Hi, I'm Melissa Christino from Boston Children's, and I'll be speaking about the extra articular extraficial ACL reconstruction. I have no relevant disclosures. And our surgical indications for this procedure are skeletally immature patients who are prepubescent with unstable ACL tears and significant growth remaining. Our secondary indication is for those with congenital ACL deficiency. And on the diagram you see here on the lower right is a really nice depiction of the different surgical options that are available to us at different levels of skeletal age. For the purpose of this talk, we're talking about our prepubescent, skeletally immature patients for which we do not want to do iatrogenic damage to the physis by drilling tunnels. So this is a tunnel-free procedure. Specifically described by Dr. McHaley and Dr. Coker, where a strip of IT band is used and it is left attached to Gertie's tubal distally. It is wrapped around the lateral femoral condyle through the knee under the intermeniscal ligament and secured to the proximal aspect of the tibia. And these are some interoperative photos of how we do this procedure. So isolating the IT band, you want to make sure you harvest a good length of graft to be able to make sure you have enough length to complete the reconstruction. We then dilate a path around the lateral femoral condyle in the over-the-top position using either a full-length Kelly clamp or a kidney pedicle clamp. And you can see this clamp passed here around the lateral femoral condyle and out the lateral incision. And we'll use that clamp to pull the graft through the knee, as you can see in this video here. Here's our graft coming through. And we subsequently prepare the proximal tibia by rasping a trough in the tibial epiphysis. And then we pass the graft underneath the intermeniscal ligament, as you see in this photo here. In terms of our fixation, it is suture fixation on both the femoral and tibial sides. On the femoral side, I usually keep the knee at about 90 degrees of knee flexion and neutral rotation of the foot. And the tibial side, you want to make a full-thickness periosteal cut and really overlap the periosteum over the graft for optimal fixation. And this is our final graft position here. In terms of surgical outcomes, there's been three main studies that have looked at outcomes. The earliest study is from 2005, looking at 44 patients with low revision rate and good surgical outcomes. The subsequent two studies have also shown similar data with the largest study just being published in JBGS in 2018. This was a study of 240 knees, average age of 11.2 years. You can see very good PDI-KDC scores and Lyshom scores. The revision rate for this cohort was 6.6% and a very high rate of return to sport with no cases of growth disturbance reported. So there's a lot of advantages to this type of reconstruction. The first thing is that there's no tunnels and there's no implants. So this really minimizes any iatrogenic damage to the fices that can occur with other reconstruction techniques. There's also no cases of growth disturbance reported. Also, with the lack of tunnels and implants, this really optimizes any future surgery that might be needed if revision surgery does need to occur. It has excellent results for stability and outcomes, as we saw on the last slide, low revision rates. Other studies have shown it's got a very favorable biomechanical profile and really stabilizes the knee nicely without over-constraint. It's also been shown to have improved strength parameters at the six-month time point following ACL reconstruction. And patients have been shown to maintain symmetric kinematics in their surgical and non-surgical side over time. The disadvantage to this procedure is that it's a less anatomic position of the ACL. And then a good number of patients do experience IT band fullness and thigh asymmetry compared to their other side due to the graft hardness, but this is very rarely symptomatic. In some early biomechanical studies, there was some concern with over-constraint of the knee, but this has been disproved in some of the later biomechanical studies. So in conclusion, the iliotibial band ACL reconstruction with both intra- and extra-articular components is a safe and effective technique to restore knee stability in skeletally immature patients. It has favorable biomechanics, high return to support rate, low revision rate, and it really minimizes the risk of viatrogenic bicep injury. This technique is gaining popularity throughout the country with many of our pediatric sports medicine colleagues utilizing this procedure. It was significantly represented in the PLUTO study, which is our multicenter ACL study in skeletally immature patients, for which we just concluded collecting data. And some of our colleagues are actually looking at potentially modifying this technique to be used in skeletally mature patients, and hopefully more to hear about that in the future. These are some selected references, and thank you so much for your time.

extra-articular extraficial ACL reconstruction

prepubescent patients

skeletally immature patients

ACL tears

congenital ACL deficiency