Modified ACL Reconstruction Technique in Adolescent Athletes Shows Promising Results

An emerging surgical technique added to the standard anterior cruciate ligament (ACL) reconstruction in high-risk adolescent athletes resulted in zero re-tears and zero graft failures after a minimum follow-up of two years.

According to preliminary results from patients who were treated at Hospital for Special Surgery (HSS).

These results, from 28 patients under age 20, are the first to emerge from a larger study currently in progress. This study is available online as part of the AAOS 2020 Virtual Education Experience.

Frank Cordasco, MD, MS, Surgeon at HSS

“An ACL re-injury in the young adolescent athlete, who has undergone an ACL reconstruction and nine to 12 months of rehabilitation, is a devastating clinical problem that sports medicine orthopedic surgeons continue to confront in the United States and around the world.

Our goal is to reduce the risk of re-injury as these athletes return to sports and prevent additional surgery involving the same knee or the uninjured knee to the extent that is possible,” says Frank Cordasco, MD, MS, a sports medicine surgeon at HSS and the study’s first author.

The ACL is one of the major ligaments that stabilizes the knee joint. Adolescents under age 20 who play field or court sports that involve jumping and pivoting motions or high-energy impacts to the knee, such as soccer, lacrosse, football, basketball or rugby, may tear the ACL.

The goals of ACL surgery are to reconstruct a torn ACL to help stabilize the knee and to allow athletes to return to their former level of sports activity after recovery.

The additional surgical technique is called a modified Lemaire IT band tenodesis, named after Marcel Lemaire, a surgeon in France who originally described it in 1975.

It is performed at the end of an ACL reconstruction. It involves using an 8-cm-by-1-cm strip of the iliotibial (IT) band, which is the long strap of connective tissue that extends from the hip to the knee on the outer side of the leg.

This requires an additional, small, 5 cm incision.

Surgeons pass the strip deep under the lateral collateral ligament, another large stabilizing ligament in the knee, and secure it in place, creating a tether or checkrein that limits the potential for recurrent rotational instability.

The method has been used in Europe for many years.

Daniel Green, MD, MS, FAAP, FACS, a Pediatric Surgeon at HSS

“The biggest study so far has been from Europe, where studies have demonstrated the modified Lemaire IT band tenodesis has been proven successful in professional or semi-professional soccer players.

At HSS, we’re proud to be one of the first groups to use this technique in high-risk teenage athletes in North America,” says Daniel Green, MD, MS, FAAP, FACS, a pediatric orthopedic surgeon at HSS and senior study author.

Dr. Cordasco and Dr. Green recently described the technique and their rationale for using it to treat athletes under the age of 20 years with a high risk of re-injury in a paper published in Arthroscopy Techniques.

They identified that patients who had an ACL reconstruction and were in the eighth and ninth grade had a higher risk of re-injury and lower rates of returning to sports compared to those who were in the seventh grade and younger, and those who were in the tenth grade and older.

They speculated that among the multiple risk factors, athletes in the eighth and ninth grades had a higher risk of re-injury because they return to play with athletes in the tenth grade who are skeletally mature and did not lose a year of physical and sports-specific development.

The results were published in the American Journal of Sports Medicine.

The new data looks at results in patients from this higher-risk age group who received an ACL reconstruction with modified Lemaire IT band tenodesis, returned to sport for at least one season and were followed for a minimum of two years.

Patients were 14.9 years old, on average, with a range of 11.1 to 19.1 years. Dr. Green and Dr. Cordasco performed the surgeries at HSS, starting in 2015.

To date, patient-reported outcomes have been highly positive, with all patients giving their injured joint a Single Assessment Numeric Evaluation (SANE) score higher than 90% on a scale from 0% to 100%, where 100% represents normal function.

“We now have more than 100 patients in our database. We are continuing to track outcomes and plan to publish a larger report on results for this patient population in the future,” Dr. Cordasco says.

“We are excited about our preliminary results and plan to follow patients for at least five years until they reach skeletal maturity, around the age of 20,” Dr. Green says. “We anticipate there will be some failures, but we hope to see far fewer than if we had not supplemented the ACL reconstruction with this additional surgical method.”

For more information, visit www.hss.edu

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