Summary

Adding an anterolateral modified Lemaire tenodesis to hamstring anatomic ACL reconstruction improve objective stability and reduce failure rate skeletally immature patients with a low risk of growth-related changes.

Abstract

Objective

Anterior cruciate ligament (ACL) ruptures in pediatric patients are becoming increasingly common and the reconstruction failure rates range from 8.7% to 20% regardless of the technique and graft used. Combining extraarticular tenodesis with ACL reconstruction has been reported to decrease failure rate and improve objective stability in adult patients. The aim of the present study is to evaluate clinical result of adding an extraarticular procedure in skeletally immature ACL deficient knees.

Method

A multicentric comparative study was conducted with a minimum 2-year follow-up, evaluating skeletally immature patients who had undergone an anatomic hamstring ACL reconstruction (AHACLR). 32 consecutive patients underwent combined AHACLR and modified Lemaire anterolateral tenodesis between January 2017 and December 2018 were prospectively evaluated (Group 1). The control group was an historical cohort of skeletally immature patients (n=34) that had had surgery from October 2014 to December 2016 (Group 2). In the control group only AHACLR have been performed. Patients were classified as skeletally immature when both tibial and femoral physis were still open on MRI. Bone skeletal age was evaluated on X-Ray.
The femoral tunnel was performed using a physeal-sparing technique and a trans-physeal tibial tunnel was drilled in every case. A Lemaire modified anterolateral tenodesis was additionally performed in the patients of group 1. The exclusion criteria included rupture of other ligament rather than ACL, root or bucket handle meniscal tears, ramp lesion or any cartilage injury that needed surgical treatment. Graft diameter, Pedi-IKDC subjective knee evaluation, graft failure and return to sports were recorded. Pre and postoperative objective laxity of the knee was also measured using KT-1000 arthrometer and the KiRA triaxial accelerometer. Postoperative lower limb deformity or growth disturbances were recorded.

Results

The mean age in group 1 was 13.8 (range 12-16) years and 14 (range 12-16) years in group 2 (p=0.48). The mean graft diameter was 8.2 (range: 7-9) mm, with no significant differences between the groups (p=0.63). The mean follow-up was 26.1 ± 4.2 months for group 1 and 29.6 ± 7.2 months in group 2 (p = 0.11). Three patients had a <3º genu valgus deformity on the operated limb, two of which belonged to group 1 and one to group 2. Both better anteroposterior stability measured with KT-1000 (p = 0.041) or KiRA (p= 0.033) and better rotational stability measured with a KIRA (p= 0.019) have been detected in group 1. The graft failure rate was also lower in group 1 (11,8% group 2 vs 6,2% group 1; p = 0.042). The patients in group 1 had a return to sports rate of 91%, while in group 2 this rate was of 85%, without statistical difference (p=0.069). The Pedi-IKDC subjective knee evaluation recorded for both groups showed no difference between the 2 groups (p = 0.27).

Conclusion

From the data obtained in the present study we can conclude that adding an anterolateral modified Lemaire tenodesis to hamstring anatomic ACL reconstruction improve objective stability and reduce failure rate in skeletally immature patients with a low risk of growth-related changes.