Lateral tenodesis for ACL injury: Do you need one?
Why does an ACL graft fail?
Although an ACL reconstruction is a successful procedure it still has a significant graft re-rupture rate. The reasons for this are multifactorial but are usually related to the type of graft used, technical issues with the surgery or a traumatic re-injury.
The ACL serves to provide knee stability with:
- Front to back motion (sagittal plane)
- Rotational motion
Rotational control of the knee is not exclusively provided by the ACL[1]. There are structures on the outside of knee like the iliotibial band and Kaplan’s fibres that provide a significant contribution to rotational control. The meniscus inside the knee also contributes to the stability of the knee.
Reconstruction the ACL alone without considering the effects of damage to the other structures can lead to failure.
Patient factors also need to be considered. A patient that hyperlaxity in their joints can put more stress on the ACL graft and cause it to fail. If a patient’s tibia (shin) bone has a larger downslope at the level of the knee joint, this can also put more stress on an ACL graft.
As time goes on, we are slowly realising that there is more to an ACL reconstruction than just the ACL itself! All these other factors may contribute to graft failure.
What is a lateral tenodesis?
A lateral tenodesis involves taking a strip of tissue (1cm thick and 8–10cm long) from the iliotibial band on the outer side of the knee and re-routing it beneath the lateral collateral ligament. The lateral collateral ligament acts a pulley, allowing the strip of tenodesis tissue to more effectively control rotational movement at the knee.
Is there any evidence to back this additional procedure?
Yes. There has been a recent high-quality study[2] published that shows that a lateral tenodesis decreases the graft re-rupture rate in young patients who had an ACL reconstruction with a hamstrings graft. The graft re-rupture rate dropped from 11% to 4%.
Are there any drawbacks to this procedure?
Performing a lateral tenodesis involves an extra scar on the outer side of the knee. There may be slightly more pain on the outside of the knee in the first 3 months following surgery. However, by 12 months there should be no difference compared to ACL surgery without a tenodesis.
Does everyone having an ACL reconstruction need a lateral tenodesis?
No, not everyone needs a lateral tenodesis. There are guidelines for patients that would benefit from a lateral tenodesis. Some of these indications include young patients (<25 years old), hyperlax patients, a lack of rotational control with clinical examination (clunk on pivot-shift test) and revision ACL surgery.
Summary
A lateral tenodesis is a procedure performed with ACL reconstruction surgery that improves the rotational stability of the knee and has been shown to decrease the risk of your ACL graft failing.
References:
1. Kittl C, El-Daou H, Athwal KK, et al. The Role of the Anterolateral Structures and the ACL in Controlling Laxity of the Intact and ACL-Deficient Knee. Am J Sports Med. 2016;44(2):345-354. doi:10.1177/0363546515614312 ↩
2. Getgood AMJ, Bryant DM, Litchfield R, et al. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med. 2020;48(2):285-297. doi:10.1177/0363546519896333 ↩
Kittl C, El-Daou H, Athwal KK, et al. The Role of the Anterolateral Structures and the ACL in Controlling Laxity of the Intact and ACL-Deficient Knee. Am J Sports Med. 2016;44(2):345-354. doi:10.1177/0363546515614312 ↩
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Getgood AMJ, Bryant DM, Litchfield R, et al. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med. 2020;48(2):285-297. doi:10.1177/0363546519896333 ↩