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

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

Research has long demonstrated that young adolescents (typically in eighth and ninth grades) who return to a pivoting or high-risk high school sport have the highest re-tear rate after an ACL reconstruction, the current standard-of-care treatment for ACL tears. In the New York City metro area alone, over 80% of ACL injuries in adolescents stem from participation in sports such as basketball, soccer, lacrosse, skiing, and football, noted the researchers.

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

“The risk of re-injury has been too high, leading to 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 years who underwent simultaneous ACL reconstruction and LET; 97% of the patients participated in organized sports, with soccer being the most popular. These patients were identified as being at high risk for re-tear because they had 1 or more of the following factors: participated in high-risk competitive sports such as football, lacrosse, soccer, or basketball or that involved grade 3 pivot shift; hyperlaxity; recurvatum; revision ACL reconstruction; contralateral ACL reconstruction; or chronic ACL insufficiency.

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

At a minimum 2-year follow-up, the researchers looked at patient-reported outcome measures as well as data on return to sports and additional surgeries. The results were positive, with a median Single Assessment Numeric Evaluation (SANE) score of 95%, where 100% represents normal function. The mean Pediatric International Knee Documentation Committee (Pedi-IKDC) score was 91, where 100 indicates no limitations on 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 to quantify the activity of children. 

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

This study expanded upon 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 underwent a quadriceps autograft ACL reconstruction.

Origins of the Technique

About a decade ago, surgeons in France innovated the standard ACL reconstruction procedure after identifying elite soccer players as at increased high risk for re-tear. They added the LET to the reconstruction and successfully demonstrated that this combination decreased the re-tear rate in adult soccer players by nearly 50%.

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

“Not only does this technique not disturb children’s growth plates or cause post-operative stiffness, but we also found that this demonstrates a remarkably low re-tear rate in this high-risk group,” said Dr Cordasco.


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