Advertisement

Combining Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Procedures in Skeletally Immature Patients Is Safe and Associated With a Low Failure Rate

Open AccessPublished:October 09, 2022DOI:https://doi.org/10.1016/j.asmr.2022.08.002

      Purpose

      To analyze the rates of graft ruptures and growth disorders, the level of return to sport, and the clinical results of 2 lateral extra-articular procedures in growing children.

      Methods

      This study was a retrospective, single-center study of patients undergoing anterior cruciate ligament (ACL) surgery combined with 2 different lateral extra-articular procedures (anatomic reconstruction with a gracilis graft or modified Lemaire technique with a strip of fascia lata). The measurements of side-to-side anterior laxity and pivot shift were performed preoperatively and at the last follow-up. The sports level and the complications rate were assessed. The minimal clinically important differences (MCID) and patient acceptable symptoms state threshold scores were calculated.

      Results

      Thirty-nine patients (40 ACLs) were included (20 anatomic and 20 modified Lemaire) at an average follow-up of 57 months ± 10 [42-74]. One patient (2.5%) was lost to follow-up. The mean age at surgery was 13.8 ± 1.4 years old [9.8; 16.5]. One graft failure was reported (2.6% [0.06-13.5]) at 35.6 months after surgery. Two cases (5.4%) of femoral overgrowth were observed, and one of them required distal femoral epiphysiodesis. Ninety-two percent of the patients returned to sports. At the final follow-up, side-to-side anterior laxity was significantly improved, and no residual pivot shift was recorded in 95% of patients. Eighty-nine percent of the patients presented a Pedi-International Knee Documentation Committee score greater than the MCID postoperatively, and 77% presented a Lysholm score greater than the MCID.

      Conclusions

      This series of ACL reconstructions combined with 2 different lateral extra-articular procedures in skeletally immature patients demonstrated promising findings. The low rate of observed complications, including graft rupture and growth disturbance, is encouraging, but the small study population and lack of comparative group precludes reliable conclusions.

      Level of Evidence

      IV, therapeutic case series.
      The management of anterior cruciate ligament (ACL) ruptures in skeletally immature patients has been undergoing rapid development since the early 2000s. Historically, in the absence of anatomical reconstruction techniques and because of the risk of secondary growth disorders, nonsurgical treatments were favored. These treatments were based on an adapted rehabilitation program and modification or restriction of the patient’s sporting activities.
      • Mohtadi N.
      • Grant J.
      Managing anterior cruciate ligament deficiency in the skeletally immature individual: A systematic review of the literature.
      • Aichroth P.M.
      • Patel D.V.
      • Zorrilla P.
      The natural history and treatment of rupture of the anterior cruciate ligament in children and adolescents. A prospective review.
      • Moksnes H.
      • Engebretsen L.
      • Risberg M.A.
      Management of anterior cruciate ligament injuries in skeletally immature individuals.
      However, failures of nonoperative management, with meniscus and cartilage consequences,
      • Mizuta H.
      • Kubota K.
      • Shiraishi M.
      • Otsuka Y.
      • Nagamoto N.
      • Takagi K.
      The conservative treatment of complete tears of the anterior cruciate ligament in skeletally immature patients.
      • Moksnes H.
      • Engebretsen L.
      • Risberg M.A.
      Prevalence and incidence of new meniscus and cartilage injuries after a nonoperative treatment algorithm for ACL tears in skeletally immature children: A prospective MRI study.
      • James E.W.
      • Dawkins B.J.
      • Schachne J.M.
      • et al.
      Early operative versus delayed operative versus nonoperative treatment of pediatric and adolescent anterior cruciate ligament injuries: A systematic review and meta-analysis.
      the desire to return to sports, the increasing incidence of ACL ruptures in children,
      • Shea K.G.
      • Pfeiffer R.
      • Wang J.H.
      • Curtin M.
      • Apel P.J.
      Anterior cruciate ligament injury in pediatric and adolescent soccer players: An analysis of insurance data.
      • Parkkari J.
      • Pasanen K.
      • Mattila V.M.
      • Kannus P.
      • Rimpelä A.
      The risk for a cruciate ligament injury of the knee in adolescents and young adults: A population-based cohort study of 46 500 people with a 9 year follow-up.
      • Maffulli N.
      • Del Buono A.
      Anterior cruciate ligament tears in children.
      • Stracciolini A.
      • Casciano R.
      • Levey Friedman H.
      • Meehan W.P.
      • Micheli L.J.
      Pediatric sports injuries: An age comparison of children versus adolescents.
      • Morgan M.D.
      • Salmon L.J.
      • Waller A.
      • Roe J.P.
      • Pinczewski L.A.
      Fifteen-year survival of endoscopic anterior cruciate ligament reconstruction in patients aged 18 years and younger.
      • Shea K.G.
      • Grimm N.L.
      • Ewing C.K.
      • Aoki S.K.
      Youth sports anterior cruciate ligament and knee injury epidemiology: Who is getting injured? In what sports? When?.
      and the development of pediatric surgical procedures are at the origin of the increase in surgical treatment of ACL reconstruction.
      • Dodwell E.R.
      • Lamont L.E.
      • Green D.W.
      • Pan T.J.
      • Marx R.G.
      • Lyman S.
      20 years of pediatric anterior cruciate ligament reconstruction in New York State.
      Nevertheless, the conclusions of the meta-analysis by Ramski et al.
      • Ramski D.E.
      • Kanj W.W.
      • Franklin C.C.
      • Baldwin K.D.
      • Ganley T.J.
      Anterior cruciate ligament tears in children and adolescents: A meta-analysis of nonoperative versus operative treatment.
      favored early surgical management in children. ACL reconstruction in young patients remains linked to a high rate of graft failure
      • Andernord D.
      • Desai N.
      • Björnsson H.
      • Ylander M.
      • Karlsson J.
      • Samuelsson K.
      Patient predictors of early revision surgery after anterior cruciate ligament reconstruction: A cohort study of 16,930 patients with 2-year follow-up.
      • Webster K.E.
      • Feller J.A.
      Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction.
      • Hansson F.
      • Moström E.B.
      • Forssblad M.
      • Stålman A.
      • Janarv P.M.
      Long-term evaluation of pediatric ACL reconstruction: High risk of further surgery but a restrictive postoperative management was related to a lower revision rate.
      and to potential growth disorders
      • Chotel F.
      • Henry J.
      • Seil R.
      • Chouteau J.
      • Moyen B.
      • Bérard J.
      Growth disturbances without growth arrest after ACL reconstruction in children.
      ,
      • Ardern C.L.
      • Ekås G.R.
      • Grindem H.
      • et al.
      2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries.
      : being a child has been described as a major risk factor for graft failure in comparison with an adult population in a large cohort of 5,479 patients (18.0% [pediatric <20 years old] vs 9.2% [adults 20-29 years old] and 7.1% [adults 30-39 years old]; P < .0001 at 5 years postoperatively).
      • Lemme N.J.
      • Yang D.S.
      • Barrow B.
      • O’Donnell R.
      • Daniels A.H.
      • Cruz A.I.
      Risk factors for failure after anterior cruciate ligament reconstruction in a pediatric population: A prediction algorithm.
      Additionally, persistent poor rotational control is reported in 17% to 30% of patients who undergo ACL surgery.
      • Sonnery-Cottet B.
      • Lutz C.
      • Daggett M.
      • et al.
      The involvement of the anterolateral ligament in rotational control of the knee.
      ,
      • Samuelsen B.T.
      • Webster K.E.
      • Johnson N.R.
      • Hewett T.E.
      • Krych A.J.
      Hamstring autograft versus patellar tendon autograft for ACL reconstruction: Is there a difference in graft failure rate? A meta-analysis of 47,613 patients.
      The existence of the anterolateral ligament (ALL) was mentioned by Paul Segond in 1879,
      • Segond P.
      Recherches Cliniques et Expérimentales Sur Les Épanchements Sanguins Du Genou Par Entorse.
      ,
      • Murgier J.
      • Devitt B.M.
      • Sevre J.
      • Feller J.A.
      • Cavaignac E.
      The origin of the knee anterolateral ligament discovery: A translation of Segond’s original work with commentary.
      which he defined at that time as “a pearly fibrous strip” on the anterolateral portion of the capsule. It was then updated in 2013 by Claes et al.
      • Claes S.
      • Vereecke E.
      • Maes M.
      • Victor J.
      • Verdonk P.
      • Bellemans J.
      Anatomy of the anterolateral ligament of the knee.
      ALL tears in association with ACL tears have been reported by several authors.
      • Ferretti A.
      • Monaco E.
      • Fabbri M.
      • Maestri B.
      • De Carli A.
      Prevalence and classification of injuries of anterolateral complex in acute anterior cruciate ligament tears.
      ,
      • Song Y.
      • Yang J.H.
      • Choi W.R.
      • Lee J.K.
      Magnetic resonance imaging-based prevalence of anterolateral ligament abnormalities and associated injuries in knees with acute anterior cruciate ligament injury.
      The role of the ALL has now been demonstrated in rotational control of the knee,
      • Sonnery-Cottet B.
      • Lutz C.
      • Daggett M.
      • et al.
      The involvement of the anterolateral ligament in rotational control of the knee.
      ,
      • Lutz C.
      • Sonnery-Cottet B.
      • Niglis L.
      • Freychet B.
      • Clavert P.
      • Imbert P.
      Behavior of the anterolateral structures of the knee during internal rotation.
      and its reconstruction during ACL surgery has shown its effectiveness in adults
      • Sonnery-Cottet B.
      • Vieira T.D.
      • Ouanezar H.
      Anterolateral ligament of the knee: Diagnosis, indications, technique, outcomes.
      ,
      • Littlefield C.P.
      • Belk J.W.
      • Houck D.A.
      • et al.
      The anterolateral ligament of the knee: An updated systematic review of anatomy, biomechanics, and clinical outcomes.
      by significantly reducing the rate of iterative rupture.
      • Sonnery-Cottet B.
      • Saithna A.
      • Cavalier M.
      • et al.
      Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: A prospective comparative study of 502 patients from the SANTI study group.
      ,
      • Sonnery-Cottet B.
      • Haidar I.
      • Rayes J.
      • et al.
      Long-term graft rupture rates after combined ACL and anterolateral ligament reconstruction versus isolated ACL reconstruction: A matched-pair analysis from the SANTI study group.
      Few studies have analyzed the results of ACL reconstruction associated with anterolateral procedures in children.
      • Lanzetti R.M.
      • Pace V.
      • Ciompi A.
      • et al.
      Over the top anterior cruciate ligament reconstruction in patients with open physes: A long-term follow-up study.
      • Wilson P.L.
      • Wyatt C.W.
      • Wagner K.J.
      • Boes N.
      • Sabatino M.J.
      • Ellis H.B.
      Combined transphyseal and lateral extra-articular pediatric anterior cruciate ligament reconstruction: A novel technique to reduce ACL reinjury while allowing for growth.
      • Roberti di Sarsina T.
      • Macchiarola L.
      • Signorelli C.
      • et al.
      Anterior cruciate ligament reconstruction with an all-epiphyseal “over-the-top” technique is safe and shows low rate of failure in skeletally immature athletes.
      • Kocher M.S.
      • Heyworth B.E.
      • Fabricant P.D.
      • Tepolt F.A.
      • Micheli L.J.
      Outcomes of physeal-sparing ACL reconstruction with iliotibial band autograft in skeletally immature prepubescent children.
      • Willimon S.C.
      • Jones C.R.
      • Herzog M.M.
      • May K.H.
      • Leake M.J.
      • Busch M.T.
      Micheli Anterior cruciate ligament reconstruction in skeletally immature youths: A retrospective case series with a mean 3-year follow-up.
      Kocher et al.
      • Kocher M.S.
      • Heyworth B.E.
      • Fabricant P.D.
      • Tepolt F.A.
      • Micheli L.J.
      Outcomes of physeal-sparing ACL reconstruction with iliotibial band autograft in skeletally immature prepubescent children.
      published an article in 2018 with encouraging results over a short-term follow-up with excellent functional outcomes, minimal risk of growth disturbance (0%), and a low graft rupture rate (6.6%).
      The purposes of this study were to analyze the rates of graft ruptures and growth disorders, the level of return to sport, and the clinical results of 2 lateral extra-articular procedures in growing children. Our hypothesis was that combined ACL and lateral extra-articular procedure would provide good clinical results and low failure and complications rates.

      Methods

      Institutional review board approval (COS-RGDS-2021-04-001) was granted for this study, and all of the participants provided valid consent to participate.

      Patients

      This study was a single-center retrospective study undertaken between April 2014 and December 2016. The inclusion criteria were as follows: any child with growth potential (bone age younger than 13.5 years old for girls and younger than 15.5 years old for boys) who underwent a surgical technique combining ACL and lateral extra-articular procedure. In our institution, all patients younger than 25 years old undergo a lateral extra-articular procedure when an ACL reconstruction is performed. The exclusion criteria were the absence of follow-up until skeletal maturity bone age >13.5 for girls and 15.5 for boys or fusion of the proximal tibial or distal femoral epiphyseal growth plate on preoperative radiographs, previous knee injury, and multiligamenteous injuries

      Operating Methods

      Expert surgeons were involved (M.T., B.S.C. and J.M.F.). Two different surgical techniques were performed, chosen according to the preference of the surgeon (Fig 1). These surgical procedures were based on a vertical transphyseal tibial tunnel and a physeal-sparing femoral tunnel using an outside-in technique on both side without any fluoroscopy. Entry point on the lateral side of the femur was located slightly posterior and proximal to the lateral epicondyle to match with the natural insertion of the ALL.
      • Sonnery-Cottet B.
      • Daggett M.
      • Helito C.P.
      • Fayard J.M.
      • Thaunat M.
      Combined anterior cruciate ligament and anterolateral ligament reconstruction.
      Hamstrings were left pediculated on the tibia so that no extra fixation were used at this level. The target diameter of the tunnels was ≤9 mm. ACL graft was fixed at 25° of flexion, anterolateral procedure was fixed in full extension. The first method (method A) consisted in ACL reconstruction with a tripled semitendinosus (ST) and 1 strand of gracilis graft and ALL reconstruction using a gracilis graft: the ACL graft was composed of 3 strands of ST and one strand of gracilis; femoral fixation was provided by a screw; a double bundle of gracilis was used to reconstruct the ALL, the anterior tunnel was positioned slightly posterior to Gerdy’s tubercle and the posterior tunnel was placed midway between Gerdy’s tubercle and the fibular head. The second method (method B) consisted in ACL reconstruction with a tripled ST graft fixed on the femur with a button through a blind tunnel performed with a retrodrill device; anterolateral procedure, inspired by the modified Lemaire technique,
      • Muller B.
      • Willinge G.J.A.
      • Zijl J.A.C.
      Minimally invasive modified Lemaire tenodesis.
      was performed using a strip of fascia lata left pediculaled on Gerdy’s tubercle passed medially to the lateral collateral ligament and fixed on the femoral side using the wires of the button.
      Figure thumbnail gr1
      Fig 1Operative technique. Common points: tunnel diameter ≤9 mm; tibial tunnel = transphyseal; femoral tunnel = intraepiphyseal, no screw in the tibial tunnel. (A) ST/G + G (right knee): ST and G are left pediculated on the tibia. The ACL graft is composed of 3 strands of ST and one strand of G. Femoral fixation is provided by a screw. A double bundle of G is used to reconstruct the ALL, the anterior tunnel is positioned slightly posterior to Gerdy’s tubercle, and the posterior tunnel is placed midway between Gerdy’s tubercle and the fibular head. (B) ST + FL (right knee): ST is left pediculated on the tibia. The ACL graft is composed of tripled strands of ST. All of the inside femoral sockets were performed, and the graft was fixed with a button. Lateral extra-articular procedure was performed using the fascia lata left pediculated on Gerdy’s tubercule and fixed on the femoral side using the wires of the button. (ACL, anterior cruciate ligament; ALL, anterolateral ligament; FL, fascia lata; G, gracilis; ST, semitendinosus.)

      Evaluation Methods

      All the patients and all measurements were assessed by experimented orthopaedic surgeons (C.F., E.C., I.H. and L.G.). Preoperatively, anthropometric data, range of motion, evaluation of anterior laxity with the Lachman test, a measurement of side-to-side anterior laxity at 30° of flexion with the Rolimeter (Aircast Europa, Neubeuern, Germany), and an analysis of the pivot shift were recorded. Sports activity level was quantified using the Tegner score.
      • Tegner Y.
      • Lysholm J.
      Rating systems in the evaluation of knee ligament injuries.
      ACL rupture was confirmed by magnetic resonance imaging. In addition, standard anteroposterior and lateral radiographic views, as well as wrist radiographs, were performed to confirm the residual growth potential.
      • Greulich W.W.
      • Pyle S.I.
      Radiographic atlas of skeletal development of the hand and wrist.
      Intraoperatively, cruciate ligament, cartilage and meniscus status, and their various treatments were clearly noted on the operative report.
      Patients were reviewed with a minimum of 3.5 years of follow-up. At the last follow-up, complete clinical assessment was performed again. Physical activity was evaluated by the Tegner score, and subjective evaluation of the knee was conducted using the Lysholm score
      • Lysholm J.
      • Gillquist J.
      Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale.
      and the Pedi International Knee Documentation Committee (Pedi-IKDC) score.
      • Kocher M.S.
      • Smith J.T.
      • Iversen M.D.
      • et al.
      Reliability, validity, and responsiveness of a modified International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC) in children with knee disorders.
      ,
      • Nasreddine A.Y.
      • Connell P.L.
      • Kalish L.A.
      • et al.
      The Pediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form: Normative data.
      Postoperative complications also were noted, as well as subsequent trauma. Leg length discrepancy was evaluated clinically by measuring the intermalleolar gap with the patient in the supine position.
      • Terry M.A.
      • Winell J.J.
      • Green D.W.
      • et al.
      Measurement variance in limb length discrepancy: Clinical and radiographic assessment of interobserver and intraobserver variability.
      In the case of clinical suspicion, growth disorders were confirmed using an EOS protocol
      • Lecoanet P.
      • Vargas M.
      • Pallaro J.
      • Thelen T.
      • Ribes C.
      • Fabre T.
      Leg length discrepancy after total hip arthroplasty: Can leg length be satisfactorily controlled via anterior approach without a traction table? Evaluation in 56 patients with EOS 3D.
      (EOS Imaging, Paris, France); the length of the lower limb was the sum of the measurements of the femur and the tibia (with femoral length = from the top of the intercondylar notch to the center of the femoral head and tibial length = from the distal tibial articular surface to the center of the tibial spine).
      • Clavé A.
      • Maurer D.G.
      • Nagra N.S.
      • Fazilleau F.
      • Lefèvre C.
      • Stindel E.
      Reproducibility of length measurements of the lower limb by using EOSTM.
      The search for axis disorders of the lower limbs was performed in the same manner.
      Two patients could not be clinically reassessed but were interviewed by telephone and answered the various questionnaires sent by e-mail following the telephone interview. One patient who sustained a bilateral ACL rupture during the same trauma was excluded from side-to-side anterior laxity measurements and from the evaluation of growth disorders.

      Statistical Analysis

      Quantitative variables are expressed as the mean, standard deviation, median, minimum and maximum. Qualitative variables are expressed as the number and frequency. The exact binomial confidence interval was given for the frequencies of ACL rerupture after surgery. Comparisons between preoperative and postoperative factors were analyzed with the Student t test for matched data for normally distributed variables and the Wilcoxon test for nonnormally distributed variables for qualitative data. For quantitative data, the McNemar test for binary data and the Bhapkar test for nominal qualitative data with more than 2 classes were used. The factors associated with the resumption of sports at a lower level after the operation were explored by multinomial logistic regression. Significancy was set at P < .05.

      Calculation of Minimal Clinically Important Differences (MCID) and Patient Acceptable Symptoms State (PASS) Threshold Scores

      MCIDs were calculated via the distribution-based method using half the standard deviation for each delta between preoperative and postoperative outcomes (Table 1). The PASS was calculated using an anchor-based method. PASS values were defined via receiver operating characteristic curve analysis. Using the Youden index, the optimal cutoff to maximize sensitivity and specificity for each outcome score was identified. The area under the curve (AUC) was calculated to assess reliability. An AUC value of 0.7 to 0.8 was considered acceptable, and an AUC value greater than 0.8 was considered excellent (Table 2).
      Table 1MCID Threshold Scores
      ScoreMCID
      Pedi-IKDC9.25
      Lysholm12.85
      KOOS Symptoms9.30
      KOOS Pain8.60
      KOOS Daily Living8.10
      KOOS Sport16.25
      KOOS Quality of life14.60
      The MCID is calculated with the distribution-based method using half the standard deviation for each delta between preoperative and postoperative outcomes.
      KOOS, Knee Injury and Osteoarthritis Outcome Score; MCID, Minimally Clinically Important Difference; Pedi-IKDC, Pedi International Knee Documentation Committee.
      Table 2PASS Threshold Scores
      PROMsPASSSensibility (%)Specificity (%)AUC
      Pedi-IKDC66.1766.7100.00.84
      Lysholm86100.088.90.96
      KOOS Symptoms45.6866.797.20.86
      KOOS Pain88.89100.091.70.96
      KOOS Daily Living77.2266.797.20.88
      KOOS Sport80100.066.70.89
      KOOS Quality of Life75100.080.60.93
      AUC, area under the curve; KOOS, Knee Injury and Osteoarthritis Outcome Score; PASS, patient acceptable symptoms state; Pedi-IKDC, Pedi International Knee Documentation Committee; PROMs, patient-reported outcome measures.

      Results

      Thirty-nine patients (40 knees) were included with a mean follow-up of 57 ± 10 months (42-74 months). Twenty knees (50%, 20/40) each sustained different operating methods. One knee from method A (2.5%, 1/40) was lost to follow-up and excluded from the postoperative analysis. Five patients (13.2%, 5/38) had a contralateral ACL rupture. Demographic data are summarized in Table 3. The causes of primary injury were 1 road traffic accident (2.5% 1/40), 17 traumas during pivot sports (42.5%, 17/40), and 22 traumas during contact–pivot sports (55%, 22/40). The mean time between accident and surgery was 6.8 ± 8.4 months (0.2; 40.9) (median = 4.3 months); 3 patients (7.5%, 3/40) underwent surgery more than 2 years after the injury.
      Table 3Demographic Preoperative Data
      Total (n = 40)Method A (n=20)Method B (n=20)P value (A vs B)
      Sex (% male)32 (80%)14 (70%)18 (90%)0.24
      Injured side (% left)23 (58%)12 (60%)11 (55%)1
      Average age, y13.8 ± 1.4 [9.8-16.5]13.6 ± 1.7 [9.8-16.5]14 ± 1.2 [10.9-16.1].35
      Average height, cm165 ± 12 [138-186]162 ± 12 [141-183]167 ± 11 [138-186].22
      Average weight, kg54 ± 11 [30-85]51 ± 11 [32-72]56 ± 12 [30-85].07
      Average BMI19.6 ± 2.6 [15.1-27.8]19.2 ± 2.6 [15.1-26.4]20 ± 2.7 [15.6-27.8].28
      BMI, body mass index.
      Twenty-two knees (55%, 22/40) had associated meniscal lesions (10/40 [25%] of the medial meniscus and 13/40 [32.5%] of the lateral meniscus). One knee (2.5%, 1/40) had a lesion of both menisci. Among the medial meniscal lesions, 8 (80%, 8/10) were meniscocapsular lesions.
      All medial meniscocapsular lesions were repaired using an all inside suture hook.
      • Thaunat M.
      • Jan N.
      • Fayard J.M.
      • et al.
      Repair of meniscal ramp lesions through a posteromedial portal during anterior cruciate ligament reconstruction: Outcome study with a minimum 2-year follow-up.
      One failure of medial meniscocapsular repair was recorded (12.5%, 1/8). The patient underwent reoperation at 16.5 months for revision suturing. The 2 other medial meniscal tears were treated by partial meniscectomy (25%, 2/8).
      Concerning the lateral meniscus, 9 tears (69%, 9/13) were repaired with an all-inside suture,
      • Foissey C.
      • Thaunat M.
      • Fayard J.M.
      All-inside double-sided suture repair for longitudinal meniscal tears.
      3 tears (23%, 3/13) were treated with a partial meniscectomy, and 1 stable tear (8%, 1/13) was left in place. One suture required revision surgery at 44.1 months for partial menisectomy. One (2.5%, 1/40) International Cartilage Repair Society grade 2 cartilage lesion of the medial condyle was recorded.
      • Muller B.
      • Willinge G.J.A.
      • Zijl J.A.C.
      Minimally invasive modified Lemaire tenodesis.
      Clinical and functional results are reported in Table 4. At the last follow-up, anterior and rotational control was significantly improved: the mean side-to-side anterior laxity was 1.7 mm ± 1.6 (–2-5), 95% of patients had no pivot shift, and no patients complained of rotational instability. Pedi-IKDC, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Lysholm scores were significantly improved. Eighty-nine percent of the patients presented a Pedi-IKDC greater than the MCID postoperatively, and 77% presented a Lysholm greater than the MCID (Table 4).
      Table 4Comparison of Pre- and Postoperative Data
      Preoperative Data (n = 39)Postoperative Data (n = 39)P Value
      Clinical examination
      Lachman test
       Hard1 (3%)36 (92%)
       Soft37 (94%)1 (3%)<.001
       Delayed hard1 (3%)2 (5%)
      Pivot shift
       01 (3%)37 (95%)
       Glide7 (18%)2 (5%)
       ++13 (33%)0.04
       +++14 (36%)0
       Nontestable4 (10%)0
      Differential anterior laxity, mm
       Mean ± SD [min-max]6.9 ± 1.2 [4-10]1.7 ± 1.6 [–2 to 5]<.0001
       Median7.02.0
      Clinical score
      Pedi-IKDC (/100)
       Mean ± SD [min-max]58 ± 14 [33-93]89 ± 9 [66-100]
       Median5993<.0001
       ≥MCID35 (89%)
       ≥PASS37 (95%)
      KOOS symptom (/100)
       Mean ± SD [min-max]81 ± 13 [50-100]91 ± 14 [36-100]
       Median8296<.0001
       ≥MCID21 (53%)
       ≥PASS33 (85%)
      KOOS pain (/100)
       Mean ± SD [min-max]80 ± 15 [39-100]95 ± 10 [56-100]
       Median81100<.0001
       ≥MCID25 (64%)
       ≥PASS34 (87%)
      KOOS daily living (/100)
       Mean ± SD [min-max]88 ± 13 [56-100]97 ± 6 [72-100]
       Median90100<.0001
       ≥MCID17 (44%)
       ≥PASS38 (97%)
      KOOS sports (/100)
       Mean ± SD [min-max]47 ± 24 [0-95]85 ± 18 [25-100]
       Median4595<.0001
       ≥MCID28 (71%)
       ≥PASS27 (69%)
      KOOS quality of life (/100)
       Mean ± SD [min-max]35 ± 24 [0-100]88 ± 16 [35-100]
       Median3194<.0001
       ≥MCID35 (90%)
       ≥PASS33 (85%)
      Lysholm (/100)
       Mean ± SD [min-max]70 ± 15 [40-100]92 ± 15 [13-100]
       Median7195<.0001
       ≥MCID30 (77%)
       ≥PASS33 (85%)
      Tegner (/10)
       Mean ± SD [min-max]7.2 ± 1 [4-10]6.8 ± 1.8 [3-10]
       Median7.07.0.06
      MCID, Minimally Clinically Important Difference; Pedi-IKDC, Pedi International Knee Documentation Committee; PASS, patient acceptable symptoms state; SD, standard deviation.
      Ninety-two percent (35/38) of the patients returned to sports. Fifteen patients (39%, 15/38) did not return to their initial Tegner level, and 23 (61%, 23/38) returned to an identical or better Tegner level. Among the 15 patients who did not return to their initial Tegner level, 6 (40%, 6/15) had a graft injury or a rupture of the contralateral ACL. There were no predictive factor influencing the return to sports among all those studied (sex, body mass index, preoperative Tegner, meniscal lesion, graft rupture, or contralateral ACL rupture), although having a contralateral ACL rupture or graft rupture was at the edge of significance (P = .05) (Table 5).
      Table 5Multinomial Logistic Regression: Parameters Influencing Return to Sport
      Tegner Score
      Postoperative < Pretrauma (n = 15)Postoperative ≥ Pretrauma (n = 32)P Value
      Male11 (73%)19 (83%).62
      BMI20 ± 3 [17-28]19 ± 2 [15-22].37
      Preoperative Tegner (/10)7 ± 1 [6-10]7 ± 1 [4-10].71
      Meniscal lesion8 (53%)13 (57%).94
      Graft rupture or contralateral ACL rupture6 (40%)0.05
      ACL, anterior cruciate ligament; BMI, body mass index.
      Six knees required reoperation (15.4%, 6/39): 1 ACL graft rupture (2.6% [0.06-13.5], 1/39) at the 32.9 months of follow-up, 2 cases for meniscal suture failure (5.3%, 2/38), 2 cases for anterior arthrofibrosis (5.3%, 2/38), and 1 for contralateral epiphysiodesis (2.6%, 1/38). Reoperations occurred at a mean 29 months ± 19 (3; 44). No infection was recorded.
      Two cases (5.4%, 2/37) of growth disorders were recorded, one of 1 cm measured clinically but not perceived by the patient and the second one of 1.8 cm identified clinically and confirmed on the EOS because it was perceived by the patient. In both cases, the operated side was longer than the healthy side without frontal or sagittal deformity. The case of overgrowth of 1.8 cm required surgical epiphysiodesis on the other knee at 40 months postoperatively allowing correction of the deformity (Fig 2). The other patient was treated functionally with foot ortheses. Both patients reported good functional results (PEDI-IKDC= 97.7 for the patient reoperated, 86.21 for the patient with foot orthesis) and stabilized their sports level (Tegner = 8 and 7, respectively) at the last follow-up. All complications are presented according to the 2 subgroups (method A or B) in Table 6.
      Figure thumbnail gr2
      Fig 2Management of the overgrowth of 1.82 cm). (A) EOS radiography showing overgrowth prevailing on the left femur. (B) EOS radiography after distal left femoral epiphysiodesis with 2 screws at the last follow-up showing good recovery of the length. (d, distance.)
      Table 6Complication Rate According to the Subgroup: Method A (ST+G) or Method B (ST+FL)
      ComplicationsTotal (n = 39)Method A (n = 19)Method B (n = 20)P Value (A vs B)
      Graft failure1 (2.6%)01 (5%)1
      Meniscal suture failure2 (5.1%)1 (5.3%)1 (5%)1
      Arthrofibrosis2 (5.1%)1 (5.3%)1 (5%)1
      Growth disorders2 (5.1%)1 (5.3%)1 (5%)1
       With contralateral epiphysiodesis1 (2.6%)1 (5.3%)01
      FL, fascia lata; G, gracilis; ST, semitendinosus.

      Discussion

      The most important findings of our study are that combined ACL reconstruction associated with the lateral extra-articular procedure in skeletally immature patients is associated with a low graft rupture rate, and it provides good functional outcomes and a low clinically detectable growth disturbance rate over a medium-term follow-up (mean = 4.8 years).
      ACL reconstruction associated with the lateral extra-articular procedure in our series was associated with a low graft rupture rate. Table 7
      • Lanzetti R.M.
      • Pace V.
      • Ciompi A.
      • et al.
      Over the top anterior cruciate ligament reconstruction in patients with open physes: A long-term follow-up study.
      • Wilson P.L.
      • Wyatt C.W.
      • Wagner K.J.
      • Boes N.
      • Sabatino M.J.
      • Ellis H.B.
      Combined transphyseal and lateral extra-articular pediatric anterior cruciate ligament reconstruction: A novel technique to reduce ACL reinjury while allowing for growth.
      • Roberti di Sarsina T.
      • Macchiarola L.
      • Signorelli C.
      • et al.
      Anterior cruciate ligament reconstruction with an all-epiphyseal “over-the-top” technique is safe and shows low rate of failure in skeletally immature athletes.
      • Kocher M.S.
      • Heyworth B.E.
      • Fabricant P.D.
      • Tepolt F.A.
      • Micheli L.J.
      Outcomes of physeal-sparing ACL reconstruction with iliotibial band autograft in skeletally immature prepubescent children.
      • Willimon S.C.
      • Jones C.R.
      • Herzog M.M.
      • May K.H.
      • Leake M.J.
      • Busch M.T.
      Micheli Anterior cruciate ligament reconstruction in skeletally immature youths: A retrospective case series with a mean 3-year follow-up.
      ,
      • Fourman M.S.
      • Hassan S.G.
      • Roach J.W.
      • Grudziak J.S.
      Anatomic all-epiphyseal ACL reconstruction with “inside-out” femoral tunnel placement in immature patients yields high return to sport rates and functional outcome scores a minimum of 24 months after reconstruction.
      • Nagai K.
      • Rothrauff B.B.
      • Li R.T.
      • Fu F.H.
      Over-the-top ACL reconstruction restores anterior and rotatory knee laxity in skeletally immature individuals and revision settings.
      • Razi M.
      • Moradi A.
      • Safarcherati A.
      • et al.
      Allograft or autograft in skeletally immature anterior cruciate ligament reconstruction: A prospective evaluation using both partial and complete transphyseal techniques.
      • Longo U.G.
      • Ciuffreda M.
      • Casciaro C.
      • et al.
      Anterior cruciate ligament reconstruction in skeletally immature patients: A systematic review.
      • Geffroy L.
      • Lefevre N.
      • Thevenin-Lemoine C.
      • et al.
      Return to sport and re-tears after anterior cruciate ligament reconstruction in children and adolescents.
      • Dekker T.J.
      • Godin J.A.
      • Dale K.M.
      • Garrett W.E.
      • Taylor D.C.
      • Riboh J.C.
      Return to sport after pediatric anterior cruciate ligament reconstruction and its effect on subsequent anterior cruciate ligament injury.
      • Schmale G.A.
      • Kweon C.
      • Larson R.V.
      • Bompadre V.
      High satisfaction yet decreased activity 4 years after transphyseal ACL reconstruction.
      compares our results with those in the literature. Similar series with lateral extra-articular procedure in the pediatric population reported graft failure rates from 0% to 6.6% with similar follow-up.
      • Lanzetti R.M.
      • Pace V.
      • Ciompi A.
      • et al.
      Over the top anterior cruciate ligament reconstruction in patients with open physes: A long-term follow-up study.
      • Wilson P.L.
      • Wyatt C.W.
      • Wagner K.J.
      • Boes N.
      • Sabatino M.J.
      • Ellis H.B.
      Combined transphyseal and lateral extra-articular pediatric anterior cruciate ligament reconstruction: A novel technique to reduce ACL reinjury while allowing for growth.
      • Roberti di Sarsina T.
      • Macchiarola L.
      • Signorelli C.
      • et al.
      Anterior cruciate ligament reconstruction with an all-epiphyseal “over-the-top” technique is safe and shows low rate of failure in skeletally immature athletes.
      • Kocher M.S.
      • Heyworth B.E.
      • Fabricant P.D.
      • Tepolt F.A.
      • Micheli L.J.
      Outcomes of physeal-sparing ACL reconstruction with iliotibial band autograft in skeletally immature prepubescent children.
      Only Willimon et al.
      • Willimon S.C.
      • Jones C.R.
      • Herzog M.M.
      • May K.H.
      • Leake M.J.
      • Busch M.T.
      Micheli Anterior cruciate ligament reconstruction in skeletally immature youths: A retrospective case series with a mean 3-year follow-up.
      reported up to 14% failure with the lateral extra-articular procedure, but the surgical technique included a nonanatomical tibial tunnel. In contrast, a series of isolated ACL reconstructions was associated with greater failure rates, with an average graft rupture rate ranging from 7.1% to 24.6%. These results echo those obtained in the adult population. In 2017, Sonnery-Cottet et al.
      • Sonnery-Cottet B.
      • Saithna A.
      • Cavalier M.
      • et al.
      Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: A prospective comparative study of 502 patients from the SANTI study group.
      found graft failure rates of 10.77% for hamstring tendon grafts in isolated ACL reconstruction, 16.77% for bone–patellar tendon–bone grafts, and 4.13% for combined ACL and ALL reconstruction grafts at a mean follow-up of 38.4 months.
      Table 7Literature Review of ACL Lesions in Children With Open Physis According to Lateral Extra-Articular Procedure
      StudyMean Follow-up, yLateral Extra-Articular ProcedureSurgical TechniqueFemoral Fixation (F) and Tibial Fixation (T)Graft RuptureMean TegnerMean LysholmMean IKDCGrowth Disorder
      Current study, n = 394.8YesST + FL

      ST/G + G
      F: Intraepiphyseal

      T: transphyseal
      2.5%6.890885.4%
      Lanzetti et al., 2020,
      • Lanzetti R.M.
      • Pace V.
      • Ciompi A.
      • et al.
      Over the top anterior cruciate ligament reconstruction in patients with open physes: A long-term follow-up study.
      n = 42
      8YesST/G + GF: over the top

      T: Intraepiphyseal
      4.8%894.894.84.8%
      Wilson et al., 2019,
      • Wilson P.L.
      • Wyatt C.W.
      • Wagner K.J.
      • Boes N.
      • Sabatino M.J.
      • Ellis H.B.
      Combined transphyseal and lateral extra-articular pediatric anterior cruciate ligament reconstruction: A novel technique to reduce ACL reinjury while allowing for growth.
      n = 61
      3.2YesST/G + FLF: transphyseal

      T: transphyseal
      5.3%NANA91.25.5%
      Roberti di Sarsina et al., 2019,
      • Roberti di Sarsina T.
      • Macchiarola L.
      • Signorelli C.
      • et al.
      Anterior cruciate ligament reconstruction with an all-epiphyseal “over-the-top” technique is safe and shows low rate of failure in skeletally immature athletes.
      n = 20
      4.5YesST/G + GF: over the top

      T: Intraepiphyseal
      0%7100NA15%
      Kocher et al., 2018,
      • Kocher M.S.
      • Heyworth B.E.
      • Fabricant P.D.
      • Tepolt F.A.
      • Micheli L.J.
      Outcomes of physeal-sparing ACL reconstruction with iliotibial band autograft in skeletally immature prepubescent children.
      n = 137
      6.2YesMac FLF: over the top

      T: extraosseous
      6.6%7.893.493.30%
      Willimon et al., 2015,
      • Willimon S.C.
      • Jones C.R.
      • Herzog M.M.
      • May K.H.
      • Leake M.J.
      • Busch M.T.
      Micheli Anterior cruciate ligament reconstruction in skeletally immature youths: A retrospective case series with a mean 3-year follow-up.
      n = 22
      3YesMac FLF: over the top

      T: extraosseous
      14%89596.50%
      Fourman et al., 2021
      • Fourman M.S.
      • Hassan S.G.
      • Roach J.W.
      • Grudziak J.S.
      Anatomic all-epiphyseal ACL reconstruction with “inside-out” femoral tunnel placement in immature patients yields high return to sport rates and functional outcome scores a minimum of 24 months after reconstruction.
      5NoST/G allograftF: Intraepiphyseal

      T: Intraepiphyseal
      13.2%NANA91.326.5%
      Nagai et al., 2020,
      • Nagai K.
      • Rothrauff B.B.
      • Li R.T.
      • Fu F.H.
      Over-the-top ACL reconstruction restores anterior and rotatory knee laxity in skeletally immature individuals and revision settings.
      n = 35
      2.2NoNAF: Over the top

      T: transphyseal
      14.3%NANANANA
      Astur et al., 2018,
      • Astur D.C.
      • Cachoeira C.M.
      • da Silva Vieira T.
      • Debieux P.
      • Kaleka C.C.
      • Cohen M.
      Increased incidence of anterior cruciate ligament revision surgery in paediatric verses adult population.
      n = 46
      Minimum 0.5NoST/GF: transphyseal

      T: transphyseal
      24.6%NANANANA
      Razi et al., 2019,
      • Razi M.
      • Moradi A.
      • Safarcherati A.
      • et al.
      Allograft or autograft in skeletally immature anterior cruciate ligament reconstruction: A prospective evaluation using both partial and complete transphyseal techniques.
      n = 31
      6NoST allograftF: Intraepiphyseal

      T: transphyseal
      NANANA853.2%
      SFA prospective, 2018,
      • Geffroy L.
      • Lefevre N.
      • Thevenin-Lemoine C.
      • et al.
      Return to sport and re-tears after anterior cruciate ligament reconstruction in children and adolescents.
      n = 100 (multicenter)
      2NoMulticenterMulticenter9%7.89392NA
      Dekker et al., 2017,
      • Dekker T.J.
      • Godin J.A.
      • Dale K.M.
      • Garrett W.E.
      • Taylor D.C.
      • Riboh J.C.
      Return to sport after pediatric anterior cruciate ligament reconstruction and its effect on subsequent anterior cruciate ligament injury.
      n = 112
      4NoST/G

      BPTB
      F: Intraepiphyseal + transphyseal

      T: transphyseal
      19%NANANANA
      Schmale et al., 2014,
      • Schmale G.A.
      • Kweon C.
      • Larson R.V.
      • Bompadre V.
      High satisfaction yet decreased activity 4 years after transphyseal ACL reconstruction.
      n = 29
      4No4ST

      Allograft
      F: transphyseal

      T: transphyseal
      13.8%7NANA0%
      4ST, quadruple-bundle semitendinosus; ACL, anterior cruciate ligament; BPTB, bone–patellar tendon–bone; FL, fascia lata; G, gracilis; IKDC, International Knee Documentation Committee; NA, not available; ST, semitendinosus.
      The absence of recurrence of ACL injuries may appear to be protective of the knee; however, several studies have raised concerns about the risk of overconstraints induced by anterolateral procedures, particularly when performed in a nonanatomical manner such as during the Lemaire procedure.
      • Neri T.
      • Dabirrahmani D.
      • Beach A.
      • et al.
      Different anterolateral procedures have variable impact on knee kinematics and stability when performed in combination with anterior cruciate ligament reconstruction.
      ,
      • Ahn J.H.
      • Koh I.J.
      • McGarry M.H.
      • Patel N.A.
      • Lin C.C.
      • Lee T.Q.
      Double-bundle anterior cruciate ligament reconstruction with lateral extra-articular tenodesis is effective in restoring knee stability in a chronic, complex anterior cruciate ligament-injured knee model: A cadaveric biomechanical study.
      Then caution should be applied when using such a technique in a pediatric population, only a very long-term study, as was already performed in adults,
      • Castoldi M.
      • Magnussen R.A.
      • Gunst S.
      • et al.
      A randomized controlled trial of bone-patellar tendon-bone anterior cruciate ligament reconstruction with and without lateral extra-articular tenodesis: 19-year clinical and radiological follow-up.
      will be able to tell us whether this benefit comes at the expense of an increased risk of osteoarthritis in the external compartment.
      The addition of lateral extra-articular procedure was not done at the expense of clinical results. In the literature, the combination has led to good-to-excellent clinical outcomes
      • Lanzetti R.M.
      • Pace V.
      • Ciompi A.
      • et al.
      Over the top anterior cruciate ligament reconstruction in patients with open physes: A long-term follow-up study.
      • Wilson P.L.
      • Wyatt C.W.
      • Wagner K.J.
      • Boes N.
      • Sabatino M.J.
      • Ellis H.B.
      Combined transphyseal and lateral extra-articular pediatric anterior cruciate ligament reconstruction: A novel technique to reduce ACL reinjury while allowing for growth.
      • Roberti di Sarsina T.
      • Macchiarola L.
      • Signorelli C.
      • et al.
      Anterior cruciate ligament reconstruction with an all-epiphyseal “over-the-top” technique is safe and shows low rate of failure in skeletally immature athletes.
      • Kocher M.S.
      • Heyworth B.E.
      • Fabricant P.D.
      • Tepolt F.A.
      • Micheli L.J.
      Outcomes of physeal-sparing ACL reconstruction with iliotibial band autograft in skeletally immature prepubescent children.
      comparable with classical methods
      • Fourman M.S.
      • Hassan S.G.
      • Roach J.W.
      • Grudziak J.S.
      Anatomic all-epiphyseal ACL reconstruction with “inside-out” femoral tunnel placement in immature patients yields high return to sport rates and functional outcome scores a minimum of 24 months after reconstruction.
      • Nagai K.
      • Rothrauff B.B.
      • Li R.T.
      • Fu F.H.
      Over-the-top ACL reconstruction restores anterior and rotatory knee laxity in skeletally immature individuals and revision settings.
      • Longo U.G.
      • Ciuffreda M.
      • Casciaro C.
      • et al.
      Anterior cruciate ligament reconstruction in skeletally immature patients: A systematic review.
      ,
      • Dekker T.J.
      • Godin J.A.
      • Dale K.M.
      • Garrett W.E.
      • Taylor D.C.
      • Riboh J.C.
      Return to sport after pediatric anterior cruciate ligament reconstruction and its effect on subsequent anterior cruciate ligament injury.
      ,
      • Schmale G.A.
      • Kweon C.
      • Larson R.V.
      • Bompadre V.
      High satisfaction yet decreased activity 4 years after transphyseal ACL reconstruction.
      ,
      • Astur D.C.
      • Cachoeira C.M.
      • da Silva Vieira T.
      • Debieux P.
      • Kaleka C.C.
      • Cohen M.
      Increased incidence of anterior cruciate ligament revision surgery in paediatric verses adult population.
      regarding the mean scores (Table 7) and regarding MCID and PASS. The MCIDs presented in this study showed an excellent improvement in the scores most affected by ACL rupture (Pedi-IKDC, KOOS sport, KOOS quality of life and Lysholm). Scores with a low percentage of MCID were those least impacted by the trauma and had excellent PASS (KOOS symptom, KOOS pain, KOOS daily living).
      Growth disorders are among the specific complications of ACL surgery in children. The fear of inducing length inequalities or lower-limb axis anomalies of iatrogenic origin has long been a hindrance to surgery.
      • Ramski D.E.
      • Kanj W.W.
      • Franklin C.C.
      • Baldwin K.D.
      • Ganley T.J.
      Anterior cruciate ligament tears in children and adolescents: A meta-analysis of nonoperative versus operative treatment.
      ,
      • Kocher M.S.
      • Saxon H.S.
      • Hovis W.D.
      • Hawkins R.J.
      Management and complications of anterior cruciate ligament injuries in skeletally immature patients: Survey of the Herodicus Society and The ACL Study Group.
      In the literature, 3 types of growth disorders have been described.
      • Chotel F.
      • Henry J.
      • Seil R.
      • Chouteau J.
      • Moyen B.
      • Bérard J.
      Growth disturbances without growth arrest after ACL reconstruction in children.
      Type A corresponds to growth arrest by epiphysiodesis or by injury to the perichondral ferrule. Type B corresponds to an acceleration of growth of the operated limb, and type C corresponds to slowing of growth by the tenodesis effect, leading to axis disorders of the lower limb. In 2016, Collins et al.
      • Collins M.J.
      • Arns T.A.
      • Leroux T.
      • et al.
      Growth abnormalities following anterior cruciate ligament reconstruction in the skeletally immature patient: A systematic review.
      performed a meta-analysis of growth disorders after ACL reconstruction in children with growth potential. This meta-analysis analyzing 21 studies (n = 313) found 12.5% growth disorders of all types, including 3.5% type A, 5.8% type B, and 5.1% type C.
      In our study, we found that a 5.4% rate of growth disorders, all of which were type B on the femur. This complication is related to local hypervascularization and stimulation of the open physis,
      • Chotel F.
      • Henry J.
      • Seil R.
      • Chouteau J.
      • Moyen B.
      • Bérard J.
      Growth disturbances without growth arrest after ACL reconstruction in children.
      which could be caused by the proximity of the tunnel with the physis despite our physeal-sparing method on the femur (Fig 3) None of those 2 growth disorders could be attributed to the anterolateral procedure, as this procedure did not necessitate an extra or a wider femoral tunnel and none of those disturbances were observed on the tibia. The lack of repercussions on the tibia is not a surprise for method B, which did not create any extra tunnel and for method A, in which tunnels are strictly intraepiphyseal. None of the studies presented in Table 7 reported any growth disturbances linked to the anterolateral procedure.
      Figure thumbnail gr3
      Fig 3Relationship between the physis and the tunnels: a postoperative radiograph of method B (left knee).
      A recent systematic review attempted to evaluate the benefit of the physeal-sparing technique over the transphyseal technique and showed no differences in terms of the incidence of growth disturbances or in terms of graft survivorship.
      • Pierce T.P.
      • Issa K.
      • Festa A.
      • Scillia A.J.
      • McInerney V.K.
      Pediatric anterior cruciate ligament reconstruction: A systematic review of transphyseal versus physeal-sparing techniques.
      Regarding the 2 overgrowths, the patient who underwent reoperation for epiphysiodesis of the limb obtained very satisfactory results, providing an additional argument in favor of careful monitoring of the growth of young patients.
      The creation of a transphyseal tunnel with a diameter less than 9 mm could partly explain the absence of type A complications, as according to Gicquel et al.
      • Gicquel P.
      • Geffroy L.
      • Robert H.
      • et al.
      MRI assessment of growth disturbances after ACL reconstruction in children with open growth plates—Prospective multicenter study of 100 patients.
      Our main concern in preoperative care was the risk of teno-epiphysiodesis with genu valgus deformity as described by Kocher et al.
      • Kocher M.S.
      • Saxon H.S.
      • Hovis W.D.
      • Hawkins R.J.
      Management and complications of anterior cruciate ligament injuries in skeletally immature patients: Survey of the Herodicus Society and The ACL Study Group.
      due to the fusion of the lateral distal femoral physis. We did not find this complication in our series, suggesting that none of the growth disorders were linked to the tenodesis effect of lateral extra-articular procedure.
      For sports practice, we found no significant decrease in the median patients’ sporting level. Even though it may seem satisfactory, this result must be interpreted within the age category studied, which naturally tends to improve its Tegner level in the absence of a particular trauma. Indeed, when examining the findings more closely, 39% did not return to their former Tegner level. A large part of this result could be explained by injury to the graft or of the contralateral AC (Table 5). In addition, the high rate of injury of the contralateral knee (13.2%) is a good indicator of the return to sports and is comparable here to the review performed by Magnussen et al.
      • Magnussen R.A.
      • Meschbach N.T.
      • Kaeding C.C.
      • Wright R.W.
      • Spindler K.P.
      ACL Graft and contralateral ACL tear risk within ten years following reconstruction: A systematic review.
      (12.5%). In 2017, Hamrin Senorski et al.
      • Hamrin Senorski E.
      • Seil R.
      • Svantesson E.
      • et al.
      “I never made it to the pros…” Return to sport and becoming an elite athlete after pediatric and adolescent anterior cruciate ligament injury Current evidence and future directions.
      found that rupture of the ACL in children with growth potential was an important turning point in their sporting practice and a major obstacle to the practice of sports at an elite level. Indeed, several studies have found results similar to ours and agreed to fix the return to the preinjury level in approximately two-thirds of the patients.
      • Geffroy L.
      • Lefevre N.
      • Thevenin-Lemoine C.
      • et al.
      Return to sport and re-tears after anterior cruciate ligament reconstruction in children and adolescents.
      ,
      • Webster K.E.
      • Feller J.A.
      • Whitehead T.S.
      • Myer G.D.
      • Merory P.B.
      Return to sport in the younger patient with anterior cruciate ligament reconstruction.
      ,
      • Kamath G.V.
      • Murphy T.
      • Creighton R.A.
      • Viradia N.
      • Taft T.N.
      • Spang J.T.
      Anterior Cruciate ligament injury, return to play, and reinjury in the elite collegiate athlete: Analysis of an NCAA Division I cohort.
      There are multiple reasons for the decrease in sporting level: fear of reliving the initial trauma, rupture of the contralateral ACL, entry into higher education, failure in high-level courses, and an uncomfortable knee at high intensity.
      • Webster K.E.
      • Feller J.A.
      • Whitehead T.S.
      • Myer G.D.
      • Merory P.B.
      Return to sport in the younger patient with anterior cruciate ligament reconstruction.
      ,
      • Kamath G.V.
      • Murphy T.
      • Creighton R.A.
      • Viradia N.
      • Taft T.N.
      • Spang J.T.
      Anterior Cruciate ligament injury, return to play, and reinjury in the elite collegiate athlete: Analysis of an NCAA Division I cohort.
      Malatray et al.
      • Malatray M.
      • Raux S.
      • Peltier A.
      • Pfirrmann C.
      • Seil R.
      • Chotel F.
      Ramp lesions in ACL deficient knees in children and adolescent population: A high prevalence confirmed in intercondylar and posteromedial exploration.
      in 2018 advised a systematic inspection through the intercondylar notch to diagnose ramp lesions in ACL-deficient knees. With this technique, they found a 23% rate of such knees in a pediatric population. This result was verified more recently by Sonnery-Cottet et al.
      • Sonnery-Cottet B.
      • Praz C.
      • Rosenstiel N.
      • et al.
      Epidemiological evaluation of meniscal ramp lesions in 3214 anterior cruciate ligament–injured knees from the SANTI Study Group database: A risk factor analysis and study of secondary meniscectomy rates following 769 ramp repairs.
      and Bernardini et al.,
      • Bernardini I.
      • N’Dele D.
      • Faruch Bilfeld M.
      • et al.
      Prevalence and detection of meniscal ramp lesions in pediatric anterior cruciate ligament–deficient knees.
      who found respectively a prevalence of 23.9% and 28% of those lesions, very similar to our series (20%). This outcome finally echoes the overall prevalence in the adult population that was evaluated at 23.9% in the largest series evaluating incidence of ramp lesions
      • Kunze K.N.
      • Wright-Chisem J.
      • Polce E.M.
      • DePhillipo N.N.
      • LaPrade R.F.
      • Chahla J.
      Risk factors for ramp lesions of the medial meniscus: A systematic review and meta-analysis.
      and 21.9% in a systematic review.
      • Gicquel P.
      • Geffroy L.
      • Robert H.
      • et al.
      MRI assessment of growth disturbances after ACL reconstruction in children with open growth plates—Prospective multicenter study of 100 patients.

      Limitations

      There are some limitations to our study, and the retrospective nature of the study itself is the first limitation. The absence of a previous protocol is the other limit of our study. Thus, the Tanner score was not reported in preoperative care, but all of the patients were evaluated with radiography assessing the physis and bone age. Also, we did not have any systematic orthostatic anteroposterior radiographs of the lower limbs to detect growth disorders. They were only detected clinically, and some of them may have been missed. One of the main limitations of this study is the lack of a control group; we unfortunately could not have a control group because in our institution we usually perform lateral extra-articular procedure in all patients younger than 25 years of age, which is why we chose to present our results within those of the literature.
      Two different lateral extra- articular procedures have been used, which increase the heterogeneity of the series. In addition, the small population size limits the ability to draw strong conclusions about rates of complications including graft rupture, and larger studies are needed to determine this.

      Conclusions

      This series of ACL reconstructions combined with 2 different lateral extra-articular procedures in skeletally immature patients demonstrated promising findings. The low rate of observed complications, including graft rupture and growth disturbance, is encouraging, but the small study population and lack of comparative group precludes reliable conclusions.

      Supplementary Data

      References

        • Mohtadi N.
        • Grant J.
        Managing anterior cruciate ligament deficiency in the skeletally immature individual: A systematic review of the literature.
        Clin J Sport Med. 2006; 16: 457-464
        • Aichroth P.M.
        • Patel D.V.
        • Zorrilla P.
        The natural history and treatment of rupture of the anterior cruciate ligament in children and adolescents. A prospective review.
        J Bone Joint Surg Br. 2002; 84: 38-41
        • Moksnes H.
        • Engebretsen L.
        • Risberg M.A.
        Management of anterior cruciate ligament injuries in skeletally immature individuals.
        J Orthop Sports Phys Ther. 2012; 42: 172-183
        • Mizuta H.
        • Kubota K.
        • Shiraishi M.
        • Otsuka Y.
        • Nagamoto N.
        • Takagi K.
        The conservative treatment of complete tears of the anterior cruciate ligament in skeletally immature patients.
        J Bone Joint Surg Br. 1995; 77: 890-894
        • Moksnes H.
        • Engebretsen L.
        • Risberg M.A.
        Prevalence and incidence of new meniscus and cartilage injuries after a nonoperative treatment algorithm for ACL tears in skeletally immature children: A prospective MRI study.
        Am J Sports Med. 2013; 41: 1771-1779
        • James E.W.
        • Dawkins B.J.
        • Schachne J.M.
        • et al.
        Early operative versus delayed operative versus nonoperative treatment of pediatric and adolescent anterior cruciate ligament injuries: A systematic review and meta-analysis.
        Am J Sports Med. 2021; 49: 4008-4017
        • Shea K.G.
        • Pfeiffer R.
        • Wang J.H.
        • Curtin M.
        • Apel P.J.
        Anterior cruciate ligament injury in pediatric and adolescent soccer players: An analysis of insurance data.
        J Pediatr Orthop. 2004; 24: 623-628
        • Parkkari J.
        • Pasanen K.
        • Mattila V.M.
        • Kannus P.
        • Rimpelä A.
        The risk for a cruciate ligament injury of the knee in adolescents and young adults: A population-based cohort study of 46 500 people with a 9 year follow-up.
        Br J Sports Med. 2008; 42: 422-426
        • Maffulli N.
        • Del Buono A.
        Anterior cruciate ligament tears in children.
        Surgeon. 2013; 11: 59-62
        • Stracciolini A.
        • Casciano R.
        • Levey Friedman H.
        • Meehan W.P.
        • Micheli L.J.
        Pediatric sports injuries: An age comparison of children versus adolescents.
        Am J Sports Med. 2013; 41: 1922-1929
        • Morgan M.D.
        • Salmon L.J.
        • Waller A.
        • Roe J.P.
        • Pinczewski L.A.
        Fifteen-year survival of endoscopic anterior cruciate ligament reconstruction in patients aged 18 years and younger.
        Am J Sports Med. 2016; 44: 384-392
        • Shea K.G.
        • Grimm N.L.
        • Ewing C.K.
        • Aoki S.K.
        Youth sports anterior cruciate ligament and knee injury epidemiology: Who is getting injured? In what sports? When?.
        Clin Sports Med. 2011; 30: 691-706
        • Dodwell E.R.
        • Lamont L.E.
        • Green D.W.
        • Pan T.J.
        • Marx R.G.
        • Lyman S.
        20 years of pediatric anterior cruciate ligament reconstruction in New York State.
        Am J Sports Med. 2014; 42: 675-680
        • Ramski D.E.
        • Kanj W.W.
        • Franklin C.C.
        • Baldwin K.D.
        • Ganley T.J.
        Anterior cruciate ligament tears in children and adolescents: A meta-analysis of nonoperative versus operative treatment.
        Am J Sports Med. 2014; 42: 2769-2776
        • Andernord D.
        • Desai N.
        • Björnsson H.
        • Ylander M.
        • Karlsson J.
        • Samuelsson K.
        Patient predictors of early revision surgery after anterior cruciate ligament reconstruction: A cohort study of 16,930 patients with 2-year follow-up.
        Am J Sports Med. 2015; 43: 121-127
        • Webster K.E.
        • Feller J.A.
        Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction.
        Am J Sports Med. 2016; 44: 2827-2832
        • Hansson F.
        • Moström E.B.
        • Forssblad M.
        • Stålman A.
        • Janarv P.M.
        Long-term evaluation of pediatric ACL reconstruction: High risk of further surgery but a restrictive postoperative management was related to a lower revision rate.
        Arch Orthop Trauma Surg. 2022; 142: 1951-1961
        • Chotel F.
        • Henry J.
        • Seil R.
        • Chouteau J.
        • Moyen B.
        • Bérard J.
        Growth disturbances without growth arrest after ACL reconstruction in children.
        Knee Surg Sports Traumatol Arthrosc. 2010; 18: 1496-1500
        • Ardern C.L.
        • Ekås G.R.
        • Grindem H.
        • et al.
        2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries.
        Br J Sports Med. 2018; 52: 422-438
        • Lemme N.J.
        • Yang D.S.
        • Barrow B.
        • O’Donnell R.
        • Daniels A.H.
        • Cruz A.I.
        Risk factors for failure after anterior cruciate ligament reconstruction in a pediatric population: A prediction algorithm.
        Orthop J Sports Med. 2021; 92325967121991165
        • Sonnery-Cottet B.
        • Lutz C.
        • Daggett M.
        • et al.
        The involvement of the anterolateral ligament in rotational control of the knee.
        Am J Sports Med. 2016; 44: 1209-1214
        • Samuelsen B.T.
        • Webster K.E.
        • Johnson N.R.
        • Hewett T.E.
        • Krych A.J.
        Hamstring autograft versus patellar tendon autograft for ACL reconstruction: Is there a difference in graft failure rate? A meta-analysis of 47,613 patients.
        Clin Orthop Relat Res. 2017; 475: 2459-2468
        • Segond P.
        Recherches Cliniques et Expérimentales Sur Les Épanchements Sanguins Du Genou Par Entorse.
        Aux Bureaux du progrès médical, Paris1879
        • Murgier J.
        • Devitt B.M.
        • Sevre J.
        • Feller J.A.
        • Cavaignac E.
        The origin of the knee anterolateral ligament discovery: A translation of Segond’s original work with commentary.
        Arthroscopy. 2019; 35: 684-690
        • Claes S.
        • Vereecke E.
        • Maes M.
        • Victor J.
        • Verdonk P.
        • Bellemans J.
        Anatomy of the anterolateral ligament of the knee.
        J Anat. 2013; 223: 321-328
        • Ferretti A.
        • Monaco E.
        • Fabbri M.
        • Maestri B.
        • De Carli A.
        Prevalence and classification of injuries of anterolateral complex in acute anterior cruciate ligament tears.
        Arthroscopy. 2017; 33: 147-154
        • Song Y.
        • Yang J.H.
        • Choi W.R.
        • Lee J.K.
        Magnetic resonance imaging-based prevalence of anterolateral ligament abnormalities and associated injuries in knees with acute anterior cruciate ligament injury.
        J Knee Surg. 2019; 32: 866-871
        • Lutz C.
        • Sonnery-Cottet B.
        • Niglis L.
        • Freychet B.
        • Clavert P.
        • Imbert P.
        Behavior of the anterolateral structures of the knee during internal rotation.
        Orthop Traumatol Surg Res. 2015; 101: 523-528
        • Sonnery-Cottet B.
        • Vieira T.D.
        • Ouanezar H.
        Anterolateral ligament of the knee: Diagnosis, indications, technique, outcomes.
        Arthroscopy. 2019; 35: 302-303
        • Littlefield C.P.
        • Belk J.W.
        • Houck D.A.
        • et al.
        The anterolateral ligament of the knee: An updated systematic review of anatomy, biomechanics, and clinical outcomes.
        Arthroscopy. 2021; 37: 1654-1666
        • Sonnery-Cottet B.
        • Saithna A.
        • Cavalier M.
        • et al.
        Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: A prospective comparative study of 502 patients from the SANTI study group.
        Am J Sports Med. 2017; 45: 1547-1557
        • Sonnery-Cottet B.
        • Haidar I.
        • Rayes J.
        • et al.
        Long-term graft rupture rates after combined ACL and anterolateral ligament reconstruction versus isolated ACL reconstruction: A matched-pair analysis from the SANTI study group.
        Am J Sports Med. 2021; 49: 2889-2897
        • Lanzetti R.M.
        • Pace V.
        • Ciompi A.
        • et al.
        Over the top anterior cruciate ligament reconstruction in patients with open physes: A long-term follow-up study.
        Int Orthop. 2020; 44: 771-778
        • Wilson P.L.
        • Wyatt C.W.
        • Wagner K.J.
        • Boes N.
        • Sabatino M.J.
        • Ellis H.B.
        Combined transphyseal and lateral extra-articular pediatric anterior cruciate ligament reconstruction: A novel technique to reduce ACL reinjury while allowing for growth.
        Am J Sports Med. 2019; 47: 3356-3364
        • Roberti di Sarsina T.
        • Macchiarola L.
        • Signorelli C.
        • et al.
        Anterior cruciate ligament reconstruction with an all-epiphyseal “over-the-top” technique is safe and shows low rate of failure in skeletally immature athletes.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 498-506
        • Kocher M.S.
        • Heyworth B.E.
        • Fabricant P.D.
        • Tepolt F.A.
        • Micheli L.J.
        Outcomes of physeal-sparing ACL reconstruction with iliotibial band autograft in skeletally immature prepubescent children.
        J Bone Joint Surg Am. 2018; 100: 1087-1094
        • Willimon S.C.
        • Jones C.R.
        • Herzog M.M.
        • May K.H.
        • Leake M.J.
        • Busch M.T.
        Micheli Anterior cruciate ligament reconstruction in skeletally immature youths: A retrospective case series with a mean 3-year follow-up.
        Am J Sports Med. 2015; 43: 2974-2981
        • Sonnery-Cottet B.
        • Daggett M.
        • Helito C.P.
        • Fayard J.M.
        • Thaunat M.
        Combined anterior cruciate ligament and anterolateral ligament reconstruction.
        Arthrosc Tech. 2016; 5: e1253-e1259
        • Muller B.
        • Willinge G.J.A.
        • Zijl J.A.C.
        Minimally invasive modified Lemaire tenodesis.
        Arthrosc Tech. 2021; 10: e29-e36
        • Tegner Y.
        • Lysholm J.
        Rating systems in the evaluation of knee ligament injuries.
        Clin Orthop Relat Res. 1985; 198: 43-49
        • Greulich W.W.
        • Pyle S.I.
        Radiographic atlas of skeletal development of the hand and wrist.
        Stanford University Press, Stanford, CA1959
        • Lysholm J.
        • Gillquist J.
        Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale.
        Am J Sports Med. 1982; 10: 150-154
        • Kocher M.S.
        • Smith J.T.
        • Iversen M.D.
        • et al.
        Reliability, validity, and responsiveness of a modified International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC) in children with knee disorders.
        Am J Sports Med. 2011; 39: 933-939
        • Nasreddine A.Y.
        • Connell P.L.
        • Kalish L.A.
        • et al.
        The Pediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form: Normative data.
        Am J Sports Med. 2017; 45: 527-534
        • Terry M.A.
        • Winell J.J.
        • Green D.W.
        • et al.
        Measurement variance in limb length discrepancy: Clinical and radiographic assessment of interobserver and intraobserver variability.
        J Pediatr Orthop. 2005; 25: 197-201
        • Lecoanet P.
        • Vargas M.
        • Pallaro J.
        • Thelen T.
        • Ribes C.
        • Fabre T.
        Leg length discrepancy after total hip arthroplasty: Can leg length be satisfactorily controlled via anterior approach without a traction table? Evaluation in 56 patients with EOS 3D.
        Orthop Traumatol Surg Res. 2018; 104: 1143-1148
        • Clavé A.
        • Maurer D.G.
        • Nagra N.S.
        • Fazilleau F.
        • Lefèvre C.
        • Stindel E.
        Reproducibility of length measurements of the lower limb by using EOSTM.
        Musculoskelet Surg. 2018; 102: 165-171
        • Thaunat M.
        • Jan N.
        • Fayard J.M.
        • et al.
        Repair of meniscal ramp lesions through a posteromedial portal during anterior cruciate ligament reconstruction: Outcome study with a minimum 2-year follow-up.
        Arthroscopy. 2016; 32: 2269-2277
        • Foissey C.
        • Thaunat M.
        • Fayard J.M.
        All-inside double-sided suture repair for longitudinal meniscal tears.
        Arthrosc Tech. 2021; 10: e2043-e2048
        • Fourman M.S.
        • Hassan S.G.
        • Roach J.W.
        • Grudziak J.S.
        Anatomic all-epiphyseal ACL reconstruction with “inside-out” femoral tunnel placement in immature patients yields high return to sport rates and functional outcome scores a minimum of 24 months after reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2021; 29: 4251-4260
        • Nagai K.
        • Rothrauff B.B.
        • Li R.T.
        • Fu F.H.
        Over-the-top ACL reconstruction restores anterior and rotatory knee laxity in skeletally immature individuals and revision settings.
        Knee Surg Sports Traumatol Arthrosc. 2020; 28: 538-543
        • Razi M.
        • Moradi A.
        • Safarcherati A.
        • et al.
        Allograft or autograft in skeletally immature anterior cruciate ligament reconstruction: A prospective evaluation using both partial and complete transphyseal techniques.
        J Orthop Surg Res. 2019; 14: 85
        • Longo U.G.
        • Ciuffreda M.
        • Casciaro C.
        • et al.
        Anterior cruciate ligament reconstruction in skeletally immature patients: A systematic review.
        Bone Joint J. 2017; 99-B: 1053-1060
        • Geffroy L.
        • Lefevre N.
        • Thevenin-Lemoine C.
        • et al.
        Return to sport and re-tears after anterior cruciate ligament reconstruction in children and adolescents.
        Orthop Traumatol Surg Res. 2018; 104: S183-S188
        • Dekker T.J.
        • Godin J.A.
        • Dale K.M.
        • Garrett W.E.
        • Taylor D.C.
        • Riboh J.C.
        Return to sport after pediatric anterior cruciate ligament reconstruction and its effect on subsequent anterior cruciate ligament injury.
        J Bone Joint Surg Am. 2017; 99: 897-904
        • Schmale G.A.
        • Kweon C.
        • Larson R.V.
        • Bompadre V.
        High satisfaction yet decreased activity 4 years after transphyseal ACL reconstruction.
        Clin Orthop Relat Res. 2014; 472: 2168-2174
        • Neri T.
        • Dabirrahmani D.
        • Beach A.
        • et al.
        Different anterolateral procedures have variable impact on knee kinematics and stability when performed in combination with anterior cruciate ligament reconstruction.
        J ISAKOS. 2021; 6: 74-81
        • Ahn J.H.
        • Koh I.J.
        • McGarry M.H.
        • Patel N.A.
        • Lin C.C.
        • Lee T.Q.
        Double-bundle anterior cruciate ligament reconstruction with lateral extra-articular tenodesis is effective in restoring knee stability in a chronic, complex anterior cruciate ligament-injured knee model: A cadaveric biomechanical study.
        Arthroscopy. 2021; 37: 2220-2234
        • Castoldi M.
        • Magnussen R.A.
        • Gunst S.
        • et al.
        A randomized controlled trial of bone-patellar tendon-bone anterior cruciate ligament reconstruction with and without lateral extra-articular tenodesis: 19-year clinical and radiological follow-up.
        Am J Sports Med. 2020; 48: 1665-1672
        • Astur D.C.
        • Cachoeira C.M.
        • da Silva Vieira T.
        • Debieux P.
        • Kaleka C.C.
        • Cohen M.
        Increased incidence of anterior cruciate ligament revision surgery in paediatric verses adult population.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 1362-1366
        • Kocher M.S.
        • Saxon H.S.
        • Hovis W.D.
        • Hawkins R.J.
        Management and complications of anterior cruciate ligament injuries in skeletally immature patients: Survey of the Herodicus Society and The ACL Study Group.
        J Pediatr Orthop. 2002; 22: 452-457
        • Collins M.J.
        • Arns T.A.
        • Leroux T.
        • et al.
        Growth abnormalities following anterior cruciate ligament reconstruction in the skeletally immature patient: A systematic review.
        Arthroscopy. 2016; 32: 1714-1723
        • Pierce T.P.
        • Issa K.
        • Festa A.
        • Scillia A.J.
        • McInerney V.K.
        Pediatric anterior cruciate ligament reconstruction: A systematic review of transphyseal versus physeal-sparing techniques.
        Am J Sports Med. 2017; 45: 488-494
        • Gicquel P.
        • Geffroy L.
        • Robert H.
        • et al.
        MRI assessment of growth disturbances after ACL reconstruction in children with open growth plates—Prospective multicenter study of 100 patients.
        Orthop Traumatol Surg Res. 2018; 104: S175-S181
        • Magnussen R.A.
        • Meschbach N.T.
        • Kaeding C.C.
        • Wright R.W.
        • Spindler K.P.
        ACL Graft and contralateral ACL tear risk within ten years following reconstruction: A systematic review.
        JBJS Rev. 2015; 3
        • Hamrin Senorski E.
        • Seil R.
        • Svantesson E.
        • et al.
        “I never made it to the pros…” Return to sport and becoming an elite athlete after pediatric and adolescent anterior cruciate ligament injury Current evidence and future directions.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 1011-1018
        • Webster K.E.
        • Feller J.A.
        • Whitehead T.S.
        • Myer G.D.
        • Merory P.B.
        Return to sport in the younger patient with anterior cruciate ligament reconstruction.
        Orthop J Sports Med. 2017; 52325967117703399
        • Kamath G.V.
        • Murphy T.
        • Creighton R.A.
        • Viradia N.
        • Taft T.N.
        • Spang J.T.
        Anterior Cruciate ligament injury, return to play, and reinjury in the elite collegiate athlete: Analysis of an NCAA Division I cohort.
        Am J Sports Med. 2014; 42: 1638-1643
        • Malatray M.
        • Raux S.
        • Peltier A.
        • Pfirrmann C.
        • Seil R.
        • Chotel F.
        Ramp lesions in ACL deficient knees in children and adolescent population: A high prevalence confirmed in intercondylar and posteromedial exploration.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 1074-1079
        • Sonnery-Cottet B.
        • Praz C.
        • Rosenstiel N.
        • et al.
        Epidemiological evaluation of meniscal ramp lesions in 3214 anterior cruciate ligament–injured knees from the SANTI Study Group database: A risk factor analysis and study of secondary meniscectomy rates following 769 ramp repairs.
        Am J Sports Med. 2018; 46: 3189-3197
        • Bernardini I.
        • N’Dele D.
        • Faruch Bilfeld M.
        • et al.
        Prevalence and detection of meniscal ramp lesions in pediatric anterior cruciate ligament–deficient knees.
        Am J Sports Med. 2021; 49: 1822-1826
        • Kunze K.N.
        • Wright-Chisem J.
        • Polce E.M.
        • DePhillipo N.N.
        • LaPrade R.F.
        • Chahla J.
        Risk factors for ramp lesions of the medial meniscus: A systematic review and meta-analysis.
        Am J Sports Med. 2021; 49: 3749-3757