Pediatric Data Needed on Combined ACL Reconstruction

Pediatric orthopedic surgeons cite a lack of evidence as the most common reason for not performing Anterolateral Ligament Reconstruction (ALL) or Lateral Extra-Articular Tenodesis (LET) in combination with anterior cruciate ligament reconstruction (ACLR) in children and adolescents, according to data presented at the 2021 annual meeting of the American Academy of Orthopedic Surgeons.

Both procedures when added to ACLR have shown promise in enhancing knee stability and reducing rate of graft failure, however, there is little data focusing on the use of these procedures in pediatric populations, lead researcher Neeraj M. Patel, MD, MPH, MBS, attending surgeon at the Ann & Robert H. Lurie Children’s Hospital of Chicago and assistant professor of orthopaedic surgery at Northwestern University Feinberg School of Medicine told Orthopedics This Week.

Collecting this pediatric data is especially crucial, he said, because children and adolescents have the highest risk of re-injury and of severe laxity.

For the study, “Trends in Anterolateral Ligament Reconstruction and Lateral Extra-Articular Tenodesis in Children and Adolescents,” Patel and his colleagues administered an electronic survey to surgeons in the Pediatric Research in Sports Medicine (PRISM) society. The purpose was to quantify surgeon practices regarding the two procedures in children and adolescents.

Both surgeon and practice demographic information was collected and then the surgeons were asked about indications, preferences, and techniques for ALL or LET in the context of primary and revision pediatric ACLR.

Overall, 63 surgeons were surveyed. Out of the 63, 62% performed 50 or more pediatric ACLR annually. And in the setting of primary ACLR 35 of 63 (56%) sometimes perform ALL or LET.  Fifty out of the 63 patients (79%) performed either the ALL or LET with revision ACLR.

These procedures were more commonly performed in a primary setting when there was high-grade pivot shift, knee hyperextension, generalized laxity and sports participation.

Surgeons whose practice was primarily sports medicine were more likely to perform these procedures with both primary and revision ACLR (p = 0.005 and 0.001, respectively).

The researchers also reported that those surgeons who had completed a sports medicine fellowship were more likely to perform these procedures than those with only pediatric orthopedic training in both primary (68% vs. 36%, p = 0.01) and revision settings (92% vs. 60%; p = 0.002).

For those surgeons who do not perform ALL or LET with primary ACLR, 75% cited insufficient evidence as the reasons. However, 95% of the surgeons that do perform them say they’d be interested in studying them prospectively and 86% said they were willing to randomize patients.

Patel explained that the advantage of adding these procedures to ACLR is that it is generally low risk and they are not technically demanding. He acknowledged though that some surgeons have concerns that in the long-term they might over-constrain the knee and increase the potential for arthritis. He said there isn’t a lot of data on this though.

The lack of pediatric data on the use of ALL and LET was the driving force behind why some surgeons choose not to perform them, Patel said. While there has been promising clinical data on improved outcomes, it has been mostly in adults.

To gather some of this data, Patel is leading a multicenter clinical trial to determine whether combining ALL reconstruction with ACLR will result long-term in a lower rate of grate failure compare with ACL reconstruction alone.

The Clevelend Clinic recently provided additional information on hyperextended knees.