In this presentation, we will demonstrate the modified LAMIRE technique for lateral extra-articular tenodesis. Despite many advancements in ACL reconstruction techniques over the years, many patients continue to feel persistent rotatory laxity after ACL reconstruction. Prior studies have demonstrated that lateral extra-articular tenodesis in the setting of ACL reconstruction can lead to significant reduction in pivot shift and reduction in graft failure. Many LAT procedures have been described, with the modified LAMIRE being a popular technique as it has been well-studied. An LAT is typically performed simultaneously with an ACL reconstruction. The indications for performing an LAT are in patients under the age of 25, patients with a high-grade pivot shift, such as grade 2 or grade 3, and those with generalized ligamentous laxity, patients with an increased posterior tibial slope, those with concomitant meniscal deficiency, patients participating in pivoting sports, and an LAT should be considered in the setting of an ACL reconstruction revision. The advantages of adding an LAT to an ACL reconstruction include improved rotational stability and decreased graft rupture rates. The disadvantages include a potential for lateral compartment over-constraint, particularly when done in isolation for an ACL-deficient knee, as well as the risk of development of a postoperative hematoma over the lateral aspect of the knee. The patient is positioned supine and GERDI's tubercle, the FCL, fibular head, and lateral epicondyle are identified. A 4-centimeter lateral incision is made over the posterior half of the IT band from the lateral epicondyle towards GERDI's tubercle. The incision is dissected down to the level of the IT band and full-thickness skin flaps are made. Using a double 10-blade and METs, an 11-millimeter-wide strip of the IT band is harvested 5 millimeters anterior from the posterior border, from just distal to the level of the FCL, to proximal until the vastus lateralis muscle belly is encountered. This is then elevated off of the fat pad just deep to the IT band. The FCL is then identified and it is dissected out anteriorly and posteriorly to create a tunnel to pass the graft deep to the FCL. Placing the knee in the figure-of-four position can facilitate identification of the FCL as needed. A passing suture is then shuttled underneath the FCL to assist with graft passage later in the case. A number 2 fiber loop is then placed in the proximal 2 centimeters of the graft and it is then shuttled underneath the FCL. 2.7 mm double-loaded knotless fibertac anchor is then placed just proximal and posterior to the lateral epicondyle. At this point, one should be cautious about the tunnel trajectory to avoid convergence with an ACL tunnel if present. We aim distal and anterior to miss the proximal and posterior ACL femoral socket. with the knee in 60 degrees of knee flexion and neutral rotation, the IT band is then tensioned and fixed to the lateral femur with the FibreTac anchor. The excess graft is then folded back upon itself distally and sewn in place with ovicral sutures. The IT band is then closed over top of the graft with ovicral. The STABILITY trial, a recent two-year outcome multicenter randomized control trial, reported on the effect of a lateral extraticular tenodesis at the time of an ACL reconstruction. The authors demonstrated a significant decrease in both clinical failure, defined as persistent asymmetric pivot shift, as well as a significant decrease in graft rupture when a lateral extraticular tenodesis was added to the ACL reconstruction. They found a number needed to treat of 14.3 to prevent one additional graft rupture. Additional studies have had similar findings reporting reduced risk of graft ruptures with no increase in need for secondary procedures and improved ACL graft incorporation.

LAMIRE technique

lateral extra-articular tenodesis

ACL reconstruction

rotational stability

graft rupture

STABILITY trial