ACL Reconstruction and Modified Lemaire Tenodesis Utilizing Common Suspensory Femoral Fixation

Lateral Extra-Articular Tenodesis with Indirect Femoral Fixation Using an Anterior Cruciate Ligament Reconstruction Suspensory Device

“…However, extracortical suspensory devices are widely employed for ligament reconstructions with optimal biomechanical strength, and in our technique the femoral button mimics the function of a suture anchor, where the high-resistance sutures are used to fix the ITB graft. Furthermore, as highlighted in a prior study [64], proximity to the femoral tunnel may promote enhanced integration of the ITB graft due to the presence of healing factors associated with bleeding through the femoral tunnel itself. Based on our current provisional and unpublished data on almost one-hundred patients, recurrent instability, re-tear and complications specifically related to the described procedure (hematoma, lateral irritative pain, skin complications, infection) were not observed in our series.…”

“…Suturing the ITB graft onto itself theoretically poses a risk, especially in thin patients or patients with low muscle mass, of creating lateral prominence with associated discomfort. Additionally, fixation to the femoral button allows, as also highlighted by Koukoulias et al [64], a hypothetically greater integration and healing of the ITB graft due to its proximity to the femoral tunnel and the associated bleeding under it. The technique described by Koukoulias et al [52] appears, therefore, very similar to ours from a functional and anatomical standpoint; however, we believe that the fixation of the ACL graft and the LET should be performed independently in order to achieve a secure embedding of the femoral button onto the lateral femoral cortex and avoid issues related to simultaneous tensioning of the two grafts, which could compromise their stability.…”

“…The combination of all these features is what makes this technique unique and worthy of consideration. To the best of our knowledge, one study [63] in the literature described a similar technique in pediatric all-inside partial epiphyseal ACLR, while two other studies performed a modified lateral tenodesis in adult patients by fixing the ITB graft onto itself using high-resistance sutures [56] or by interposing it between the bone and the femoral button [64]. In our experience, this technique can be used in adult patients as well without major complications; moreover, it can be associated with an ACL reconstruction performed using the standard transportal technique, thus not requiring additional instruments as in the case of the all-inside or out-in technique.…”

Lateral Extra-articular Tenodesis: The Onlay Technique

“…Other proposed techniques have tried to mitigate these concerns by incorporating the LET graft into the suture button used to secure the ACL graft in the lateral femoral tunnel. 15 Although this approach solves the concern of tunnel convergence, changing the ACL femoral tunnel trajectory or placing the LET graft in a non-isometric position becomes more problematic long-term. Our technique allows independent decisions on both graft placements in the optimal positions without affecting placement of either.…”