Hi, my name is Henry Ellis from Scott Shriver Children's. I'm going to be talking about lateral extra-articular tenodesis, how do I do it, and who is indicated. These are my disclosures, neither of which are pertinent in this discussion. So a historical look at the ACL, and really the treatment of an ACL injury and the iliotibial band have really gone hand-in-hand for quite some time. In the 1970s, several authors had described ways in which to reestablish stability following an ACL injury, primarily using the iliotibial band. Most common are the McIntosh and the Lemire that you see here, which a portion of the IT band is used through an interosseous tunnel and then sutured onto itself. Well, at Scottish Rite, we did a fisiole-sparing ACL reconstruction in young kids, and we also did trans-fisiole and found that our fisiole-sparing had fantastic outcomes, while trans-fisiole utilizing hamstrings at the time really had a slightly higher failure rate. So we decided to combine these two techniques so that in the older adolescent or perhaps the high-risk injury, you had both a combination of an intra-articular ACL reconstruction as well as the effect of a lateral extra-articular tenoresis that you see here. We wrote up our results, 57 patients, a two-year minimum follow-up, and what we identified was that we had just over a 5% failure rate. Most of these were adolescent kids, youth that played sports. ACL reconstruction with an ALL reconstruction or LAT is really not new. It's becoming more and more popularized. The stability trial at a large Canadian randomized controlled trial demonstrates that using the LAT decreased the failure rates by about half. Others have also described similar techniques with improved outcomes. So who do we use it for? Well, I'll credit Phil Wilson, my partner, who says that every adolescent ACL we treat should be considered high-risk until proven otherwise, but when you really look at indications, my indications are in a revision setting, someone with a high grade pivot shift, generalized ligamentous laxity with maintenance of five or greater, pivoting or cutting sports, female gender or female sex, posterior tibial slopes greater than 10 degrees, and genuine recurve bottom. I would say not any one of these is an absolute indication, and many times these patients have a combination. These are just certain clinical cues to consider an indication for a lateral extra-articular tenoresis. So how do I perform it? Well, before we get started on that, you really need to know the anatomy. Stripping the iliotibial band historically has described the central third, but as you can see in some of these anatomy studies from our anatomy lab, if you take the central third, it sometimes doesn't go all the way down to GERDI's tubercle. In fact, the central third actually has tendons fibers that go to the patella tendon, and what we found is the money is really in the posterior third of the harvest towards GERDI's tubercle. It actually is the thickest portion of the tendon, as well as those fibers are the ones that actually go to GERDI's and give you a bony attachment. Now what I do is I harvest about 70% of the IT band, one to two millimeters anterior to the intermuscular septum, and then usually between 15 and 20 millimeters anterior to that, as you can see here. Here's the technique. As you can see, the knee is up top. It's a bent knee, and so I'm on the lateral side of a right knee. I'm describing the distal insertion of the iliotibial band as it trifurcates to the patella, patella tendon, as well as to GERDI's, and so taking that posterior third, as you'll see here, this is a three centimeter incision. Once I make my skin incision, what you'll see is I'll undermine the IT band in all directions to remove any of the residual soft tissue attachments, fasciculturalis. I also use a cob superficially in order to remove some of the soft tissue superficial over the IT band, and you can see I do this both proximally and now my curved MEOs are undermining the tissue just to clear out any of the residual capsular or soft tissue layer underneath that IT band. Once I've done that, now I use the curved portion of the curved MEOs, and I'll just slide it along the IT band, but I want to be sure I follow those collagen fibers. I don't want to amputate those because then you'll lose the strength of your graft and it's attachments, so the anterior portion I'll usually go to the inferior pole of the patella. The distal portion I'll oftentimes go straight to GERDI's tubercle, going in line with the collagen fibers at their insertions over the IT band. You can see here we've got a nice robust IT band. I'll do the same thing proximally, usually somewhere between 115 and 120 millimeters. I usually make a small counter incision to amputate the graft. Once I've got it nice and secured, I place a whip stitch on the distal aspect of the IT band, and in order to create that lateral extraticular tenodesis, I usually loop it around the lateral form of condyle into the knee, and then I will secure it on the lateral form of condyle. What you'll see here is this is how I secure the IT band. IT band as I go over and around the lateral form of condyle right into the knee. You can see I've already drilled my ACL tunnel there, and now I'm just creating a window to bring in my iliotibial band. Now this brings in an intra-articular portion of the IT band, but it also gives stability for the lateral extraticular tenodesis. Now what you can see here is once I've created that, I dilate that capsular layer. I use a grasper. I'll pull the IT band into the knee. I will then subsequently pull it into my tibial tunnel, so I have both that extra-articular lateral extraticular tenodesis as well as additional bulk with inside the graft itself. Now I'll use this now with hamstring, quads, or BTV. The key then becomes the fixation. Now this is a drawing from our article, but what's really important is to create that lateral extraticular tenodesis effect. You really need to fix it. In small children, you can use the periosteum, which is very strong, and I'll place sutures around it, but I think you can also use an anchor in older adolescents, which periosteum is not too thick, so I prefer a suture anchor, but you can use suture or even a socket tunnel if you like. What's probably the most important is that when you secure your lateral extraticular tenodesis or your IT band, based on some biomechanical studies, I really prefer to do this at 90 degrees in neutral rotation so that you do not over-constraint that lateral compartment. The ACL protocol is similar to an ACL protocol. I do not change it when the lateral extraticular tenodesis is performed. I do caution for lateral, for vastus lateralis muscle bulging, which can happen about 5% of patients. So whether you like to use the Lemaire, which is a great option, or you use a modified McIntosh in which you strip the IT band, you stay on the outside of the knee, and you also give bulk inside your knee, I think it should be considered in certain adolescent ACL reconstructions, particularly those that are high risk. Thank you very much.

lateral extra-articular tenodesis

ACL reconstruction

iliotibial band

GERDI's tubercle

fixation methods