Extra-articular Anterior Cruciate Ligament Reconstruction Research Articles

Physeal-Sparing Anterior Cruciate Ligament Reconstruction with Iliotibial Band Autograft in the Skeletally Immature Knee

Conventional adult anterior cruciate ligament reconstruction techniques are controversial in skeletally immature patients due to the risk of iatrogenic physeal damage and potential growth disturbance. The physeal-sparing, combined intra- and extra-articular anterior cruciate ligament reconstruction using an autogenous iliotibial band was developed to mitigate this risk in prepubescent, skeletally immature patients, with excellent functional outcomes and a low revision rate. This article describes the surgical details of this reproducible reconstruction technique.

Outcomes of Physeal-Sparing ACL Reconstruction with Iliotibial Band Autograft in Skeletally Immature Prepubescent Children.

Anterior cruciate ligament (ACL) tears are occurring in youth athletes with increasing frequency. Many ACL reconstruction procedures designed to allow for continued growth in patients with open physes have been described, but large series with mid- to long-term outcomes data are lacking. The purpose of the current study was to assess the clinical outcomes of a large cohort of prepubescent children who underwent a physeal-sparing, combined intra- and extra-articular ACL reconstruction with iliotibial (IT) band autograft over a 23-year period. Included in our analysis were 237 patients (240 knees) who underwent ACL reconstruction using IT band autograft at Tanner stage 1 or 2 (mean age of 11.2 ± 1.7 years). Physical examination data were analyzed for 225 of the 240 knees (mean follow-up, 25.8 months), and 137 (57%) of the knees had corresponding patient-reported clinical outcomes (patient-reported graft rupture and Pediatric International Knee Documentation Committee [Pedi-IKDC], Tegner activity scale, and Lysholm scores; mean follow-up, 6.2 years). Rates of growth arrest, IT band graft-harvest morbidity, and return to sports were analyzed. Physical examination revealed that 96.8% of the knees were grade A on the Lachman test and 98.8% were grade A on the pivot-shift test. Graft rupture occurred in 9 (6.6%) of 137 knees, at an average of 33.5 months (range, 8.2 months to 8.0 years) postoperatively. For patients who did not sustain a graft rupture, the mean Pedi-IKDC score was 93.3 ± 11.0, the mean Lysholm score was 93.4 ± 9.9, and the mean score on the Tegner activity scale was 7.8 (mode, 7). While lateral thigh asymmetry at the IT band harvest site was noted by 48% of the subjects, only 1.6% reported associated pain. No cases of limb-length discrepancy or angular deformity were observed. This procedure was associated with excellent functional outcomes, minimal risk of growth disturbance, and a low graft-rupture rate in skeletally immature prepubescent children. These results appear durable at mid- to long-term follow-up, at an average of >6 years postoperatively. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Short-term complications in intra- and extra-articular anterior cruciate ligament reconstruction. Comparison with the literature on isolated intra-articular reconstruction. A multicenter study by the French Arthroscopy Society

IntroductionLateral tenodesis (LT) is performed to limit the risk of iterative tear following anterior cruciate ligament (ACL) reconstruction in at-risk patients. By adding an extra procedure to isolated ACL graft, LT reconstruction increases operating time and may complicate postoperative course. The objective of the present study was to evaluate the rate of early complications. The study hypothesis was that associating ALL reconstruction to ACL reconstruction does not increase the complications rate found with isolated ACL reconstruction. Material and methodsA prospective multicenter study included 392 patients: 70% male; mean age, 29.9 years; treated by associated ACL and LT reconstruction. All adverse events were inventoried. ResultsMean hospital stay was 2 days, with 46% day-surgery. Walking was resumed at a mean 27 days, with an advantage for patients treated by the hamstring technique. The early postoperative complications rate was 12%, with 1.7% specifically implicating LT reconstruction: pain, hematoma, stiffness in flexion and extension, and infection. There was a 5% rate of surgical revision during the first year, predominantly comprising arthrolysis for extension deficit. The 1-year recurrence rate was 2.8%. DiscussionThe complications rate for combined intra- and extra-articular reconstruction was no higher than for isolated intra-articular ACL reconstruction, with no increase in infection or stiffness rates. The rate of complications specific to ALL reconstruction was low, at 1.7%, and mainly involved fixation error causing lateral soft-tissue impingement. Level of evidenceIV, prospective multicenter study.

Midterm results of combined intra- and extra-articular ACL reconstruction compared to historical ACL reconstruction data. Multicenter study of the French Arthroscopy Society

IntroductionDuring anterior cruciate ligament (ACL) reconstruction procedures, anterolateral reconstruction (ALR) can also be performed to improve the knee's rotational stability. However, the effectiveness of this supplemental technique and its impact on the risk of retears and on the onset of secondary degenerative changesare controversial. HypothesisALR improves control over the pivot shift, reduces the retear risk and delays the appearance of secondary degenerative lesions. Material and methodsClinical examination, knee laxity measurements and X-ray evaluations were done in 478 patients with more than 3years’ follow-up after combined ACL and ALR from 11 participating hospitals. The mean patient age at the time of surgery was 28years. Eighty-eight percent of the patients participated in pivot sports and 45% were competitive athletes. The findings of this study were compared to historical isolated ACL reconstruction data. ResultsThe average follow-up was 6.8years. No detectable pivot shift was found in 83% of patients, while 12.8% of patient had a smooth glide. The side-to-side difference in anteroposterior knee laxity with maximum manual force was less than 3mm in 66% of patients and less than 5mm in 95%. The retear rate was 5.4%, with half of these patients undergoing revision ACL surgery. Secondary meniscus damage requiring surgery occurred in 6.3% of patients; the radiological osteoarthritis rate was 17.5%. DiscussionWhen compared to historical ACL reconstruction data, combined intra- and extra-articular reconstruction does not increase the complication rate. At a mean follow-up of 6.8years, it provides better control over the pivot shift along with a low retear rate and low occurrence of secondary meniscus injuries. Level of evidenceIV, multicenter study.

Micheli Anterior Cruciate Ligament Reconstruction in Skeletally Immature Youths

Background: The management of anterior cruciate ligament (ACL) tears in the skeletally immature patient remains controversial. Outcomes on a physeal-sparing technique using the iliotibial band for combined intra-articular and extra-articular ACL reconstruction, called the Micheli technique, have been described and reported by the original authors. Purpose: To evaluate the clinical outcomes of a physeal-sparing technique using the iliotibial band for combined intra-articular and extra-articular ACL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Between 2005 and 2011, all patients who underwent Micheli ACL reconstruction performed by a single surgeon were identified. A minimum of 3 years’ growth remaining was a prerequisite for Micheli reconstruction. Patients were excluded if postoperative follow-up was less than 1 year. Patients were evaluated for functional outcomes, satisfaction, graft survival, radiographic and clinical evidence of growth disturbance, and the need for additional procedures. Results: Twenty-one patients (22 knees) met the inclusion criteria for this study. The mean age at the time of surgery was 11.8 years (range, 9.9-14.0 years). All patients were male. There were 4 concomitant meniscal repairs and 5 partial meniscectomies performed. All patients (100%) completed follow-up at a mean duration of 3.0 years (range, 1.0-6.9 years). Overall, 6 knees (27%) underwent reoperation. Of these, 3 knees (14%) underwent revision ACL surgery: 2 revision reconstructions at 2.8 and 4.0 years postoperatively and 1 graft shrinkage at 4.7 months postoperatively. Three knees (14%) underwent subsequent meniscal procedures, including 2 partial meniscectomies and 1 meniscal repair. Of the 19 knees that did not require revision ACL surgery, the median patient satisfaction score was 10 (range, 9-10). The mean Pediatric International Knee Documentation Committee score was 96.5 ± 2.9, and the mean Lysholm score was 95.0 ± 6.1. The median preinjury Tegner activity level was 8 (range, 6-10), and the median postoperative Tegner activity level was 8 (range, 6-10). Of the 19 knees that did not require revision ACL surgery, all had a normal Lachman test result, with a firm endpoint and normal pivot shift. At follow-up, 53% of knees had closed physes. There were no angular deformities or limb-length discrepancies. Conclusion: At a mean 3-year follow-up, the study findings confirmed excellent functional outcomes, a low ACL revision rate, and no growth disturbances. Patients returned to their preoperative activity level after reconstruction. This procedure offers a safe and effective ACL reconstruction option in children with several years of growth remaining.

Micheli ACL Reconstruction in Prepubescent Youths: A Retrospective Outcomes Study

Objectives:Management of anterior cruciate ligament (ACL) tears in the skeletally immature patient remains controversial. In patients with significant growth remaining, physeal injury from conventional surgical reconstruction risks creating a limb length inequality or angular deformity; however, continued instability poses significant long-term morbidity from subsequent chondral and meniscal injuries. Done with appropriate precautions, transphyseal reconstructions are reasonably safe in older adolescents; however, little evidence of safety in the prepubescent athlete exists. Micheli has described a physeal sparing technique using the iliotibial band for a combined intra-articular and extra-articular ACL reconstruction. The purpose of this study is to analyze another surgeon’s experience with this procedure.Methods:This study was IRB approved. Between 2005 and 2011, all patients who underwent Micheli ACL reconstruction, performed by a single surgeon, were identified. Three or more years of growth remaining was a prerequisite for Micheli reconstruction. Patients were excluded if postoperative follow-up was less than one year. Patients with associated knee injuries and/or concomitant knee procedures were not excluded. Functional outcome, graft survival, radiographic outcome, growth disturbance and additional procedures were evaluated.Results:Twenty-one patients (22 knees) met the inclusion criteria for this study. Mean chronological age at time of surgery of 11.8 years (range: 9.9-14.3 years). All patients were male with a minimum of three years of growth remaining. There were four concomitant meniscal repairs and five concomitant partial meniscectomies performed at the index procedure. Of the included patients, 19 patients (20 knees)(90%) completed follow-up at mean postoperative duration of 3.1 years (range: 1.0-6.9 years). Two knees (9%) underwent revision ACL reconstruction for graft failure at 2.8 and 4.0 years postoperatively. Of the remaining 18 knees, the median patient satisfaction was 10 (range: 9 to 10). Mean pedi-IKDC knee score was 96.3± 2.9 points. Mean Lysholm score was 94.7 ± 6.2 points. Mean pre-injury Tegner activity level was 8 (range: 6-10) and mean postoperative Tegner activity level was 8 (range: 6-10). All patients had a normal Lachman examination with firm endpoint and a normal pivot-shift examination. At time of follow-up, 50% of patients had closed physes. There were no radiographic angular deformities or leg length discrepancies appreciated. Four of 18 knees (22%) underwent subsequent procedures including 1 graft shrinkage, 2 partial meniscectomies and 1 meniscal repair.Conclusion:At mean follow-up of 3.1 years, our findings confirm excellent functional outcomes, a low revision rate and no growth disturbances associated with the Micheli ACL reconstruction. Patients are able to return to the preoperative activity level following reconstruction. This procedure offers a safe and effective alternative to trans-physeal reconstruction in prepubescent children with several years of growth ahead.