lateral extra-articular tenodesis. And I would just reference that Henry and Phil have done some outstanding research on the IT band and where the most quality tissue is located. We're gonna be, we started by marking out Gertie's tubercle, which is more anterior, the distal tibia. This is a left knee. Gertie's tubercle, fibular head, has already been marked. There's, what we're gonna discuss here is as much as anything, we're gonna talk about principles rather than this as being a single technique. So you can certainly use, what we'll use is the iliotibial band. You're welcome to use hamstring tendon. You can use cadaver tissue, all of which are stronger than the native anterolateral ligament capsular redundancy. So what we've marked here, again, is Gertie's tubercle, fibular head. We'll start equidistant between there. There's many techniques. What we could have done is done multiple incisions and made those smaller. For the purposes of you to visualize this, we've made one single incision for that. We've made a straight line. You can certainly make this oblique as well. And we will, so the incision, the graph that we harvest is 10 centimeters. We made the incision that length as well. We certainly have a clamp there as well. We'll release that now. And then earlier, we've shown IT band harvest for the interarticular extrafacial ACL reconstruction. So because of that, that's the same principles. We've taken a one centimeter strip in this case of iliotibial band in line with the fibers. So I'll flex 90 degrees. And then you can see the fibers of the IT band. We've run along, just because of quality of tissue, I made it a little wider, more disc-less. But it looks like this tissue's not too bad in terms of quality anyway. And then it's functionally a one centimeter strip. We've gone proximally. You can take an army-navy. You can certainly make this shorter as well and then retract. At the last 20 millimeters, we have whip-stitched with a high-strength suture. And so we baseball-stitched that proximally. And this is this turquoise suture that is shown here. So that's your graft. So you're ready to go with your graft. The next thing you're gonna do is reflect that back. Same thing, you're gonna release that from the underlying soft tissue structures. Make sure to reserve the capsule. And then next, you'd like to feel for the lateral collateral ligament. In morbidly obese patients, it can be really helpful to do a figure of four position. Can't really do that quite as well here, but we're gonna just show, and I have tagged this earlier. So I'll probably just release that, but if you can give me a hemostat. So you're gonna go to the, a little bit posterior to the midline and feel the lateral collateral ligament. Right there, curved one, if I can get that. Yeah. And again, that's marked here. That'll be the back portion of it. And there we are. And can I have a pickup and another? Actually have it. Okay. We'll take that. Here's our suture that we have that's through. So here's your lateral collateral ligament. So we've gone back to front, so we can start by being our graft under that. We've sized our graft, and it's a five millimeter graft when it's tubularized. We will now bring the suture through. Okay. So the graft is brought behind the LCL. Now, some, there's different ways. Some have not brought it behind here and simply brought it up to whatever your anatomic footprint. Again, we showed earlier today in some of the anatomic studies that the footprint is just distal to the physis and just slightly posterior is probably the most common location for this anatomic footprint. Some, it's sometimes been described as at, sometimes slightly anterior to this lateral collateral ligament origin. And so some have sewn that, and that's an extra articular tenodesis, but doesn't recreate the anterolateral ligament, which runs from that location, equidistant between the GERDES tubercle and the fibular head. So what we're gonna do is then you can take this with a high-strength suture and sew it simply at that location. You can add, what we've done is add a FibroTac suture anchor. Again, there was a discussion we had earlier, which was that your ACL button is, or fixation tunnel is gonna be slightly more proximal and slightly more anterior to this location. And if you're placing a tunnel, then you want a slight angle, slightly more proximal to distal and slightly from anterior to posterior. So keep that in mind when you're creating, if you're creating any tunnels. If you're using suture, that's a non-factor. If you put this under a periosteal patch in a very skeletally immature patient, you don't have to worry about that. And this is suture only, and that has already been brought up snug. So we can actually, we can run through the anchors later, but in the interest of time, again, sewing at this location, or in this case, we'll run it through our anchor. So what we'll do here is, so for this, there's a blue and a black limb. You wanna bring the black limb with this suture tack and there's a loop on the end of this. So you bring, fold that blue limb over. Now we're pulling this through. At that point, we can bring our graft through and we can cinch that down. Okay, so that's it. At whatever desired footprint you'd like for that. Now I won't bring it all the way down quite yet because from a, and then from a length perspective with this graft, you can make it much longer and you can whip stitch all of it and bring some sutures back, or in this case, this is measured and we're right on to go equidistantine, GERDES, tubercle, and fibular head. So one thing is, I like to secure this point, this anterolateral capsular ligament. We're gonna bring, sew that with a knee at 90 degrees of flexion and neutral rotation and then we will bring our anterolateral ligament, we're gonna bring that at full extension and neutral rotation. And so then, what I did was placed a pin at our anatomic footprint, which we know is consistent from our anatomic studies, at that location and if we have, so right now, we're gonna bring our hemostat through. So again, we'll bring this into full extension and we're gonna localize. Do we have a pin? Like a B-H-H pin? We just see it. I always spell out B-H-H pin because in my dictations, they usually write B-E-E-F. So here we are. So this, we can fully dock and fully seat that and then you can place this. This is a swivelock anchor. If your graft is a little on the shorter side, some have used instead or they prefer to use a pushlock anchor and the sutures get docked through there and then they'll take this end and just sew it to the periosteum. I tend to like to put it into a tunnel. If you have scolioimmature patients, you can check that with a C-arm to make sure you're appropriately below the joint surface and above the physis and then, and then again, we can dock this in more proximally too and seat that down more fully. Place your anchor and that's gonna be your, and I'll just place this and secure it in the interest of time. Ted, in your practice right now, what are your indications to augment an ACL reconstruction with an L-E-T? Yeah, so that would be revision ACL reconstruction. Patients that hyperextend over 10 degrees, they've been shown to have a threefold increased risk of ACL re-injury. Doing a lateral extraticular tenodesis can diminish their re-injury rate with multiple graft sources threefold. And then there are the patients that are in, I've addressed one knee and they've come back and they have a little hyperextension and they've injured their contralateral knee. I'll have a frank discussion. I can't say I've done it every time, but that's patients and those young year-round multi-sport athlete, that adolescent females on two and three soccer teams simultaneously year-round. There's a strong consideration for that. And then also a dramatic tibial slope, posterior tibial slope. You think, I feel rarely in my practice do I regret doing the lateral extraticular tenodesis. Do you think there's a downside or ways in which you can really create more of a problem than you're fixing? Yeah, I tend to tell people I wanna have the gold standard of everything. I don't wanna have them, I say nothing is without risk, so I don't wanna have anything more than they need, but I tend to lean, I use the term lean toward an antralateral slash lateral extraticular tenodesis if it's an in-between situation. And last question, what do you do with the residual IT band? Do you repair it, you put some stitches in it, or do you leave it alone? I have not just, and I've taken a little nod from our McKaylee Coker colleagues and their strong work with that and have not seen residual issues from that. Great, thanks so much. Great, thanks everyone. All right, so feel free to continue finishing what you're doing.

lateral extra-articular tenodesis

ACL reconstruction

graft options

iliotibial band

hamstring tendon