Combined Transphyseal and Lateral Extra-articular Pediatric Anterior Cruciate Ligament Reconstruction: A Novel Technique to Reduce ACL Reinjury While Allowing for Growth

Abstract

Background: Treatment of anterior cruciate ligament (ACL) injuries in the adolescent population continues to be complicated by an unacceptably high rate of secondary ACL injury. Purpose: To describe the failure rate and outcomes after a hybrid pediatric ACL reconstruction (ACLR) employing transphyseal hamstring (TPH) autograft combined with an extra-articular technique using an iliotibial band (ITB) autograft. Study Design: Case series; Level of evidence, 4. Methods: Consecutive patients undergoing combined TPH-ITB ACLR between January 2012 and April 2017 with a minimum 2-year follow-up were reviewed. With the goal of decreasing ACL graft injury in this high-risk group, this technique employed anteromedial portal drilling for TPH with an extraosseous femoral ITB technique and intra-articular TPH-ITB grafts fixed within the tibial bone tunnel. Demographics, bone age, standing alignment radiograph for growth and mechanical axis grade, return to sport, graft failure, and patient-reported outcome measures were analyzed. Results: A total of 61 knees in 60 adolescents underwent the combined TPH-ITB ACLR, with 57 knees (93.4%) meeting inclusion criteria with a mean follow-up of 38.5 months (range, 24-78 months). Only 3 of 57 knees (5.3%) sustained ACL reinjury. The mean age was 13.0 years (range, 11-16 years) with 36 male patients (mean bone age, 14.2 years) and 21 female patients (mean bone age, 13.3 years), and 91% of patients (52 of 57) returned to sport. Participants demonstrated a high functional level at final follow-up, with a mean score of 91.2 (range, 46.7-100) on the Pediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form and mean score of 22.4 (range, 4-30) on the Pediatric Functional Activity Brief Scale (Pedi-FABS). To critically assess growth, a cohort with ≥18 months of growth remaining at surgery was evaluated at maturity. No difference was seen in mean operative and nonoperative leg growth (49.7 mm and 49.8 mm). Although no family reported cosmetic or functional alignment or length concerns, 1 of 18 (5.5%) had a final limb length discrepancy >10 mm (12 mm) and a perioperative alignment difference (0-Grade II valgus). Conclusion: Combined TPH-ITB ACLR in adolescents resulted in high activity levels (Pedi-FABS, 22.4; median, 25) and a low (5.3%) graft failure rate at a mean 38.5 months.

ACL or ACL+

“…A 2019 case series of 60 adolescents who received a 4-stranded hamstring ACL graft combined with a modified MacIntosh extra-articular tenodesis documented a return to a high activity level with a 5.3% failure rate 38 months after surgery. 35 In still another case series, the Scientific ACL Network International (SANTI) Study Group reported the outcomes of a 4-stranded hamstring graft combined with a 2-armed reconstruction of the ALL. 33 Their patients averaged 24 years old (range, 11-55) and were selected according to anatomic- or activity-related factors that might predispose to an elevated rate of failure.…”

Pediatric Simple Knee Value: A simple patient-reported outcome measure for the knee

“…In their study, Gagliardi et al 13 found a median Lysholm score of 99.5 (IQR 89.0 to 100.0) and a median Pedi-IKDC of 94 (IQR 89 to 98) two years after ACLR in children ten to 18 years of age. Wilson et al 14 found a mean Pedi-IKDC of 91.2 (46.7 to 100) at 38.5 months after ACLR in 11- to 16-year-old children. In their literature review, Liechti et al 15 found the Lysholm score ranged between 85.4 and 96.3 at 12 months minimum after meniscal repair, whether or not ACLR was done in patients who averaged 15 years of age.…”

Lesões do Joelho associadas à Rotura do Ligamento Cruzado Anterior em População Pediátrica

“…34 Um estudo recente demonstrou que o uso de tenodese extra-articular lateral associada à reconstrução do LCA transfisária na população pediátrica tem bons resultados (apenas 5% de nova lesão), sem compromisso clinicamente relevante no crescimento do membro inferior intervencionado. 35…”