Lateral augmentation procedures in anatomic anterior cruciate ligament reconstruction. How to avoid tunnel collision with intraoperative tunnel visualization: A technical note.

Lateral extra-articular tenodesis (LET) or anterolateral ligament (ALL) reconstruction can be used as an augmentation procedure in anatomic anterior cruciate ligament (ACL) reconstruction and are thought to minimize rotational instability, lower re-rupture rates of the ACL graft and improve functional outcomes after surgery. Young patients with high-grade pivot shift or generalized laxity participating in high demand/pivoting sports are considered as the ideal candidates for such a procedure. Both in LET and in ALL reconstruction, femoral fixation of the graft using an interference screw remains a challenge due to the possibility of tunnel convergence of the two tunnels created in the femur, namely the ACL femoral tunnel and the tunnel created in the lateral femur for the LET or ALL procedure. With this technical note, we aim to describe a safe approach for femoral tunnel creation by providing the surgeon not only with instructions for a safe orientation but also with the possibility to check for a possible tunnel collision by using the arthroscope through the anteromedial portal. Although instructions can be used both for LET and ALL reconstruction (same femoral tunnel), a modified Lemaire LET is extensively described since this procedure is the authors' preference for augmenting anatomic ACL reconstruction.