Tips for iliotibial band tenodesis with a retensionable knotless all-suture anchor
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ACL reconstruction remains among the most common sports medicine surgeries performed worldwide.
The overall goal of ACL reconstruction is to create a stable knee that allows function at a high level for activities of daily living, recreation and sport. While outcomes are generally favorable, postoperative laxity and/or retears are not uncommon. Factors contributing to postoperative laxity and/or retear are variable and include (but are not limited to) patient-specific factors, such as age, sex, sport, compliance with rehabilitation and presence of baseline hyperlaxity, as well as surgeon-specific factors, including graft choice, technique and experience (among other factors).
Source: Beau M. McGinley, MD, MBA; Daniel J. Stokes, MD; and Rachel M. Frank, MD
Certainly, traumatic re-rupture is always possible, even if the surgery was performed perfectly and the patient rehabilitated perfectly. One strategy for improving postoperative stability and reducing retear rates includes lateral extra-articular tenodesis (LET) via the modified Lemaire technique.
Iliotibial band harvest
The patient is placed supine on the operating table with all bony prominences padded. General anesthesia is induced, followed by an examination under anesthesia. A well-padded tourniquet is applied high on the operative thigh, and the leg is prepped and draped in the usual standard fashion. The leg is then elevated, exsanguinated and the tourniquet inflated. Bony landmarks, including the fibular head, lateral femoral epicondyle and Gerdy’s tubercle, are identified and marked on the skin.
The exposure for the LET can be performed before the arthroscopy and tunnel drilling or can be performed after the femoral tunnel is drilled (but not before the ACL graft is passed into the femoral tunnel). The senior author prefers to perform the exposure following ACL graft harvest but before starting the arthroscopy. The final fixation of the LET is performed after the ACL graft is passed and tensioned. Centered over the lateral femoral epicondyle, a 3-cm to 4-cm incision is made longitudinally along the distal lateral aspect of the femur in line with the iliotibial band (ITB). After full-thickness skin flaps are established, the ITB is identified, and the overlying soft tissue cleared with a Cobb elevator (Figure 1a).
Next, a 10-mm wide (from anterior to posterior) by approximately 80-mm long (from distal to proximal) strip of ITB is harvested from the central third of the ITB, with the harvest cheating toward the posterior third of the ITB, leaving approximately 5 mm to 10 mm of intact ITB posteriorly. The ITB is released proximally and left attached distally to Gerdy’s tubercle (Figure 1b). Care should be taken to avoid cutting too deep at the level of the lateral epicondyle and distal to avoid injury to the underlying lateral collateral ligament (LCL).
With the ITB harvest complete, the proximal free end of the ITB graft is whipstitched with a high strength, nonabsorbable suture. Next, the LCL is identified via palpation just distal to the lateral epicondyle. It can be helpful to apply a gentle varus force to the knee to better identify the LCL (Figure 2). The free end of the ITB is then passed from distal to proximal deep to the LCL.
Anchor placement
Attention is then turned to anchor placement for future LET fixation, which should be just posterior and proximal to the lateral femoral epicondyle. Once the site has been identified, the drill guide for the anchor is positioned. To avoid placing the anchor into the femoral tunnel and/or converging with the tunnel, it can be useful at this time to perform “tunneloscopy” by placing the arthroscope in the anteromedial portal and looking up into the femoral tunnel.
With the drill guide just proximal and posterior to the lateral epicondyle, aiming anteriorly and proximally to avoid convergence with the femoral ACL reconstruction tunnel (Figure 3), a 2.6-mm drill pin is used to prepare a pilot hole under arthroscopic visualization. Next, a 2.6-mm knotless knee FiberTak (Arthrex Inc.) all-suture anchor is inserted (Figure 4a and b). The drill guide handle and anchor inserter are removed. The blue and black suture loops from the anchor are separated, and the white retention suture is discarded. A probe is placed through the black and blue loops, and tension is applied to set the anchor.
ACL reconstruction graft
Attention is then turned to passing the ACL reconstruction graft. Once the ACL graft is tensioned, the ITB graft, which was previously passed from distal to proximal deep to the LCL, is pulled through both the blue and black anchor loops (Figure 5). With the knee in approximately 60° of flexion and neutral rotation, the ITB is secured to the fixation site at the lateral femur and tensioned. First, the free-suture limb attached to one of the knotless loops of suture (black or blue) is pulled to tighten the loop around the graft. The ITB is shuttled back through the other knotless suture loop distally, and its corresponding free-suture limb is pulled, ensuring this second loop is cinched distal to the first loop (Figure 6; black loop is first, blue loop is second). The knee is cycled and, if needed, the sutures are re-tensioned until the desired constraint is achieved.
For additional reinforcement, the excess ITB graft is tied to itself using high strength, nonabsorbable suture tape. Alternatively, the senior author will use a hybrid-knotless anchor (instead of the double-knotless) and, using the same process, the knotless loop is tightened around the graft, the graft is folded over itself and the hybrid suture tape is used to suture the graft back to itself.
The LET wound is copiously irrigated, and the ITB is reapproximated with interrupted 0-vicryl sutures (Ethicon Inc.). A self-retrieving arthroscopic suture-passer can be used for this step to reach proximally if the incision is small. The incisions are then closed in standard fashion. The wounds are covered with sterile dressings, and a hinged knee brace locked in full extension is applied. Of note, this procedure can be performed as a minimally invasive approach through an incision that is 2 cm or smaller (Figure 7).
Click here to watch a video of this technique.
- For more information:
- Rachel M. Frank, MD; Beau M. McGinley, MD, MBA; and Daniel J. Stokes, MD, can be reached at the department of orthopedic surgery at the University of Colorado School of Medicine in Aurora, Colorado. Frank’s email: rachel.frank@cuanschutz.edu.
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