Isolated Lateral Extra-articular Tenodesis After Prior Anterior Cruciate Ligament Reconstruction.

Lateral extra-articular tenodesis (LET), as an adjunct to anterior cruciate ligament (ACL) reconstruction, is gaining popularity among pediatric and sports medicine orthopaedic surgeons for the treatment of ACL injury, especially in the female, hyperflexible, and high-risk athlete population. The addition of LET or anterolateral ligament (ALL) reconstruction is typically recommended at the time of index ACL reconstruction surgery and is performed after the ACL graft is tensioned. Rotational instability has been described in cases where the ACL graft was malpositioned too vertically, and in those cases, ACL revision is indicated. In our case, ACL reconstruction was performed in isolation in a hyperflexible, high-risk (volleyball) female athlete, and she had persistent complaints of rotational instability despite an intact and well-positioned ACL graft on magnetic resonance imaging (MRI) scan. She demonstrated excessive internal rotation of the tibia in relation to the femur and exhibited symptomatic anterolateral instability on clinical examination, with a negative pivot shift but pain on internal rotation stress. She underwent a second surgery consisting of isolated modified Lemaire LET after examination under anesthesia (EUA) demonstrated negative Lachman and pivot shift. Second-look arthroscopy demonstrated an intact quadriceps autograft ACL graft. She recovered uneventfully, and her rotational instability problem was resolved. She returned to sports 12 months after the surgery and has been pleased with her result.

Key concepts: (1)Lateral extra-articular tenodesis (LET) can be added to increased rotational stability in the setting of anterior cruciate ligament (ACL) reconstruction.(2)Although typically added during the index procedure, it can be successfully completed later if needed.(3)The ACL confers both anteroposterior and rotational stability to prevent excessive anterior translation and excessive internal rotation of the tibia with respect to the femur.(4)LET can augment the ACL graft in preventing rotational instability in the setting of an ACL-deficient knee.