We present the case of a 46-year-old male patient, who owns a travel agency specialized in skiing and therefore skis over 60 days per season. He had an ACL tear 12 years ago and a Bone-Tendon-Bone autograft ACL reconstruction was performed at the time. He had a very good function until he sustained a motorcycle accident. Since then he complained of rotational instability with giving-way episodes and he was unable to resume his sporting activities.
At exploration he presented a positive Lachman test, a positive pivot shift test, and medial joint line tenderness. Plain radiographs revealed staples as the fixation method in his previous ACL reconstruction, with an intra-articular femoral staple (Figure 1(a)). Magnetic resonance imaging (MRI) showed absence of the ACL graft, a medial meniscus tear, and the presence of tibial and femoral metal staples (Figure 1(b)).
The plan was to remove staples and perform an anatomic single bundle ACL reconstruction with autologous quadruple hamstring graft, with a new, more anatomic, femoral tunnel with an outside-in retrograde femoral drilling, which is our standard technique at the present time.
Intra-articular arthroscopic exploration revealed a nonreparable-degenerative tear of the medial meniscus that was resected. Exploration of the intercondylar notch revealed the absence of the previous ACL graft. We were unable to remove the metal staple arthroscopically and the patient had refused an arthrotomy. We did have space to perform an anatomic femoral tunnel, more posterior and distal on the lateral wall, but we were concerned with staple acting as a knife and cutting our graft once placed (Figure 2).
We decided to perform an extra-articular tenodesis, by means of a modified Lemaire procedure. An 8 cm long incision was carried out centred over the lateral epicondyle. Dissection was carried down to the iliotibial band (ITB) fascial layer. The graft was designed having 8 to 10 cm in length and 1 cm wide (Figure 3(a)). Distal insertion in Gerdy's tubercule was left in place.
The lateral collateral ligament (LCL) was identified and a space under it was developed (Figure 3(b)). The graft was passed under the LCL and the isometric point proximal and posterior to the lateral epicondyle was identified. A guide pin was passed through the distal femur from lateral to medial. The graft was then prepared. We find it important to reinforce the graft with strong, solid-core sutures such as the Fiber-Loop (Arthrex, Naples, FL) to avoid graft damage when the interference screw is placed (Figure 4). We also do this on the tibial side of our standard ACL grafts.
The graft diameter was then measured and a 3 cm deep socket was drilled over the guide pin. The graft was introduced in the socket. Isometry of the graft was checked in range of motion and the role the tenodesis plays in limiting tibial internal rotation could be seen. The graft is secured with an interference screw (Bio-Interference Screw, Arthrex, Naples, FL) (Figure 5).
Postoperative care was slightly faster than we do in standard ACL reconstruction due to the favourable biologic environment of extra-articular tunnel graft healing. The patient presented a completely negative pivot shift and a slightly positive Lachman test with a soft endpoint. At 8-month followup the patient is satisfied with the treatment, feels that his knee is stable, has not had giving-way episodes, and has fully resumed his sporting activities.