulargraft is then passed under the iliotibial band and anchored with an interference screwin a tibial tunnel made in the Gerdy tubercle. Navigation can be used to optimizetunnel placement.</p><p>Bone-tendon-bone graft for ACL reconstruction and hamstrings for extra-articulartenodesis (authors preferred technique)Neyret22 has reported a technique based on 3 articles,1,23,24 described in detail byMagnussen and colleagues25 in Techniques in Knee Surgery. A patellar tendon auto-graft is used for an intra-articular reconstruction of the ACL and a gracilis autograft isused for the extra-articular tenodesis. The semitendinosus tendon is preserved. Thegracilis is passed through the tibial bone block of the ACL graft, making a single graftfor both ACL reconstruction and extra-articular tenodesis (Fig. 3). The ACL graft isintroduced into the knee through the femoral tunnel and the tibial bone block isimpacted into the tunnel and press-fit. This procedure also fixes the gracilis in thefemoral tunnel as it was previously passed through the bone block (Fig. 4A). The distalinsertion of the gracilis is secured by a drill hole in the Gerdy tubercle on the tibia. The 2free ends of the gracilis graft are passed distally. The most posterior is passed underthe LCL, superficial to the popliteus tendon and through the bony tunnel in the Gerdytubercle from posterior to anterior. The most anterior is passed under the LCL, super-ficial to the popliteus tendon and under the posterior portion of the iliotibial band andthen through the same tunnel in the Gerdy tubercle from anterior to posterior.Tensioning of the graft is done at 30 of knee flexion and in neutral rotation. The 2 limbs</p><p>of the graft are sutured to one another, side to side (see Fi...</p></li></ul>

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