Summary

The early outcomes of a novel technique of combined ACL and ALL reconstruction using iliotibial band autograft suggest a similar safety and clinical effectiveness profile to patellar tendon ACLR and, through preserving the extensor mechanism, may minimize BTB-related donor site morbidity and optimize early ACLR rehabilitation and recovery.

Abstract

Introduction

The iliotibial band (ITB) autograft has been historically used for physeal-sparing ACL reconstructions (ACLR) in skeletally immature children (Modified-Macintosh/Micheli-Kocher technique), with an extra-articular component that replicates an anterolateral ligament reconstruction (ALLR). The procedure has demonstrated excellent patient-reported outcomes (PROs), return to sports (RTS), and relatively low ACL graft rupture rate, compared to other techniques in children and adolescents. The purpose of the current study was to assess the peri-operative complications, safety, and early outcomes of a novel ITB-ACLR+ALLR technique modified for skeletally mature patients (Figure 1) and compare it to a standard technique using patellar tendon/bone-tendon-bone autograft (BTB-ACLR). The hypothesis was that there would be no outcome differences between groups.

Methods

Patients aged 13-25 years-old with closing or closed physes who underwent either primary ITB-
ACLR+ALLR or primary BTB-ACLR by one of three surgeons at a single institution over a one-year period were included. All intra-operative and post-operative complications were retrospectively recorded. Physical exam findings were collected at baseline, 3, and 6 month follow up visits, and RTS testing was performed at 6 and 9 months, post-operatively. PROs were collected at baseline and 6 month follow-up visits, with ongoing collection of 12 and 24 month follow-up PROs underway.

Results

79 patients (37 ITB, 42 BTB) were included in the current analysis. There were no significant differences in age, sex, BMI, PROs, operative time, tourniquet time, or RTS time between the two treatment groups (Table 1). Peri-operative complications for ITB-ACLR+ALLR included one case of graft rupture, one case of medial meniscus tear, one case of lateral thigh cramping, one case of stiffness, and one superficial wound infection. Peri-operative complications for BTB-ACLR included four cases of arthrofibrosis. All post-operative Lachman and pivot-shift tests demonstrated symmetry with the contralateral knee, within 1 IKDC grade. All 6-month PROs were not statistically different between groups (Table 2).

Conclusion

Preliminary safety and clinical results suggest that a novel ACLR+ALLR technique utilizing an ITB autograft may be safe and effective for restoring knee stability and returning skeletally mature adolescents to sports, with comparable early complications and PROs to ACLR-BTB. Given the advantages of the ITB-ACLR+ALLR—which includes an extra-articular reconstruction designed to optimize rotational stability, preservation of both the dynamic knee extensor and flexor muscle groups, and relatively smaller bony tunnels—ongoing monitoring of graft rupture rates and PROs in the current cohort and future randomized, prospective clinical trials are warranted to assess the technique in methodologically rigorous, multicenter fashion.