Abstract
BACKGROUND: Despite excellent midterm clinical outcomes in several studies of pediatric anterior cruciate ligament (ACL) treatment, the modified McIntosh ACL reconstruction (ACLR) with iliotibial band (ITB) autograft (ITB ACLR) has been referred to as "nonanatomic" in nature. Moreover, the technique remains underinvestigated in terms of postoperative lower extremity recovery, strength, balance metrics, and hop tests, with little evidence on the effect of time from surgery. PURPOSE: To assess performance parameters between ITB ACLR and contralateral noninjured knees of patients who underwent the procedure at various time points before testing. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent ITB ACLR between 1 and 20 years before study initiation were identified from the surgical database of 3 high-volume ACL surgeons at a tertiary care pediatric hospital. Each patient in the cohort, which was randomly selected to achieve a broad distribution of times from surgery, participated in isometric strength tests (quadriceps, hamstring, and hip abductor), dynamic Y-balance tests, and functional hop tests. The limb symmetry index (LSI) was utilized for comparisons between knees, with equivalence and correlation analyses performed. Patient-reported outcomes (Pediatric International Knee Documentation Committee [Pedi-IKDC] form) and activity level (Hospital for Special Surgery Pediatric Functional Activity Brief Scale [HSS Pedi-FABS]) were recorded on the day of testing. RESULTS: A total of 40 patients (9 in 1 to <2 years, 13 in 2 to <5 years, 10 in 5 to 10 years, and 8 in >10 years after ACLR) were enrolled. The mean time at which testing was completed was 5.8 years (SD, 4.8 years; range, 1.1-17.2 years) postoperatively. The mean Pedi-IKDC score was 95.9 (SD, 4.9), and the mean HSS Pedi-FABS score was 22.2 (SD, 6.0). When comparing the operative limb to the contralateral limb, the mean LSI for the single-leg hop test was 100.8% (SD, 13%) and that for the dynamic Y-balance test was 98.4% (SD, 4.8%). Of the strength tests, no significant differences were seen in mean strength testing for the hip abductor (LSI, 97.9%; P = .207), quadriceps (LSI, 97.9%; P = .260), or hamstring (LSI, 102.6%; P = .264). Equivalence analysis confirmed equivalency between limbs for all measures (all P < .05). No correlation between scores and time from reconstruction was observed, other than improvement in hip abductor LSI (r = 1.1; P = .027) and decline in HSS Pedi-FABS scores (r = -0.37; P = .019) with increasing time from surgery. CONCLUSION: Lower extremity strength and functional testing after ITB ACLR demonstrates equivalence or minimal (<3%) variation when comparing ACLR and contralateral noninjured limbs, with functional outcome scores in both short- and long-term follow-up. These findings suggest no discernible performance-based or functional perturbations or adverse effects from the nonanatomic features of ITB ACLR performed in children, even as they age into the skeletally mature and adult years of life.