Lemaire Tenodesis: Procedure, Indications, Benefits, and Risks in ACL Reconstruction

What is Lemaire Tenodesis?

Lemaire Tenodesis is an extra-articular (outside the joint) reconstructive surgical procedure, often performed in conjunction with anterior cruciate ligament (ACL) reconstruction, to enhance knee stability by addressing anterolateral rotational instability (ALRI) and reduce the risk of ACL graft failure.

Understanding ACL Injuries and Rotational Instability

The anterior cruciate ligament (ACL) is a critical stabilizer of the knee, primarily preventing excessive anterior translation of the tibia relative to the femur and controlling rotational movements. An ACL tear often results from non-contact pivoting or landing mechanisms, leading to significant knee instability. While ACL reconstruction effectively addresses anterior instability, a subset of patients, particularly those involved in high-demand pivoting sports or with significant knee laxity, may continue to experience "giving way" sensations due to persistent anterolateral rotational instability (ALRI). This phenomenon, often identified by a positive "pivot shift" test, indicates a complex instability involving the ACL, the anterolateral ligament (ALL), and the lateral meniscus. It is this rotational instability that Lemaire Tenodesis aims to mitigate.

The Lemaire Tenodesis Procedure Explained

Lemaire Tenodesis is a historical yet increasingly revisited technique that augments intra-articular ACL reconstruction by providing additional stability on the outside (lateral aspect) of the knee joint. It is a form of lateral extra-articular tenodesis (LET).

• Purpose: The primary goal is to limit excessive internal rotation of the tibia and reduce the pivot shift phenomenon, thereby protecting the newly reconstructed ACL graft from undue stress.
• Key Components: The procedure typically involves harvesting a strip of the iliotibial band (ITB), a thick band of fascia running along the outside of the thigh. This ITB strip is then routed in a specific anatomical path to create a passive check-rein against rotational forces.
• Mechanism: The ITB strip is passed deep to the lateral collateral ligament (LCL) and fixed to the femur, often near the lateral epicondyle, or routed and fixed to Gerdy's tubercle on the tibia. This anatomical routing creates a tether that becomes taut during internal rotation and knee flexion, effectively reducing the pivot shift and providing a more stable "feel" to the knee.

Why is it Performed? Indications for Lemaire Tenodesis

While not indicated for every ACL injury, Lemaire Tenodesis is typically considered for specific patient profiles to improve outcomes and reduce the risk of re-injury. Indications often include:

• High-grade pivot shift: Patients demonstrating a significant "giving way" sensation or a prominent pivot shift test under anesthesia.
• Revision ACL reconstruction: Patients who have experienced a previous ACL graft failure.
• Generalized ligamentous laxity: Individuals with hypermobility or "loose joints."
• Young, active athletes: Especially those returning to high-risk pivoting and cutting sports (e.g., soccer, basketball, football, skiing).
• Concomitant injuries: Such as a significant lateral meniscal tear or avulsion of the anterolateral ligament (ALL).
• Elite athletes: To maximize knee stability and reduce re-rupture rates.

Surgical Technique: A Brief Overview

The Lemaire Tenodesis is performed through a small incision on the lateral side of the knee, typically concurrently with the intra-articular ACL reconstruction.

• ITB Graft Harvest: A strip of the iliotibial band, usually 8-10 mm wide, is carefully harvested while maintaining its distal attachment.
• Passage and Routing: The ITB strip is then passed underneath the lateral collateral ligament (LCL).
• Femoral Fixation: The proximal end of the ITB strip is tensioned and secured to the lateral femoral epicondyle or a similar anatomical landmark on the femur, often using a screw and washer or a suture anchor. The precise tensioning is crucial to provide stability without over-constraining the knee.

Benefits and Potential Advantages

The addition of a Lemaire Tenodesis to an ACL reconstruction offers several potential benefits:

• Improved Rotational Stability: Directly addresses and significantly reduces anterolateral rotational instability, leading to a more stable knee.
• Reduced ACL Graft Failure Rates: By offloading stress from the intra-articular ACL graft, it may decrease the risk of re-rupture, particularly in high-risk populations.
• Enhanced Subjective Stability: Patients often report a greater feeling of knee stability and confidence during activities.
• Better Long-Term Outcomes: Some studies suggest improved long-term functional outcomes and lower rates of secondary meniscal tears.

Potential Risks and Considerations

As with any surgical procedure, Lemaire Tenodesis carries potential risks and considerations:

• Standard Surgical Risks: Including infection, bleeding, nerve damage, and adverse reaction to anesthesia.
• Lateral Knee Pain: Some patients may experience persistent pain or tenderness over the ITB or at the fixation site.
• ITB Friction Syndrome: Although rare, the alteration of ITB mechanics could theoretically contribute to this condition.
• Over-Constraint: Improper tensioning could lead to over-constraining the knee, potentially affecting range of motion or kinematics.
• Cosmetic Scarring: An additional incision on the lateral aspect of the knee.
• No Significant Increase in Stiffness: Studies generally show that when performed correctly, Lemaire tenodesis does not significantly increase knee stiffness or limit range of motion.

Rehabilitation After Lemaire Tenodesis

Rehabilitation after Lemaire Tenodesis is generally similar to that of a standalone ACL reconstruction, focusing on restoring range of motion, strength, and neuromuscular control.

• Early Range of Motion: Crucial to prevent stiffness.
• Controlled Strengthening: Progressive strengthening of quadriceps, hamstrings, and gluteal muscles.
• Neuromuscular Retraining: Emphasizing balance, proprioception, and dynamic stability exercises.
• Gradual Return to Sport: A phased progression, typically 9-12 months post-surgery, with specific attention to cutting and pivoting drills once sufficient strength and stability are achieved.
• Emphasis on Protecting the ITB: While the ITB graft is extra-articular, care is taken to avoid excessive early stress on the lateral structures, though this is often integrated into standard ACL rehabilitation protocols.

Who is a Candidate?

The decision to perform a Lemaire Tenodesis is highly individualized and made in consultation with an orthopedic surgeon specializing in knee injuries. It is typically reserved for patients who present with specific risk factors for ACL graft failure or significant rotational instability. Patient selection is paramount to ensure the benefits outweigh the potential risks and to optimize surgical outcomes.

Conclusion: The Role of Lemaire Tenodesis in Modern ACL Management

Lemaire Tenodesis has re-emerged as a valuable adjunct to intra-articular ACL reconstruction, particularly for patients at high risk of re-injury or those with significant anterolateral rotational instability. By providing external buttressing against rotational forces, it helps to create a more robust and stable knee, potentially reducing the incidence of ACL graft failure and improving long-term functional outcomes. As our understanding of knee biomechanics evolves, procedures like Lemaire Tenodesis underscore the importance of addressing the multifaceted nature of knee instability beyond just the ACL.