High Long-term Survivorship From Revision After Physeal-Sparing “Over-the-Top” Anterior Cruciate Ligament Reconstruction and Lateral Tenodesis in Skeletally Immature Patients: 8- to 17-Year Follow-up

Background: While the rate of anterior cruciate ligament (ACL) injuries and reconstruction procedures in children and adolescents is increasing, evidence of long-term outcomes after ACL reconstruction in skeletally immature patients is still lacking. Purpose: To assess the long-term survivorship from revision and reoperations and to analyze the functional results and patient-reported outcomes (PROs) in skeletally immature patients (with an open physis present at magnetic resonance imaging evaluation) who underwent ACL reconstruction with hamstrings tendon with an over-the-top (OTT) technique and a lateral extra-articular tenodesis (LET). Study Design: Case series; Level of evidence, 4. Methods: The database of a single institution was retrospectively searched for skeletally immature patients who underwent ACL reconstruction. Ipsilateral and/or contralateral reoperations were recorded. Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, and Tegner Activity Level scores were collected at final follow-up. Survivorship was inspected through Kaplan-Maier method with ipsilateral ACL revision as endpoint. Differences in demographics and PROs were assessed through Student t test. Results: A total of 43 patients (mean age at surgery, 13.3 ± 1.6 years), all of whom underwent an OTT technique associated with a LET, at mean follow-up of 11.0 ± 2.7 years were included. Four patients (9%) underwent revision ACL in the ipsilateral knee at a mean of 5.3 ± 2.4 years after surgery, with a revision rate of 5% at 5-year and 10% at 10- and 15-year follow-ups. Four patients (9%) underwent arthroscopy for a new meniscal tear, and a further 5 patients (12%) underwent staple removal because of local discomfort. A total of 11 patients (26%) underwent ≥1 reoperation in the ipsilateral knee after a mean of 3.0 ± 2.1 years; and 8 patients (19%) underwent contralateral ACL reconstruction after a mean of 3.7 ± 3.0 years after surgery. Mean KOOS subscales were all above the Patient Acceptable Symptom State. Patients <13 years old at surgery showed worse Lysholm (82.0 vs 94.6; P = .025) and KOOS–Activities of Daily Living (96.7 vs 99.9; P = .025) compared with those ≥13 years. Conclusion: Patients showed high survivorship (90% of cases) from ACL revision at long-term follow-up. Still, more than one-quarter (26%) of skeletally immature patients who underwent physeal-sparing OTT plus LET technique needed a further operation in the ipsilateral knee. Higher rate of hardware removal procedures and lower functional reported outcomes were detected in patients aged <13.