Graft Preparation for Combined ACL and ALL Reconstruction With a Single Femoral Tunnel

Background: Combined reconstruction of the anterolateral ligament (ALL) and anterior cruciate ligament (ACL) has shown excellent results. It could potentially reduce graft failure and improve outcomes in high-risk patients. There are several surgical techniques described. Hamstrings are the most frequently used graft for ALL reconstruction. The distal portion of the iliotibial band is used for the modified Lemaire procedure. Indications: Anterior cruciate ligament reconstructions associated with the following risk factors: pivoting sports, high-demand athletes, high-grade pivot-shift, chronic ACL injury, lateral femoral condyle notch, Segond fractures, young patients (<20 years), ACL revision, generalized hyperlaxity, and Lachman >7 mm. Technique Description: Semitendinosus and gracilis tendons are harvested and their extremities are prepared with continuous suture. The semitendinosus graft is folded in 3 parts leaving the ends of the graft internalized. The triple semitendinosus will be the main component of the ACL and the single gracilis will be used for both ACL and ALL. Anterolateral ligament anatomical landmarks are proximal and posterior to the lateral epicondyle in the femur, and in the mid distance from the fibular head and the Gerdy tubercle in the tibia. The ALL is fixed in knee extension with interference screws. This video also includes a brief demonstration of graft preparation for the modified Lemaire procedure. Results: Results from our group using this technique have shown excellent clinical outcomes, minimal complications, and low failure rates in high-risk populations. This graft preparation shows excellent diameter and length for combined ACL and ALL reconstruction. Conclusion: This technique is easy to perform, with minimal complications, and should be considered in high-risk patients undergoing ACL reconstruction.

Adding a modified Lemaire procedure to ACLR in knees with severe rotational knee instability does not compromise isokinetic muscle recovery at the time of return-to-play

Purpose To determine whether isokinetic muscle recovery following ACLR using a hamstring tendon (HT) would be equivalent (non-inferior) in knees that had high-grade pivot-shift and adjuvant modified Lemaire procedure versus knees that had minimal pivot-shift and no adjuvant modified Lemaire procedure. Methods We evaluated 96 consecutive patients that underwent primary ACLR. Nine were excluded because of contralateral knee injury, and of the remaining 87, ACLR was performed stand-alone in 52 (Reference group), and with a Lemaire procedure in 35 (Lemaire group) who had high-grade pivot-shift, age < 18, or genu recurvatum > 20°. At 6 months, isokinetic tests were performed at 240°/s and 90°/s to calculate strength deficits of hamstrings (H) and quadriceps (Q). At 8 months, patients were evaluated using IKDC, Lysholm, and Tegner scores. Results Compared to the Reference group, the Lemaire group were younger (23.0 ± 2.5 vs 34.2 ± 10.5, p = 0.021) with a greater proportion of males (80% vs 56%, p < 0.001). The Lemaire group had no complications, but the Reference group had one graft failure and one cyclops syndrome. Strength deficits at 240°/s and at 90°/s were similar in both groups, but mixed H/Q ratios were lower for the Lemaire group (1.02 ± 0.19 vs 1.14 ± 0.24, p = 0.011). IKDC and Lysholm scores were similar in both groups, but Tegner scores were higher in the Lemaire group (median, 6.5 vs 6.0, p = 0.024). Conclusions ACLR with a modified Lemaire procedure for knees with rotational instability grants equivalent isokinetic muscle recovery as stand-alone ACLR in knees with no rotational instability. For ACL-deficient knees with high-grade pivot-shift, a Lemaire procedure restores rotational stability without compromising isokinetic muscle recovery. Study design Level III, comparative study.

A biomechanical study after combined reconstruction of the anterior cruciate and anterolateral ligaments: Comparison between anatomic anterolateral ligament reconstruction and lateral tenodesis using the modified Lemaire technique

Objectives: To determine the stabilizing role of the anterolateral ligament reconstruction (ALLR) and the modified Lemaire lateral extraarticular tenodesis (LET) performed in combination with anterior cruciate ligament reconstruction (ACLR) and to determine if one of these two procedures was superior to the other. Methods: Six non paired cadaveric knees were tested with a 6 degrees of freedom robotic system (KUKA Robotics). Internal rotation and anterior tibial translation were measured between 0 and 90° knee flexion after applying 5 N-m Torque and a 134-N anterior load, respectively. A full kinematics assessment was performed in each following conditions: intact knee, after section of the anterior cruciate ligament (ACL), after section of the ACL and anterolateral ligament (ALL) and Kaplan fibers, after isolated ACLR, after combined ACLR+LET and ACLR+ALLR. ALLR was performed using Gracilis tendon while central strip of the ilio-tibial band was used for the modified Lemaire procedure. These different states were compared using a Tukey paired comparison test. Results: In combined ACL and anterolateral deficient knee, anterior translation and internal rotation remained significantly increased after isolated ACLR compared to intact knee (+2.33 ± 1.44 mm and +1.98 ± 1.06°; p > 0.01). On the other hand, the addition of an ALLR or a modified Lemaire LET to the ACLR allowed to restore anterior translation and internal rotation to values similar to the intact knee. Finally, the two anterolateral procedures had not significantly different values in both tests. This difference was 0.67 ± 1.46 mm for anterior translation (p=0.79) and 0.11 ± 1.11° for internal rotation (p=0.99). Conclusion: In ACL and anterolateral deficient knee, combined ACLR and anterolateral reconstruction allowed restoration of native stability of the knee in anterior translation and internal rotation contrary to isolated ACLR. Additionally, both types of extra-articular reconstruction, ALLR or modified Lemaire procedure, were similar in terms of restoring knee kinematics and neither overconstrained the knee.