High Risk of Tunnel Convergence in Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis

Abstract

Background: Lateral extra-articular tenodesis (LET) is being increasingly added to primary and revision anterior cruciate ligament (ACL) reconstruction to address residual anterolateral rotatory instability. However, currently there is a lack of knowledge on how close the femoral tunnels are when combining these procedures. Purpose/Hypotheses: To assess the risk of tunnel convergence in combined ACL and LET procedures using 2 different surgical techniques (Lemaire and MacIntosh). It was hypothesized that the risk of tunnel convergence would be greater when using the more distally located Lemaire position. The authors further hypothesized that tunnel proximity would be influenced by knee size. Study Design: Controlled laboratory study. Methods: Ten fresh-frozen cadaveric knees were used for this study. In each specimen, an anatomic ACL femoral tunnel and 2 LET tunnels were drilled using the Lemaire and MacIntosh positions, respectively. After knee dissection, minimal distances between each ACL and LET tunnel were directly measured on the lateral femoral cortex. Furthermore, computed tomography scans were obtained to measure intertunnel convergence and lateral femoral condyle (LFC) width. On the basis of the average LFC width, knees were divided into large and small knees to determine a relationship between knee size and tunnel convergence. Results: Convergence of ACL and LET tunnels occurred in 7 of 10 cases (70%) using the Lemaire attachment position. All tunnel collisions occurred directly on the lateral femoral cortex, while intertunnel (intramedullary) conflicts were not observed. Collisions emerged in both small (n = 4) and large (n = 3) knees. Critical tunnel convergence did not occur using the MacIntosh position. The mean minimal distance between the LET and ACL tunnel using the Lemaire and MacIntosh positions was 3.1 ± 4.6 mm and 9.8 ± 5.4 mm, respectively. Conclusion: Tunnel convergence was more frequently observed in combined ACL and LET reconstruction using the Lemaire technique, independent of the knee size. LET femoral tunnel positioning according to the MacIntosh reconstruction was not associated with tunnel collision. Clinical Relevance: These findings help to raise the awareness for the risk of tunnel convergence in combined ACL and LET procedures. Surgeons may contemplate adjustments on the ACL femoral tunnel drilling technique or fixation device when applying an additional Lemaire procedure. However, in the absence of clinical outcome studies comparing different LET techniques, it remains unclear which technique is superior in a clinical setting.

High Risk of Tunnel Convergence in Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis: Letter to the Editor

“…Although we agree with Jaecker et al 3 that there are no clinical studies comparing different LET techniques, we believe that there are a considerable number of biomechanical and anatomic studies that aid in the selection of the optimum femoral tunnel location, particularly if we also consider anatomic anterolateral ligament (ALL) reconstruction. 1 Unfortunately, Jaecker et al 3 did not evaluate combined ACL and ALL reconstructions in their study.…”

“…Although we agree with Jaecker et al 3 that there are no clinical studies comparing different LET techniques, we believe that there are a considerable number of biomechanical and anatomic studies that aid in the selection of the optimum femoral tunnel location, particularly if we also consider anatomic anterolateral ligament (ALL) reconstruction. 1 Unfortunately, Jaecker et al 3 did not evaluate combined ACL and ALL reconstructions in their study. Respectfully, we consider this to be an important omission, not only because a recent survey of AOSSM members 10 demonstrated that it is the most popular type of lateral extra-articular procedure in contemporary practice, but also because its inclusion enables us to demonstrate that combined procedures can be anatomic, restore normal kinematics and biomechanics, offer significant clinical advantages over isolated ACL reconstruction, and still avoid tunnel collision.…”

“…We commend Jaecker et al 3 for their study entitled ''High Risk of Tunnel Convergence in Combined Anterior Cruciate Ligament Reconstruction and Lateral Extraarticular Tenodesis'' and for highlighting important concerns regarding the potential for collision between the femoral tunnels for Lemaire procedures and femoral anterior cruciate ligament (ACL) tunnels drilled through an anteromedial portal. 6 The authors reported that using a MacIntosh (instead of Lemaire) femoral tunnel position was advantageous based on the risk of collision.…”

“…Jaecker et al 3 highlighted that there is a notable lack of publications evaluating adverse outcomes after Lemaire and MacIntosh procedures. In contrast, the SANTI Study Group specifically evaluated complications and reoperations after 548 combined ACL and ALL reconstructions.…”

High Risk of Tunnel Convergence in Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis: Response

“…In response to the letter to the editor, we thank Sonnery-Cottet et al for their interest and comments regarding our recent article “High Risk of Tunnel Convergence in Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-Articular Tenodesis,” 6 and we appreciate the time and effort they put into reading and critically reviewing our paper.…”