Trends in Anterolateral Ligament Reconstruction and Lateral Extra-articular Tenodesis With ACL Reconstruction in Children and Adolescents

Abstract

Background: Anterolateral ligament reconstruction (ALLR) and lateral extra-articular tenodesis (LET) show promise in lowering the risk of rerupture after anterior cruciate ligament reconstruction (ACLR), but there are little data on surgeon practices and preferences in children and adolescents. Purpose: To quantify surgeon practices regarding ALLR and LET in the pediatric population. Study Design: Cross-sectional study. Methods: An electronic survey was administered to 87 surgeons in the Pediatric Research in Sports Medicine society. The questionnaire asked several questions about surgeon and practice characteristics as well as indications, preferences, and techniques for ALLR or LET in the context of primary and revision pediatric ACLR. Chi-square and Fisher exact tests were used to evaluate factors that affect surgical preferences. Results: A total of 63 surgeons completed the survey, of whom 62% performed ≥50 pediatric ACLRs annually; 56% sometimes performed anterolateral augmentation with primary ACLR, and 79% with revision ACLR. The most common indications for ALLR or LET in the primary setting were high-grade pivot shift, knee hyperextension, generalized laxity, and type of sports participation. Surgeons whose practice was >75% sports medicine were more likely to perform ALLR or LET with both primary and revision ACLR ( P = .005 and P < .001, respectively). Those who had completed a sports medicine fellowship were more likely to perform these procedures than those with only pediatric orthopaedic training, in both primary (68% vs 36%; P = .01) and revision scenarios (92% vs 60%; P = .002). Of the 28 respondents who did not perform ALLR or LET with primary ACLR, 75% cited insufficient evidence as the reason. However, 96% of surgeons who did perform these procedures expressed interest in studying them prospectively, and 87% were willing to randomize patients. Conclusion: Findings indicated that 56% of pediatric sports surgeons sometimes perform anterolateral augmentation with primary ACLR and 79% with revision ACLR. Surgeons with sports medicine fellowship training or a mostly sports practice were more likely to perform these procedures. Insufficient evidence was the most common reason given by surgeons who did not perform anterolateral augmentation. However, there was substantial willingness to prospectively study and even randomize pediatric patients to assess the impact of ALLR or LET in this population.

A systematic review of transphyseal ACL reconstruction in children and adolescents: comparing the transtibial and independent femoral tunnel drilling techniques

“…In recent years there has been an increasing interest in lateral extra-articular procedures in pediatric patients with an ACL injury [ 46 , 47 ]. A recent survey among American orthopaedic surgeons has shown that 56% performed an anterolateral augmentation with primary ACL reconstruction in rare cases, and 79% in revision ACLR.…”

Impact of Lateral Extra-Articular Procedure Augmentation on Rerupture Risk and Tegner Activity Scale Outcomes in Adolescent Anterior Cruciate Ligament: A Matched Comparative Study With a Minimum 2-Year Follow-up

“…24 This study revealed that only 56% of surgeons sometimes performed LEAP with primary ACLR and 79% with revision ACLR, with the predominant deterrent being a perceived lack of sufficient evidence to support these practices. 24 The primary aim of this study was to evaluate the rate of rerupture after ACLR in adolescent patients when treated with or without LEAP. The secondary aim of this study was to compare the rates of non-graft rupture related reoperation and functional outcomes of these 2 strategies, considering several patient-reported outcome measures and return to sport (RTS).…”

A Review of Current Concepts of the Anterolateral Complex of the Knee

“…77 Madhan et al in a recent study children and adolescent patients found that 56% of pediatric sports surgeons sometimes perform anterolateral augmentation with primary ACLR and 79% with revision ACLR. 78 Another systematic review with the meta-analysis by Na et al; found that anterolateral ligament reconstruction (ALLR) appeared to be a better option for improving rotational stability compared than extra-articular tenodesis (LET). 79 However, more prospective comparative studies are needed to assess if there is a significant difference between two surgical techniques with a view to clinical outcomes.…”