Modified ACL Reconstruction Technique in High-Risk 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.
“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,” says Frank Cordasco, MD, MS, a sports medicine surgeon at HSS and the study’s first author. “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.”
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. “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,” says Daniel Green, MD, MS, FAAP, FACS, a pediatric orthopedic surgeon at HSS and senior study author. “At HSS, we’re proud to be one of the first groups to use this technique in high-risk teenage athletes in North America.”
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.”
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the tenth consecutive year), No. 3 in rheumatology by U.S. News & World Report (2019-2020), and named a leader in pediatric orthopedics by U.S. News & World Report “Best Children’s Hospitals” list (2019-2020). Founded in 1863, the Hospital has the lowest complication and readmission rates in the nation for orthopedics, and among the lowest infection rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center four consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 130 countries. Through HSS Global Ventures, the institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu.