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Anterior Cruciate Ligament Reconstruction via Quadriceps Autograft and Lateral Extra-Articular Tenodesis in Skeletally Immature Athletes

March 01, 2019

Contributors: Joseph Rund, BS; John Welsh, BA; Seth Sherman, MD; Seth Sherman, MD

Anterior cruciate ligament (ACL) injuries are common in young athletes. The management of ACL injuries has evolved considerably in the past 50 years. Historically, ACL tears were managed via isolated lateral extra-articular tenodesis (LET) to control anterior laxity. The use of isolated extra-articular reconstruction decreased after single-bundle intra-articular ACL reconstruction techniques were introduced. Double-bundle ACL reconstruction was developed to further control rotational laxity. Recently, single-bundle ACL reconstruction in combination with LET has emerged as a method to decrease rotatory laxity in high-risk athletes. Although LET usually is recommended during revision ACL surgery, LET also is considered an adjunct to primary ACL reconstruction in patients with certain risk factors, such as age younger than 18 years, a grade II pivot shift, underlying hyperlaxity, or intention to return to high-demand cutting/pivoting sports activity. This video discusses the case presentation of a 13-year-old girl with an ACL tear resulting from a noncontact, twisting injury that occurred while playing soccer. A preoperative examination performed under anesthesia revealed a range of knee motion from 15° of hyperextension to 140° of flexion (equal to that of the contralateral knee), a grade 3B Lachman test, and a grade III pivot shift. The patient underwent ACL reconstruction with use of a quadriceps autograft followed by LET with the use of an iliotibial band autograft. A postoperative examination performed under anesthesia revealed full range of knee motion, a grade 1A Lachman test, and negative pivot shift test. Additional research is required on the use of LET in patients undergoing primary ACL reconstruction. Several meta-analyses have demonstrated a considerable reduction in pivot shift in patients undergoing ACL reconstruction in combination with LET compared with patients undergoing ACL reconstruction alone; however, these studies reported no substantial difference between the two approaches with regard to International Knee Documentation Committee scores. Evidence continues to grow on the benefits of LET in combination with ACL reconstruction and the patients for whom the procedure is best suited.

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