Review Question - QID 220402

The physeal-sparing ACL reconstruction technique described in this question includes passing the iliotibial (IT) band underneath the anterior intermeniscal ligament (AIML) to provide proper stability (answer choice 2).

Anterior cruciate ligament (ACL) injuries are common sports injuries leading to anterior and lateral rotatory instability of the knee. The most common mechanism leading to an ACL injury is a non-contact pivoting injury, leading to anterior tibial translation while the knee is in slight flexion and valgus. They are diagnosed on physical exam with increased laxity on Lachmann's test and the anterior drawer test. MRI studies are required to confirm the diagnosis and any associated injuries. Pediatric ACL injuries are treated differently than adult injuries due to their open physes. The combined intra- and extra-articular techniques described in this question are typically employed in males 12 years and younger and in females 11 years and younger. This technique involves harvesting the IT band proximally while leaving its distal insertion on Gerdy's tubercle intact. Next, the IT band autograft is looped through the knee in an over-the-top position, passing it through the intercondylar notch and under the AIML. It is then sutured to the proximal tibia and lateral femoral condyle.

Kocher et al. (2005 & 2006) reviewed the results of a physeal-sparing, combined intra-articular and extra-articular reconstruction technique utilizing IT band autograft in 44 prepubescent skeletally immature children (mean age 10.3 years) from 1980-2002. Results found the mean Lysholm knee score was 95.7, with 2/44 patients undergoing revision, and no clinical leg length discrepancy. They conclude this technique in immature prepubescent children provides excellent functional outcomes with a low revision rate and a minimal risk of growth disturbance.

Kocher et al. (2018) published their future results, expanding from 44 to 237 prepubescent skeletally immature patients undergoing the physeal-sparing, combined intra-articular and extra-articular reconstruction technique utilizing IT band autograft. Results found graft rupture occurred in 9/137 knees (6.6%), at an average of 33.5 months postoperatively. The mean Lysholm score was 93.4, with 1.6% of patients reporting residual graft donor site pain. They conclude this technique demonstrates favorable functional outcomes with minimal risk of growth disturbance and a low postoperative rupture rate in this population.

Figure A is an axial PD fat saturation MRI of a left knee with the green arrow (1) pointing to the medial meniscus, the red arrow (2) pointing to the AIML, the blue arrow (3) pointing to the lateral meniscus, the pink arrow (4) pointing to the lateral collateral ligament (LCL), and the yellow arrow (5) pointing to the biceps femoris tendon. Illustration A is an anatomic illustration depicting the intra- and extra-articular physeal-sparring technique utilizing an IT band autograft.

Incorrect Answers:
Answer 1: The green arrow (#1) in Figure A is pointing to the medial meniscus, not the AIML.
Answer 3: The blue arrow (#3) is pointing to the lateral meniscus, not the AIML.
Answer 4: The pink arrow (#4) is pointing to the LCL, not the AIML.
Answer 5: The yellow arrow (#5) is pointing to the biceps femoris tendon, not the AIML.