BACKGROUND: Previous studies have shown that primary repair of proximal ligament avulsion from the femoral condyle may have reasonable recovery and stability rates after repair. As a result, selecting patients more narrowly and more specifically has been recognized to improve short- and medium-term outcomes.
OBJECTIVE: This study aimed to assess the potential benefits of primary repair for acute anterior cruciate ligament (ACL) tears with a proximal tear and to evaluate the effect of performing lateral extraarticular tenodesis (LET) in addition to primary repair on patient outcomes.
METHODS: Retrospective cohort study.
METHODS: This study was a retrospective cohort study. Thirty-eight patients between the ages of 21 and 40 years who underwent ACL repair surgery within the first 3 weeks after injury due to Sherman type 1 proximal ACL tears were evaluated. Group 1 (n = 18) underwent only primary ACL repair with knotless anchor, while Group 2 (n = 20) had LET with iliotibial band autograft in addition to primary repair. Patients were evaluated using various tests and scoring systems at 6, 12, and 24 months postoperatively.
RESULTS: There was no statistically significant difference between the groups in preoperative and postoperative 6- and 12-month visual analog scale (VAS) scores (P >0.05). However, the 24-month VAS score of Group 1 was statistically significantly higher than that of Group 2 (P <0.05). The preoperative International Knee Documentation Committee (IKDC) score of Group 1 was statistically significantly higher than that of Group 2 (p: 0.004; P <0.05). Group 1 had statistically significantly lower IKDC scores at postoperative 6, 12, and 24 months than Group 2. Similarly, Group 1 had statistically significantly lower Single Assessment Numeric Evaluation (SANE) and Tegner-Lysholm scores at postoperative 6, 12, and 24 months than Group 2 (P <0.05). The occurrence rate of Lachman positivity in the preoperative period was 28.6% in Group 1 and 33.3% in Group 2.
CONCLUSIONS: Our study suggests that performing LET with iliotibial band autograft in addition to primary ACL repair may lead to better outcomes in terms of pain relief, knee function, and stability compared with primary ACL repair alone.

OBJECTIVE: The Iliotibial band (ITB) is a fibrous thickening of the fascia lata originating at the iliac crest and inserting at Gerdy\'s tubercle on the lateral tibia. The ITB significantly contributes to lateral knee stabilisation. Due to its size, tensile strength and easy access, it is widely used in orthopaedic surgery as an autograft during reconstruction procedures. Although ITB harvesting may result in complications, such as reduced knee extension or hip flexion, no safety margins or guidelines have been proposed for the procedure. Our aim was to determine the maximal safe length of an ITB graft, that is, that does not harm the lateral collateral ligament (LCL), tensor fasciae latae (TFL), gluteus maximus (GM) or adjacent structures, and reduce the complication rate.
METHODS: The study included 50 lower limbs of 25 human cadavers, previously fixed in 10% formalin solution. The inclusion criterion was the lack of visible signs of surgical interventions in the study region. Forty lower limbs were included in the study: 16 female (mean age 83.1 ± 3.4 years) and 24 male (mean age 84.2 ± 6.8 years). Dissection was performed with a previously established protocol. Morphometric measurements were then obtained twice by two researchers.
RESULTS: The mean femur length was 404.8 mm [female (F) = 397.3 mm, male (M) = 409.9 mm, standard deviation (SD): F = 23.8 mm, M = 24.1 mm]. The mean ITB length was 318.9 mm (F = 309.4 mm, M = 325.2 mm, SD: F = 25.7 mm, M = 33.7 mm). Longer femurs were associated with longer ITB (p < 0.05). The mean distance from the insertion of the GM to the myofascial junction of TFL and ITB was 34.6 mm (F = 34.5 mm, M = 34.6 mm, SD: F = 3.2 mm, M = 3.3 mm). The longer femurs or ITBs demonstrated a greater distance from GM insertion to the myofascial junction of the TFL and ITB (p < 0.05).
CONCLUSIONS: ITB grafts longer than 21 cm may contribute to the greater risk of TFL rupture. Based on simple measurements of the femur length, the surgeon may assess approximate ITB length, and thus assess the length of the maximal graft length. Moreover, to avoid harming the LCL, the incision should be performed 5 cm proximal to the articular surface of the lateral femoral condyle or 13 mm proximal to the lateral femoral epicondyle. Such preparation and preoperative planning may greatly reduce the risk of complications during ITB harvesting, while performing, for instance, the over-the-top technique for anterior cruciate ligament reconstruction in skeletally immature patients.
UNASSIGNED: Basic I.

Patellofemoral pain (PFP) is one of the most common sports injuries of the knee joint and has a high persistence and recurrence rate. Medio-lateral patellar position in the knee extension position during contraction is associated with PFP. However, soft tissue tension that most influences the medio-lateral patellar position in the knee extension position during contraction in vivo is unclear. We aimed to clarify the relationship between medio-lateral patellar position and soft tissue tension around the knee joint. Twelve patients with PFP and 20 healthy participants were included. Medio-lateral patellar position and tension of the rectus femoris, vastus lateralis (VL), vastus medialis, iliotibial band (ITB), lateral patellofemoral ligament, and medial patellofemoral ligament were measured during contraction and rest. The tensions of the VL and ITB during contraction and the medio-lateral patellar position at rest were significantly associated with medio-lateral patellar position during contraction (β = 0.449, 0.354, and 0.393, respectively). In addition, the tension of ITB was significantly associated with the medio-lateral patellar position at rest (β = 0.646). These relationships were not affected by the presence of PFP. These findings suggest that the patellar position during contraction became more lateral as the tension in the VL and ITB increased, regardless of the presence of PFP. These results may facilitate the prevention and treatment of PFP.

OBJECTIVE: To evaluate the anxiety level to perform movements in patients after revision anterior cruciate ligament reconstruction (ACLR) combined with lateral extra-articular tenodesis (LET) compared to patients after revision ACLR without LET.
METHODS: Ninety patients who underwent revision ACLR with ipsilateral bone-patellar tendon-bone autograft and with a minimum of 12 months follow-up were included in this study. Patients were divided into two groups: patients who received revision ACLR in combination with LET (revision ACLR_LET group; mean follow-up: 29.4 months, range: 12-80 months), and patients who received revision ACLR without LET (revision ACLR group; mean follow-up: 61.1 months, range: 22-192 months). All patients filled in a questionnaire about anxiety level related to physical activity and sports, the Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee subjective form (IKDCsubjective), and the Tegner Activity Score.
RESULTS: Patients in the revision ACLR_LET group had a significantly lower anxiety level to perform movements than patients in the revision ACLR group (p < 0.05). No significant differences were found in KOOS, IKDCsubjective, and Tegner Activity Scores.
CONCLUSIONS: Patients who received LET in addition to revision ACLR have a lower anxiety level to perform movements than patients with revision ACLR alone, despite non-different subjective functional outcomes.
METHODS: Retrospective cohort study, Level of evidence: III.

Isolated lateral-sided knee pain is a unique problem following total knee arthroplasty (TKA). Reported causes include soft tissue impingement against extruded cement, an overhanging tibial tray, remnant osteophytes rubbing against the iliotibial band (ITB), popliteal tendon impingement, fabella syndrome, and synovial tissue impingement in the lateral gutter. In addition, iliotibial band traction syndrome secondary to guided motion Bi-cruciate stabilizing knee arthroplasty has been recognized as a new clinical entity. Initial work up should include ruling out the most common causes of painful TKA including infection, aseptic loosening, and instability. Radiographs and CT scan are utilized to identify potential source of pain. Ultrasound evaluation (with elicited probe tenderness) can increase diagnostic accuracy. Ultrasound guided local anesthetic injections can confirm the source of pain. Anti-inflammatory medications, physical therapy with ITB stretches, and therapeutic local steroid injections are initial treatment modalities. Satisfactory resolution of symptoms may require surgical intervention directed at the specific cause and may avoid the morbidity associated with revision TKA.

This classic discusses Marcel Lemaire\'s original publications in the context of modern surgical practice, including a description of his original lateral extra-articular tenodesis. Previously published in French, these translations shed light on his revelations regarding the anterior cruciate ligament\'s role in knee stability and his detailed insights into the ressaut rotatoire or the pivot shift phenomenon. We track the evolution of Lemaire\'s procedure since the publication of his original technique in 1967 which used a nylon cord superficial to the lateral collateral ligament followed by cast immobilisation for one month. We report his patient outcomes as he refines his methods through experiential learning. Lemaire\'s fundamental concepts in relation to anterior cruciate ligament deficiency remain relevant in contemporary clinical practice. Furthermore, the \"modified Lemaire technique\" has emerged as one of the preferred methods for lateral extra-articular tenodesis. We hope that disseminating his thoughts to a wider audience will help enlighten the ongoing debate regarding the management of rotatory instability. LEVEL OF EVIDENCE: V - Expert Opinion.

BACKGROUND: The lateral extra-articular tenodesis (LET) procedure associated with anterior cruciate ligament (ACL) reconstruction can be considered in selected patients to diminish the risk of persistent rotatory instability and achieve a protective effect on the graft. Several techniques have been described in the literature to treat rotatory instability. Usually, a strip of the iliotibial band (ITB) is harvested from its middle while leaving the distal insertion, then passed underneath the lateral collateral ligament and fixed on the lateral aspect of the distal femur with various fixation methods such as staples, screws, anchors or extracortical suspensory devices. Despite their effectiveness, these fixation methods may be associated with complications such as lateral pain, over-constraint and tunnel convergence.
METHODS: This study presents a detailed surgical description of a new technique to perform an LET during ACL reconstruction with any type of graft fixing the ITB strip with the sutures of the ACL femoral button, comparing its pros and cons in relation to similar techniques found in the literature.
CONCLUSIONS: This technique represents a reproducible, easy to learn and inexpensive solution to perform a lateral extra-articular tenodesis associated with an ACL reconstruction using the high-resistance sutures of the femoral button.

The way in which force increases in the anterolateral tissues and the lateral extra-articular tenodesis (LET) tissue to resist internal rotation (IR) of the tibia after anterior cruciate ligament (ACL) reconstruction in isolation and after LET augmentation, respectively, is not well understood.
(1) To compare in a cadaveric model how force increases (ie, engages) in the anterolateral tissues with IR of the tibia after isolated ACL reconstruction and in the LET tissue after augmentation of the ACL reconstruction with LET and (2) to determine whether IR of the tibia is related to engagement of the LET tissue.
Controlled laboratory study.
IR moments were applied to 9 human cadaveric knees at 0°, 30°, 60°, and 90° of flexion using a robotic manipulator. Each knee was tested in 2 states: (1) after isolated ACL reconstruction with intact anterolateral tissues and (2) after LET was performed using a modified Lemaire technique with the LET tissue fixed at 60° of flexion under 44 N of tension. Resultant forces carried by the anterolateral tissues and the LET tissue were determined via superposition. The way force increased in these tissues was characterized via parameters of tissue engagement, namely in situ slack, in situ stiffness, and tissue force at peak applied IR moment, and then compared (α < .05). IR was related to parameters of engagement of the LET tissue via simple linear regression (α < .05).
The LET tissue exhibited less in situ slack than the anterolateral tissues at 30°, 60°, and 90° of flexion (P≤ .04) and greater in situ stiffness at 30° and 90° of flexion (P≤ .043). The LET tissue carried greater force at the peak applied IR moment at 0° and 30° of flexion (P≤ .01). IR was related to the in situ slack of the LET tissue (R2≥ 0.88; P≤ .0003).
LET increased restraint to IR of the tibia compared with the anterolateral tissue, particularly at 30°, 60°, and 90° of flexion. IR of the tibia was positively associated with in situ slack of the LET tissue.
Fixing the LET at 60° of flexion still provided IR restraint in the more functionally relevant flexion angle of 30°. Surgeons should pay close attention to the angle of internal and/or external tibial rotation when fixing the LET tissue intraoperatively because this surgical parameter is related to in situ slack of the LET tissue and, therefore, the amount of IR of the tibia.

UNASSIGNED: Bone-patellar tendon-bone (BTB) anterior cruciate ligament reconstruction (ACLR) is one of the conventional techniques in the revision setting especially after a primary hamstring tendon graft. The use of the iliotibial band (ITB) augmented with allograft (AG) is an encouraging graft alternative for ACLR in terms of clinical and biomechanical data in the literature.
UNASSIGNED: To compare the clinical outcomes of BTB graft with lateral extra-articular tenodesis, modified Lemaire (BTB-LET), and an ITB graft augmented with hamstring AG (ITB-AG) in the setting of revision ACLR.
UNASSIGNED: Cohort study; Level of evidence, 3.
UNASSIGNED: Descriptive data and clinical outcomes were prospectively collected from patients who underwent revision ACLR with either the BTB-LET or ITB-AG technique between 2012 and 2020 and who had a minimum follow-up of 2 years. The clinical outcomes were assessed by the Lysholm, Tegner, Anterior Cruciate Ligament-Return to Sport after Injury, International Knee Documentation Committee subjective knee evaluation form, and Knee injury and Osteoarthritis Outcome Score. Return to sports, complications, and revisions were also analyzed.
UNASSIGNED: A total of 167 patients were included, with 106 patients in the BTB-LET group and 61 patients in the ITB-AG group. There were no significant group differences in sociodemographic characteristics; however, the mean follow-up was significantly longer in the BTB-LET compared with the ITB-AG group (52.0 vs 38.8 months, respectively; P = .0001). There were no significant differences in postoperative outcome scores; however, patients in the ITB-AG group had a higher rate of return to competitive pivoting sports (32.8% vs 17.9%; P = .0288) and a higher overall rate of return to preinjury sport (63.9% vs 47.2%; P = .0365). Complications, including revisions for meniscal or chondral lesions and retears (8 [8.3%] in the BTB-LET group and 2 [4.0%] in the ITB-AG group), were not significantly different. All retears were due to sports-related accidents.
UNASSIGNED: In this study, ITB-AG was not different from BTB-LET in terms of functional outcomes scores but allowed better return to sport rate. Performing ITB-AG reconstruction in the setting of revision ACLR appears to be safe, effective, and associated with a satisfying return-to-sports rate.

OBJECTIVE: External snapping hip syndrome (ESHS) was historically attributed to isolated iliotibial band (ITB) contracture. However, the gluteus maximus complex (GMC) may also be involved. This study aimed to intraoperatively identify the ESHS origin and assess the outcomes of endoscopic treatment based on the identified aetiological type.
METHODS: From 2008-2014, 30 consecutive patients (34 hips) with symptomatic ESHS cases refractory to conservative treatment underwent endoscopic stepwise \"fan-like\" release, gradually addressing all known reasons of ESHS: from the isolated ITB, through the fascial part of the GMC until a partial release of gluteus maximus femoral attachment occurred. Snapping was assessed intra-operatively after each surgical step and prospectively recorded. Functional outcomes were assessed via the MAHORN Hip Outcome Tool (MHOT-14).
RESULTS: Twenty seven patients (31 hips) were available to follow-up at 24-56 months. In all cases, complete snapping resolution was achieved intra-operatively: in seven cases (22.6%) after isolated ITB release, in 22 cases (70.9%), after release of ITB + fascial part of the GMC, and in two cases (6.5%) after ITB + fascial GMC release + partial release of GM femoral insertion. At follow-up, there were no snapping recurrences and MHOT-14 score significantly increased from a pre-operative average of 46 to 93(p<0.001).
CONCLUSIONS: Intraoperative identification and gradual addressing of all known causes of ESHS allows for maximum preservation of surrounding tissue during surgery while precisely targeting the directly involved structures. Endoscopic stepwise \"fan-like\" release of the ITB and GMC is an effective, tailor-made treatment option for ESHS regardless of the snapping origin in the patients with possibility to manually reproduce the snapping.