Anterolateral augmentation procedures during anterior cruciate ligament reconstructions in skeletally immature patients – scoping review of surgical techniques and outcomes

Abstract:
Introduction and Objectives: Graft failure rates after anterior cruciate ligament (ACL) reconstruction in children and adolescents are higher compared to adults. Studies have highlighted young age, hyperlaxity and rotatory instability as risk factors for graft failure and to require anterolateral augmentation procedures during ACL reconstruction (ACLR). The literature on anterolateral ligament recosntruction (ALLR) or lateral extra-articular tenodesis (LET) in skeletally immature children and adolescents is scarce. The aim of this scoping review is to provide an overview of the current anterolateral augmentation procedures in skeletally immature patients and to discuss biomechanical characteristics, surgical considerations regarding the physes and clinical outcomes.
Materials and Methods: This scoping review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement extension for scoping reviews. PubMed, Embase and Cochrane databases were systematically searched for literature regarding ACLR with ALLR or LET. LET or ALLR techniques combined with a transphyseal ACLR, all-epiphyseal ACLR, over-the-top or hybrid ACLR (partial epiphyseal or extra-articular and transphyseal) were included in this review. Specific parameters of the surgical technique used in each study were collected, including the femoral attachment, tibial attachment and graft type. Findings from biomechanical studies of ALLR and LET were collected. Clinical outcomes, such as graft failure and growth disturbances were extracted.
Results: Sixteen studies were included in this systematic review after screening 1.287 abstracts. Thirteen studies describe LET techniques and 3 studies ALLR techniques. Most of the LET procedures were performed during an over-the-top ACLR, with low graft failure rates. Literature on ALLR in this population is scarce.
Conclusions: there are many LET techniques for skeletally immature children, which are most often performed with an over-the-top ACLR, with promising clinical results. There are other LET and ALLR techniques for transphyseal, all-epiphyseal or hybrid ACLR in skeletally immature patients.

Keywords: ACL reconstruction, lateral extra-articular tenodesis, anterolateral ligament reconstruction, skeletally immature, open physes