Addition of a 2-Limb Lateral Extra-articular Procedure to Anterior Cruciate Ligament Reconstruction Does Not Increase Early Complications in Pediatric Patients at Minimum 1-Year Follow-Up

Purpose

To compare the rates and types of early complications in pediatric patients undergoing a 2-limb lateral extra-articular procedure (LEAP) alongside anterior cruciate ligament reconstruction (ACLR) versus ACLR alone.

Methods

The records of patients who underwent primary ACLR at a single tertiary children’s hospital were reviewed for this retrospective cohort study, excluding those with multiligament reconstructions, modified MacIntosh reconstructions, or less than 1-year follow-up. The 2-limb LEAP used a strip of iliotibial band autograft that remained attached at the Gerdy tubercle and was first fixed to the femur and then reflected distally and fixed to the tibia, resulting in 1 limb that was similar to the Lemaire tenodesis and another that reconstructed the anterolateral ligament. Demographic data, intraoperative findings and techniques, and postoperative complications were compared between patients who underwent ACLR with LEAP and those who underwent ACLR alone.

Results

A total of 268 patients with a mean follow-up period of 2.0 ± 0.8 years were included in the analysis, of whom 49 (18%) underwent a 2-limb LEAP with ACLR. Most of the patients who underwent LEAP (91.8%) received a quadriceps tendon autograft for ACLR, whereas those who underwent only ACLR had a more equal distribution of quadriceps (38.8%), patella (34.2%), and hamstring (26.9%) tendon autografts. The most common short-term complication was persistent pain (i.e., pain lasting >3 months), occurring in 4.1% of patients with LEAP and 5.9% of those with ACLR alone ( P >.99). There was no difference in the proportion of patients with arthrofibrosis (10.2% of those with LEAP vs 9.6% of those with ACLR alone, P =.90), superficial wound infection (2.0% with LEAP vs 3.7% with ACLR alone, P >.99), or reoperation for any reason (32.6% with LEAP vs 36.5% with ACLR alone, P =.78). The rate of postoperative cosmetic concerns was significantly different (6.1% of patients with LEAP vs 0.5% of patients with ACLR, P =.02).

Conclusions

Children and adolescents undergoing a 2-limb LEAP with primary ACLR reported a higher rate of cosmetic concerns after surgery than those undergoing ACLR alone. However, the addition of the LEAP did not otherwise increase the risk of early postoperative complications at a minimum 1-year follow-up.

Level of Evidence

Level III, retrospective cohort study.

Pediatric and adolescent anterior cruciate ligament (ACL) injuries are increasing in incidence. ^, Given the high risk of graft failure in these patients, the rate of reoperation for ACL reruptures is also increasing. ^, Revision ACL reconstruction (ACLR) is notably associated with inferior patient- and clinician-reported outcomes compared with primary ACLR, including residual instability, pain, and mental barriers that result in decreased satisfaction and quality of life, as well as lower likelihood of return to preinjury levels of activity. Revision ACLR may also be associated with an increased risk of early post-traumatic osteoarthritis. Therefore, development of strategies to lower the risk of primary ACLR graft rupture may be impactful in the pediatric population.

The anterolateral ligament (ALL) has been recognized as a stabilizing structure of the anterolateral aspect of the knee, with its tibial attachment midway between the Gerdy tubercle and the fibular head, as well as a variable femoral attachment at the lateral aspect of the distal femur. The native ALL plays a role in rotational stability of the knee joint, with ALL-deficient knees showing significantly increased instability and positive pivot-shift findings on examination. Given that the anterolateral complex of the knee may be injured in a high proportion of patients experiencing ACL injury, concomitant lateral extra-articular procedures (LEAPs), including ALL reconstruction or lateral extra-articular tenodesis (LET), may impact outcomes after pediatric ACLR.

A 2022 survey of pediatric sports surgeons showed that 56% perform LEAP (ALL reconstruction or LET) with primary ACLR and 79% perform LEAP with revision ACLR, with insufficient evidence being the most common reason not to perform LEAP with primary ACLR. Therefore, further investigation is necessary to compare postoperative outcomes of pediatric ACLR with and without LEAP. The purpose of this study was to compare the rates and types of early complications in pediatric patients undergoing a 2-limb LEAP alongside ACLR versus ACLR alone. We hypothesized that there would be no difference in the overall complication or reoperation rates between these groups at a minimum 1-year follow-up.

Methods

This was a retrospective cohort study of patients aged 18 years or younger who underwent primary ACLR at an urban, tertiary children’s hospital between 2011 and 2022. Institutional review board approval was obtained. Patients were identified for the study using Current Procedural Terminology code 29888. Inclusion criteria consisted of primary ACLR with complete preoperative and intraoperative documentation with a minimum 1-year postoperative follow-up. All ACL graft types were included. Patients were included regardless of the type of concomitant meniscal or chondral pathology. Exclusion criteria included age greater than 18 years, multiligament or revision ACLR, modified MacIntosh reconstruction in the setting of open physes, and less than 1-year follow-up. Additionally, patients who underwent ALL reconstruction or LET with a technique differing from the 2-limb LEAP described later were excluded. All operations were performed by 2 board-certified, fellowship-trained pediatric orthopaedic sports surgeons (N.M.P.; the other surgeon is not an author). Medical records were reviewed for demographic, preoperative, and intraoperative data. Postoperative complications and reoperations were recorded. These included any reoperations on either knee, cosmetic concerns, pain, arthrofibrosis, implant irritation, infection, deep vein thrombosis, and fracture. Patient-reported cosmetic concerns were recorded if mentioned in postoperative clinic notes. No standardized questionnaire was used in this retrospective study. Postoperative pain was noted simply based on whether this was documented in the medical record after surgery. Pain lasting greater than 3 months after surgery was considered persistent. On the basis of previous literature, arthrofibrosis was defined as a flexion deficit of 20° or greater compared with the contralateral knee or an extension deficit of 10° or greater at 3 months after surgery; this definition has been used in prior research and encompasses Shelbourne arthrofibrosis types 2 through 4. ^,^,^,^,

Surgical Technique

LEAP was recommended based on surgeon preference, and indications were not standardized in this retrospective study. However, the most common indications included participation in high-risk activities with a pivot-shift grade of 2 or higher, ipsilateral knee hyperextension greater than 10°, and a Beighton-Horan score greater than 4. The LEAP technique for this study consisted of a 2-limb graft, with 1 limb serving as a lateral tenodesis and the other serving as an ALL reconstruction ( Fig 1 ). Although clinical and biomechanical outcomes of this technique have not yet been compared with other common techniques, it was developed to theoretically offer the benefits of both a traditional lateral tenodesis and an ALL reconstruction. A modification of this technique for use in skeletally immature patients was published previously.

Image, AltText currently not available — Fig 1

ACLR is performed, with final tensioning of the ACL graft prior to completion of the LEAP. A 3-cm incision is made along the lateral aspect of the knee. The central 1 cm of the iliotibial (IT) band is identified and incised. This strip of IT band is harvested, spanning approximately 9 to 11 cm in length from the Gerdy tubercle depending on the patient’s size. It is detached proximally but left attached to the Gerdy tubercle. The free end of the graft is whipstitched and then passed deep to the lateral collateral ligament. A suture-based, knotless suture anchor is placed in the distal femur at the most commonly described attachment point of the native ALL (slightly posterior and proximal to the lateral collateral ligament attachment). To avoid convergence with the femoral ACL tunnel, this anchor is typically placed while the tunnel is visualized arthroscopically prior to passage of the ACL graft. The remainder of the LEAP is completed after tensioning of the ACL. The IT band graft is passed through the tensionable loops of the knotless anchor. With the knee in about 70° of flexion and the tibia in neutral rotation, the loops are cinched over the graft to provide onlay fixation. Next, a 1-cm incision is made over the proximal tibia, 1 cm distal to the joint line and halfway between the Gerdy tubercle and anterior border of the fibular head. Another anchor is placed in this location. The free end of the LEAP graft is passed subcutaneously to the tibial incision and through the loops of the knotless anchor. With the knee in 20° of flexion and the tibia in neutral rotation, the loops are cinched over the graft to provide onlay fixation. This second limb of the graft re-creates the native ALL. Additional suture is used for further fixation to the surrounding periosteum as needed. The IT band harvest site is not closed routinely.

Statistical Analysis

Statistical analysis was completed with SPSS for Macintosh, version 28.0 (IBM, Armonk, NY). To detect a large difference between groups at 80% power and α =.05, at least 26 patients were required in each group. Standard descriptive statistics were calculated for demographic variables. Data are reported as mean ± standard deviation, with non-normally distributed variables presented as median (interquartile range). Means were compared with independent-samples t tests. The Mann-Whitney U test was used for comparison of nonparametric variables. Categorical variables were analyzed using the χ ² or Fisher exact test, as appropriate. A significance threshold of P <.05 was applied.

Results

A total of 268 patients with a mean follow-up period of 2.0 ± 0.8 years were included in the analysis, of whom 49 (18.3%) underwent ACLR combined with the aforementioned 2-limb LEAP. Patients who underwent LEAP had a younger mean age and differences in ACLR graft choice than those who did not undergo LEAP. Details of demographic and intraoperative comparisons are noted in Table 1 . The most common short-term complication was persistent pain (i.e., pain lasting >3 months), occurring in 4.1% of patients with LEAP and 5.9% of those with ACLR alone, with no statistical difference between groups ( P >.99). The only significant difference between the two groups was in the frequency of cosmetic concerns. Whereas only 0.5% of patients who underwent isolated ACLR reported postoperative cosmetic problems, 6.1% of those who underwent ACLR combined with LEAP experienced this issue ( P =.02)—related to lateral thigh contour after IT band harvest in all cases. There was no difference in the proportions of patients with arthrofibrosis ( P =.9), superficial wound infection ( P >.99), reoperation on the ipsilateral knee ( P =.4), or reoperation for any reason ( P =.8). Additional details regarding postoperative complications are shown in Table 2 . ACL graft failure was sustained by 3 of 49 patients (6.1%) with ACLR plus LEAP and 31 of 219 (14.2%) with ACLR alone ( P =.13), although there were underlying differences in graft types between the two groups, as previously noted.

Table 1

Comparison of Demographic Characteristics

	ACLR + LEAP	ACLR Only	P Value
Age, median (IQR), yr	14.7 (2.7)	15.7 (2.6)	.009
Sex			.2
Male	27 (55.1)	98 (44.7)
Female	22 (44.9)	121 (55.3)
BMI	23.4 ± 4.6	24.9 ± 5.6	.1
Insurance			.8
Public	25 (51.0)	115 (52.5)
Private	22 (44.9)	98 (44.7)
Other	2 (4.1)	6 (2.7)
Sport			.6
Soccer	16 (32.7)	66 (30.1)
Basketball	8 (16.4)	47 (21.5)
Football	7 (14.3)	27 (12.3)
Volleyball	1 (2.0)	17 (7.8)
Other	17 (34.7)	62 (28.3)
Time between injury and surgery, d	109.3 ± 119.7	116.8 ± 155.4	.8
Graft type			<.001
Quadriceps tendon autograft	45 (91.8)	85 (38.8)
Patellar tendon autograft	4 (8.2)	75 (34.2)
Hamstring tendon autograft	0 (0.0)	59 (26.9)
Meniscal procedure
Repair	24 (49.0)	107 (48.9)	.6
Meniscectomy	6 (12.2)	35 (16.0)	.8
Chondral injury	4 (8.2)	31 (14.2)	.3