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

Trends in lateral extra-articular augmentation use and surgical technique with anterior cruciate ligament reconstruction from 2016-2023, an ACL Study Group Survey

PURPOSE

To survey the ACL study group (ACLSG) members to determine the current practice patterns surrounding the use and methodology of lateral extra-articular procedures (LEAPs), including anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) during ACL reconstruction (ACLR).

METHODS

A web-based questionnaire was distributed to members of the ACLSG during the 2016, 2018, 2020, and 2023 biennial meetings. Questions explored the indications and techniques when incorporating LEAPs in ACLR.

RESULTS

Analysis of survey responses found that the reported use of LEAPs in both primary and revision ACLR significantly increased between 2016 and 2023 and that surgeons were using lateral augmentation more frequently over time. Surgical techniques were stable across survey years, with most surgeons using iliotibial band (ITB) autograft attached at Gerdy's tubercle, passed under the lateral collateral ligament (LCL), and anchored proximal/posterior to the lateral femoral epicondyle.

CONCLUSION

Survey responses demonstrate that LEAPs are becoming more common among ACL surgeons in the ACL SG, with the modified Lemaire LET being the predominant technique. This aligns with recent clinical studies showing improved outcomes and reduced risk of failure in ACLR with lateral augmentation compared to ACLR alone.

LEVEL OF EVIDENCE

Level V, Expert Opinion.

Lateral Extra-articular Tenodesis Augmentation of Anterior Cruciate Ligament Reconstruction Is Most Commonly Indicated for Pivot Shift of Grade 2 or Greater and for Revision Anterior Cruciate Ligament Reconstruction

PURPOSE

To determine the most common indications for lateral extra-articular tenodesis (LET) augmentation of anterior cruciate ligament reconstruction (ACLR).

METHODS

A systematic review of the literature was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched PubMed, Embase, Web of Science, and Cochrane Database of Systematic Reviews from 2000 to the present (June 2022). Studies that met the following criteria were included: patients of any age who underwent LET in addition to ACLR, studies reporting at least 1 indication for LET, and observational/randomized controlled trial study designs including prevalence of indications. Publications had to be reported in English and peer reviewed and to have originated in the United States or countries offering identical protocols and procedures.

RESULTS

A total of 463 studies were identified from the initial search, 23 of which met inclusion criteria and were included in the review. Eight of the 23 studies (34.8%) used a modified Lemaire technique, seven (30.4%) used a MacIntosh modified by Arnold-Coker, and eight (34.8%) used other techniques to perform LET. A total of 2,125 patients (53% female, 47% male [3 studies did not report sex]) underwent ACLR augmented with LET. The indications along with prevalence were as follows: positive pivot shift test (grade ≥2) (19 of 23, 82.6%), revision ACLR (12 of 23, 52.2%), ligamentous laxity (11 of 23, 47.8%), general sports participation (11 of 23, 47.8%), age less than 25 years (8 of 23, 34.8%), high risk of graft failure (5 of 23, 21.7%), and positive Lachman test (4 of 23, 17.4%).

CONCLUSIONS

Pivot shift grade ≥2 was the most common reason orthopaedic surgeons chose to add LET to ACLR, with revision ACLR, patient age <25, and general sports participation following closely behind.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Transphyseal arthroscopic anterior cruciate ligament reconstruction in children under 12 years

BACKGROUND

The incidence of anterior cruciate ligament (ACL) injuries in children is on the rise. Despite this trend, the optimal management of these injuries remains a matter of ongoing debate. In this light, our study seeks to assess the clinical, radiological, and functional outcomes of transphyseal ACL reconstruction in preadolescent patients in the medium-term.

METHODS

This prospective study included preadolescent patients aged up to 12 years who underwent ACL transphyseal reconstruction between 2010 and 2020 and had a minimum follow-up of 2 years. Clinical assessments encompassed joint stability and range of motion. Furthermore, leg length discrepancy (LLD) and femorotibial alignment were evaluated both clinically and radiologically using full-length lower limb standing radiographs. Pre- and postoperative functional outcomes were assessed using the International Knee Documentation Committee (IKDC) and Lysholm scales, and the return to normal sports activity was evaluated using the ACL-Return to Sport after Injury (ACL-RSI) scale. Complications and relevant follow-up data were also recorded. Statistical analyses were conducted to evaluate these outcomes.

RESULTS

A total of 35 preadolescent patients, consisting of 24 males and 11 females, with a mean age at surgery of 11.2 ± 0.7 years (8.7-12), were included in the study. The mean follow-up was 52.3 ± 20.7 months (24.1-95.9). No significant growth disturbances or clinically relevant LLD were evidenced. All patients demonstrated clinically stable knees with full range of motion at the 2-year follow-up. There were statistically significant improvements in pre- and postoperative IKDC (39.3 ± 13.5 vs. 99.7 ± 0.8, p < 0.005) and Lysholm scores (48.2 ± 15.1 vs. 99.6 ± 1.4, p < 0.005). All but two patients were able to return to their pre-injury level of sports activity, with a mean ACL-RSI score of 93.5 ± 1.3. The analysis revealed an 8.6% rerupture rate and an 11.4% rate of contralateral ACL injuries, with 5-year survival rates of 92.3% and 88.8%, respectively. Subgroup analyses based on age, gender, surgical delay, or associated meniscal lesions did not reveal any significant differences in functional outcomes. Additionally, there was no discernible relationship between age or timing of ACL reconstruction and the risk of meniscal injuries.

CONCLUSIONS

Our study reinforces the value of ACL reconstruction in skeletally immature preadolescent patients, with transphyseal technique proven to be a safe, effective, and technically simpler option, even for children under the age of 12. The findings indicate excellent functional outcomes, a high rate of successful return to sporting activities, and minimal to no incidence of growth-related complications in the medium-term.

LEVEL OF EVIDENCE

Level II, prospective comparative cohort study, before and after intervention.

Secondary restraints in ACL reconstruction: State-of-the-art

At-risk patients continue to experience a high likelihood of graft rupture after anterior cruciate ligament (ACL) reconstruction (ACLR). This narrative review seeks to provide the reader with an evidence-based synopsis of state-of-the-art concepts related to secondary restraint lesions, and how addressing them surgically might result in improved outcomes of ACLR.

Principles for optimizing anterior cruciate ligament reconstruction outcomes in elite athletes: a review of current techniques

Anterior cruciate ligament (ACL) tears are one of the most common sport-related injuries and occur in greater than 3% of athletes in a four-year window of sports participation. Non-contact injuries are the most common mechanism for ACL injury in elite-level athletes, especially with increased valgus and external rotation of the knee when loading eccentrically in flexion. Because of the immense toll these injuries and their recovery take on athletes especially, optimal treatment has been a subject of great interest for some time. Many ACL reconstruction (ACLR) and repair techniques have been implemented and improved in the last two decades, leading to many surgical options for this type of injury. The surgical approach to high-level athletes in particular requires additional attention that may not be necessary in the general population. Important considerations for optimizing ACL treatment in high-level athletes include choosing repair vs. reconstruction, surgical techniques, choice of auto- or allograft, and associated concomitant procedures including other injuries or reinforcing techniques as well as attention to rehabilitation. Here, we discuss a range of surgical techniques from repair to reconstruction, and compare and contrast various reconstructive and reinforcing techniques as well as associated surgical pearls and pitfalls. Good outcomes for athletes suffering from ACL injury are attainable with proper treatment including the principles discussed herein.

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

BACKGROUND

Despite the well-established role of lateral extra-articular procedures (LEAPs) in reducing failure rates after anterior cruciate ligament (ACL) reconstruction (ACLR) in the adult population, similar in-depth research for the adolescent and pediatric population remains lacking.

PURPOSE

To examine the effect of the LEAP augmentation on the rerupture rate after ACLR in patients aged <18 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This was a retrospective analysis of prospectively collected data from October 2012 to June 2020, involving adolescents <18 years old undergoing primary ACLR with a minimum follow-up of 2 years. Two groups, matched for age, sex, Tegner activity scale, and presence of meniscal injury, were established: ACLR alone and ACLR+LEAP augmentation. The primary outcome measure was the rate of rerupture after ACLR. The secondary outcome measures were the rate of non-graft rupture related reoperation after ACLR; rate of return to sport (RTS) rate, timing, and level compared with preinjury status; and functional scores including the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) (Pain, Symptoms, Activities of Daily Living, Sport and Recreation, and Quality of Life), Tegner activity scale score, ACL Return to Sport after Injury (ACL-RSI) score, and Lysholm score.

RESULTS

After accounting for follow-up losses, we analyzed 132 patients who underwent ACLR alone and 121 patients who underwent ACLR+LEAP from the initial 147 per group. The mean age of the patients in both groups was 16.1 years (SD, 1.1 and 1.0 years, respectively), with similar patient and injury characteristics across both groups (P > .05). Both groups also showed comparable preoperative functional scores. A significantly lower preoperative ACL-RSI score was observed in the ACLR-alone group compared with the ACLR+LEAP group (P = .0044). Graft rupture was significantly less common in the ACLR+LEAP group (2.5%) than in the ACLR-alone group (13.6%) (P = .002). The attributable risk reduction for ACLR+LEAP was 11.1%, and the calculated number needed to treat was 9. Kaplan-Meier analysis showed significantly better rerupture-free survival at 5 years for the ACLR+LEAP group (P = .001). Cox regression confirmed a 6-fold increased rerupture risk in the ACLR-alone group (P = .004). At the final follow-up, despite similar IKDC, KOOS, Lysholm, and ACL-RSI values across both groups, the ACLR+LEAP group had a significantly higher Tegner score (7.2 vs 6.3; P = .0042). No significant differences were observed in RTS rates or sport level compared with preinjury states between the groups.

CONCLUSION

ACLR+LEAP augmentation significantly reduced rerupture risk and facilitated higher postoperative activity levels in adolescents.

REGISTRATION

NCT02511158 (ClinicalTrials.gov identifier).

Role of Lateral Extra-articular Tenodesis in Restraining Internal Tibial Rotation: In Vitro Biomechanical Assessment of Lateral Tissue Engagement

BACKGROUND

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.

PURPOSE

(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.

STUDY DESIGN

Controlled laboratory study.

METHODS

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).

RESULTS

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).

CONCLUSION

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.

CLINICAL RELEVANCE

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.

Anterolateral augmentation procedures during anterior cruciate ligament reconstructions in skeletally immature patients: Scoping review of surgical techniques and outcomes

Purpose

Graft failure rates after anterior cruciate ligament reconstruction (ACLR) in children and adolescents are higher compared to adults. Anterolateral augmentation procedures have recently generated increased focus regarding their ability to reduce graft failure rates. Concerns in skeletally immatures are potential growth disturbances and overconstraint after anterolateral augmentation. The aim of this scoping review is to provide an overview of all current anterolateral augmentation procedures in skeletally immature patients and to discuss surgical techniques, clinical and biomechanical outcomes.

Methods

This scoping review was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement extension for scoping reviews. On 22 December 2022, an information specialist performed a systematic literature search in Cochrane, PubMed (Medline) and EMBASE databases. Inclusion criteria were anterolateral augmentation procedures, including lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), in combination with ACLR in skeletally immatures.

Results

Twenty studies were included after screening 1.485 abstracts. Seventeen studies describe LET techniques, four studies ALLR techniques and one study both techniques. Biomechanical data is scarce and shows conflicting results. Two studies compared ACLR with LET to ACLR in skeletally immatures with promising results in favour of the combined procedure. There were no differences in outcomes between LET and ALLR.

Conclusions

Several LET and ALLR techniques have been described for skeletally immature patients and the first clinical data on LET and ALLR is available, which showed promising results. Further research is necessary to evaluate the risk of growth disturbances and overconstraint in skeletally immatures.

Level of Evidence

Level IV.

The Anterolateral Ligament of the Knee in Pediatric Patients: What Do We Know? A Scoping Review

The knowledge on the anatomy, function and biomechanics and the role of surgical procedures on the anterolateral ligament (ALL) of the knee is still controversial. Only a few papers have examined the ALL in children. The aim of this review is to analyze all the available literature about ALL in the pediatric population. Following the PRISMA criteria, the literature was systematically reviewed, examining all the articles about ALL in pediatric patients. Eight articles were involved in this study. Five cadaveric studies, two diagnostic studies, and one cross-sectional study were found. The identification of the ALL is not always possible in diagnostic studies using magnetic resonance (MRI) or in dissecting specimens. A high variability in the presence of the ligament and in its origin and insertion were found among the studies. It is more difficult to identify the ligament in younger patients than in older children, suggesting that its presence may develop at some point during the growth. Further studies are needed for a detailed knowledge of the ALL.

Combined anterolateral complex and anterior cruciate ligament injury: Anatomy, biomechanics, and management-State-of-the-art

Anterior cruciate ligament (ACL) rupture typically occurs because of sudden axial loading of the knee in conjunction with a coupled valgus and rotational moment about the tibia. However, the ACL is not the only structure damaged during this mechanism of injury, and studies have shown that the anterolateral complex (ALC) of the knee is also commonly involved. Biomechanical studies have established that the ALC plays an important role as a secondary stabiliser to control anterolateral rotatory laxity (ALRL). Indeed, it has been suggested that failure to address injury to the ALC at the time of ACL reconstruction (ACLR) may increase the risk of graft failure owing to persistent ALRL. The concept of combining a lateral extra-articular procedure to augment ACLR for the treatment of ACL injury emerged with a view to decrease the failure rate of either procedure in isolation. This state-of-the-art review discusses the history of the anatomy of the ALC, the biomechanics of a variety of lateral extra-articular augmentation procedures, and provides clinical guidelines for their use in primary ACLR.

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

PURPOSE

Aim of this systematic review was to analyze the outcome after transphyseal ACL reconstruction in children and adolescents regarding the femoral drilling technique.

METHODS

A systematic literature search was carried out in various databases on studies on transphyseal ACL reconstruction in children and adolescents. The literature search was limited to the last 20 years. Primary outcome criterion was the failure rate. Secondary outcome criteria were growth disturbances such as leg length discrepancies or deformities and clinical scores. The present study was registered prospectively ( www.crd.york.ac.uk/PROSPERO ; CRD42022345964).

RESULTS

A total of 22 retrospective or prospective case series (level 4 evidence) were identified that reported on transphyseal ACL reconstruction in children and adolescents. The overall failure/rupture rate after transphyseal ACL reconstruction was 11.0%. The overall ACL rupture rate of the contralateral side was 9.7%. No statistical significant difference in the failure rates between independent and transtibial drilling techniques could be detected ((p = 0.76/p = 0.28)). Furthermore no statistical significant differences in the rate of reported growth disturbances between independent and transtibial drilling techniques were shown (p = 0.15). The reported clinical scores at follow-up (mean follow-up 5.05 years) revealed good to very good results.

CONCLUSION

This systematic review demonstrates that children and adolescents have a relatively high failure rate after transpyseal ACL reconstruction without any statistically significant differences between independent or transtibial drilling techniques regarding reruptur rates or the rate of growth disturbances. The results of this systematic review warrant a comparison of both techniques for femoral tunnel drilling in a controlled randomized trial.

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

The anterolateral complex (ALC) of the knee has gained increased interest over the last decades due to the high revision rates of anterior cruciate ligament reconstruction (ACLR). Furthermore, in patients with an ACL tear, the injury of at least one of the ALC's anatomic structures has been shown to be significantly higher, thus affecting its secondary stabilizing role at the knee joint. As such, ACLR augmentation techniques, that embrace the ALC, have been proposed recently, and indications for these procedures are still evolving. This review aims to present and discuss the most current anatomical, biomechanical, and imaging data, current reconstruction techniques, and the clinical results of ALC reconstruction.