Isolated ACL Reconstruction Versus ACL Reconstruction Combined With Lateral Extra-articular Tenodesis: A Comparative Study of Clinical Outcomes in Adolescent Patients

Abstract

Background: Young patients undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) are at a particularly high risk of graft ruptures compared with adults. Recent studies have demonstrated significant reductions in ACL graft rupture rates in high-risk adult populations when a lateral extra-articular procedure is performed, but comparative studies in pediatric and adolescent populations are currently lacking in the literature. Purpose/Hypothesis: The purpose of this study was to compare the clinical outcomes of isolated ACLR versus combined ACLR and lateral extra-articular tenodesis (LET) when using the Arnold-Coker modification of the MacIntosh procedure in early adolescent patients. The hypothesis was that combined procedures would be associated with a significantly reduced risk of graft ruptures. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective analysis of consecutive early adolescent patients who underwent ACLR using a hamstring tendon autograft with or without the Arnold-Coker modification of the MacIntosh procedure was conducted. Patients with ≥1 additional risk factors for a graft rupture were offered LET in addition to ACLR (pivot-shift grade 2 or 3, high level of sporting activity defined as Tegner activity score ≥7, participation in pivoting sports, and Segond fractures). Clinical outcomes including graft rupture rates, patient-reported outcome measure scores (Knee injury and Osteoarthritis Outcome Score and subjective International Knee Documentation Committee), knee stability, return-to-sports rates, reoperation rates, and complications were assessed. Comparisons between variables were assessed with the chi-square or Fisher exact test for categorical variables and the Student or Wilcoxon test for quantitative variables. Multivariate analyses were undertaken to evaluate risk factors for a graft rupture. Results: A total of 111 patients with a mean follow-up of 43.8 ± 17.6 months (range, 24-89 months) were included in the study; 40 patients underwent isolated ACLR, and 71 underwent ACLR + LET. The addition of LET to ACLR was associated with a significantly lower graft rupture rate compared with isolated ACLR (0.0% vs 15.0%, respectively; odds ratio, 15.91 [95% CI, 1.81-139.44]; P = .012). It was also associated with significantly better knee stability (pivot-shift grade 3: 0.0% vs 11.4%, respectively; P = .021) (side-to-side anteroposterior laxity difference >5 mm: 0.0% vs 17.1%, respectively; P = .003) and Tegner activity scores (7 vs 6, respectively; P = .010). There were no significant differences between the groups regarding the Patient Acceptable Symptom State for the patient-reported outcome measures, nor for any of the other outcome measures evaluated, and no differences in the rate of non–graft rupture related reoperations or complications. The ACLR + LET group exceeded the minimal clinically important difference with respect to the Tegner activity scale. Conclusion: In a retrospective comparative cohort study of adolescents, combined ACLR and LET was associated with a significantly lower graft rupture rate and no difference in non–graft rupture related reoperations or complications compared with isolated 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

“…12,20,25,31 Nevertheless, the calculated NNT to prevent 1 rerupture was found to be 9 in our study, offering a promising improvement compared with the NNT of 14.3 reported by Getgood et al 12 Thus, we believe the LEAP procedure could potentially be a gamechanger in reducing rerupture rates among young athletes. Perelli et al 31 Monaco et al 25 Getgood et al 12 Laboudie et al 20 Current The RR for ACLR alone was calculated by taking the reciprocal of the reported RR for ACLR 1 LEAP (ie, 1/RR for ACLR 1 LEAP).…”

“…4,17,20,25,31,37 Regarding non-graft rupture related reoperations, our study reported a total rate of 10.6%, with no significant difference between the 2 groups. A similar rate of 10.8% was reported by Monaco et al 25 Although LEAP has not been shown to be associated with long-term osteoarthritis, 7,10,44 these findings are yet to be confirmed and validated in the pediatric population. Furthermore, the risk of these procedures in patients with open physes has not been well explored.…”

“…The literature presents contradictory findings on this issue. Monaco et al 25 found superior TAS scores in the ACLR 1 LET group, although their data also showed significantly higher preoperative scores in this group. In contrast, Laboudie et al 20 did not find any significant difference in the postoperative TAS scores between the groups.…”

Management of Pediatric Anterior Cruciate Ligament Injuries

“…In recent years, there has been increasing interest in using extra-articular procedures to augment ACL reconstruction. Monaco et al reported lower rerupture rates with the addition of lateral extra-articular tenodesis (LET) when compared with isolated ACL reconstruction in the adolescent population 96 ; however, clinical outcomes were comparable. In a systematic review by Carrozzo et al ACL reconstruction augmented with LET in skeletally immature pediatric patients demonstrated a graft failure ranging from 0% to 13.6% at a mean follow-up of 50.1 months, with an overall graft failure rate of 4.65%.…”

Defining Failure

“…A sampling of other recent studies of ACL repair, reconstruction, or revision reconstruction in AJSM and OJSM reveals a variety of definitions of failure, including history of giving way, 16,19,21,22 laxity on instrumented physical examination, 2,6,15,16,19,22 MRI evidence of disruption, 2,3,6,10,15,21,22 graft rupture by history, 11 symptomatic instability, 10 and rerupture or symptomatic instability requiring revision surgery. 3,6,10,11,16,21 Studies often used multiple criteria, and symptoms suggestive of possible failure frequently led to further documentation by instrumented examination and MRI.…”