## 1 Introduction  
Medial rotation laxity after anterior cruciate ligament reconstruction (ACLr) has a profound impact on the quality of life [1, 2] and is a key clinical challenge for single-bundle reconstruction in different femoral drillings [3, 4, 5, 6]. Thus, lateral extra-articular tenodesis (LET) has developed because all anterolateral knee structures contribute to minimizing anterolateral rotational laxity, and LET accounts for an increased rotatory knee arm [7, 8, 9], complementing single-bundle ACLr. Unfortunately, double-bundle ACLr promotes enlarged femoral tunnels, being the highest obstacle for ACLr revision surgeries due to a lack of bone stock [10]. Because of that, there is clinical interest in exploring how LET and femoral tunnel drillings for single-bundle ACLr may diminish the maximal stress of grafts during knee medial rotation and how this can change the graft stress distribution to avoid early graft failure or femoral tunnel windowing or enlargement [5; 6; 11]. It is expected that a more deflected graft as part of the anteromedial (AM) portal technique would better constrain the knee rotation compared to the traditional transtibial technique (TT) and the hybrid transtibial technique (HTT) [3; 12; 13; 14; 15], but whether LET combined with the HTT or TT would diminish the stress graft during medial knee rotation is unknown. The LET is an augmentation technique made for residual rotatory knee movements [6; 16; 17] and is able to reduce up to 43% of graft stress [18]. This stress reduction is relevant to prevent graft failure and stress concentration in single-bundle ACLr [6]. LET biomechanics is generally similar to anterolateral ligament biomechanics because they have similar orientations, and both constrain medial knee rotation [19; 20]. Lemaire, Macintosh, Losee, Arnold-Coker, Ellison, and others are different LET choices [6; 17; 18]. However, these techniques demand a higher surgical time and are expensive due to the need for fixation elements and tunneling, procedures that can increase the risk of persistent knee pain [21; 22]. As an alternative, one of the LET techniques that involves only soft tissue is the litoibial band, which passes under the fibular or lateral collateral ligament (LCL) and goes through the femoral intermuscular septum [16]. The final fixation is distally made with five independent high-resistance stitches [23]. This technique is based on the Macintosh and Arnold-Coker procedure, discarding the osteoperiosteal flap [24]. It is reproducible, easy to replicate, inexpensive, and without risk of tunnel coalition [24]. In addition, according to the LET state of the art, a proximal attachment to the lateral femoral epicondyle and beneath the LCL will prevent excessive tightening or slackening during knee movement [18]. On the other hand, finite element (FE) is a numerical and computational method that allows the division of complex structures into smaller ones to simplify the analysis of the entire structure [25]. It has emerged as a potent method in orthopedic surgery, providing surgeons, physical therapists, and biomechanics with enhanced insights into biomechanical factors associated with surgical techniques [25]. Although the FE method could give interesting outcomes and allow an understanding of the mechanical factor roles, there are several limitations associated with geometric complexity or material properties that can complicate the accuracy of the models [25; 26], as well as other non-modeling elements that can occur during clinical settings with patients that limit its complete extrapolation to real-life applications. Regarding FE advantages, this technique would allow an understanding of the maximum principal stresses and the stress distribution on grafts following the addition of an litoibial band-intermuscular septum LET for TT, HTT, and AM femoral tunnels in ACLr under medial knee rotation.