LATERAL TENODESIS FOR ACL

HISTORY AND
INDICATIONS OF
LATERAL TENODESIS
IN ATHLETES
– Written by Philippe Landreau, Qatar

The treatment of anterior cruciate ligament Different terms are still used for time. He was in charge of several athletes,
injuries remains challenging in young this kind of surgical procedure: lateral particularly football (soccer) players, and
athletic populations. A residual laxity, even tenodesis, lateral extra-articular procedure, he noticed that some of these patients were
if only slight, can compromise the return lateral extra-articular plasty, Lemaire, complaining of instability of the knee and
to sport. Intra-articular anatomic and monoloop and anterolateral ligament (ALL) he described in French as a ‘ressaut’, which
especially double bundle reconstructions reconstruction. means a sort of jump inside the knee that
have been advocated to improve results, The objective of these different surgical would later be termed pivot shift. At this
but the benefits of these procedures have procedures is the same: controlling the time, intra-articular ACL reconstruction had
not been proven. Therefore, a renewed internal rotation and lateral tibial plateau not been developed and Lemaire wanted
interest in lateral tenodesis and, recently, translation. to address this rotational instability he
anterolateral ligament reconstruction, has had observed in the athletic population.
been observed. THE PIONEERS: ISOLATED LATERAL He described his procedure as the isolated
TENODESIS lateral tenodesis, but it came to be known
DEFINITION Aside from some anecdotal accounts of as the Lemaire procedure by the French
Lateral tenodesis of the knee can be surgeries performed at the beginning of the orthopaedic community.
defined as any lateral extra-articular last century, Marcel Lemaire was the first
procedure which will control anterolateral to describe an isolated lateral tenodesis, Principles of the Lemaire procedure
laxity and contribute to decreased pivot in 19671. It is interesting to mention that The technique used an 18 cm long by
shift after a rupture of the anterior cruciate Lemaire was not actually an orthopaedic 10 mm wide strip of the iliotibial band
ligament (ACL). surgeon but a general surgeon at this (ITB) that remained attached to Gerdy’s

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 1 2

Figure 1: Lemaire procedure. Figure 2: MacIntosh extra-articular procedure.

tubercle (Figure 1). The graft was passed distally-based strip of the ITB passed deep long-term results, especially in the young
deep into the fibular collateral ligament to the FCL, through a sub-periostal femoral athletic population, were disappointing8.
(FCL), then through a periosteal bridge and tunnel, then routed back through the distal Recurrent or residual laxity, secondary
then through a femoral tunnel located intermuscular septum, again passed deep meniscus tears and degenerative changes
proximal to the lateral femoral epicondyle. to the FCL and, finally, anchored to the were the main concerns after isolated extra-
This tunnel was performed using a special anterolateral tibia (Figure 2). In the Losee articular lateral tenodesis.
curved rasp designed by Lemaire himself technique4, a tunnel is made through the
(a riffler). Then the graft came back under lateral femoral condyle, starting anterior DEVELOPMENT OF INTRA-ARTICULAR ACL
the FCL to be sutured to itself or fixed in a and distal to the attachment of the FCL and RECONSTRUCTION
tibial tunnel. A Dujarier staple was added exiting through the origin of the lateral During the 1980s and 90s, the progress of
to fix and secure the graft on the femoral gastrocnemius tendon. The graft is passed arthroscopy and the better understanding
epicondyle to avoid any breakage of the through the anteroposterior femoral tunnel, of the ACL anatomy allowed the
bone or the periosteal bridge. The graft sutured to the periosteum, passed through development of reproducible intra-articular
was fixed in external rotation, between the lateral gastrocnemius tendon, exiting reconstructions with better success rates.
30° and 45° of flexion. After the surgery, through the posterolateral capsule then Therefore, many surgeons abandoned the
no immobilisation was applied and the routed back under the FCL (Figure 3). Ellison5 isolated extra-articular procedure in favour
patient could walk with full weight- detached a bone block from Gerdy’s tubercle of the isolated intra-articular procedure.
bearing protected by crutches for 3 weeks. along with the attached ITB. The graft with However, other surgeons continued to
Physiotherapy was only started at the end the bone block was then routed deep to perform combined extra-articular and intra-
of these 3 weeks2. the FCL and fixed to the tibia with a staple articular procedures either systematically or
At this time, no intra-articular recon- at 90° of knee flexion (Figure 4). Andrews6 occasionally.
struction of the ACL was performed. Marcel described a true ITB tenodesis with two The usual justifications for surgeons
Lemaire published a series of 46 patients small drill holes made in the distal femur who combined both procedures were and
operated with this procedure. The results allowing sutures to be passed through these still are:
were good on return to sports activity with holes and tied over the medial aspect of the 1. Protection of the ACL graft. Engebretsen
an excellent control of anterolateral laxity femur (Figure 5). et al, in a 1990 cadaveric study, showed
and pivot shift on a short follow-up. The early results of these techniques that lateral extra-articular tenodesis
Thereafter, different authors described were generally good, reported success reduced the forces going through an
comparable procedures. MacIntosh3 used a ranged from 75% and 90%7. However, the intra-articular reconstruction by 43%9.

THE ATHLETE’S KNEE TARGETED TOPIC 323

3
2. The treatment of concomitant injuries
to anterolateral structures. During Figure 3: Losee
an ACL rupture there is frequently procedure.
significant internal rotation of the tibia
with a true subluxation or luxation of
the tibial plateau. Bone bruise observed
on MRI on the posterior tibial plateau
and the lateral condyle is the best
illustration of displacement during
the ACL rupture. This displacement
probably doesn’t exist without damage
to the anterolateral structures. Segond
described an avulsion of the distal
capsule, but it is probable that the
other anatomic structures can also be
damaged10.
3. The counterbalance of an imperfect in-
tra-articular ACL reconstruction. Despite
the improvement in surgical techniques
for intra-articular reconstruction, it is
clear that it does not always provide
perfect control of anterolateral instabil-
ity. This can warrant combined ante-
rolateral reconstruction to reinforce the
imperfections of intra-articular recon-
struction.

4 5

Figure 4: Ellison procedure. Figure 5: Andrews procedure.

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6

Figure 6: MacIntosh extra- and intra-articular procedure.

Numerous combined intra- and extra- or quadriceps graft and the lateral tenodesis including the double bundle graft in order to
articular reconstruction techniques have (modified Lemaire technique) is added case restore the original anatomy of the ACL and to
been developed, the most popular being the by case. control internal rotation of the tibia. Despite
MacIntoch technique11. In 1977, he modified The results of this combined procedure this clear improvement of the technique and
his original extra-articular procedure by are still controversial as varying techniques of the anatomical reconstruction of the ACL,
routing the ITB over the top of the lateral are used, making comparison difficult. The many patients were still unable to return
femoral condyle (Figure 6). The graft was addition of a lateral tenodesis reduces pivot to sports and up to 25% of patients had a
then brought through the knee joint and shift more than an isolated intra-articular persistent pivot shift. Concomitant injuries
into a tibial tunnel to restore the ACL. reconstruction, although there is no obvious to lateral capsuloligamentous structures
Marshall popularised this technique by difference in term of patient-reported may explain some failures of intra-articular
using a quadriceps-patellar tendon graft. outcome scores15. ACL reconstructions. As a result, there has
This technique was quite popular and some Unlike isolated lateral tenodesis, the been a renewed interest in the anatomy
modifications were developed, such as the addition of a lateral tenodesis to an intra- of the lateral part of the knee and extra-
‘MacInJones’12. Marcacci et al described articular procedure have not shown an articular procedures. The anterolateral
a technique using the gracilis and semi- increased risk of osteoarthritis16. ligament of the knee was initially described
tendinous tendon to perform the MacIntosh. by Vincent et al in 201217 and then by Claes18
The tendons remain attached to the tibia, Patient selection in the Journal of Anatomy, in 2013, which
are passed through an ACL tibial tunnel and The usual indications for combined accurately described the anatomy of this
then brought ‘over the top’ onto the lateral intra- and extra-articular procedures are ‘new’ ligament. Despite several anatomical
femoral condyle, where the intra-articular currently high-grade rotation laxity (pivot and biomechanical studies, the exact
portion of the graft is fixed with staples. The shift grade 3), high-demand and contact anatomy and role of the anterolateral
tendons are then passed underneath the ITB athletes, generalised ligamentous laxity ligament are still debated. Nevertheless
and fixed at Gerdy’s tubercle with two staples. and ACL revision. There is still no evidence some surgeons have already developed
That team is still using the same procedure13. about exact and accurate indications for specific anterolateral reconstruction
Nowadays the majority of the surgeons lateral tenodesis. techniques with good clinical results19.
combine an independent intra-articular
graft and a modified Lemaire technique14. The THE ANTEROLATERAL LIGAMENT YEARS THE PRESENT AND THE FUTURE
intra-articular reconstruction is performed Since 2000, several teams have developed Nowadays there is clearly an enthusiasm
using either bone-tendon-bone, hamstrings the concept of anatomic ACL reconstruction for the anterolateral ligament and its

THE ATHLETE’S KNEE TARGETED TOPIC 325

Figure 7:
Identification
of an anatomic
ligamentous
structure controlling
anterolateral
stability of the
knee. A=iliotibial
band. B=anatomic
structure providing
a tenodesis effect,
beside the Kaplan
fibers. C=Gerdy's
tubercule.

reconstruction, however there are still and could be clearly distinguished from the References available at
unsolved questions: anterolateral ligament (Figure 7). www.aspetar.com/journal
• Is the ALL the only or the main lateral
control of tibia translation? CONCLUSION
• Is the ALL the only structure to be The use of lateral tenodesis procedures
repaired or restored? started 50 years ago and a variety of
Some recent anatomical studies reconstructions have been described Philippe Landreau M.D.
have shown that the role of the ALL is over the past 5 decades. Even though an Chief of Surgery
probably overestimated in comparison isolated extra-articular procedure should Aspetar – Orthopaedic and Sports
to the iliotibial band tract, which could not be recommended as it can lead to early Medicine Hospital
be the primary restraint of tibial plateau osteoarthritis, the combination of an intra-
Doha, Qatar
displacement20. At the same time, other and extra-articular procedures can decrease
Contact: Philippe.landreau@aspetar.com
anatomical studies have shown that the rotatory laxity.
lateral extra-articular tenodesis using a ALL reconstructions have been described
modified Lemaire technique to be superior recently but constitute the same concept
at controlling anterolateral rotational laxity as a lateral tenodesis. We still don’t know
and anterior translation compared with ALL accurately which patients would benefit
reconstruction21. Kaplan, in 195822, noted that from a lateral tenodesis procedure and
there are strong connections between the the ideal technique is still unidentified.
deep surface of the iliotibial band and the Further anatomic studies26, considering
lateral epicondyle. Terry and Hughston in all the lateral structures, especially the ITB
198623, and Viera et al in 200724 confirmed the and not only the ALL, will likely guide us to
complexity of the anterolateral structure, define the optimal lateral tenodesis to be
which could certainly not be summarised performed for a patient with a high risk of
only by the anterolateral ligament. residual rotational knee laxity.
A recent anatomical study by Landreau et
al25 on the anterolateral structure described
an anatomic ligamentous structure located
in the deep layer of the iliotibial band, in The author would like to thank Fawaz Hamie
the area of the Kaplan fibres. This structure and Khloud Sebak for their contributions to
had a clear iliotibial band tenodesis effect this manuscript.

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