New surgical technique reduces ACL tears in teens

A new surgical technique performed during anterior cruciate ligament (ACL) reconstruction has resulted in lower recurrence rates and favorable patient-reported outcomes in young adolescents 2 years after surgery, according to study results presented at the American Academy of Orthopedic Surgeons (AAOS) 2022 Annual Meeting held March 22-26, 2022 in Chicago.

Study researchers evaluated the safety and effectiveness of performing lateral extra-articular tenodesis (LET) using a modified Lemaire technique (MLT) in conjunction with ACL reconstruction in children and adolescents who are at increased risk of ACL reconstruction failure. The New York Hospital for Special Surgery (HSS) surgical team reported that the technique was associated with favorable patient-reported outcomes, a high return to athletic participation, and a low rate of ACL recurrence. .

Research has long demonstrated that young adolescents (typically in eighth and ninth grades) who return to a pivotal or high-risk sport in high school have the highest recurrence rate following ACL reconstruction, the current gold standard treatment for ACL tears. . In the New York metropolitan area alone, more than 80% of ACL injuries in adolescents come from participation in sports such as basketball, soccer, lacrosse, skiing and soccer, researchers noted. .

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“Reconstruction alone hasn’t been enough for kids who haven’t finished growing yet and want to stay active in sports,” said Daniel W. Green, MD, MS, FAAP, FACS, lead author and pediatric orthopedic surgeon at HSS.

“The risk of re-injury has been too high, with devastating consequences for a young athlete,” added Frank A. Cordasco, MD, MS, lead author and sports medicine surgeon at HSS.

study design

The researchers followed 61 patients aged 11 to 19 who underwent simultaneous ACL and LET reconstruction; 97% of patients participated in organized sports, with football being the most popular. These patients were identified as being at high risk for recurrence because they had 1 or more of the following factors: participation in high-risk competitive sports such as football, lacrosse, soccer, or basketball or who involved a level 3 pivot change; hyperlaxity; recurvatum; ACL reconstruction revision; contralateral ACL reconstruction; or chronic ACL insufficiency.

Depending on the skeletal maturity of the patient, ACL reconstruction was performed either using full-thickness quadriceps tendon, bone-patellar tendon-bone autograft, all-epiphyseal, or full transphyseal techniques.

At a minimum follow-up of 2 years, researchers looked at patient-reported outcome measures as well as data on return to sport and additional surgeries. Results were positive, with a median Single Numerical Assessment (SANE) score of 95%, where 100% represents normal function. The average Pediatric International Knee Documentation Committee (Pedi-IKDC) score was 91, where 100 indicates no limitations in daily living or sports activities. Patients also reported a median score of 27/30 on the HSS Functional Activity Brief Scale (HSS Pedi-FABS), which is a validated 8-item instrument for quantifying children’s activity.

Nearly 92% of patients were able to resume sport. One patient had ACL revision surgery and 3 had subsequent contralateral ACL reconstructions.

This study expanded on research that Drs. Cordasco and Green published in 2020 showing that LET performed with an MLT can be performed safely in skeletally immature athletes who have undergone quadriceps autograft ACL reconstruction .

Origins of the technique

About a decade ago, French surgeons innovated the standard ACL reconstruction procedure after identifying elite soccer players as having an increased risk of recurrence. They added the LET to the reconstruction and successfully demonstrated that this combination reduced the tear rate in adult footballers by almost 50%.

Drs. Cordasco and Green are 2 of the first doctors to apply this European technique to adolescent athletes in North America. “We are proud to have published one of the first surgical technique papers describing how this procedure can be performed safely in young patients who still have open growth plates,” said Dr Green, who has explained that this study is also unique in that it reports clinical outcomes at 2 years in adolescents who underwent this particular procedure.

“Not only does this technique not disrupt children’s growth plates or cause postoperative stiffness, but we have also found that it demonstrates a remarkably low recurrence rate in this high-risk group,” Dr. Cordasco said.


Green DW, Perea SH, Chipman DE, Cordasco FA. Reconstruction of the anterior cruciate ligament of the quadriceps tendon in skeletally immature patients: clinical and patient-reported results. Poster presented at the 2022 Annual Meeting of the American Academy of Orthopedic Surgeons (AAOS), March 22-26, 2022.

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