Summary

Combined ACLR+LET is associated with significant advantages over isolated ACLR in pediatric and adolescent patients, as a 12.8-fold reduction in graft rupture rates, better knee stability, and higher Tegner activity level with no increase in the rate of non-graft rupture related re-operations or complication

Abstract

Young patients undergoing ACLR are at particularly high risk of graft rupture when compared to adults. Recent studies in adults have demonstrated significant reductions in graft rupture rates in high risk populations when a lateral extra-articular procedure is performed, but comparative studies in pediatric and adolescent populations do not exist. The purpose of this study was to compare the clinical outcomes of isolated ACLR versus combined ACLR+LET when using the Arnold-Coker modification of the MacIntosh procedure in young patients. The hypothesis was that combined procedures would be associated with a significantly reduced risk of graft rupture.

Methods

A retrospective analysis of prospectively collected data for consecutive pediatric and adolescent patients who underwent ACLR at (institution blinded for journal review), between January 1, 2013, and December 31, 2017 was conducted. Only patients with additional risk factors for graft rupture (high grade pivot shift grade, high level of sporting activity, participation in pivoting sports, and those with Segond fractures) were offered a LET in addition to ACLR. This was performed using the Arnold Coker modification of the MacIntosh procedure. All patients were recalled for in-office evaluation between September 2019 and June 2020. Clinical outcomes including graft-rupture rates, PROMS (state which ones), knee stability, return to sport rates, re-operation rates and complications were assessed. Comparisons between variables were assessed with Chi-square or the Fisher exact test for categorical variables and the Student test or Wilcoxon test for quantitative variables. Multivariate analyses were undertaken to evaluate risk factors for graft rupture.

Results

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 ACLRs and 71 underwent ACLR+LET. The addition of an LET to ACLR was associated with a significantly lower graft rupture rate when compared to isolated ACLR (15% vs 0%, OR=16.96, 95% CI 1.91-142.85, P = .01), it was also associated with significantly better knee stability (rate of grade 3 pivot shift, 0% ACLR+ LET, 11% ACLR, p <0.01; side-to-side AP laxity difference >5mm 0% ACLR+LET, 17.2%, p=<0.01) and Tegner activity level (isolated ACLR, 6; ACLR+LET 7 P=.01). There were no significant differences exceeding known MCID thresholds with respect to any of the other outcome measures evaluated, and no differences in the rate of non-graft rupture related re-operations or complications between groups.

Conclusions

Combined ACLR+LET is associated with significant advantages over isolated ACLR in pediatric and adolescent patients. These advantages include a 16.9-fold reduction in graft rupture rates, better knee stability, and higher Tegner activity level with no increase in the rate of non-graft rupture related re-operations or complication