We’re starting to see more and more ACL reconstruction procedures with an LET, or lateral extra-articular tenodesis. Especially in revisions and younger female athletes.
In this episode we talk about the technique, how it changes the rehab progression, and some tips on what to watch out for.
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#AskMikeReinold Episode 353: ACL Reconstruction with Lateral Extra-Articular Tenodesis (LET)
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Show Notes
• Eval and Treatment of the Knee Masterclass
Transcript
Gavin Harden:
All right, so the first question we have, Joseph from Texas asks, “I’m starting to see more patients from a surgeon near me that have an LET procedure in addition to their ACL reconstruction. I’m not 100% sure what that means. Questions for the group. What exactly is an LET? Why should someone need it, and how does that impact the rehabilitation?”
Mike Reinold:
Awesome. Great job, Gav. Welcome. First one, he’s in. I think future episodes we’re going to see that you just continue to grow. I think it’s going to be great. I love it. But all right. LET with ACL reconstruction. So LET, lateral extra-articular tenodesis, that’s what means.
Dave Tilley:
Never heard of it.
Mike Reinold:
You could argue it could be LEAT. Do you hyphenate the extra-articular and then would you use that? Is extra-articular one word or is it hyphenated?
Dave Tilley:
I think it’s one word.
Lenny Macrina:
I think it’s one word.
Mike Reinold:
Okay. All right. My bad then, sometimes I like to throw a hyphen in. That’s just…
Dan Pope:
Google says hyphen.
Dave Tilley:
It’s just me, I’m just that guy.
Mike Reinold:
I don’t know, I guess so, because interarticular I wouldn’t put one. Anyway, I feel like we’re off-topic. Let’s get back on topic.
All right, so what’s an LET? Let’s start with that because that was Joseph’s first question is, “What is an LET, a lateral extra-articular tenodesis? Len is our resident knee… That’s all you. I think that’s all you know how to do at this point.
Lenny Macrina:
Yeah.
Mike Reinold:
Why don’t you start with talking about what it is and then we can talk a little bit about what that does. But what is an LET and why would somebody get it?
Lenny Macrina:
Right. An LET is basically using the IT band as an extra stabilizer of the knee. And so, if you know the IT band comes down, laterally attaches to Gerdy’s tubercle on the tibia. They leave the distal attachment attached. They take out a middle portion, picture they just take this little saw and just cut a little piece, long enough to create a ligament, but leave it attached, proximally and distally, and it’s just this flap that’s coming from the distal attachment. And they move that to the lateral, basically, femur. And it’s trying to create more of a rotatory stabilizer for the knee because the ALL, which is one of those newer, quote-unquote, I’m quote-unquoting, for people just listening, newer ligaments that was discovered or something like that a decade ago… That ligament has been shown to be a stabilizer.
But from talking to surgeons, it’s a tough thickening to identify when you’re in the heat of battle, from what I understand. And so, a lot of surgeons can either try to repair that or they do this lateral extra-articulate tenodesis, also known as a Lemaire’s tenodesis, I think he’s like a French surgeon or something like that, who came up with the procedure. And so it’s, again, a rotatory stabilizer of the knee.
Research has been done on it, and with a concomitant ACL reconstruction, and it’s been shown to decrease the incidence of tears and re-tears in people. So I think it’s more appropriate for the people that are higher risk, your teenage, female, maybe your teenage male, who’s got super laxity, a previous history of an ACL, things like that, are the people that will get this procedure done.
And it’s, again, it’s a surgical decision. It’s something’s probably made prior to surgery, it’s not like they’re in there… Or maybe they’re in there and they’re doing a pivot shift test and they see that the knee is still not stable and they’ve already agreed to potentially do this surgery, prior to the surgery, where they’ll add this on, if the patellar tendon graft, or hamstring graft, or quad tendon graft is not sufficient with the intraarticular or intraoperative pivot shift.
Mike Reinold:
You know what, Len? I’m not going to lie. You far exceeded my expectations on that question. That was impressive. Did you just Google that this morning?
Lenny Macrina:
It’s somewhere in this melon. The coffee’s flowing, so apparently I pulled it out appropriately.
Mike Reinold:
That’s awesome.
Kev, I know you’re, to use Lenny’s term, you’re in the heat of the battle right now. What do these people look like after surgery? Do they look any different to you? What do you guys experience on some of these and how they present?
Kevin Coughlin:
Yeah, I have one person on my caseload with it now, and just to reinforce what Lenny said, it is someone who is in that younger, higher-risk cohort. So the younger adolescent female who’s very hypermobile, on her non-operative side, she has about 10 degrees of hyperextension in her knee.
So, the surgeon that she went to, I think for this cohort, tends to just do this procedure all the time with his ACLs. And I would say she had a hamstring graft. So, I think with the LET she had a little more anterior knee pain than I would traditionally see in just a hamstring graft. But otherwise, this doctor doesn’t put extra restrictions on it in terms of range of motion, or weight-bearing, or anything like that. So it does seem to be a pretty traditional rehab. There’s not a lot of big changes, at least early on.
As we’re getting a little further down the road, I think some of the times that we see the IT band working a lot, which would be motions that are resisting or controlling hip extension with the knee flexing. But traditional things that are challenging in ACL rehab are still challenging. And I wonder if it’s a little bit because of the LET or just because it’s challenging because it’s post-op ACL.
So, from my experience with the few that I’ve seen, it doesn’t seem to impact it too, too much.
The other cohort that I’ve seen it in, like Lenny mentioned, I think we co-treated a college baseball player last year, Lenny, that had… He re-tore, popping over the fence, the pitcher, and that was a tough re-tear, but they did an LET on him as well.
Do you remember, was that the same surgeon, or was that someone different?
Lenny Macrina:
Different.
Kevin Coughlin:
Yeah. So it does seem like the revision surgeries, they’re doing it as well to try to prevent another one. But it doesn’t seem like the rehab process is all that different.
Mike Reinold:
Right. Makes sense. Are there any differences in the rehab process?
Lenny Macrina:
I would say you’re not going to see different precautions, typically. Yeah, I think you’ll see a little bit more pain and swelling with these just because of the nature of taking down more tissue. You’re dissecting the IT band, you’re screwing it into the lateral femur, and then there’s a big incision. It’s not a tiny quad tendon graft incision. It’s got some size to it so they can get full dissection. But I think that’s painful.
And a generalization that I’ve observed in talking to Kevin, and Dr. Andrews, and people like that over the years is lateral structural stuff causes more pain and swelling. Medial structural stuff causes more stiffness. So MCLs get stiff. Lateral stuff, lateral IT band stuff, gets more swollen. I don’t know if it has to do with blood flow to the knee, arteries, lateral or whatever, or nerve bundles, but they tend to get more painful and more swollen with the old school lateral release IT band, LETs versus that medial side, where it’s like an MPFL that gets stiff or an MCL that gets stiff. So just a generalization little pearl for the audience.
Mike Reinold:
Yeah, makes sense. I feel like any time we add something to a procedure, the majority of people are probably going to be more cautious with it. Physical therapy-wise, they’re going to want to go a little slower. They’re going to want to be more deliberate with it.
And I don’t know if that’s the answer here. There’s really no reason why we couldn’t. Anything that’s going to stress the LET also stresses the ACL and is already built into the protocol, theoretically.
So, I’ll go back to what Lenny said, and you have more tissue involved, you have the potential for more swelling. That’s a person I want to be more on top of in the early phases of the rehab process because there’s more trauma being done, more done to the joint, that you just need to be really, really careful with.
The procedure makes sense to me, though.
Lenny Macrina:
It does. And the research is backing it up with decreased re-tear rates. So it’s one of those things that we have in our back pocket to do for somebody, especially who already had one, and they’re fearful they’re going to re-tear again, and this seems to significantly help, which is encouraging.
Mike Reinold:
Yeah. Yeah, I’m excited for it. I think we’re going to start seeing it more and more with people, especially just being done, almost prospectively in the young female athlete or somebody that you think just might be really tough.
But again, maybe this is why our ACL rates aren’t as high as we want. Maybe. It’s crazy to think that you have an injury in the knee, you hurt one ligament, and everything else around the knee is magically fine. There’s no capsular issues, there’s no rotary issues. So, it’s almost like this is taking that three-dimensional step.
And don’t get me wrong, the ACL, you could argue, works three-dimensionally. Of course it does biomechanically, but it definitely works in one point more than the others. So a capsular, this is pretty cool.
Lenny Macrina:
And keep in mind the ACL, the native ACL is a two-bundle ligament. And we only reconstruct one bundle. So we put it at an angle to try to capture that rotatory stability and the AP translation, but we only put one bundle in it and that’s what Freddie Fu, out of Pittsburgh, tried to do. He did that with his surgeries and I don’t think the research screamed it was a game changer, so it didn’t really catch on with everybody.
So, you’re trying to reconstruct what the native is there, but it’s not perfect.
I will say going back to the rehab portion, I would be cautious with doing some AB duction-type stuff, like a sidelining AB duction, like the basic stuff we do early on, you just don’t want to stress that lateral side too early. Remember they did take a chunk of the IT band out, so a weighted, heavy-weighted sideline hip AB duction, I tend to be a little cautious with that. It’s one of those, why stress it too much? It’s already stressed from the surgery, so I would just be cautious with sideline AB duction.
Mike Reinold:
Yeah, and you can accomplish… You can get some hip strengthening in other positions, in other things too, but IT band’s huge. You don’t need it all.
Lenny Macrina:
Right.
Mike Reinold:
That’s awesome. Lisa?
Lisa Lowe:
Just as one of us who doesn’t really treat ACLs very often, I have a question. As the IT band heals and over time do you guys see it get wicked sticky, where that piece came out? What happens to the donor part that they pull from there?
Lenny Macrina:
Yeah, I haven’t seen anything in my patients. It tends to heal pretty well. And I don’t know if I’ve ever seen a second, I don’t know if anybody’s ever doing a second look, or maybe an ultrasound to see. I imagine the tissue fills in with scar tissue or something like that. Or it’s just like the gap is big enough that they took, that it just remains like that.
But I haven’t seen any issues longer-term or short-term, short-term, midterm where there’s an issue.
So, there’s probably going to be somebody up there that had that, but nothing that I’ve seen. How about you, Kevin?
Kevin Coughlin:
No, yeah, I would agree. I haven’t really seen anything from a mobility standpoint changing. But I think I remember Dan and I did a little review on the IT band. And it is pretty important, it acts like a tendon when you’re running. So I would imagine that some of that capacity is decreased and the load has to go somewhere else. So I would think it’s important to just, in the rehab process, continue to strengthen all the lower extremity tendons important in running and take a little load off the IT band. But I hadn’t seen any mobility changes, per se.
Mike Reinold:
I would imagine all the things that we do already probably mitigate that, right? Our soft tissue work, our patellar mobility, our range of motion progression probably mitigates that, too. So, awesome.
Well, I’m looking forward to seeing this in 10 years. I don’t want to see it in one year. I want to see it in 10 years and just see how these outcomes have improved because I think that’s the key to this sort of thing. But pretty exciting.
So, great question, Joseph. Thanks for asking.
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