Homan Morgan D, Kramer Riley, Banovetz Mark T, Kennedy Nicholas I, LaPrade Robert F
Twin Cities Orthopedics, Edina, Minnesota, USA.
University of Minnesota Medical School, Minneapolis, Minnesota, USA.
Video J Sports Med. 2023 May 16;3(3):26350254231163594. doi: 10.1177/26350254231163594. eCollection 2023 May-Jun.
Anterior cruciate ligament (ACL) reconstructions in skeletally immature patients have an increased risk of graft failure and a decreased rate of successful return to sports. Anterior cruciate ligament reconstructions (ACLRs) combined with lateral extra-articular tenodesis (LET) procedures are reported to limit anterolateral rotary instability of the knee, decreasing tension on the ACL graft. However, the open physes found in pediatric patients present unique challenges for ACLR. This video demonstrates a technique to avoid the femoral physis and necessary precautions for performing an ACLR with LET in a skeletally immature patient.
The indications for combined ACLR and LET, as opposed to ACLR alone, mainly center on the risk factors for graft failure. These include the following: posterior tibial slope >12°, revision ACLR, high-grade pivot shift on physical examination, meniscal deficiency, generalized ligamentous hyperlaxity, and-especially pertinent to this procedure-skeletally immature patients.
Standard plain radiographs and long-leg alignment films, along with a magnetic resonance imaging (MRI) study, are necessary to assess for malalignment, bone age, and concomitant meniscal and chondral pathology. This technique describes the senior author's preferred technique for pediatric ACLR with LET. The senior author's preferred order of operations includes performing the autologous hamstring graft harvest and LET before performing the diagnostic arthroscopy. This is followed by the intra-articular work including the ACLR. It is also the senior author's preference to perform physeal-sparing femoral tunnels, using fluoroscopy for tunnel placement.
Getgood et al reported that an ACLR with an LET in young patients with a high risk of graft failure had a significant reduction in graft rupture compared to an ACLR alone. Furthermore, Noyes et al reported a significantly lower rate of graft failure and a higher rate of return to sports in those who received LET in addition to ACLR compared with those who received ACLR alone.
An ACLR combined with an LET has been reported to reduce graft failure rates and improve clinical outcomes in high-risk patients. An ACLR with LET may also be considered in skeletally immature patients with appropriate indications and extra precautions to avoid growth arrest or deformity.
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
骨骼未成熟患者的前交叉韧带（ACL）重建术发生移植物失败的风险增加，且成功恢复运动的比率降低。据报道，前交叉韧带重建术（ACLR）联合外侧关节外肌腱固定术（LET）可限制膝关节的前外侧旋转不稳定，减轻ACL移植物上的张力。然而，儿科患者中发现的开放骨骺给ACLR带来了独特的挑战。本视频展示了一种避免股骨骨骺的技术，以及在骨骼未成熟患者中进行ACLR联合LET时的必要预防措施。
与单纯ACLR相比，ACLR联合LET的适应证主要集中在移植物失败的风险因素上。这些因素包括：胫骨后倾>12°、ACLR翻修术、体格检查时严重的轴移、半月板缺损、全身性韧带松弛，以及——尤其与本手术相关的——骨骼未成熟患者。
标准的平片和长腿对线片，以及磁共振成像（MRI）检查，对于评估对线不良、骨龄以及合并的半月板和软骨病变是必要的。本技术描述了资深作者在儿科患者中进行ACLR联合LET时的首选技术。资深作者首选的手术顺序包括在进行诊断性关节镜检查之前采集自体腘绳肌腱移植物并进行LET。接下来是包括ACLR在内的关节内操作。资深作者还倾向于采用保留骨骺的股骨隧道，使用荧光透视进行隧道定位。
Getgood等人报告称，与单纯ACLR相比，在移植物失败风险高的年轻患者中进行ACLR联合LET可显著降低移植物破裂率。此外，Noyes等人报告称，与单纯接受ACLR的患者相比，接受ACLR联合LET的患者移植物失败率显著降低，恢复运动的比率更高。
据报道，ACLR联合LET可降低高风险患者的移植物失败率并改善临床结果。对于有适当适应证且采取额外预防措施以避免生长停滞或畸形的骨骼未成熟患者，也可考虑进行ACLR联合LET。
作者证明已获得本出版物中出现的任何患者的同意。如果个体可能被识别，作者已随本投稿附上患者的豁免声明或其他书面批准形式以供发表。
