A lateral tenodesis is an extra procedure that can be added to an ACL reconstruction to improve rotational control of the knee. It uses a strip of tissue from the outer side of the knee to act as a second restraint alongside the new ACL graft.
In a large trial of young patients, adding a lateral tenodesis reduced the rate of ACL graft re-rupture. [2] Not everyone needs one, and it adds a second scar and some early discomfort on the outer side of the knee.
At a Glance
- ACL graft failure has several causes, including graft type, surgical factors, re-injury and your own anatomy.
- Structures on the outer side of the knee help control rotation alongside the ACL.
- A lateral tenodesis uses a strip of the iliotibial band to add rotational control.
- In the STABILITY trial, adding a lateral tenodesis reduced graft re-rupture from 11% to 4% in young patients with a hamstring graft.
- It is usually considered for younger, hyperlax or revision patients, or when rotational instability is marked.
Why does an ACL graft fail?
ACL reconstruction is a successful operation, but ACL grafts can still re-rupture. The reasons are usually related to the type of graft, technical factors in the surgery or a new injury.
The ACL stabilises the knee in two directions:
- front-to-back movement (the sagittal plane)
- rotational movement.
Rotational control does not come from the ACL alone. Structures on the outer side of the knee, such as the iliotibial band and Kaplan’s fibres, make a significant contribution, and the meniscus also helps stabilise the knee. [1] Reconstructing the ACL without considering damage to these other structures can lead to failure.
Your own anatomy matters too. People with hyperlax (very flexible) joints can put more stress on an ACL graft. A steeper downward slope of the top of the shin bone (tibia) can also increase the load on the graft.
There is more to an ACL reconstruction than the ACL itself, and all of these factors may contribute to graft failure.
What is a lateral tenodesis?
A lateral tenodesis uses a strip of tissue, about 1 cm wide and 8–10 cm long, from the iliotibial band on the outer side of the knee. The strip is re-routed beneath the lateral collateral ligament, which acts as a pulley so that the tissue can help control rotation of the knee.
Is there evidence for adding a lateral tenodesis?
Yes. The STABILITY trial, a large randomised study of young patients having ACL reconstruction with a hamstring graft, found that adding a lateral tenodesis reduced the graft re-rupture rate from 11% to 4%. [2] That is roughly 11 in 100 compared with 4 in 100.
The trial studied young, high-risk patients with hamstring grafts, so the results may not apply in the same way to everyone.
Are there drawbacks to a lateral tenodesis?
A lateral tenodesis involves an extra scar on the outer side of the knee. You may have slightly more pain on the outer side of the knee in the first three months after surgery. By 12 months, this difference generally settles compared with ACL surgery without a tenodesis.
As with any addition to an operation, it also slightly extends the surgery, and the usual risks of ACL reconstruction still apply.
Does everyone having an ACL reconstruction need a lateral tenodesis?
No. A lateral tenodesis is usually considered for:
- younger patients, generally under 25
- people with hyperlax joints
- marked rotational instability on examination
- revision ACL surgery.
Whether it is worthwhile for you depends on your age, activities, examination findings and any previous surgery.
Summary
A lateral tenodesis is a procedure performed with ACL reconstruction to improve rotational stability of the knee. In young, high-risk patients it has been shown to reduce ACL graft failure, but it is not needed by everyone.
If you would like to discuss how this applies to your knee, you can book a consultation with Dr Vishal Pai.
References
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- Kittl C et al. 2016. The role of the anterolateral structures and the ACL in controlling laxity of the intact and ACL-deficient knee. The American Journal of Sports Medicine.
- Getgood AMJ et al. 2020. Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the STABILITY study randomized clinical trial. The American Journal of Sports Medicine.
Wondering whether a lateral tenodesis may suit you?
Dr Vishal Pai performs ACL reconstruction and can assess whether an additional lateral tenodesis may be worthwhile for your knee. You can arrange a consultation to discuss your injury and options.
Written by Dr Vishal Pai
Vishal is an experienced knee surgeon based in Bayside, Melbourne. He consults at Sandringham Orthopaedic Specialists and operates at The Avenue Hospital and Calvary Holmesglen Private Hospital. His practice focuses on sports knee surgery, including ACL reconstruction and meniscal repair, as well as robotic knee replacement.