Abstract
Purpose
To compare the rates and types of early complications in pediatric patients undergoing a 2-limb lateral extra-articular procedure (LEAP) alongside anterior cruciate ligament reconstruction (ACLR) versus ACLR alone.
Methods
The records of patients who underwent primary ACLR at a single tertiary children’s hospital were reviewed for this retrospective cohort study, excluding those with multiligament reconstructions, modified MacIntosh reconstructions, or less than 1-year follow-up. The 2-limb LEAP used a strip of iliotibial band autograft that remained attached at the Gerdy tubercle and was first fixed to the femur and then reflected distally and fixed to the tibia, resulting in 1 limb that was similar to the Lemaire tenodesis and another that reconstructed the anterolateral ligament. Demographic data, intraoperative findings and techniques, and postoperative complications were compared between patients who underwent ACLR with LEAP and those who underwent ACLR alone.
Results
A total of 268 patients with a mean follow-up period of 2.0 ± 0.8 years were included in the analysis, of whom 49 (18%) underwent a 2-limb LEAP with ACLR. Most of the patients who underwent LEAP (91.8%) received a quadriceps tendon autograft for ACLR, whereas those who underwent only ACLR had a more equal distribution of quadriceps (38.8%), patella (34.2%), and hamstring (26.9%) tendon autografts. The most common short-term complication was persistent pain (i.e., pain lasting >3 months), occurring in 4.1% of patients with LEAP and 5.9% of those with ACLR alone (P > .99). There was no difference in the proportion of patients with arthrofibrosis (10.2% of those with LEAP vs 9.6% of those with ACLR alone, P = .90), superficial wound infection (2.0% with LEAP vs 3.7% with ACLR alone, P > .99), or reoperation for any reason (32.6% with LEAP vs 36.5% with ACLR alone, P = .78). The rate of postoperative cosmetic concerns was significantly different (6.1% of patients with LEAP vs 0.5% of patients with ACLR, P = .02).
Conclusions
Children and adolescents undergoing a 2-limb LEAP with primary ACLR reported a higher rate of cosmetic concerns after surgery than those undergoing ACLR alone. However, the addition of the LEAP did not otherwise increase the risk of early postoperative complications at a minimum 1-year follow-up.
Level of Evidence
Level III, retrospective cohort study.
Pediatric and adolescent anterior cruciate ligament (ACL) injuries are increasing in incidence.1,2 Given the high risk of graft failure in these patients, the rate of reoperation for ACL reruptures is also increasing.3,4 Revision ACL reconstruction (ACLR) is notably associated with inferior patient- and clinician-reported outcomes compared with primary ACLR,5 including residual instability, pain, and mental barriers that result in decreased satisfaction and quality of life, as well as lower likelihood of return to preinjury levels of activity.6 Revision ACLR may also be associated with an increased risk of early post-traumatic osteoarthritis.7 Therefore, development of strategies to lower the risk of primary ACLR graft rupture may be impactful in the pediatric population.
The anterolateral ligament (ALL) has been recognized as a stabilizing structure of the anterolateral aspect of the knee, with its tibial attachment midway between the Gerdy tubercle and the fibular head, as well as a variable femoral attachment at the lateral aspect of the distal femur.8 The native ALL plays a role in rotational stability of the knee joint, with ALL-deficient knees showing significantly increased instability and positive pivot-shift findings on examination.9 Given that the anterolateral complex of the knee may be injured in a high proportion of patients experiencing ACL injury,10 concomitant lateral extra-articular procedures (LEAPs), including ALL reconstruction or lateral extra-articular tenodesis (LET), may impact outcomes after pediatric ACLR.
A 2022 survey of pediatric sports surgeons showed that 56% perform LEAP (ALL reconstruction or LET) with primary ACLR and 79% perform LEAP with revision ACLR, with insufficient evidence being the most common reason not to perform LEAP with primary ACLR.11 Therefore, further investigation is necessary to compare postoperative outcomes of pediatric ACLR with and without LEAP. The purpose of this study was to compare the rates and types of early complications in pediatric patients undergoing a 2-limb LEAP alongside ACLR versus ACLR alone. We hypothesized that there would be no difference in the overall complication or reoperation rates between these groups at a minimum 1-year follow-up.
Methods
This was a retrospective cohort study of patients aged 18 years or younger who underwent primary ACLR at an urban, tertiary children’s hospital between 2011 and 2022. Institutional review board approval was obtained. Patients were identified for the study using Current Procedural Terminology code 29888. Inclusion criteria consisted of primary ACLR with complete preoperative and intraoperative documentation with a minimum 1-year postoperative follow-up. All ACL graft types were included. Patients were included regardless of the type of concomitant meniscal or chondral pathology. Exclusion criteria included age greater than 18 years, multiligament or revision ACLR, modified MacIntosh reconstruction in the setting of open physes, and less than 1-year follow-up. Additionally, patients who underwent ALL reconstruction or LET with a technique differing from the 2-limb LEAP described later were excluded. All operations were performed by 2 board-certified, fellowship-trained pediatric orthopaedic sports surgeons (N.M.P.; the other surgeon is not an author). Medical records were reviewed for demographic, preoperative, and intraoperative data. Postoperative complications and reoperations were recorded. These included any reoperations on either knee, cosmetic concerns, pain, arthrofibrosis, implant irritation, infection, deep vein thrombosis, and fracture. Patient-reported cosmetic concerns were recorded if mentioned in postoperative clinic notes. No standardized questionnaire was used in this retrospective study. Postoperative pain was noted simply based on whether this was documented in the medical record after surgery. Pain lasting greater than 3 months after surgery was considered persistent. On the basis of previous literature, arthrofibrosis was defined as a flexion deficit of 20° or greater compared with the contralateral knee or an extension deficit of 10° or greater at 3 months after surgery; this definition has been used in prior research and encompasses Shelbourne arthrofibrosis types 2 through 4.12, 13, 14, 15, 16
Surgical Technique
LEAP was recommended based on surgeon preference, and indications were not standardized in this retrospective study. However, the most common indications included participation in high-risk activities with a pivot-shift grade of 2 or higher, ipsilateral knee hyperextension greater than 10°, and a Beighton-Horan score greater than 4. The LEAP technique for this study consisted of a 2-limb graft, with 1 limb serving as a lateral tenodesis and the other serving as an ALL reconstruction (Fig 1). Although clinical and biomechanical outcomes of this technique have not yet been compared with other common techniques, it was developed to theoretically offer the benefits of both a traditional lateral tenodesis and an ALL reconstruction. A modification of this technique for use in skeletally immature patients was published previously.17
Fig 1.
Surgical technique for the 2-limb lateral extra-articular procedure (LEAP), in which the first limb provides a lateral tenodesis and the second reconstructs the anterolateral ligament. (A) The central 1 cm of the iliotibial (IT) band is incised. This strip of IT band is detached proximally but is left attached to the Gerdy tubercle. (B) The graft is passed deep to the lateral collateral ligament (LCL). (C) A knotless suture anchor is placed in the distal femur, slightly posterior and proximal to the LCL attachment. The IT band graft is passed through the tensionable loops of the knotless anchor, which are cinched over the graft to provide onlay fixation. (D) Another incision is made distal to the joint line and halfway between the Gerdy tubercle and anterior border of the fibular head. Another anchor is placed in this location. The free end of the LEAP graft is passed subcutaneously to the tibial incision and through the loops of the knotless anchor, which are cinched over the graft to provide onlay fixation.
ACLR is performed, with final tensioning of the ACL graft prior to completion of the LEAP. A 3-cm incision is made along the lateral aspect of the knee. The central 1 cm of the iliotibial (IT) band is identified and incised. This strip of IT band is harvested, spanning approximately 9 to 11 cm in length from the Gerdy tubercle depending on the patient’s size. It is detached proximally but left attached to the Gerdy tubercle. The free end of the graft is whipstitched and then passed deep to the lateral collateral ligament. A suture-based, knotless suture anchor is placed in the distal femur at the most commonly described attachment point of the native ALL (slightly posterior and proximal to the lateral collateral ligament attachment).18 To avoid convergence with the femoral ACL tunnel, this anchor is typically placed while the tunnel is visualized arthroscopically prior to passage of the ACL graft. The remainder of the LEAP is completed after tensioning of the ACL. The IT band graft is passed through the tensionable loops of the knotless anchor. With the knee in about 70° of flexion and the tibia in neutral rotation, the loops are cinched over the graft to provide onlay fixation. Next, a 1-cm incision is made over the proximal tibia, 1 cm distal to the joint line and halfway between the Gerdy tubercle and anterior border of the fibular head. Another anchor is placed in this location. The free end of the LEAP graft is passed subcutaneously to the tibial incision and through the loops of the knotless anchor. With the knee in 20° of flexion and the tibia in neutral rotation, the loops are cinched over the graft to provide onlay fixation. This second limb of the graft re-creates the native ALL. Additional suture is used for further fixation to the surrounding periosteum as needed. The IT band harvest site is not closed routinely.
Statistical Analysis
Statistical analysis was completed with SPSS for Macintosh, version 28.0 (IBM, Armonk, NY). To detect a large difference between groups at 80% power and α = .05, at least 26 patients were required in each group.19 Standard descriptive statistics were calculated for demographic variables. Data are reported as mean ± standard deviation, with non-normally distributed variables presented as median (interquartile range). Means were compared with independent-samples t tests. The Mann-Whitney U test was used for comparison of nonparametric variables. Categorical variables were analyzed using the χ2 or Fisher exact test, as appropriate. A significance threshold of P < .05 was applied.
Results
A total of 268 patients with a mean follow-up period of 2.0 ± 0.8 years were included in the analysis, of whom 49 (18.3%) underwent ACLR combined with the aforementioned 2-limb LEAP. Patients who underwent LEAP had a younger mean age and differences in ACLR graft choice than those who did not undergo LEAP. Details of demographic and intraoperative comparisons are noted in Table 1. The most common short-term complication was persistent pain (i.e., pain lasting >3 months), occurring in 4.1% of patients with LEAP and 5.9% of those with ACLR alone, with no statistical difference between groups (P > .99). The only significant difference between the two groups was in the frequency of cosmetic concerns. Whereas only 0.5% of patients who underwent isolated ACLR reported postoperative cosmetic problems, 6.1% of those who underwent ACLR combined with LEAP experienced this issue (P = .02)—related to lateral thigh contour after IT band harvest in all cases. There was no difference in the proportions of patients with arthrofibrosis (P = .9), superficial wound infection (P > .99), reoperation on the ipsilateral knee (P = .4), or reoperation for any reason (P = .8). Additional details regarding postoperative complications are shown in Table 2. ACL graft failure was sustained by 3 of 49 patients (6.1%) with ACLR plus LEAP and 31 of 219 (14.2%) with ACLR alone (P = .13), although there were underlying differences in graft types between the two groups, as previously noted.
Table 1.
Comparison of Demographic Characteristics
| ACLR + LEAP | ACLR Only | P Value | |
|---|---|---|---|
| Age, median (IQR), yr | 14.7 (2.7) | 15.7 (2.6) | .009 |
| Sex | .2 | ||
| Male | 27 (55.1) | 98 (44.7) | |
| Female | 22 (44.9) | 121 (55.3) | |
| BMI | 23.4 ± 4.6 | 24.9 ± 5.6 | .1 |
| Insurance | .8 | ||
| Public | 25 (51.0) | 115 (52.5) | |
| Private | 22 (44.9) | 98 (44.7) | |
| Other | 2 (4.1) | 6 (2.7) | |
| Sport | .6 | ||
| Soccer | 16 (32.7) | 66 (30.1) | |
| Basketball | 8 (16.4) | 47 (21.5) | |
| Football | 7 (14.3) | 27 (12.3) | |
| Volleyball | 1 (2.0) | 17 (7.8) | |
| Other | 17 (34.7) | 62 (28.3) | |
| Time between injury and surgery, d | 109.3 ± 119.7 | 116.8 ± 155.4 | .8 |
| Graft type | <.001 | ||
| Quadriceps tendon autograft | 45 (91.8) | 85 (38.8) | |
| Patellar tendon autograft | 4 (8.2) | 75 (34.2) | |
| Hamstring tendon autograft | 0 (0.0) | 59 (26.9) | |
| Meniscal procedure | |||
| Repair | 24 (49.0) | 107 (48.9) | .6 |
| Meniscectomy | 6 (12.2) | 35 (16.0) | .8 |
| Chondral injury | 4 (8.2) | 31 (14.2) | .3 |
NOTE. Data are reported as number (percentage) or mean ± standard deviation, unless otherwise indicated.
ACLR, anterior cruciate ligament reconstruction; BMI, body mass index; IQR, interquartile range; LEAP, lateral extra-articular procedure.
Table 2.
Comparison of Complications
| ACLR + LEAP | ACLR Only | P Value | |
|---|---|---|---|
| Reoperation on ipsilateral knee | 13 (26.5) | 73 (33.3) | .4 |
| ACL graft failure | 3 (6.1) | 31 (14.2) | .1 |
| Arthrofibrosis | 5 (10.2) | 21 (9.6) | .9 |
| New meniscus injury | 2 (4.1) | 13 (5.9) | .6 |
| Implant irritation | 3 (6.1) | 5 (2.3) | .2 |
| Deep infection | 0 (0.0) | 3 (1.4) | >.99 |
| Pain >3 mo | 2 (4.1) | 13 (5.9) | >.99 |
| Infection (not requiring IV antibiotics or surgery) | 1 (2.0) | 8 (3.7) | >.99 |
| Cosmetic concerns | 3 (6.1) | 1 (0.5) | .02 |
| Fracture | 0 (0.0) | 2 (0.9) | >.99 |
| Deep vein thrombosis | 0 (0.0) | 1 (0.5) | >.99 |
| Contralateral ACL injury | 6 (12.2) | 24 (11.0) | .8 |
| New contralateral meniscus injury | 1 (2.0) | 6 (2.7) | .8 |
| Other complication | 0 (0.0) | 5 (2.3) | >.99 |
| Reoperation for any reason | 16 (32.7) | 80 (36.5) | .8 |
NOTE. Data are reported as number (percentage).
ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; IV, intravenous; LEAP, lateral extra-articular procedure.
Discussion
In this investigation, children and adolescents who underwent a 2-limb LEAP in conjunction with ACLR reported more cosmetic concerns postoperatively but otherwise experienced no significant differences in short-term complications at a minimum 1-year follow-up compared with those who underwent isolated ACLR. As anterolateral extra-articular procedures rise in popularity, an understanding of both short- and long-term complications is critical. Although the addition of these procedures to ACLR has been well characterized in adults and mixed-age cohorts, there are limited data regarding complications after such procedures in the pediatric population. Our findings suggest the addition of a 2-limb LEAP to ACLR is relatively safe in the short term.
Although less characterized in purely pediatric populations, the literature on adult or mixed-age patients has shown favorable clinical and functional outcomes with the addition of other LEAPs to ACLR.20,21 When compared with patients who underwent ACLR alone, patients who underwent ALL reconstruction with ACLR showed decreased knee laxity and a lower rate of graft failure, as well as increased rotational stability and greater odds of returning to preinjury levels of sport.20,21 Similar findings have been reported with the addition of LET to ACLR in patients with a high risk of ACL graft failure, with multiple studies noting decreased postoperative pivot shift and rotational laxity, increased postoperative patient-reported outcome scores, and reduced rerupture rates compared with ACLR alone.21, 22, 23, 24 The literature on concomitant anterolateral procedures in pediatric patients is limited. A systematic review by Dietvorst et al.25 included 17 studies describing LET techniques, 4 describing ALL reconstruction techniques, and only 2 comparing outcomes of ACLR with those of ACLR plus LET. Both comparative investigations showed a decreased rate of graft rupture and improved postoperative stability with the addition of LET compared with ACLR alone.26,27 When comparing other complications in a pediatric population of 111 patients (mean age, 16.2 years), Monaco et al.26 evaluated postoperative anterior knee pain, symptomatic tibial tunnel cysts, dysesthesia, hemarthrosis, growth disturbance, and secondary operations for reasons other than graft failure and found no significant difference between patients who underwent ACLR and LET (Arnold-Coker modification of the MacIntosh procedure) and those who underwent ACLR alone. In a slightly younger cohort of 66 patients, Perelli et al.27 similarly found no significant difference in postoperative infection, thrombosis, range-of-motion deficit, and persistent knee pain with the addition of LET (modified Lemaire procedure) to ACLR. No comparative studies were found addressing complications of ALL reconstruction in children and adolescents. The technique used in our study combines a technique similar to the Lemaire procedure with an ALL reconstruction to create a 2-limb graft. The only statistically significant difference between the two study groups was a higher rate of cosmetic concerns in children who underwent LEAP. This was mostly related to contour differences or herniation resulting from incision of the IT band. Closure of part of the IT band may help lower the risk of this complication.
The overall complication rates observed in our study are consistent with prior studies investigating ACLR alone. This study showed a 9.7% overall rate of arthrofibrosis, compared with 6.9% to 8.3% reported in other studies.12,13 However, the frequency of postoperative stiffness may vary depending on ACL graft type. The rate of surgical site infection after ACLR has been reported to be 0.52% to 1%,28,29 compared with 3.4% in our study, which is likely elevated by the inclusion of superficial wound problems for which oral antibiotics were prescribed prophylactically. Reoperation for any reason was reported in 35.8% of patients in this study, compared with rates of 16.5% to 34.7% in other studies.30,31 The most common reasons for reoperation included graft rupture, secondary meniscal procedure, arthrolysis, manipulation under anesthesia, hardware removal, and contralateral ACLR. Although our reoperation rate may seem higher than expected for a study requiring only a 1-year follow-up, the mean follow-up was greater than 2 years. Therefore, these findings are in line with the results of similar studies in the pediatric population. Graft failure was reported in 8.7% to 19% of pediatric patients in other studies,32,33 compared with 12.7% in this investigation. Specifically, ACL graft tear was sustained by 6.1% of patients who underwent the 2-limb LEAP and 14.2% of those who did not. Although these results seem promising, the study was underpowered to detect significance and there was a significant difference in the types of ACL grafts used in each study group. For example, nearly all patients undergoing LEAP received a quadriceps tendon autograft, whereas hamstring, quadriceps, and patellar tendon autografts were more evenly represented in the group of patients undergoing isolated ACLR. Further study on the impact of LEAP on ACL graft failure is critical given that pediatric patients are at significantly higher risk of this complication than adults. A multicenter, randomized controlled trial on this question is currently underway.
As the potential benefits of ACLR combined with anterolateral procedures emerge,34 their indications continue to evolve. Indications are debated in the pediatric population. A survey of pediatric sports surgeons found that the most common indications for performing a concomitant anterolateral procedure with primary ACLR are high-grade pivot shift, knee hyperextension, generalized laxity, and high-risk sports participation.11 These are similar to the indications used for the patients in our study. As evidence in this area continues to grow, an understanding of complications is also important for patient counseling and clinical decision making. This study found no significant increase in the rate of nearly any short-term complication when LEAP was added to primary ACLR. Additional data are required to fully understand the long-term risks and benefits of this procedure. A multicenter, randomized controlled trial is currently in progress and will provide such information while addressing many of the methodologic shortcomings of a retrospective study (NM Patel, unpublished data, October 2025).
Limitations
This study has some limitations. Given its retrospective nature, some variables, including the Beighton-Horan score, were not consistently recorded and could not be incorporated into the analysis. These factors also may have influenced which patients were initially selected to receive LEAP combined with ACLR versus ACLR alone. In addition, the retrospective design limited the detail and consistency of data available. For example, although we were able to collect general information on postoperative pain, the specific location of pain was not always noted. The nature of the 2-limb LEAP described in this study, as well as the relatively small size of the LEAP group, could limit the power of our analyses and generalizability of our findings, as could the confinement to a single, tertiary children’s hospital. As previously noted, there were significant differences in ACL graft types between the two study groups. This could potentially affect outcomes, although the only statistically significant difference between the groups involved cosmetic appearance related to IT band harvest. Regarding cosmetic concerns, it is possible that surgeon bias influenced postoperative documentation. Inclusion of patients with varying degrees of concomitant meniscal or chondral pathology makes this study more generalizable but may also potentially impact outcomes. However, there was no difference in rates of meniscus repair, meniscectomy, or chondral injury between the study groups. Furthermore, given that patient-reported outcome measures were not collected on a regular basis, further investigations are necessary to evaluate these outcomes.
Conclusions
Children and adolescents undergoing a 2-limb LEAP with primary ACLR reported a higher rate of cosmetic concerns after surgery than those undergoing ACLR alone. However, the addition of the LEAP did not otherwise increase the risk of early postoperative complications at a minimum 1-year follow-up.
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: N.M.P. reports that financial support was provided by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. All other authors (S.I.R., E.H.M.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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