Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-Articular Tenodesis: The "Over-the-Top"...

The anterior cruciate ligament (ACL) is a primary restraint to anteroposterior as well as rotatory knee laxity. In case of concomitant lesion of menisci or other ligamentous structures, further dynamic instability is encountered. A lateral extra-articular tenodesis (LET) augmentation has been proposed by the Authors to treat or prevent residual laxity.

ACL reconstruction is recommended in young athletes involved in pivoting sports, non-contact pivoting injuries, high-grade pivot shift, deep notch sign and double bone bruise, meniscal loss, and revision of previous bone-patellar tendon-bone autograft.

A 2 to 3 cm oblique incision is made over the pes anserinus. Gracilis and semitendinosus tendons are harvested with their attachment preserved and sutured together. Tibial tunnel is reamed after positioning of a guide pin. A wire-loop passer is directed from the tibial tunnel to the anteromedial portal. A 2 to 3 cm longitudinal incision is made superior-laterally, the ileotibial band is divided and retracted anteriorly. A suture-loop is retrieved from the lateral incision through the anteromedial portal with a curved Kelly clamp. The suture is placed into the wire-loop and retrieved with it from the tibial tunnel. The graft is retrieved from the lateral incision, tensioned with the knee at 70° to 90° of flexion and foot in neutral rotation and secured with 2 staples to the femur. A 1-cm skin incision is performed just below the Gerdy tubercle. The graft is retrieved from this incision below the fascia with a small Kelly clamp, tensioned and secured with a staple. The iliotibial tract defect is closed.

At long-term follow-up, a revision rate of 3% has been reported, while patient-reported outcome measures (PROMs) were excellent. At very-long-term follow-up, most patients were still involved in sports with a very low rate of positive Lachman and pivot shift tests. No overconstraint and lateral osteoarthritis were encountered. Medial osteoarthritis was related only to medial meniscectomy.

The ACL reconstruction plus LET over-the-top technique is a safe and reliable surgery with a low rate of reoperations and peri-operative complications at very-long-term follow-up.

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.