Functional Outcome of Lateral Extraarticular Tenodesis with Anterior Cruciate Ligament Reconstruction Using Modified Lemaire’s Procedure: A Prospective Study

Varrdhaman H Dhariwal¹ https://orcid.org/0000-0001-8700-9603, Mathan C Kumar² https://orcid.org/0009-0008-4967-9698, Elayaraja Mani³ https://orcid.org/0009-0002-4618-2455, Sukumaran S Subramanian⁴ https://orcid.org/0009-0007-3152-6282

^1–4Department of Orthopedics, Stanley Medical College and Hospital, Chennai, Tamil Nadu, India

Corresponding Author: Varrdhaman H Dhariwal, Department of Orthopedics, Stanley Medical College and Hospital, Chennai, Tamil Nadu, India, Phone: +91 9444045056, e-mail: varrdh@gmail.com

Received: 04 January 2023; Accepted: 21 February 2024; Published on: 14 June 2024

ABSTRACT

Aims and background: The standard arthroscopic intraarticular anterior cruciate ligament (ACL) reconstruction with various grafts and techniques has failure rates of up to 16%. Modified Lemaire’s technique is one procedure done to reduce the rate of revision ACL surgeries by adding a tenodesis laterally, thereby reducing anterolateral laxity. This study has been done to analyze the functional outcome of modified Lemaire’s procedure in a 2-year follow-up period.

Materials and methods: A prospective outcome study involving 30 patients who underwent modified Lemaire’s procedure with ACL reconstruction in the Department of Orthopedics in Stanley Medical College and Hospital, Chennai, Tamil Nadu, India, were followed up in 6 months, 1 year, and 2 years and their preoperative (pre-op) and postoperative (post-op) pivot shift score, Tegner–Lysholm scoring and International Knee Documentation Committee (IKDC) scoring were analyzed.

Results: All 30 patients who have undergone modified Lemaire’s procedure have improved post-op Tegner–Lysholm scores and IKDC scores and reduced pivot shift scores. A statistically significant difference in mean between pre-op Lysholm and at 6 months Lysholm, at 1- and 2-year Lysholm with a p-value of <0.05.

Conclusion: Improved post-op Tegner–Lysholm scoring and IKDC scoring show that the modified Lemaire’s technique is a good procedure to reduce the rate of revision ACL surgeries. This procedure also addresses the anterolateral deficiency by reducing the prevalence of pivot-shift.

Clinical significance: By adding modified Lemaire’s procedure to ACL reconstruction, we can augment the ACL reconstruction and reduce the anterolateral laxities in patients with high-grade pivot shift.

How to cite this article: Dhariwal VH, Kumar MC, Mani E, et al. Functional Outcome of Lateral Extraarticular Tenodesis with Anterior Cruciate Ligament Reconstruction Using Modified Lemaire’s Procedure: A Prospective Study. J Orth Joint Surg 2024;6(2):114–118.

Source of support: Nil

Conflict of interest: None

Keywords: Anterior cruciate ligament, Anterolateral rotatory instability, Lateral extraarticular tenodesis, Modified Lemaire’s, Prospective outcome study, Pivot shift.

INTRODUCTION

The standard arthroscopic intraarticular anterior cruciate ligament (ACL) reconstruction using various grafts and techniques has shown various incidences of failure rates up to 16%. To minimize the failure and revision rate of ACL reconstruction, various studies¹ have shown to augment the ACL reconstruction/repair by adding an extraarticular tenodesis laterally. A variety of studies done to address anterolateral rotatory laxity have been described. The most common procedures include modified Lemaire’s procedure² (IT band graft released in the proximal portion, passed beneath the fibular collateral ligament, and attached to the lateral femoral condyle²) or Ellison’s procedure [iliotibial (IT) band graft released in the distal portion, passed beneath the fibular collateral ligament (FCL), and secured at Gerdy’s tubercle] or FCL/anterolateral ligament (ALL) reconstructions. Modified Lemaire’s technique is one procedure done to reduce the rate of revision ACL surgeries by adding tenodesis laterally, thereby reducing the anterolateral rotatory laxity.³ This study has been done to analyze the efficacy of whether adding an extraarticular tenodesis procedure laterally reduces the rate of revision ACL surgeries and the rate of anterolateral laxities in a follow-up period of 2 years.

MATERIALS AND METHODS

A prospective observational study involving 30 patients (convenience sampling) with ACL rupture had undergone modified Lemaire’s procedure with ACL reconstruction in Stanley Medical College and Hospital, Chennai, Tamil Nadu, India. Patients above 17 years of either sex with high-grade anterolateral rotatory instability having high-grade pivot shift (grade >2), revision ACL reconstruction patients, patients with generalized ligament and tendon laxity, and those having high body mass index (BMI) and patients involved in contact pivoting sports were included in the study. Those having concomitant fractures around the knee and coexisting neurovascular damage, posterolateral corner injury, lateral compartment osteoarthritis, and medically unfit for surgery have been excluded from the study. Patients have been followed up at 6 months, 1-year, and 2-year periods. Their preoperative (pre-op) pivot shift, Lachman, and anterior drawer test scores have been noted. Subjective scores such as Tegner–Lysholm and International Knee Documentation Committee (IKDC) scores have been determined. Their difference in mean pre-op and postoperative (post-op) scores has been calculated in the Wilcoxon signed-rank test (nonparametric test for not normally distributed variables) (Table 1).

**Table 1:** Descriptive statistics
	Minimum	Maximum	Mean	Standard deviation	95% confidence interval of mean
Age	17.0	34.0	24.6	4.5	22.99–26.21
Pre-op pivot shift	2.0	3.0	2.7	0.5	2.53–2.86
Pre-op Lysholm	22.0	30.0	26.2	2.6	25.27–27.13
Pre-op IKDC	25.0	32.0	28.2	1.7	27.60–28.79
Post-op pivot shift	0.0	1.0	0.2	0.4	0.05–0.3
Post-op 6 months Lysholm	90.0	98.0	94.8	2.2	94.0–95.59
Post-op 6 months IKDC	92.0	98.0	94.9	1.6	94.31–95.48
Post-op 1-year Lysholm	92.0	98.0	96.3	1.6	95.77–96.88
Post-op 1-year IKDC	95.0	98.0	96.7	0.9	96.39–97.06
Post-op 2-year Lysholm	96.0	98.0	97.3	0.8	96.98–97.53
Post-op 2-year IKDC	97.0	99.0	97.5	0.6	97.29–97.70

Procedure

Completion of ACL reconstruction using a standard technique using various autograft tendons.
The knee is positioned at 80° of flexion and rotation in near neutral; a lateral skin incision around 6 cm is placed just behind the lateral epicondyle, 2 cm above the Gerdy’s tubercle (Figs 1A and B).
Dissect down the subcutaneous layer to the IT band.
Iliotibial (IT) band graft harvested around 7–8 cm in length and 1–1.5 cm in breadth from the posterior one-third of the entire band (Figs 1C to E).
Tibial attachment of the IT band graft at the Gerdy’s tubercle left intact. Place a whipstitch with 5-0 Ethibond in the free end (Fig. 1F).
Pass the graft beneath the FCL by tunneling under it (Fig. 1G).
Then, knee in 60° flexion and neutral rotation, IT band graft fixed to the lateral femoral condyle by drilling tunnel anterior and proximal to the femoral tunnel for ACL graft. To avoid tunnel collision, tunnel view scope is done while passing the guide pin. The graft is fixed with an interference screw depending on the graft and tunnel size (Figs 1H and I).
Closure of IT Band using number-1 vicryl (Fig. 1J and Table 2).

Figs. 1A to J: (A, B) Position in 80° flexion and lateral skin incision made; (C, D, E) Harvesting 8 × 1 cm IT band graft; (F) Whipstitching free end; (G) Passing under FCL; (H, I) IT band fixation to femur; (J) IT band closure

**Table 2:** Distribution of study participation (n = 30)
Mode of injury	Frequency	Percentage
RTA	11	36.6
Sports injury	13	43.3
Others	6	20.0
Type of sports participation
Professional	12	40.0
Recreational	18	60.0
Gender
Male	26	86.7
Female	4	13.3

RTA, road traffic accident

Postoperative Rehabilitation

Same as for standard ACL reconstruction. Weight-bearing with hinged knee support for the first 4 weeks with cold therapy and ankle-pump exercises started. Strengthening exercises for quadriceps and hamstrings with multiangle isometrics, closed chain exercises and later open chain done to achieve full ROM of the knee. After 12 weeks, Impact loading exercises from running and jumping to plyometrics started (Table 3).

**Table 3:** Wilcoxon signed-rank test (*p < 0.05)
Test statistics ^a
	Pre-op pivot shift test vs post- op pivot shift test	Pre-op Lysholm vs post-op 6 months Lysholm	Pre-op IKDC vs post-op 6 months IKDC	Post-op 6 months Lysholm vs post-op 1-year Lysholm	Post-op 1-year Lysholm vs post-op 2-year Lysholm	Post-op 1-year IKDC vs post-op 2-year IKDC
Z	−4.7821^b	−4.7821^c	−4.7821^c	−3.911^c	−3.562^c	−3.862^c
p-value	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05

^aWilcoxon signed-rank test; ^bbased on positive ranks; ^cbased on negative ranks

RESULTS

Wilcoxon Signed-rank Test

As few predictor variables like post-op pivot shift test, post-op 1-year Lysholm, post-op 2-year Lysholm, post-op 1-year IKDC, and post-op 2-year IKDC are not normally distributed. Wilcoxon signed-rank test, a nonparametric test is used to find the mean difference (Fig. 2).

Figs. 2A to D: A 22-year-old male showing post-op X-ray of modified Lemaire’s procedure, improved straight leg raise (SLR), and flexion of knee at 6 months

DISCUSSION

A statistically significant difference in mean pre-op pivot shift score and mean post-op pivot shift test score with a p-value of <0.05 and a statistically significant difference in mean between pre-op Lysholm and at 6-months Lysholm, at 1 year and at 2-year Lysholm with a p-value of <0.05 noted. Therefore, lateral extraarticular tenodesis using modified Lemaire’s technique was found to be an effective augmentation procedure for standard ACL reconstruction.⁴ Improved post-op Tegner–Lysholm scores, IKDC scores, and reduced pivot shift scores indicate improved post-op knee function and improved anterolateral rotational control. Out of 30 patients, one patient developed post-op knee stiffness, which improved with a range of motion exercises. Another patient developed a scar site infection at the hamstring graft harvest site, which improved with IV antibiotics and wound wash. Intraoperatively, one patient had an ACL graft cut out while drilling a tunnel for IT band fixation in the femoral side. However, graft length was maintained, and femoral graft fixation was done with an interference screw in the same setting. To avoid femoral tunnel collision, we monitored with tunnel scope view while drilling guide pin for Lemaire’s procedure for the subsequent cases. By adding Lemaire’s procedure to standard ACL reconstruction,⁵ ACL graft failure rate and the rate of revision ACL procedures can be reduced, especially in patients with high BMI and patients with generalized ligamentous laxity (Beighton score >6).

CONCLUSION

Modified Lemaire’s procedure stands as an effective technique to signify the anterolateral rotational instability and reduces the rate of revision ACL surgeries. Improved anterolateral rotational control can be achieved in patients with high-grade or explosive pivot shift⁶ and in patients returning to contact sports and heavy manual work. Especially faster rehabilitation and early return to work and sports can be achieved. Although the functional outcome is good, we need a multicentric study to validate the above findings.

ORCID

Varrdhaman H Dhariwal https://orcid.org/0000-0001-8700-9603

Mathan C Kumar https://orcid.org/0009-0008-4967-9698

Elayaraja Mani https://orcid.org/0009-0002-4618-2455

Sukumaran S Subramanian https://orcid.org/0009-0007-3152-6282

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