Next, we'll hear from Mr. Andy Williams about LET, when and how. Good afternoon, ladies and gentlemen. These are my indications for a teen adhesis. I use it in 100% of my revision cases and also primaries in which I'm worried about the increased risk of re-rupture, such as juveniles. All of those are still growing, I'll use it. Those are malaligned in the coronal plane. Also, hyperextenders, as we've heard earlier on, those with a big pivot shift or generally rather lax, those with an increased tibial slope, and also all professional athletes, hence my extremely high rate of usage in primary cases. I can summarise my indications. Basically, anybody I'm worried about, I'll add a teen adhesis. So I make my incision on the lateral side of the knee, crossing just below the epicondyle of the femur, and I go distally, aiming at Gurdie's tubercle, and you can see my index finger pointing to it just there. I deepen the incision to expose the IT band, I place a retractor, which you can see on the right, over Gurdie's tubercle, and make two parallel incisions a centimetre apart, which just happen to be the width of the retractor. Once I've separated the graft, I've got to decide how long it's going to be, and I continue dissecting so I've got a window in which I can palpate the lateral collateral ligament, and so with a finger through that upper window, I can feel that, and I want two to three centimetres more IT band graft proximal to the LCL. Next, I've got to clear the soft tissue off the LCL to create a tunnel medial to it, and I remove that soft tissue, some of which of course will include the ALL, not that I care a damn, and I then create, I spent five years arguing about this, use dissection scissors to create this tunnel through which I'm going to pass my graft. It's absolutely essential that the graft goes deep to the LCL so that it can behave appropriately. Christoph Kistler in our lab in London with Andrew Amos looked at ideal fixation points, and those points, three, four, and five, that's Lemaire, Krakow, and McIntosh, the places to put your graft. If you place it there, it behaves extremely isometrically. What you don't want to do is to place it too posteriorly, and that will tension an extension, and you may lose extension, or you'll have a non-functioning graft. Ivan Inderhaug had looked at the position of flexion of the knee when the graft is fixed, and for a tenodesis, it doesn't really make any difference. Our results were good at zero, 30, and 60 degrees. So I've chosen my point, which here is the Lemaire point, that's 10 millimetres proximal to the LCL attachment of the femur, and five millimetres posterior to it. I create a bleeding bed to accept the graft, and then I place a suture anchor. The suture anchor is 15 millimetres in length, and because it's so small, there's no chance of hitting the femoral tunnel of the ACL. We've done a study with some colleagues in Singapore and shown that clearly. Anything more than 15 millimetres has a significant chance of coalition. In children, I use x-ray to ensure that that suture anchor is distal to the growth plate. You don't want to place it proximal, otherwise you'll cause a tethering effect, and that might cause growth arrest. You can use a staple, but you need to place that staple more proximal than the Lemaire point, because as you can see here, it's prominent. It'll irritate the IT band, and it has a risk of conflicting with the ACL, as you can see. So I've got the graft. I take it deep to the LCL, and place it in that position. Next, we've got to consider how much we tension the graft, and Ivan looked at that in the lab, and if you excessively tension, if you end up with a fixed external rotational contracture, then you will abnormally affect kinematics, adversely so, and also raise the contact pressures in the patellofemoral and tibiofemoral joints. So you've got to think of this graft as a check crane, a bit like an MPFL reconstruction. You just make it taut, no more than that. Just take out the slack, and you must ensure that the tibia is not in a forced external rotation position. And so we place it in a so-called neutral axial rotation, which means effectively about 10 degrees of external rotation. Once I've done that, we then fix it with two number two sutures, and the remaining graft proximal to the LCL is folded over the LCL distally, and sutured onto itself for extra fixation. And you can see there's still the ability to internally rotate. Finally, I tend to close the defects in the IT band, because patients don't like feeling it, particularly proximally, where the muscle may form a hernia. But biomechanically, we've tested it in the lab, and it doesn't make any difference to the contact pressures or kinematics. Just finally, I'd let you know that we published recently in AGSM 455 professional athletes of mine, and the effect of adding a tenodesis was very significant. Without a tenodesis, there was a rerupture rate of 9.5%, and with a tenodesis, 3.4%. And this series was written up by Carl Bork, who now works in Houston. I must thank all of the people who did the hard work in the lab, under Andrew Amos's guidance, and these are my disclosures. Thank you very much indeed.

tenodesis

knee surgeries

revision cases

primary cases

graft placement