Outcomes of Physeal-Sparing ACL Reconstruction with Iliotibial Band Autograft in Skeletally Immature Prepubescent Children

2018 ◽  
Vol 100 (13) ◽  
pp. 1087-1094 ◽  
Author(s):  
Mininder S. Kocher ◽  
Benton E. Heyworth ◽  
Peter D. Fabricant ◽  
Frances A. Tepolt ◽  
Lyle J. Micheli
Keyword(s):  
Acl Reconstruction ◽  
Iliotibial Band ◽  
Skeletally Immature ◽  
Physeal Sparing

scholarly journals ILIOTIBIAL BAND AUTOGRAFT: WHAT SIZE IS THE GRAFT? A MATHEMATICAL AND CADAVERIC MODEL

2019 ◽  
Vol 7 (3_suppl) ◽  
pp. 2325967119S0010
Author(s):  
Jennifer Beck ◽  
Karren Takamura ◽  
Jeanne Beck ◽  
Richard E. Bowen
Keyword(s):  
Acl Reconstruction ◽  
Clinical Relevance ◽  
Iliotibial Band ◽  
Skeletally Immature ◽  
Graft Size ◽  
Technical Requirements ◽  
Graft Thickness ◽  
Males And Females ◽  
Primary Acl Reconstruction ◽  
Cadaveric Model

Background The Iliotibial Band (ITB) is used as a primary ACL reconstruction in skeletally immature patients and as autograft during other orthopedic reconstructions. The size of the ITB as a single and doubled graft is unknown. Methods Nine adult cadaveric ITB were used to determine the size of the ITB as a single and doubled graft. Thickness and width of the ITB were determined. In decreasing 5 mm measurements, single and double graft sizes were determined using standard surgical graft size technique. Geometric calculations based on average graft thickness were used to mathematically confirm the graft size of the ITB. Results The ITB is less than 1 mm in thickness in males and females. Cadaveric measurements were less than 1 mm larger than mathematical measurements, in majority of measurements. In adults, ITB autograft can be harvested to a maximum 9 mm single stranded graft or >12 mm doubled graft. A minimum of 50 mm of ITB width is required to make a 8 mm graft. Conclusions ITB is a versatile graft that can be considered when a large amount autograft tissue is required. Partial vs whole width ITB should be considered based on patient age, graft size desired, and technical requirements of the graft. Clinical Relevance Surgeons have a quick reference for the width of ITB they should harvest based on the size of graft they require for a successful surgery.

scholarly journals LONG-TERM FOLLOW-UP OF SKELETALLY IMMATURE PATIENTS WITH THE PHYSEAL-SPARING COMBINED EXTRA-/INTRA-ARTICULAR ILIOTIBIAL BAND ACL RECONSTRUCTION: KINEMATIC AND KINETIC RESULTS

2019 ◽  
Vol 7 (3_suppl) ◽  
pp. 2325967119S0012
Author(s):  
Dai Sugimoto ◽  
Amy Whited ◽  
Jeffery Brodeur ◽  
Elizabeth S. Liotta ◽  
Kathy Williams ◽  
...  
Keyword(s):  
Vertical Jump ◽  
Iliotibial Band ◽  
Initial Contact ◽  
Jump Height ◽  
Skeletally Immature ◽  
Patient Level ◽  
Vertical Jump Height ◽  
Physeal Sparing

Background: Anterior cruciate ligament (ACL) tears are among the most devastating orthopaedic injuries affecting young athletes, especially when they occur in children and adolescents. Growing interest in physeal-sparing techniques has prompted various investigations into the combined extra-articular/intra-articular modified-Macintosh ACL reconstruction with Iliotibial band autograph (ACLR-ITB), which is often used for younger skeletally immature patients with complete ACL ruptures. However, several aspects of the long-term function of knees undergoing this technique remain under-investigated. Therefore, the purpose of the current study was to determine two critical parameters of knee function—the vertical ground reaction force (VGRF) and vertical jump height - at various time intervals following the ACLR-ITB: 1-2 years, 2-5 years, 5-10 years, and >10 years post-surgically. Methods: The current investigation was conducted at a single pediatric tertiary care center using a cross-sectional, laboratory-controlled study design. Inclusion criteria were skeletally immature patients with ACL tears who underwent an ACLR-ITB procedure. Exclusion criteria were major knee injuries (requiring rehabilitation > 3 months) or subsequent surgery on the ipsilateral knee and/or any surgery on the contralateral knee. During data collection, 29 reflective markers were applied to participants who performed drop vertical jumps (DVJ) three consecutive times and vertical single-limb hops (one time, each limb). A three dimensional (3D) motion analysis system with force plates was used. Kinematic and kinetic data were collected at 240 Hz and 1080 Hz respectively, and synchronized in time. The sequence of which limb was tested first in the vertical single-limb hop test was randomized. The instance of initial contact was identified and the landing phase was defined as the first 500 ms after initial contact. Major outcome variables included VGRF and vertical jump height. The VGRF were normalized by mass (kg), and mean peak values of the landing phase were used for analysis. Vertical jump height was calculated through following equation: ½ g(t/2)2, where g=9.81 m/s2 and t=time in seconds in the air. Descriptive statistics were used to analyze basic demographic characteristics. Paired t-tests were employed to compare VGRF and vertical jump height between the two limbs by four groups (1-2 years, 2-5 years, 5-10 years, and >10 years) separately. Additionally, equivalence analysis using two one-sided paired t-tests was applied to further support comparison of the two limbs. Any difference in the outcome measures (VGRF and vertical jump height) at the 26 patient-level was further tested to examine equivalency between the two limbs using a margin of equivalence of 4 (a difference less than 4 was not considered clinically important). The a priori statistical significance was set as p=0.05. Results: The study population consisted of 40 subjects (1-2 years: N=9; 2-5 years: N=13; 5-10 years: N=10; >10 years: N=8), with demographic information presented at Table 1. Based on available data (26 of 40, 19 males and 7 females, 1-2 years: N=6, 2-5 years: N=9, 5-10 years: N=7, >10 years: N=4), paired t-tests showed no statistically significant differences in VGRF and vertical jump height between ACLR-ITB and non-ACLR limbs in DVJ (Table 2) and vertical single-limb hop (Table 3) in any of the follow-up time groups. The equivalence analysis identified that the main outcome measures for the ACLR-ITB limb were equivalent to those of the non-reconstructed limb at the 26 patient-level (DVJ: p=0.016, VSH: p<0.001, JH: p=0.01; Note: p<0.05 confirms equivalency that the measures for the two limbs are close enough so that reconstructed limb cannot be considered superior or inferior to the native limb). Conclusion/Significance: Based on VGRF and vertical jump height in DVJ and vertical single-limb hop maneuvers through kinematic and kinetic analyses, ACLR-ITB knee demonstrated equivalent or superior function to the contralateral uninjured limbs at 1-2 years, 2-5 years, 5-10 years, and >10 years following reconstruction. These data contribute broader scientific support for the ACLR-ITB procedure offering lasting functional benefits for skeletally immature athletes with complete ACL tears. [Table: see text][Table: see text][Table: see text]

scholarly journals DOES A COMBINED INTRA-ARTICULAR AND EXTRA-ARTICULAR ACL RECONSTRUCTION EFFECT EXTERNAL KNEE VALGUS MOMENT ASYMMETRY?

2019 ◽  
Vol 7 (3_suppl) ◽  
pp. 2325967119S0008
Author(s):  
Aaron J. Zynda ◽  
Henry B. Ellis ◽  
Kirsten Tulchin-Francis ◽  
Anthony Anderson ◽  
Parker Mitchell ◽  
...  
Keyword(s):  
Acl Reconstruction ◽  
Iliotibial Band ◽  
Knee Valgus ◽  
Clinical Difference ◽  
Valgus Angle ◽  
Drop Landing ◽  
Peak Knee ◽  
Significant Difference ◽  
Patient Reported ◽  
Physeal Sparing

Introduction: Peak external knee valgus moment can predict future ACL injury and is, often times, asymmetric following anatomic intra-articular ACL reconstruction. The purpose of this study is to evaluate the external knee valgus moment during a drop landing and a single limb squat 2 years following an iliotibial band (ITB) intra-articular and extra-articular physeal-sparing ACL reconstruction. Methods: Fourteen study subjects (mean age: 14.3 ± 2.6 yrs) who had previously undergone a physeal-sparing ACL reconstruction, as originally described by McIntosh using an ITB autograft, were enrolled in this IRB-approved study. All subjects were seen at a minimum of 24 months after surgery (mean follow-up: 55.0 ± 28.9 mos) and clinical, radiographic, and patient reported outcomes were collected. During functional testing, subjects underwent drop landing (DL) and unilateral squat (US) tasks. Isokinetic muscle strength of the hip and knee was collected using an isokinetic dynamometer at 60°/s. Paired student’s t-tests evaluated differences between affected (AFF) and unaffected (UNAFF) limbs. Results: During a drop landing, the AFF limb, compared to the UNAFF limb, did not demonstrate a difference in external knee valgus moment (0.50° vs. 0.51°, p=0.736). However, in the AFF limb, the mean knee peak knee valgus angle was 2.8 degrees less than the UNAFF limb during a drop landing (p=0.039). This difference was not considered within the range of a minimal clinical difference (MCD) of 5.1 degrees. Similar trends were found during a single limb squat with no significant difference seen in peak knee valgus moment between AFF and UNAFF (0.14° vs. 0.07°, p=0.150) with a statistical, yet not minimal clinical difference, in knee valgus angle at 45° squat position (-2.4° vs. 0.7°, p=0.033; MCD = 5.2). Thus, no asymmetry in peak knee valgus moment during a drop landing or a single limb squat following an ITB intra- and extra-articular ACL reconstruction was observed. In this series at 2 years’ post-op, the Pedi-IKDC and HSS Pedi-FABS were 96.54 ± 5 and 22.6 ± 5, respectively. Subjects demonstrated return to pre-operative Tegner Activity scores (8.42 vs. 8.17, p=0.33). Normalized hip abduction strength was significantly stronger in AFF (1.05 Nm/kg) vs. UNAFF (0.93 Nm/kg, p=0.02). Conclusion: Overall, there were no clinically significant differences, or asymmetry, in functional knee valgus in subjects following combined intra- and extra-articular iliotibial band ACL reconstruction during a drop landing or single leg squat. Young athletes can be expected to return to pre-operative activity levels and demonstrate appropriate knee valgus control following this physeal-sparing ACL reconstruction.

scholarly journals THE PHYSEAL-SPARING COMBINED EXTRA-/INTRA-ARTICULAR ILIOTIBIAL BAND ACL RECONSTRUCTION IN CHILDREN: A LONG-TERM STRENGTH, BALANCE, AND FUNCTIONAL ANALYSIS

2019 ◽  
Vol 7 (3_suppl) ◽  
pp. 2325967119S0007
Author(s):  
Benton E. Heyworth ◽  
Elizabeth S. Liotta ◽  
Dai Sugimoto ◽  
Kathryn Williams ◽  
Nicole Goldhaber ◽  
...  
Keyword(s):  
Acl Reconstruction ◽  
Activity Level ◽  
Iliotibial Band ◽  
Isokinetic Strength ◽  
Patient Reported ◽  
Hip Abductor ◽  
Functional Outcome Measures ◽  
Physeal Sparing

Background: While ACL reconstruction (ACLR) in skeletally immature patients was traditionally delayed until physeal closure, the development of techniques that avoid physeal disturbance have allowed surgical intervention with minimization of growth compromise. Previous reports have shown excellent patient outcomes and functional stability with low re-tear rates at short and mid-term follow-up in one of the most widely used physeal-sparing techniques, the combined extra-articular/intra-articular modified-MacIntosh ACL reconstruction with Iliotibial band autograph (ACLR-ITB). However, there is a lack of evidence regarding the kinematic performance of the reconstruction, which has been referred to as ‘non-anatomic’, as well as the effect of time on function and effectiveness. This component of a single-site, prospective, cross-sectional study of ACLR-ITB patients at different times following their reconstruction, between 1 and 20 years post-operatively, was designed to compare the sports performance-based features of the ACLR-ITB knee to the contralateral, uninjured contralateral knee, including strength, dynamic balance, and functional hop testing, as well as patient-reported functional outcome measures and activity scores. The primary hypothesis is that similar function will be found, between the ACLR-ITB and Non-ACL of individuals, and that the degree of similarity will be maintained with increasing age, growth, and/or time from reconstruction. Methods: Patients who underwent an ACLR-ITB between 1-20 years prior to study initiation were identified from the surgical database of three high-volume surgeons at a tertiary care pediatric hospital. Exclusion criteria were major injury or surgery on the contralateral knee at any time point, or on the ACLR-ITB knee since the time of reconstruction. The resulting study cohort of 40 subjects participated in a single day of testing at a specialized sports injury prevention center. Evaluation consisted of isometric and isokinetic strength (quadriceps, hamstring, hip abductor, hamstring: quadriceps ratio), dynamic Y-balance, and single leg hop testing, with the limb symmetry index (LSI) tabulated to allow for comparisons between knees. Patient-reported functional outcomes and activity level were recorded by Pedi-IKDC and HSS-Pedi FABS questionnaires, respectively. For the comparisons between knees, the LSI values minus 100 were compared to 0 using the Wilcoxon signed rank test. Additionally, equivalence analysis using two one-sided paired t-tests was applied to further support comparison of the two limbs. The LSI-100 measures were tested to examine equivalency between the two limbs using a margin of equivalence of 8 (a difference less than 8 was not considered clinically important). The magnitude of the relationship between test results and time was assessed using Pearson correlation coefficients (r). Results: The 40 study subjects had a mean age of 10.6 years (range 6-14) at time of reconstruction and 18.0 years (range: 9-30) at time of testing. Time between ACLR and time of testing ranged from 1-17 years with 8 patients beyond 10 years (Table 1). Completed Pedi-IKDC and HSS-Pedi FABS resulted in mean scores of 96 (range: 79-100) and 22 (range 0-30), respectively. The outlier subject who reported an athletic activity level of ‘0’ attributed the low score to a busy career in construction. Mean LSI for the single leg hop was 99.2% (p=0.727) and 98.4% (p=0.045) for dynamic Y-balance. Of the isometric and isokinetic strength tests, the three major muscle groups (hip abductors (LSI: 97.9%, p=0.207), quadriceps (LSI: 97.9%, p=0.260) hamstring (LSI: 102.6%, p=0.264)) showed no significant differences. Hamstring to quadriceps ratio for both limbs showed a mean value of 0.5. The equivalence analysis of LSI minus 100 confirmed equivalency, that the measures for the two limbs are close enough so that the reconstructed limb cannot be considered superior or inferior to the native limb (all p<0.05). No correlation between scores and time from reconstruction was observed, other than an expectable decline in HSS-Pedi FABS activity scores (r=-0.37, p=0.018) and improvement in hip abductor LSI (r=0.36, p=0.027) with increasing time from surgery. Conclusion / Significance: Similar to other long-term follow-up studies following ACLR, the current study demonstrated expectably decreasing activity with increasing patient age and time from ACLR-ITB. However, mean activity scores and functional outcome measures in this cohort are superior to age-based normative values, with outcome scores showing no decline in excellent knee function over time, up to 17 years following ACLR-ITB. Moreover, strength and functional hop testing show no clinically significant differences between the uninjured and reconstructed knees after at least 1 year, regardless of time from reconstruction. Equivalence in the measures between the two knees was shown for all LSI measures. The reported ‘non-anatomic’ features of the ACLR-ITB procedure do not appear to translate into clinically meaningful limitations in knee performance and function, which remain absent over time. Tables and figures: [Figure: see text]

Long-Term Follow-up of Skeletally Immature Patients With Physeal-Sparing Combined Extra-/Intra-articular Iliotibial Band Anterior Cruciate Ligament Reconstruction: A 3-Dimensional Motion Analysis

2020 ◽  
Vol 48 (8) ◽  
pp. 1900-1906
Author(s):  
Dai Sugimoto ◽  
Amy J. Whited ◽  
Jeff J. Brodeur ◽  
Elizabeth S. Liotta ◽  
Kathryn A. Williams ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Motion Analysis ◽  
Cruciate Ligament ◽  
Vertical Jump ◽  
Iliotibial Band ◽  
Skeletally Immature ◽  
3 Dimensional ◽  
Anterior Cruciate ◽  
Physeal Sparing

Background: The physeal-sparing iliotibial band (ITB) anterior cruciate ligament (ACL) reconstruction (ACLR) is a well-established technique for treating skeletally immature patients with ACL rupture. However, the long-term implications of the procedure on the intricacies of kinetic and kinematic function of the knee have not been comprehensively investigated. Purpose: To assess the short-, mid-, and long-term effects of ITB ACLR on kinetic and kinematic parameters of knee functions. Study Design: Case series; Level of evidence, 4. Methods: A total of 38 patients who had undergone an ITB ACLR as a skeletally immature child were recruited to participate in a 3-dimensional (3D) motion analysis testing protocol at an institutional injury prevention center between 1 and 20 years after reconstruction. Exclusion criteria were congenital ACL deficiency and any other major knee injury (defined as an injury requiring surgery or rehabilitation >3 months) on either knee. 3D and force plate parameters included in the analysis were knee moment, ground-reaction force, and vertical jump height measured during drop vertical jump and vertical single-limb hop. Paired t tests and equivalency analyses were used to compare the parameters between cases (ITB ACLR limb) and controls (contralateral/nonsurgical limbs). Results: Paired t tests showed no statistically significant differences between limbs, and equivalency analyses confirmed equivalency between limbs for all tested outcome variables. Conclusion: The ITB ACLR appears to restore normal, symmetric, physiologic kinetic and kinematic function in the growing knee by 1 year after reconstruction, with maintenance of normal parameters for up to 20 years.

scholarly journals A Long-term Follow-up Of Patients With Physeal-Sparing Iliotibial Band ACL Reconstruction: Kinetic Analyses

2019 ◽  
Vol 51 (Supplement) ◽  
pp. 462
Author(s):  
Dai Sugimoto ◽  
Amy Whited ◽  
Jeff Brodeur ◽  
Kathryn Williams ◽  
Kocher Mininder ◽  
...  
Keyword(s):  
Acl Reconstruction ◽  
Iliotibial Band ◽  
Long Term Follow Up ◽  
Physeal Sparing

scholarly journals OVER-THE-TOP VERSUS ALL-EPIPHYSEAL TECHNIQUE FOR PHYSEAL SPARING ACL RECONSTRUCTION

2019 ◽  
Vol 7 (3_suppl) ◽  
pp. 2325967119S0014
Author(s):  
Nirav K. Pandya ◽  
Brian Feeley ◽  
Stephanie Wong
Keyword(s):  
Acl Reconstruction ◽  
Skeletal Maturity ◽  
Angular Deformity ◽  
Skeletally Immature ◽  
Growth Disturbance ◽  
Patient Reported ◽  
Over The Top ◽  
Physeal Sparing ◽  
The Ideal

BACKGROUND A variety of techniques are utilized for physeal sparing ACL reconstruction, however, no clear consensus exists on the ideal surgical technique, the frequency of complications, and how to best avoid growth disturbance. The purpose of this systematic review is to compare outcomes and complications between over-the-top and all-epiphyseal ACL reconstruction techniques. METHODS The EMBASE and PubMed databases were queried for studies on ACL ruptures in the skeletally immature from 1985 to 2016. Full-text, English studies discussing operative intervention on skeletally immature patients with ACL tears were included (n = 160). Studies that reported re-rupture and/or complications after physeal sparing ACL reconstruction, specifically growth disturbance, were then included in a secondary analysis (n=10). Studies were separated into two groups: an all-epiphyseal group with femur and tibia fixation points within the epiphysis and a group that had over-the-top femur and tibia physeal-sparing reconstruction. Complications that were not specific to the pediatric population were excluded. Angular deformity greater than 3 degrees between the operative and non-operative extremities was used as the threshold. Patient demographics, evaluation of skeletal maturity and growth disturbance, graft type, surgical technique, follow up, growth disturbance, re-rupture, and patient reported outcome scores were collected. Data was analyzed in aggregate. RESULTS Ten studies were included with 280 knees in 279 patients. The average age was 11.8 years, 79% were male, and the mean post-operative follow up was 46.2 months. There were 178 patients who underwent all-epiphyseal reconstruction and 102 patients who underwent ACL reconstruction with the femoral graft placed in an over-the-top position. The overall re-rupture rate was 8.2% (23 of 280). There were 16 re-ruptures in the all-epiphyseal group (9%), and 7 re-ruptures in the over-the-top group (6.9%). Of those studies that specified treatment for re-rupture, 80% of patients required revision ACL reconstruction. Two studies did not conduct objective assessment of skeletal maturity. The majority of studies (50%) did not assess for baseline limb length inequality or angular deformity. 30% of studies performed routine hips-to-ankles bilateral lower extremity radiographs. 20% of studies assessed baseline LLD/angular deformity using clinical examination. Post-operatively, 50% of studies obtained routine hips-to-ankles lower extremity radiographs. 30% of studies obtained post-operative alignment imaging only if there was clinical suspicion of growth disturbance. There were ten total growth disturbances (3 required corrective surgery, or 30%). Seven knees developed limb overgrowth (six in the all-epiphyseal group (mean 1.8 cm) and one in the over-the-top group, 1.5 cm). Two of the patients with overgrowth from the all epiphyseal group required epiphysiodesis (28.6%). Five patients were observed. There were two angular deformities (one with 4 degrees of valgus, and another with 4 degrees varus), both in the over-the-top group which were treated with observation. There were no knees which developed angular deformity in the all epiphyseal group. One patient from the over-the-top group developed a multi-planar flexion-valgus deformity and required distal femoral osteotomy for correction. Five studies reported excellent Lysholm scores of 96.4. Six studies reported IKDC scores (range 88.5-100, 93% grade A or B). CONCLUSIONS / SIGNIFICANCE Growth disturbance after physeal sparing ACL reconstruction was overall uncommon and mild. The phenomenon of overgrowth was common likely due to younger patients receiving physeal sparing procedures. Overgrowth was more common in the all-epiphyseal group and angular deformity in the over-the-top group. Re-rupture rates were similar between the two groups. Evaluation of pre-operative skeletal maturity and comparison of baseline to post-operative growth disturbance was limited by lack of routine imaging assessment. We recommend routine PA hand radiographs, and pre- and post-operative hips-to-ankles alignment radiographs in all skeletally immature patients prior to undergoing ACL reconstruction. Further multi-center study with patient reported outcomes and long-term follow-up are necessary to determine the ideal reconstructive technique in the young, skeletally immature population.

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