Editorial Commentary: Lateral Extra-Articular Tenodesis Reduces Anterior Cruciate Ligament Graft Rerupture Rates: Proper Anterior Cruciate Ligament and Lateral Extra-Articular Tenodesis Technique Is Vital to Prevent Complications

Lateral extra-articular tenodesis (LET) reduces anterior cruciate ligament (ACL) graft rerupture rates in high-risk patients. I believe in ilio-tibial band (ITB)-related LET to restrain anterolateral rotatory instability (ALRI) in ACL that is injured and reconstructed, and not in the "anterolateral ligament" or related techniques. However, the potential for conflict of a modified Lemaire LET femoral tunnel with an ACL femoral tunnel is higher than appreciated, and it risks iatrogenic ACL graft damage or compromised fixation. For MacIntosh LET, I use a staple to fix a strip of ITB (left attached distally to Gerdy's tubercle) at the lateral femoral metaphysis. The tines of the staple are proximal to the ACL femoral tunnel and fixation, so conflict cannot occur. For modified Lemaire LET, the ITB graft is (taken deep to the LCL and) attached at "Lemaire's point" on the lateral femur (proximal and posterior to the LCL femoral attachment). For fixation, I use a 15-mm length suture anchor, sufficiently short to avoid conflict. I presume fixation is less strong with sutures, so the 2-3 cm of ITB graft proximal to the suture are turned distally back over the LCL and sutured to itself. This does create a thickened contour to the lateral knee, but excellent clinical outcomes. Finally, I recommend the anteromedial bundle (AMB) position for the femoral tunnel, as in my experience in professional soccer players, using the central "anatomic" position increases rates of ACL graft rerupture. Moreover, "anatomic" femoral tunnel position results in a flatter trajectory increasing the risk of conflict with a LET tunnel (or lateral physical damage in patients with open growth plates).