Combining Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Procedures in Skeletally Immature Patients Is Safe and Associated With a Low Failure Rate

Abstract

Purpose: To analyze the rates of graft ruptures and growth disorders, the level of return to sport, and the clinical results of 2 lateral extra-articular procedures in growing children.

Methods: This study was a retrospective, single-center study of patients undergoing anterior cruciate ligament (ACL) surgery combined with 2 different lateral extra-articular procedures (anatomic reconstruction with a gracilis graft or modified Lemaire technique with a strip of fascia lata). The measurements of side-to-side anterior laxity and pivot shift were performed preoperatively and at the last follow-up. The sports level and the complications rate were assessed. The minimal clinically important differences (MCID) and patient acceptable symptoms state threshold scores were calculated.

Results: Thirty-nine patients (40 ACLs) were included (20 anatomic and 20 modified Lemaire) at an average follow-up of 57 months ± 10 [42-74]. One patient (2.5%) was lost to follow-up. The mean age at surgery was 13.8 ± 1.4 years old [9.8; 16.5]. One graft failure was reported (2.6% [0.06-13.5]) at 35.6 months after surgery. Two cases (5.4%) of femoral overgrowth were observed, and one of them required distal femoral epiphysiodesis. Ninety-two percent of the patients returned to sports. At the final follow-up, side-to-side anterior laxity was significantly improved, and no residual pivot shift was recorded in 95% of patients. Eighty-nine percent of the patients presented a Pedi-International Knee Documentation Committee score greater than the MCID postoperatively, and 77% presented a Lysholm score greater than the MCID.

Conclusions: This series of ACL reconstructions combined with 2 different lateral extra-articular procedures in skeletally immature patients demonstrated promising findings. The low rate of observed complications, including graft rupture and growth disturbance, is encouraging, but the small study population and lack of comparative group precludes reliable conclusions.

Level of evidence: IV, therapeutic case series.

Fig 1

Operative technique. Common points: tunnel diameter ≤9 mm; tibial tunnel = transphyseal; femoral tunnel = intraepiphyseal, no screw in the tibial tunnel. (A) ST/G + G (right knee): ST and G are left pediculated on the tibia. The ACL graft is composed of 3 strands of ST and one strand of G. Femoral fixation is provided by a screw. A double bundle of G is used to reconstruct the ALL, the anterior tunnel is positioned slightly posterior to Gerdy’s tubercle, and the posterior tunnel is placed midway between Gerdy’s tubercle and the fibular head. (B) ST + FL (right knee): ST is left pediculated on the tibia. The ACL graft is composed of tripled strands of ST. All of the inside femoral sockets were performed, and the graft was fixed with a button. Lateral extra-articular procedure was performed using the fascia lata left pediculated on Gerdy’s tubercule and fixed on the femoral side using the wires of the button. (ACL, anterior cruciate ligament; ALL, anterolateral ligament; FL, fascia lata; G, gracilis; ST, semitendinosus.)

Fig 2

Management of the overgrowth of 1.82 cm). (A) EOS radiography showing overgrowth prevailing on the left femur. (B) EOS radiography after distal left femoral epiphysiodesis with 2 screws at the last follow-up showing good recovery of the length. (d, distance.)

Fig 3

Relationship between the physis and the tunnels: a postoperative radiograph of method B (left knee).