Meniscal injury after adolescent anterior cruciate ligament injury: how long are patients at risk?

Is Delayed Anterior Cruciate Ligament Reconstruction Associated With a Risk of New Meniscal Tears? Reevaluating a Longstanding Paradigm

Background

Delayed anterior cruciate ligament (ACL) reconstruction has been associated with an increased risk of meniscal tears. However, studies comparing early versus delayed ACL reconstruction have not clearly demonstrated that meniscal tears diagnosed arthroscopically are new injuries as opposed to concomitant injuries sustained during ACL rupture.

Purpose

To determine whether and how delay of ACL reconstruction is associated with risk of "new" meniscal tears (defined as those visualized arthroscopically that had not been detected on magnetic resonance imaging [MRI]) in adult and pediatric patients.

Study Design

Cohort study; Level of evidence, 3.

Methods

We retrospectively identified patients who underwent primary ACL reconstruction between 2013 and 2022 at our institution. To ensure that MRI reflected initial intra-articular pathology, we included only patients who had an MRI scan within 3 weeks after injury (173 pediatric and 369 adult patients). Multivariate Poisson regression was performed to calculate the adjusted relative risk (ARR) of new meniscal tears after delayed (≥8 weeks from injury) operative treatment.

Results

The mean (± SD) time from injury to MRI was 1.0 ± 0.8 weeks for pediatric patients and 1.1 ± 0.7 weeks for adults. Less than half of the meniscal tears observed arthroscopically had been absent on initial MRI. New medial meniscal tears occurred in 15% of pediatric patients and 16% of adults. New lateral meniscal tears occurred in 48% of pediatric patients and 34% of adults. Among pediatric patients, delayed ACL reconstruction was associated with higher risk of new medial tears (ARR, 3.9; 95% CI, 1.5-10) but not lateral tears (ARR, 0.8; 95% CI, 0.4-1.5). In contrast, adults had no significant increase in risk of meniscal tears associated with operative delay.

Conclusion

Delayed ACL reconstruction may be acceptable in adults, who may be less active and less injury-prone than children and adolescents.

Effect of Delayed Anterior Cruciate Ligament Reconstruction on Repair of Concomitant Medial Meniscus Tears in Young Athletes

BACKGROUND

Delayed anterior cruciate ligament (ACL) reconstruction (ACLR) is associated with an increased risk of meniscal injury. Limited data are available regarding the relationship between surgical delay and meniscal repairability in the setting of ACLR in young patients.

PURPOSE

To determine whether time from ACL injury to primary ACLR was associated with the incidence of medial and/or lateral meniscal repair in young athletes who underwent meniscal treatment at the time of ACLR.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Records were retrospectively reviewed for patients aged 13 to 25 years who underwent primary ACLR between January 2017 and June 2020 by surgeons from a single academic orthopaedic surgery department. Demographic data were collected, and operative reports were reviewed to document all concomitant pathologies and procedures. Univariable and multivariable logistic regression analyses were used to determine factors associated with meniscal repair, including time elapsed from ACL injury to surgery.

RESULTS

Concomitant meniscal tears were identified and treated in 243 of 427 patients; their mean age was 17.9 ± 3.3 years, and approximately half (47.7%) of patients were female. There were 144 (59.3%) medial tears treated and 164 (67.5%) lateral tears treated; 65 (26.7%) patients had both medial and lateral tears treated. Median time from ACL injury to ACLR was 2.4 months (interquartile range, 1.4-4.7 months). Adjusted univariate analysis showed a statistically significant correlation between medial meniscal repair and time to surgery, with a 7% decreased incidence of medial meniscal repair per month elapsed between injury and surgery (odds ratio, 0.93 per month; 95% CI, 0.89-0.98; P = .006). No similar relationship was found between lateral meniscal repair and time to surgery (odds ratio, 1.02; 95% CI, 0.99-1.06; P = .24).

CONCLUSION

In the setting of concomitant ACL and meniscal injuries, surgical delay decreased the incidence of medial meniscal repair in young athletes by 7% per month from time of injury.

Revision Soft-Tissue Allograft Anterior Cruciate Ligament Reconstruction Is Associated With Lower Patient-Reported Outcomes Compared With Primary Anterior Cruciate Ligament Reconstruction in Patients Aged 40 and Older

PURPOSE

To evaluate patient-reported outcomes (PROs) and graft failure rates in revision allograft anterior cruciate ligament reconstruction (ACLR) in patients aged 40 and older and compare them with primary ACLRs.

METHODS

Patients aged 40 and older who underwent arthroscopic soft-tissue allograft ACLR between 2005 and 2016 with a minimum 2-year follow-up were retrospectively reviewed. Patients were grouped based on revision versus primary ACLR. The rate of achieving an International Knee Documentation Committee (IKDC) patient acceptable symptom state (PASS) score was recorded. Patient satisfaction, PROs, and graft failure were compared between groups using the χ² test, Fisher exact test, and Mann-Whitney U test.

RESULTS

We identified 32 patients who underwent revision ACLR and 201 patients who underwent primary ACLR aged 40 and older who met inclusion criteria with a mean follow-up of 6.2 and 6.9 years, respectively (P = .042). There was a lower rate of concomitant meniscal repair in the primary ACLR group (6% vs 21.9%, P = .007) There were no other differences in chondral injuries, mechanism of injury, or meniscal injuries between groups. The median IKDC score was greater in the primary ACLR group as compared with the revision ACLR group (83.9 vs 70.6, P < .001). Patients who underwent revision ACLR were less likely to achieve the IKDC PASS threshold (82.5% vs 56.3%, P = .001) and were less likely to report satisfaction as compared with patients who underwent primary ACLR (90.5% vs 78.1%, P =.038). No difference in graft failure rates was identified between groups (8% vs 15.6%, P = .180).

CONCLUSIONS

Revision allograft ACLR in patients aged 40 and older was associated with lower PROs compared with primary ACLR. Patients who underwent revision ACLR failed to meet the IKDC PASS threshold more often and were dissatisfied with procedure results more than twice as often as patients that underwent primary ACLR.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Risk of reoperation after primary anterior cruciate ligament reconstruction in children and adolescents

OBJECTIVE

To examine the incidence and risk factors of any-cause reoperation after primary ACLR in children and adolescents.

DESIGN

Retrospective Cohort.

SETTING

Electronic medical records from a large tertiary care, single institution integrated healthcare delivery system.

PATIENTS

Patients were under the age of 18 years and had anterior cruciate ligament reconstruction. They were excluded if they had a multi-ligamentous knee injury or <1 year follow-up.

INTERVENTIONS

Patients were further identified to have undergone a subsequent knee operation ipsilaterally or contralateral ACLR.

MAIN OUTCOME MEASURES

The rate of any-cause reoperation was our primary outcome measure.

RESULTS

The median age was 16. There were 208 females (53.9%) and 178 males (46.1%) included. The median follow-up was 25 months with a minimum of 12 months (interquartile range: 16.0, 46.0). The rate of any-cause reoperation was 34.7%. There was no statistically significant difference between those who underwent reoperation versus those who did not undergo reoperation relative to age, sex, BMI, graft type, or the presence of concomitant meniscal injury. The rates of ipsilateral ACLR and contralateral ACLR at any time during the study period was 8.0% and 10.9% respectively. There was no statistically significant difference for rate of reoperation between graft types, between various concomitant injuries, between those who underwent meniscus repair or no repair.

CONCLUSIONS

This study reflects a 34.7% rate of a subsequent knee operation after ACLR in patients younger than 18 years. These findings can be used to inform pediatric patients undergoing primary ACLR on their risk of returning to the operating room.

Agreement Between Clinical Examination and Magnetic Resonance Imaging in Acute Knee Trauma With Hemarthrosis

OBJECTIVE

Hemarthrosis after knee trauma often indicates serious joint injury. Few studies have evaluated agreement between clinical examination and findings from magnetic resonance imaging (MRI). We aimed to describe the agreement between acute clinical examination and subacute MRI findings after acute knee trauma with hemarthrosis and the importance of the subspecialty of the examiner.

DESIGN

Longitudinal cohort study. Agreement with MRI findings was evaluated by logistic regression.

SETTING

Helsingborg hospital.

PATIENTS

Thousand one hundred forty-five consecutive patients with hemarthrosis after knee trauma.

INTERVENTIONS

Clinical examination and MRI.

MAIN OUTCOME MEASURES

agreement between clinical examination and findings from MRI. We considered the radiologist's report as the gold standard.

RESULTS

Median time (25th, 75th percentile) from injury to clinical examination was 2 (1, 7) days, and from injury to imaging was 8 (5, 15) days. The overall sensitivity and specificity of clinical examination versus MRI for major ligament injury or lateral patella dislocation (LPD) were 70% [95% confidence interval 67-73) and 66% (61-72), respectively. Orthopedic subspecialist knee had the highest agreement with anterior cruciate ligament rupture (adjusted odds ratios were 1.7 (95% confidence interval 1.2-2.3), 1.9 (1.2-3.0) and 5.9 (3.7-9.5) for orthopedic trainees, orthopedic subspecialists other, and orthopedic subspecialist knee, respectively]. For other ligament injuries and LPD, we did not find statistically significant differences.

CONCLUSIONS

Clinical diagnosis after acute knee injury is relatively unreliable versus MRI findings even when performed by orthopedic specialists. However, the agreement is improved when the examination is performed by an orthopedic knee subspecialist.

A longer duration from injury to surgery is associated with preoperative deterioration of an isolated meniscal tear in patients aged 40 years or older

PURPOSE

To evaluate the preoperative deterioration of an isolated meniscal tear in patients aged 40 years or older, and whether time from injury to surgery is associated with worsening of a meniscal tear.

METHODS

Patients aged 40 years or older who underwent arthroscopic surgery for isolated meniscal tear between 2014 and 2019 were retrospectively reviewed. The diagnostic magnetic resonance imaging (MRI) findings and arthroscopic findings were compared to evaluate the deterioration of meniscal tears. Predictors of the development of meniscal tears; patient demographic factors, duration from injury to surgery (injury to MRI and MRI to surgery), and image findings were assessed.

RESULTS

A total of 58 patients (58 knees) were included (mean age, 55.9 ± 8.5 years; male/female, 31/27). An isolated meniscal tear deteriorated in 28 (48.3%). Compared patients with and without deteriorated meniscal tear, significant differences were found in the MRI grade of meniscal tear (p = 0.03), duration from injury to MRI (164.2 ± 167.9 vs 45.2 ± 48.7 days, p < 0.001), and from MRI to surgery (148.8 ± 91.1 vs 67.6 ± 56.7 days, p < 0.001). A multivariate regression analysis showed that the duration from injury to MRI (odds ratio [OR], 1.03; p < 0.001) and from MRI to surgery (OR, 1.02; p < 0.001) were independent predictors.

CONCLUSION

Approximately 50% of isolated meniscal tears deteriorated preoperatively in patients aged 40 years or older. The duration from injury to surgery was an independent predictor of worsening of an isolated meniscal tear.

The Majority of Patients Aged 40 and Older Having Allograft Anterior Cruciate Ligament Reconstruction Achieve a Patient Acceptable Symptomatic State

PURPOSE

To evaluate patient satisfaction, retear rates, and patient-reported outcomes (PROs) in patients aged 40 and older undergoing allograft anterior cruciate ligament reconstruction (ACLR). The secondary goal was to compare these parameters between groups of patients with intact versus failed grafts, and to evaluate these in relation to a historically reported International Knee Documentation Committee (IKDC) patient-acceptable symptoms state (PASS) score.

METHODS

Records of patients aged 40 and older who underwent ACLR between 2005 and 2016 at a single institution with a minimum 2-year follow-up were retrospectively reviewed. Patient-reported satisfaction, outcome scores, and failure rates were analyzed. The rate of achieving a previously defined IKDC PASS score based on younger cohorts was reported, and an updated PASS threshold for older patients was calculated.

RESULTS

201 patients were included with a mean age of 48.6 years (range: 40-68) and mean follow-up of 6.2 years (range: 2.8-11.2). 182 (90.5%) patients reported satisfaction following surgery. 16 (8.0%) patients experienced failure of their ACLR, 10 of which underwent revision ACLR. The median IKDC score in the intact ACLR group was 86.2, compared to 66.7 in the failure group (P < .001). In total, 134 (72.4%) patients in the intact group achieved the historical PASS score of 75.9 on IKDC compared to only 4 (25%) in the failure group (χ² = 15.396, P < .001). An updated IKDC PASS threshold for older cohorts was calculated to be 66.7.

CONCLUSION

Patients aged 40 and older who underwent allograft ACLR had an 8.0% failure rate at a mean follow-up of 6 years. Graft failure in patients aged 40 and older was associated with worse PROs. The majority of patients achieved the historically reported IKDC PASS threshold. Additionally, an updated age-appropriate IKDC PASS score of 66.7 was calculated to aid in future ACLR studies assessing older patients.

STUDY DESIGN

Level IV.

Graft Choice for Anterior Cruciate Ligament Reconstruction in Women Aged 25 Years and Younger: A Systematic Review

CONTEXT

Although anterior cruciate ligament (ACL) tears are relatively common in athletic populations, few studies have systematically reviewed graft choice in young women.

OBJECTIVE

To quantitatively and qualitatively examine reported outcomes for graft choice in women aged 25 years and younger undergoing primary ACL reconstruction.

DATA SOURCE

A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An electronic search in the PubMed (includes MEDLINE) and EMBASE databases was completed using a combination of key terms.

STUDY SELECTION

Studies were included if they reported graft choice outcomes in women aged 25 years and younger.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

The following information was extracted: title, author, year of publication, number of female patients and age, graft type, follow-up, and patient-reported outcome measures. The following outcome scores were identified as being reported or not reported by each study: graft failure, contralateral ACL (CACL) rupture, IKDC (International Knee Documentation Committee), graft survival (Kaplan-Meier), Lysholm, Tegner, KT-1000, kneeling pain, return to sport, and Lachman.

RESULTS

Of 1170 identified articles, 16 met inclusion criteria, reporting on 1385 female patients aged 25 years and younger. Comparison of 655 bone-patellar tendon-bone (BPTB) versus 525 hamstring tendon (HT) autografts showed significant differences in mean failure rate between BPTB autografts (6.13% ± 2.58%) and HT autografts (17.35% ± 8.19%), P = 0.001. No statistically significant differences in CACL failure rates were found between BPTB autografts and HT autografts (P = 0.25). Pooled results for IKDC were possible in 3 of the HT autograft studies, showing a mean score of 88.31 (95% CI 83.53-93.08). Pooled Lysholm score results were possible in 2 of the HT autograft studies, showing a mean score of 93.46 (95% CI 91.90-95.01).

CONCLUSION

In female patients aged 25 years and younger, BPTB autografts showed significantly less graft failure compared with HT autografts. However, BPTB autografts had comparable patient-reported outcomes compared with HT autografts with the available data. The overall state of evidence for graft choice in female patients aged 25 years and younger is low. Future studies should report statistics by age and sex to allow for further analysis of graft choice for this specific population that is known to be more vulnerable to ACL injury.

What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study

Background:

The uncommon nature of tibial spine fractures (TSFs) may result in delayed diagnosis and treatment. The outcomes of delayed surgery are unknown.

Purpose:

To evaluate risk factors for, and outcomes of, delayed surgical treatment of pediatric TSFs.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

The authors performed a retrospective cohort study of TSFs treated surgically at 10 institutions between 2000 and 2019. Patient characteristics and preoperative data were collected, as were intraoperative information and postoperative complications. Surgery ≥21 days after injury was considered delayed based on visualized trends in the data. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders.

Results:

A total of 368 patients (mean age, 11.7 ± 2.9 years) were included, 21.2% of whom underwent surgery ≥21 days after injury. Patients who experienced delayed surgery had 3.8 times higher odds of being diagnosed with a TSF at ≥1 weeks after injury (95% CI, 1.1-14.3; P = .04), 2.1 times higher odds of having seen multiple clinicians before the treating surgeon (95% CI, 1.1-4.1; P = .03), 5.8 times higher odds of having magnetic resonance imaging (MRI) ≥1 weeks after injury (95% CI, 1.6-20.8; P < .007), and were 2.2 times more likely to have public insurance (95% CI, 1.3-3.9; P = .005). Meniscal injuries were encountered intraoperatively in 42.3% of patients with delayed surgery versus 21.0% of patients treated without delay (P < .001), resulting in 2.8 times higher odds in multivariate analysis (95% CI, 1.6-5.0; P < .001). Delayed surgery was also a risk factor for procedure duration >2.5 hours (odds ratio, 3.3; 95% CI, 1.4-7.9; P = .006). Patients who experienced delayed surgery and also had an operation >2.5 hours had 3.7 times higher odds of developing arthrofibrosis (95% CI, 1.1-12.5; P = .03).

Conclusion:

Patients who underwent delayed surgery for TSFs were found to have a higher rate of concomitant meniscal injury, longer procedure duration, and more postoperative arthrofibrosis when the surgery length was >2.5 hours. Those who experienced delays in diagnosis or MRI, saw multiple clinicians, and had public insurance were more likely to have a delay to surgery.

Outcomes of pediatric anterior cruciate ligament reconstructions in patients with and without bucket handle meniscus repairs

The purpose of this study was to report the outcomes of concomitant bucket handle meniscal tear (BHMT) repair and anterior cruciate ligament (ACL) reconstruction and to compare the outcomes with those after isolated ACL reconstruction in patients aged ≤16 years. Patients in our database from 2013 to 2017 were retrospectively analyzed. Patients were assigned to one of two treatment groups based on the presence of BHMTs: no meniscal tear group (group A) and BHMT group (group B). All BHMTs were repaired using the combined inside-out with all-inside technique. This study included 64 knees divided into two groups: 47 knees in group A and 17 knees in group B. There was a significant difference in the interval between ACL injury and surgery between groups A and B (69 vs. 150 days, respectively; P < 0.001). Mean postoperative International Knee Documentation Committee and Lysholm scores in group A were slightly, although significantly, improved compared to those in group B (96.5 vs. 92.6, respectively; P < 0.05, and 98 vs. 95, respectively; P < 0.05). There were no significant differences in postoperative anteroposterior laxity and graft failure rate between the groups. In group B, four patients (23.5%) required surgery for incomplete meniscal healing. Postoperative International Knee Documentation Committee and Lysholm scores of patients with BHMTs were significantly lower than those of patients without any meniscal tear, although with significant improvement in the amount of instability. Level of evidence was Level III.

Early Operative Versus Delayed Operative Versus Nonoperative Treatment of Pediatric and Adolescent Anterior Cruciate Ligament Injuries: A Systematic Review and Meta-analysis

BACKGROUND

Treatment options for pediatric and adolescent anterior cruciate ligament (ACL) injuries include early operative, delayed operative, and nonoperative management. Currently, there is a lack of consensus regarding the optimal treatment for these injuries.

PURPOSE/HYPOTHESIS

The purpose was to determine the optimal treatment strategy for ACL injuries in pediatric and adolescent patients. We hypothesized that (1) early ACL reconstruction results in fewer meniscal tears than delayed reconstruction but yields no difference in knee stability and (2) when compared with nonoperative management, any operative management results in fewer meniscal tears and cartilage injuries, greater knee stability, and higher return-to-sport rates.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A systematic search of databases was performed including PubMed, Embase, and Cochrane Library using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were a pediatric and adolescent patient population (≤19 years old at surgery), the reporting of clinical outcomes after treatment of primary ACL injury, and original scientific research article. Exclusion criteria were revision ACL reconstruction, tibial spine avulsion fracture, case report or small case series (<5 patients), non-English language manuscripts, multiligamentous injuries, and nonclinical studies.

RESULTS

A total of 30 studies containing 50 cohorts and representing 1176 patients met our criteria. With respect to nonoperative treatment, knee instability was observed in 20% to 100%, and return to preinjury level of sports ranged from 6% to 50% at final follow-up. Regarding operative treatment, meta-analysis results favored early ACL reconstruction over delayed reconstruction (>12 weeks) for the presence of any meniscal tear (odds ratio, 0.23; P = .006) and irreparable meniscal tear (odds ratio, 0.31; P = .001). Comparison of any side-to-side differences in KT-1000 arthrometer testing did not favor early or delayed ACL reconstruction in either continuous mean differences (P = .413) or proportion with difference ≥3 mm (P = .181). Return to preinjury level of competition rates for early and delayed ACL reconstruction ranged from 57% to 100%.

CONCLUSION

Delaying ACL reconstruction in pediatric or adolescent patients for >12 weeks significantly increased the risk of meniscal injuries and irreparable meniscal tears; however, early and delayed operative treatment achieved satisfactory knee stability. Nonoperative management resulted in high rates of residual knee instability, increased risk of meniscal tears, and comparatively low rates of return to sports.

The influence of the steep medial posterior tibial slope on medial meniscus tears in adolescent patients: a retrospective case-control study

Background

Several studies have demonstrated a relationship between the posterior tibial slope (PTS) and meniscal tears in adults. However, little is known about the association between the PTS of the adolescents and medial meniscal tears (MMT). The purpose of this study was to evaluate the association between the PTS and MMT in adolescents, and to determine the optimal cut-off values of PTS for discriminating between the MMT and the control groups.

Methods

Between January 2018 and January 2020, a retrospective case-control study was performed. In this study, isolated MMT adolescent patients with no ligamentous injuries were matched by age and sex to a control group of radiologically normal images. The PTS was defined as the angle between the perpendicular line to proximal tibial cortex (PTC) and the tangent line along the tibial plateau. Then, both the medial posterior tibial slope (MPTS) and lateral posterior tibial slope (LPTS) were measured by plain radiographs on the lateral views. In addition, the optimal cut-off values of PTS were determined by the receiver operating characteristic (ROC) curve analysis.

Results

A total of seventy-two patients who met the inclusion criteria were enrolled in the final analysis (36 patients with isolated MMT, 36 controls). The MPTS was greater in the knees with isolated MMT (10.7° ± 2.1°) than that of the control group (8.8° ± 1.7°), showing significant difference (P<0.001). However, there was no significant difference regarding the LPTS between the isolated MMT and controls (11.5 ± 3.4 vs 10.9 ± 2.6, p>0.05). In the ROC curve analysis, the calculated cutoff value of the MPTS discriminating between the groups was 10.3°, with a sensitivity of 73.3% and specificity of 78.9%.

Conclusions

This study demonstrated that steep MPTS is associated with MMT, and MPTS≥10.3° was identified to be a risk factor for MMT in adolescents.

Association Between Knee Alignment and Meniscal Tear in Pediatric Patients with Anterior Cruciate Ligament Injury

BACKGROUND

The present study aimed to evaluate the association between elapsed time from anterior cruciate ligament (ACL) injury to surgical treatment and the incidence of meniscal tears in a cohort of patients ≤16 years old with varus-aligned and non-varus-aligned knees.

METHODS

The study cohort included 123 patients ≤16 years old who underwent primary ACL reconstruction between January 2016 and March 2020. Knee alignment was expressed as the hip-knee-ankle angle (HKAA), as measured preoperatively on an anteroposterior view of 3-dimensional computed tomography of the full length of the lower limb. Varus alignment was defined as an HKAA ≥181.0°, and non-varus alignment was defined as an HKAA <181.0°. Patients were divided into groups according to knee alignment and the elapsed time from injury to surgical treatment: early-treatment group (<60 days) and delayed-treatment group (≥60 days).

RESULTS

A total of 64 varus-aligned and 59 non-varus-aligned knees were identified. Among patients with varus-aligned knees, those in the delayed-treatment group showed a significantly lower rate of lateral meniscal tears (6 of 30, 20%) compared with those in the early-treatment group (17 of 34, 50%; p = 0.015). Among patients with non-varus-aligned knees, there was no significant difference in meniscal tears of any type between the early and delayed-treatment groups. Among patients without medial meniscal injury identified on initial magnetic resonance imaging, those with varus-aligned knees in the delayed-treatment group showed a significantly higher rate of medial meniscal tears at the time of the surgical procedure (8 of 20, 40%) compared with those with non-varus-aligned knees (1 of 18, 6%; p = 0.015).

CONCLUSIONS

Delayed ACL reconstruction in patients ≤16 years old with varus-aligned knees might be associated with an increased incidence of secondary medial meniscal tears. Accordingly, earlier ACL reconstruction in patients with varus-aligned knees should be considered.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Delayed anterior cruciate ligament reconstruction increases the incidence of medial meniscal bucket handle tears and medial compartment chondral injuries in patients aged 40 years and older

INTRODUCTION

No widely accepted evidence-based indications exist for the initial surgical management of patients with anterior cruciate ligament (ACL) injuries ≥ 40 years old, and treatment for these patients remains controversial. This study aimed to evaluate the association between elapsed time from ACL injury to surgery and the incidence of meniscal tears and chondral injury in patients aged ≥ 40 years.

MATERIALS AND METHODS

The patients who underwent primary ACL reconstruction were divided into two groups based on elapsed time from injury to surgery: early group, < 12 months; and delayed group, ≥ 12 months. Patient records were reviewed for incidence and types of meniscal tears and chondral injuries in each group. Chondral injury grades were evaluated with International Cartilage Regeneration and Joint Preservation Society (ICRS) Criteria.

RESULTS

This study evaluated 67 knees in the early group and 33 knees in the delayed group. Mean ages in each group were 46.9 ± 6.5 and 46.9 ± 6.0. The delayed group showed significantly higher rates of medial meniscal tear [31 of 33, 93.9% vs 29 of 67, 43.3%; P < 0.0001; odds ratio (OR), 20.31; 95% confidence interval (CI), 4.49-91.9], medial femoral condyle chondral injuries ≥ ICRS grade II (15 of 33, 45.5% vs 8 of 67, 11.9%; P < 0.001; OR, 6.15; 95% CI 2.24-16.83), and medial tibial chondral injuries ≥ ICRS grade II (7 of 33, 21.2% vs 3 of 67, 4.5%; P < 0.05; OR, 5.74; 95% CI 1.38-23.9) compared with the early group. With respect to types of medial meniscal tear, the delayed group showed a significantly higher frequency of bucket handle tears (11 of 33, 33.3%) compared with the early group (2 of 67, 3.0%; P < 0.0001; OR, 16.25; 95% CI 3.34-79.1).

CONCLUSIONS

Delayed ACL reconstruction was associated with increased incidence of chondral injuries and medial meniscal tears, particularly bucket handle tears in this cohort.

LEVEL OF EVIDENCE

Level III.

Anterior Cruciate Ligament Reconstruction and Lateral Plasty in High-Risk Young Adolescents: Revisions, Subjective Evaluation, and the Role of Surgical Timing on Meniscal Preservation

BACKGROUND

In adolescents, the rate of meniscal injury at the time of anterior cruciate ligament (ACL) reconstruction, the rate of ACL graft revision, and clinical outcomes has not yet been investigated.

HYPOTHESIS

In patients younger than 16 years, the rate of meniscal injuries at the time of ACL reconstruction increases with time from injury. The mid-term revision rate and reoperation rate after ACL reconstruction with hamstrings and lateral tenodesis are lower than those reported in literature for isolate ACL reconstruction.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level 4.

METHODS

Patients younger than 16 years who underwent ACL reconstruction with hamstring and lateral tenodesis, with a follow-up ≥2 years were included. The number of meniscal lesions was stratified according to the delay between injury-to-surgery (<3, 3-12, >12 months). All reoperations, Lysholm score, Knee Injury and Osteoarthritis Outcome Score subscales for pain (at rest and during activity), and return to sport were collected.

RESULTS

A total of 151 patients (mean age 14.8 ± 1.2 years) were included. Patients undergoing surgery at <3 months after injury had a lower meniscal injury rate (36%) than those treated at 3 to 12 months (55%) and >12 months (63%) after injury (P = 0.04). Medial meniscal lesions were more likely to be repaired when surgery was performed <3 months after injury (91%). Subjective follow-up data were available for 132 patients, and 19 were lost to follow-up. At 6.0 ± 2.6 years, 6% of patients underwent ACL revision; 1 of 20 (5%) patients with posterior tibial slope ≥12° and 4 of 45 (9%) patients with Tegner level ≥8. Nine new meniscal procedures were performed; 19% of repaired menisci underwent meniscectomy. Good or excellent Lysholm score was reported by 88% of patients; 56% of patients with concurrent lateral meniscectomy had pain during activity, 91% returned to sport, and 79% were still participating at final follow-up.

CONCLUSION

Patients younger than 16 years undergoing ACL reconstruction within 3 months from injury had the lowest rate of meniscal injuries. ACL reconstruction with lateral tenodesis had low revision rate (6%) and good or excellent clinical outcomes in 88% of young adolescents.

CLINICAL RELEVANCE

Sport physicians should be aware that adolescent patients undergoing ACL reconstruction within 3 months after injury have the lowest rate of meniscal injuries; the mid-term revision rate of ACL reconstruction with lateral plasty is lower than 10% and the patients' perceived outcomes are good with almost all patients returning to sport activity.

Predicting Autologous Hamstring Graft Diameter in the Pediatric Population Using Preoperative Magnetic Resonance Imaging and Demographic Data

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction before 18 years of age has been linked with an increased risk for failure when the graft diameter is <8 mm.

PURPOSE/HYPOTHESIS

The purpose of this study was to determine whether autologous hamstring graft size can be reliably predicted with the use of preoperative magnetic resonance imaging (MRI) measurements. We hypothesized that the average of multiple axial cross-sectional area MRI measurements for the semitendinosus tendon and gracilis tendon would alone accurately predict graft diameter. Additionally, factoring in specific demographic data to the MRI cross-sectional areas would provide a synergistic effect to the accuracy of graft diameter predictions.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

We retrospectively reviewed 51 pediatric patients undergoing ACL reconstructions (age <18 years) performed using either a quadruple-strand semitendinosus tendon or combined double-bundle semitendinosus tendon-gracilis tendon autograft. Preoperative axial MRI scans at multiple points along the craniocaudal axis-specifically, at the level of the joint line, 3 cm cephalad to the medial tibial plateau, and 5 cm cephalad to the medial tibial plateau-were used to determine the combined cross-sectional area of the semitendinosus and gracilis tendons. The MRI measurements were analyzed using Pearson correlation as well as regression analysis to evaluate strength of correlation between measurements. Binomial linear regression was used to analyze the same predictive variables assessed by multiple regression.

RESULTS

The predicted graft diameter was within 0.5 mm of the intraoperative graft size in 37 of 51 (72.5%) patients and within 1 mm of the intraoperative graft size in 49 of 51 (96.1%). With the addition of demographics, the accuracy of predictions increased to 78.4% within 0.5 mm and 98% within 1 mm of the actual graft size. Additionally, 38 of 42 patients whose true graft diameter was ≥8 mm were correctly classified, giving a sensitivity of 90.4%. For those whose true graft diameter was <8 mm, 8 of 9 patients were correctly classified; therefore, the specificity was 88.9%.

CONCLUSION

The results of our study suggest that taking the average of multiple preoperative MRI measurements can be used to accurately predict autologous hamstring graft size when approaching pediatric patients undergoing ACL reconstruction.

Rates of Concomitant Meniscal Tears in Pediatric Patients With Anterior Cruciate Ligament Injuries Increase With Age and Body Mass Index

Background

Anterior cruciate ligament (ACL) tears are frequently associated with meniscal injury. Risk factors for concomitant meniscal injuries have been studied in the adult population but less so in pediatric patients.

Purpose

To evaluate the relationship between age and body mass index (BMI) and the presence of a concomitant meniscal tear at the time of ACL reconstruction (ACLR) in pediatric patients.

Study Design

Case-control study; Level of evidence, 3.

Methods

A single-institution retrospective review was performed of patients aged <19 years who underwent primary ACLR over a 3.5-year period. Revision ACLR and multiligament knee reconstructions were excluded. Logistic regression was used to identify risk factors associated with having a meniscal tear at the time of surgery. Subgroup analysis was performed for medial and lateral meniscal tears.

Results

Included in this study were 453 patients (230 males, 223 females; median age, 15 years). Of these, 265 patients (58%) had a meniscal tear, including 150 isolated lateral meniscal tears, 53 isolated medial meniscal tears, and 62 patients with both lateral and medial meniscal tears. Median time from injury to surgery was 48 days. For every 1-year increase in age, there was a 16% increase in the adjusted odds of having any meniscal tear (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.05-1.27; P = .002), with a 20% increase in the odds of having a medial meniscal tear (OR, 1.20; 95% CI, 1.07-1.35; P = .002) and a 16% increase in the odds of having a lateral meniscal tear (OR, 1.16; 95% CI, 1.05-1.27; P = .003). For every 2-point increase in BMI, there was a 12% increase in the odds of having any meniscal tear (OR, 1.12; 95% CI, 1.02-1.22; P = .016) and a 10% increase in the odds of having a lateral meniscal tear (OR, 1.10; 95% CI, 1.01-1.19; P = .028).

Conclusion

Pediatric patients undergoing ACLR had a 58% incidence of concomitant meniscal pathology. Increasing age and BMI were independent risk factors for these injuries, while no association was found between time to surgery and meniscal pathology.

Incidence of Medial and Lateral Meniscal Tears After Delayed Anterior Cruciate Ligament Reconstruction in Pediatric Patients

Background:

The treatment of pediatric anterior cruciate ligament (ACL) injuries is controversial, and no clear management guidelines have been established.

Purpose:

To evaluate the association between elapsed time from ACL injury to surgery and the incidence of meniscal tears and chondral injuries in patients aged ≤16 years.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Between December 2012 and April 2019, a total of 207 consecutive knees in 207 patients aged ≤16 years underwent primary ACL reconstruction and were included in this study. Patients were divided into 1 of 2 groups (early group [≤150 days] and delayed group [>150 days]) based on the time between injury and surgery. Patient records, including arthroscopic findings identified by 2 experienced knee surgeons at the time of surgery, were reviewed for demographic information, incidence and types of medial and lateral meniscal tears, and chondral injuries and their locations in each group.

Results:

There were 180 knees in the early group and 27 knees in the delayed group. The delayed group showed a significantly higher rate of medial meniscal tears than the early group: 16 of 27 (59.2%) and 46 of 180 (25.6%), respectively (odds ratio [OR], 4.24 [95% CI, 1.83-9.33]; P = .0011). The delayed group had a significantly lower rate of lateral meniscal tears than the early group: 6 of 27 (22.2%) and 90 of 180 (50.0%), respectively (OR, 0.29 [95% CI, 0.11-0.70]; P = .007). The delayed group had significantly higher rates of chondral injuries in the medial femoral condyle and the medial tibial plateau than the early group: 8 of 27 (29.6%) and 25 of 180 (13.9%), respectively (OR, 2.61 [95% CI, 1.03-6.62]; P = .049), and 2 of 27 (7.4%) and 1 of 180 (0.6%), respectively (OR, 14.32 [95% CI, 1.58-208.10]; P = .045).

Conclusion:

Delayed ACL reconstruction was associated with an increased incidence of medial chondral injuries and medial meniscal tears but with a decreased incidence of lateral meniscal tears.

Revision ACL Reconstruction in Adolescent Patients

Background:

High failure rates have been documented after anterior cruciate ligament reconstruction (ACLR) in pediatric patients, and revision surgery is indicated due to high activity levels of children and adolescents.

Purpose:

To define trends in revision ACLR in patients who underwent initial ACLR at younger than 18 years.

Study Design:

Case series; Level of evidence, 4.

Methods:

An electronic medical record was used to retrospectively identify revision ACLR procedures performed by 2 surgeons between the years 2010 and 2016 in patients younger than 18 years at initial reconstruction. Descriptive information, intraoperative findings, surgical techniques, and rehabilitation data were recorded from initial and revision surgeries. Descriptive statistics were used.

Results:

A total of 32 patients (17 girls, 15 boys) met the inclusion criteria, with a mean age of 15.8 years at initial reconstruction. For initial reconstructions, 15 patients underwent transphyseal procedures, 3 patients underwent adult-type procedures using an anatomic reconstruction technique that did not take into account the physis, and 2 patients underwent partial intraepiphyseal procedures. Graft types included hamstring autograft (n = 17), allograft (n = 5), hybrid (n = 4), and bone–patellar tendon–bone autograft (BTB; n = 3). Average primary reconstruction graft diameter was 8.0 mm (girls, 7.72 mm; boys, 8.36 mm; P = .045). After initial reconstruction, 10 patients had postoperative protocol noncompliance, and 8 patients reported delayed recovery. Mean time to retear was 565 days (range, 25-1539 days). At revision, BTB autograft was used in 50% (n = 16), followed by hamstring autograph (31.3%; n = 10) and allograft (12.5%; n = 4); mean graft diameter was 9.05 mm. Chondral surgery was more common during revision (25% for revision vs 0% for index; P = .031). There were 4 patients who required staged reconstruction with bone grafting. At mean final follow-up of 29.5 months (SD, 22.2 months), there were 3 graft failures (9.4%) and 5 contralateral ACL ruptures (15.6%).

Conclusion:

Most patients with ACL graft failure were adequately treated with a single revision. Conversion from a soft tissue graft to a BTB autograft was the most common procedure. Infrequently, patients required staged reconstructions. Providers should have a high index of suspicion for associated intra-articular injuries resulting from graft failure in adolescent patients.

ACL injuries before 15 years of age: could the young become an athlete?

PURPOSE

The purpose of this study was to systematically assess the possibility for a patient younger than 15 to return to a competitive level of sport following an ACL injury.

METHODS

Four databases were analyzed (PubMed, MedLine, Cinahl, Cochrane Library and LISTA). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to guide the screening of the literature. Studies about functional and surgical treatments were included with a minimum of 5 years of mean follow-up. Methodological quality of individual studies was assessed with the Methodological Index for Non-Randomized Studies scale.

RESULTS

Ten studies were included, corresponding to a total of 217 patients. All studies were retrospective with level 4 evidence. Seven studies reported results of a transphyseal technique reconstruction, two studies a physeal-sparing reconstruction, and one studied the results of a repair (« healing response »). Only one study compared functional treatment and surgery. The mean age of patients at the time of surgery was 12.29 years (range 2-16) with a mean follow-up of 7.9 years (range 5.5-18.3). Return to sport was possible for 80 to 100% of patients (average of 91.7%) at the final follow-up but the level for return to sport was reported in only four studies and found between 61 and 89% for return to the same level and at 42% for return to a competitive level. Evolution of the Tegner score was analyzed in five studies and was reported to decrease at the follow-up in three studies. ACL re-ruptures can be considered as failure of the graft (nine studies with surgical technique) and occurred with an average of 16%.

CONCLUSION

This review demonstrate that ACL reconstruction is superior to conservative treatment and 'healing response' in terms of revision rates and knee laxity. Return to sport is possible for more than 4/5 of patients but only two thirds of them were able to return to the same level or to competitive level, and failure rates of the graft were not superior to global population. However, qualities of included studies and variability of treatment limited the clinical application of results. Despite this, patients and parents should be informed that ACL injuries are lesions that may influence the level of sport at a 5-year follow-up.

LEVEL OF EVIDENCE

Level IV, systematic review.

Transphyseal anterior cruciate ligament reconstruction using living parental donor hamstring graft: excellent clinical results at 2 years in a cohort of 100 patients

PURPOSE

To determine outcomes of transphyseal ACL reconstruction using a living parental hamstring tendon allograft in a consecutive series of 100 children.

METHODS

One hundred consecutive juveniles undergoing ACL reconstruction with a living parental hamstring allograft were recruited prospectively and reviewed 2 years after ACL reconstruction with IKDC Knee Ligament Evaluation, and KT1000 instrumented laxity testing. Skeletally immature participants obtained annual radiographs until skeletal maturity, and long leg alignment radiographs at 2 years. Radiographic Posterior tibial slope was recorded.

RESULTS

Of 100 juveniles, the median age was 14 years (range 8-16) and 68% male. At surgery, 30 juveniles were graded Tanner 1 or 2, 21 were Tanner 3 and 49 were Tanner 4 or 5. There were no cases of iatrogenic physeal injury or leg length discrepancy on long leg radiographs at 2 years, despite a median increase in height of 8 cm. Twelve patients had an ACL graft rupture and 9 had a contralateral ACL injury. Of those without further ACL injury, 82% returned to competitive sports, IKDC ligament evaluation was normal in 52% and nearly normal in 48%. The median side to side difference on manual maximum testing with the KT1000 was 2 mm (range - 1 to 5). A radiographic PTS of 12° or more was observed in 49%.

CONCLUSIONS

ACL reconstruction in the juvenile with living parental hamstring tendon allograft is a viable procedure associated with excellent clinical stability, patient-reported outcomes and return to sport over 2 years. Further ACL injury to the reconstructed and the contralateral knee remains a significant risk, with identical prevalence observed between the reconstructed and contralateral ACL between 12 and 24 months after surgery.

LEVEL OF EVIDENCE

III (Cohort Study).

One in 5 Athletes Sustain Reinjury Upon Return to High-Risk Sports After ACL Reconstruction: A Systematic Review in 1239 Athletes Younger Than 20 Years

CONTEXT

Anterior cruciate ligament (ACL) reconstruction (ACLR) is frequently performed in patients younger than 20 years whose goal is to return to sport (RTS). Varying reinjury rates have been reported, and the factors responsible are unclear. Studies differ with regard to age, graft type, surgical techniques, postoperative rehabilitation, RTS guidelines, and methods used to determine ACL failures.

OBJECTIVE

To determine RTS rates; the effect of participation in high-risk sports, sex, and graft type on ACL reinjury rates; and whether objective test criteria before RTS correlate with lower reinjury rates.

DATA SOURCES

A systematic review of the literature from inception to May 31, 2019, was conducted using the PubMed and Cochrane databases.

STUDY SELECTION

Studies on transphyseal ACLR in athletes <20 years old with a minimum mean follow-up of 2 years that reported reinjury rates, the number that RTS, and detailed the type of sport were included.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

A total of 1239 patients in 8 studies were included; 87% returned to sport and 80% resumed high-risk activities. Of the patients, 18% reinjured the ACL graft and/or the contralateral ACL. Nine percent of patellar tendon autografts and 15% of hamstring autografts failed (odds ratio [OR], 0.52; P = 0.002). Of reinjuries, 90% occurred during high-risk sports. Male patients had a significantly higher rate of ACL graft failure than female patients (OR, 1.64; P = 0.01). There was no sex-based effect on contralateral ACL injuries. Only 1 study cited objective criteria for RTS.

CONCLUSION

A high percentage of athletes returned to sport, but 1 in 5 suffered reinjuries to either knee. Male patients were more likely to reinjure the ACL graft. Objective criteria for RTS were rarely mentioned or not detailed. The need for testing of knee stability, strength, neuromuscular control, agility, and psychological measures before RTS remains paramount in young athletes.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury - Secondary publication

BACKGROUND

This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS).

METHODS

The JOA ACL guideline committee revised the previous guideline based on "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of "the balance of benefit and harm" was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

RESULTS

We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature.

CONCLUSIONS

This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.

Meniscal Repair in Pediatric Populations: A Systematic Review of Outcomes

Background:

Loss of meniscal tissue in the pediatric population can have long-term consequences on joint health, highlighting the importance of meniscal preservation in this group.

Purpose:

To systematically review reported knee outcome measures and complication rates after repair of meniscal tears in children and adolescents.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A review of the literature regarding the existing evidence for pediatric meniscal tear outcomes was performed through use of the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-present), and MEDLINE (1980-present). Included were articles in English that reported the outcomes of meniscal tears in the pediatric population (<18 years old) with a follow-up of more than 12 months. Clinical outcome scores were reviewed.

Results:

A total of 1003 total studies were initially retrieved, with 8 meeting the inclusion criteria. The review included 287 patients (165 male, 122 female), mean age 15.1 years (range, 4-18 years), with 301 meniscal tears (reported: 134 medial, 127 lateral, and 32 both medial and lateral, 8 location unspecified). Concomitant anterior cruciate ligament reconstruction was performed in 52% (158/301) of meniscal repairs. The average reported postoperative Lysholm scores ranged from 85.4 to 96.3, and the average reported postoperative Tegner activity scores ranged from 6.2 to 8.

Conclusion:

Arthroscopic repair of a meniscal tear in the pediatric and adolescent population is an effective treatment option that has a low failure rate, enhances postoperative clinical outcomes, and preserves meniscal tissues.

Allograft or autograft in skeletally immature anterior cruciate ligament reconstruction: a prospective evaluation using both partial and complete transphyseal techniques

OBJECTIVE

We compared autografts and allograft using partial and complete transphyseal anterior cruciate ligament (ACL) reconstruction techniques among skeletally immature individuals.

METHODS

Male and females younger than 18 and 16 years old, respectively, diagnosed with ACL tear from April 2006 to March 2012 entered the study. One group had four-strand hamstring autograft, and the other had tibialis posterior allograft reconstruction. Those who had allografts either had hyper-laxity or recurvatum.

RESULTS

Achieved mean (± SD) 2000 International Knee Documentation Committee subjective score was not statistically different (P = 0.385) between allograft (n = 13) (84.3 ± 3.2) and autograft groups (n = 18) (85.6 ± 4.4). Mean Knee injury and Osteoarthritis Outcome Score (KOOS) subscale Knee-Related Quality of Life at 2 years was 78.0 ± 7.2 and 75 ± 7.4 for allograft and autograft groups, respectively (p = 0.261). Mean 2-year KOOS subscale Sports and Recreation was 82.1 ± 5.8 and 84.8 ± 6.6 for allograft and autograft groups, respectively (p = 0.244). No patient reported instability, giving way, or locking of the knee. Pivot shift test was negative in all patients; however, a minor positive Lachman test was found in six cases (46%) within the allograft group and seven cases (39%) in the autograft group. One postoperative septic arthritis was documented in the autograft group.

CONCLUSION

Considering existing concern that joint laxity and recurvatum are among the precursors of non-contact ACL injury in adolescents, bone-patellar-bone autografts are not applicable in this age group because of the open physis; furthermore, considering that hamstring autografts are insufficient (size thickness and stretchability), we recommend soft tissue allografts for ACL reconstruction in skeletally immature patients.

Delayed ACL Reconstruction in Patients ≥40 Years of Age Is Associated With Increased Risk of Medial Meniscal Injury at 1 Year

BACKGROUND

Anterior cruciate ligament (ACL) tears in the pediatric and young adult ACL-deficient knee are often associated with meniscal or chondral injury with delayed time to surgery. The incidence of ACL reconstruction performed in patients aged ≥40 years is rising, and it is unclear if delayed surgery in this cohort similarly affects the health of the meniscus and cartilage.

PURPOSE

To evaluate whether delayed reconstruction in a cohort of patients aged ≥40 years is associated with an increased risk of meniscal or chondral injury.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Records of patients aged ≥40 years who underwent primary arthroscopic ACL reconstruction between 2012 and 2016 at an academic hospital were retrospectively reviewed. Patient characteristic data and time to surgery were recorded. Operative reports were analyzed for meniscal and chondral injuries as well as treatment. Patients were grouped according to time to surgery, defined as early (<90 days) or delayed (≥90 days). Logistic regression modeling was used to form associations between elapsed time to surgery and patient characteristics to meniscal and chondral damage. Additionally, risks for meniscal and chondral injury were analyzed at time points of 180 days and 1 year from injury to surgery.

RESULTS

A total of 227 patients met the study criteria: 106 patients underwent early surgery, and 121 underwent delayed surgery. The authors identified 127 medial meniscal tears and 106 lateral meniscal tears. Medial, lateral, and patellofemoral compartment chondral injury was reported in 127, 82, and 130 patients, respectively. Delayed surgery (≥90 days) was not associated with increased risk of medial or lateral meniscal tears or any chondral injury at 90 days. Each year of increased age was associated with an increased odds ratio: 1.09 ( P = .001) for medial meniscal tears, 1.06 ( P = .014) for lateral meniscal tears, 1.10 ( P = .001) for medial compartment chondral injuries, and 1.07 ( P = .007) for patellofemoral compartment chondral injuries. Additionally, each unit of increased body mass index was associated with an increased odds ratio: 1.09 ( P = .039) for medial meniscal tears and 1.14 ( P = .003) for medial compartment cartilage injury. Analysis of 180-day and 1-year time points revealed an increased risk (odds ratio, 3.47; 95% CI, 1.55-7.77; P = .002) for medial meniscal injury when surgery was delayed for >1 year.

CONCLUSION

Delayed ACL reconstruction (≥90 days) among patients aged ≥40 years was not associated with an increased risk of meniscal or chondral injury. Increasing age and body mass index were associated with higher risks of meniscal and chondral injuries in this cohort. Delay in surgery for >1 year was associated with increased risk of medial meniscal tear.

Delayed reconstruction and high BMI z score increase the risk of meniscal tear in paediatric and adolescent anterior cruciate ligament injury

PURPOSE

The purpose of this study was to identify epidemiologic risk factors for secondary meniscal tears in paediatric and adolescent patients who sustain an anterior cruciate ligament (ACL) tear. The hypothesis was that delayed reconstruction and elevated BMI z score, increase the risk for secondary meniscal tears.

METHODS

A prospective, descriptive and analytical study of consecutively accrued children and adolescents with an ACL tear was performed. One hundred and sixty subjects (114 males and 46 females) were identified between 2006 and 2015 at one institution. The age range was between 7 and 19 years. Fifteen parameters were recorded and analysed: age at initial trauma, initial trauma circumstance, sex, BMI z score, affected side, type of sport, Tegner score, athletic level, time to MRI, time to first referral, time to surgery, age at surgery, attempted non-operative treatment, operative report and associated meniscal tear. These meniscal lesions could be diagnosed by an MRI and / or during surgery.

RESULTS

Out of the 160 cases, 143 were treated surgically and 17 cases non-operatively. Median corrected BMI z score was 0.5 (range - 1.8 to 4.7). 41.9% had one or more meniscal lesions. 55 patients were initially treated non-operatively, of which 39 patients were secondarily operated. There was a positive relationship between meniscal lesion and: BMI z score (p = 0.0364), attempted non-operative treatment (p = 0.001) and time to surgery (p = 0.002). The median time to ACL reconstruction was 229 days for patients with secondary meniscal lesions.

CONCLUSIONS

Patients with ACL tears treated non-operatively developed secondary meniscal lesions requiring delayed surgical management. There was a positive correlation between BMI z score and secondary meniscal lesions. Thus, early ACL reconstruction is advocated in young athletes.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

The Effects of Delays in Diagnosis and Surgical Reconstruction of ACL Tears in Skeletally Immature Individuals on Subsequent Meniscal and Chondral Injury

BACKGROUND

Although studies have shown increased rates of chondral injury with delayed surgical treatment of pediatric anterior cruciate ligament (ACL) injuries, it is unknown if this is related to a delay in diagnosis and appropriate activity restrictions. The purpose of this study was to determine if the time from injury to diagnosis, time from diagnosis to reconstruction, and preoperative activity level correlate with the degree of cartilage injury seen intraoperatively.

METHODS

A retrospective review of skeletally immature patients who underwent ACL reconstruction was performed. Patients were stratified based on the time from injury to diagnosis (≤6 vs. >6 wk), diagnosis to surgery (≤6 vs. >6 wk), and injury to surgery (≤12 vs. >12 wk). Weight-bearing status, brace usage, athletic participation, and meniscus tears were characterized as binary variables. Articular cartilage injury was graded on a scale of 0 to 3. Differences between groups were analyzed using the χ test.

RESULTS

In total, 91 subjects with mean age of 13 years (range, 9 to 16 y) were included. In total, 71% were diagnosed within 6 weeks of injury and 40% underwent surgery within 6 weeks of diagnosis. No differences were found in the presence of medial or lateral meniscus tears or the grade of articular cartilage damage when groups were analyzed by time from injury to diagnosis, diagnosis to surgery, and injury to surgery (P>0.05 in all cases). When stratified by weight-bearing status, brace status, and athletic activity, there were no significant differences between groups for meniscal tears or cartilage injury in any compartment (P>0.05).

CONCLUSIONS

Diagnosis of ACL rupture within 6 weeks of injury and surgical reconstruction within 6 weeks of diagnosis or 12 weeks of injury do not appear to affect the rate of cartilage injury in skeletally immature patients. Weight-bearing status, brace use, and participation in athletic activities between the time of injury and diagnosis also did not impact the rate of intra-articular injury following ACL tear.

LEVEL OF EVIDENCE

Level IV.

Earlier anterior cruciate ligament reconstruction is associated with a decreased risk of medial meniscal and articular cartilage damage in children and adolescents: a systematic review and meta-analysis

PURPOSE

To evaluate the association between surgical timing and the incidence of secondary meniscal or chondral damage in children and adolescents with anterior cruciate ligament (ACL) ruptures.

METHODS

Three electronic databases, PubMed, MEDLINE, and EMBASE, were systematically searched from database inception until October 16, 2017 by two reviewers independently and in duplicate. The inclusion criteria were English language studies that reported the incidence of meniscal and articular cartilage damage in children or adolescent athletes with ACL injuries as well as the timing of their ACL reconstruction (ACLR). Risk ratios were combined in a meta-analysis using a random effects model.

RESULTS

A total of nine studies including 1353 children and adolescents met the inclusion criteria. The mean age of patients included was 14.2 years (range 6-19), and 45% were female. There was a significantly decreased risk of concomitant medial meniscal injury in those reconstructed early (26%) compared to those with delayed reconstruction (47%) [pooled risk ratio (RR) = 0.49, 95% CI 0.36-0.65, p < 0.00001]. There was also a significantly reduced risk of medial femoral chondral (RR = 0.48, 95% CI 0.31-0.75, p = 0.001), lateral femoral chondral (RR = 0.38, 95% CI 0.20-0.75, p = 0.005), tibial chondral (RR = 0.45, 95% CI 0.27-0.75, p = 0.002), and patellofemoral chondral (RR = 0.41, 95% CI 0.20-0.82, p = 0.01) damage in the early reconstruction group in comparison to the delayed group.

CONCLUSION

Pooled results from observational studies suggest that early ACLR results in a significantly decreased risk of secondary medial meniscal injury, as well as secondary medial, lateral, and patellofemoral compartment chondral damage in children and adolescents. This study provides clinicians with valuable information regarding the benefits of early ACL reconstruction in children and adolescents, and can be used in the decision making for athletes in this population.

LEVEL OF EVIDENCE

IV.

Incidence and patterns of meniscal tears accompanying the anterior cruciate ligament injury: possible local and generalized risk factors

AIM OF THE WORK

Injury to the anterior cruciate ligament (ACL) is frequently accompanied by tears of the menisci. Some of these tears occur at the time of injury, but others develop over time in the ACL-deficient knee. The aim of this study was to evaluate the effects of the patient characteristics, time from injury (TFI), and posterior tibial slope (PTS) on meniscal tear patterns. Our hypothesis was that meniscal tears would occur more frequently in ACL-deficient knees with increasing age, weight, TFI, PTS, and in male patients.

METHODS

Of the ACL-injured patients, 362 were analyzed, and details of meniscal lesions were collected. The medial and lateral tibial slopes (MTS, LTS) were measured via computed tomography. Patient demographics, TFI, MTS, and LTS were correlated with the diagnosed meniscal tears.

RESULTS

Of the patients, 113 had a medial meniscus (MM) tear, 54 patients had a lateral meniscus (LM) tear, 34 patients had tears of both menisci, and 161 patients had no meniscal tear. The most common tear location was the posterior horn (PH) of the MM, followed by tear involving the whole MM. Patient age, BMI, and TFI were significantly associated with the incidence of MM tear. Female patients had a higher incidence of injury than males in all tear sites except in the body and PH. Male patients had more vertical and peripheral tears. The median MTS and LTS for patients with MM tears were 7.0°and 8.7°, respectively, while those of patients with LM tears were 6.9° and 8.1°. Steeper LTS was significantly associated with tears of LM and of both menisci.

CONCLUSION

Older age, male sex, increased BMI, and prolonged TFI were significant factors for the development of MM tears. An increase in the tibial slope, especially of the lateral plateau, seems to increase the risk of tear of the LM and of both menisci.

LEVEL OF EVIDENCE

Level III.

Operative Treatment of Isolated Meniscus Injuries in Adolescent Patients: A Meta-Analysis and Review

Context:

With the rise in sports participation and increased athleticism in the adolescent population, there is an ever-growing need to better understand adolescent meniscus pathology and treatment.

Objective:

To better understand the operative management of meniscus tears in the adolescent population.

Data Sources:

A systematic review of PubMed (MEDLINE) and Google Scholar was performed for all archived years.

Study Selection:

Studies that reported on isolated meniscus tears in adolescent patients (age, 10-19 years) were included.

Study Design:

Systematic review and meta-analysis.

Level of Evidence:

Level 4.

Data Extraction:

Two authors reviewed and extracted data from studies that fulfilled all inclusion criteria.

Results:

Nine studies on isolated meniscus tears in adolescent patients were found, with level of evidence ranging from 3 to 4. These studies evaluated a total of 373 patients (248 males, 125 females) and 390 knees. Seven studies were published between 1979 and 2000, all of which discuss meniscectomy as the primary treatment. Two studies were published after 2000 and report on meniscus repair surgery. The mean patient age was 14.4 years. A total of 308 meniscectomies and 64 meniscus repairs were performed. Follow-up ranged from 1.8 to 30 years (mean, 10.8 years). A 37% retear rate was reported for patients undergoing meniscus repair. Different outcome measures were used for meniscectomy versus meniscus repair. Three studies evaluating meniscectomy reported Tapper-Hoover scores, showing 54 patients with an excellent result, 58 with good, 57 with fair, and 23 with poor results.

Conclusion:

A shift in the management of isolated adolescent meniscal tears is reflected in the literature, with a recent increase in operative repair. This is likely secondary to poor outcomes after meniscectomy reflected in long-term follow-up studies. The current literature highlights the need for improved description of tear patterns, standardized reporting of outcome measures, and improved study methodologies to help guide orthopaedic surgeons on operative treatment of meniscal tears in adolescent patients.

2018 International Olympic Committee Consensus Statement on Prevention, Diagnosis, and Management of Pediatric Anterior Cruciate Ligament Injuries

In October 2017, the International Olympic Committee hosted an international expert group of physical therapists and orthopaedic surgeons who specialize in treating and researching pediatric anterior cruciate ligament (ACL) injuries. The purpose of this meeting was to provide a comprehensive, evidence-informed summary to support the clinician and help children with ACL injury and their parents/guardians make the best possible decisions. Representatives from the following societies attended: American Orthopaedic Society for Sports Medicine; European Paediatric Orthopaedic Society; European Society for Sports Traumatology, Knee Surgery, and Arthroscopy; International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine; Pediatric Orthopaedic Society of North America; and Sociedad Latinoamericana de Artroscopia, Rodilla, y Deporte. Physical therapists and orthopaedic surgeons with clinical and research experience in the field and an ethics expert with substantial experience in the area of sports injuries also participated. This consensus statement addresses 6 fundamental clinical questions regarding the prevention, diagnosis, and management of pediatric ACL injuries. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision making with children and the potential long-term ramifications of the injury.

What's New in Pediatric and Adolescent Anterior Cruciate Ligament Injuries?

BACKGROUND

Anterior cruciate ligament (ACL) tears in children and adolescent patients are being diagnosed and treated at an ever-increasing rates. We performed a review of recent literature regarding care of children and adolescent athletes with an ACL injury.

METHODS

PubMed database was searched for all papers related to treatment of children and adolescents with ACL injuries from October 1, 2012 to September 30, 2015, yielding 114 publications.

RESULTS

A total of 59 papers were found to have contributed important new findings. Papers were selected based on new findings in the following categories: epidemiology, anatomy, risk factors, sex disparity, prevention, surgical outcomes, timing and associated pathologies, and rehabilitation and return to sport.

CONCLUSIONS

Pediatric ACL injuries continue to rise and there are multiple surgical procedures that restore clinical function with good outcomes. Early surgical treatment is favored to prevent concomitant articular injuries. Early return to play can increase risk of reinjury and should be met with caution in this age group. Prevention strategies should be further studied and implemented in hopes of decreasing the incidence of this injury and the long-term potential damage.

LEVEL OF EVIDENCE

Level 4-titerature review.

2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries

In October 2017, the International Olympic Committee hosted an international expert group of physiotherapists and orthopaedic surgeons who specialise in treating and researching paediatric ACL injuries. Representatives from the American Orthopaedic Society for Sports Medicine, European Paediatric Orthopaedic Society, European Society for Sports Traumatology, Knee Surgery & Arthroscopy, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Pediatric Orthopaedic Society of North America and Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte attended. Physiotherapists and orthopaedic surgeons with clinical and research experience in the field, and an ethics expert with substantial experience in the area of sports injuries also participated. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision-making with children and the potential long-term ramifications of the injury. This consensus statement addresses six fundamental clinical questions regarding the prevention, diagnosis and management of paediatric ACL injuries. The aim of this consensus statement is to provide a comprehensive, evidence-informed summary to support the clinician, and help children with ACL injury and their parents/guardians make the best possible decisions.

Challenges in the Management of Anterior Cruciate Ligament Ruptures in Skeletally Immature Patients

Although initially considered rare, anterior cruciate ligament (ACL) ruptures in pediatric patients recently have increased substantially as a result of greater awareness of the injury and increased participation in youth sports. Although pediatric patients with an ACL injury and a clinically stable joint may handle the injury well and return to sports activity without requiring surgical reconstruction, young, active patients with an ACL rupture and an unstable joint may be good candidates for ACL reconstruction to prevent ongoing instability and additional joint damage. ACL reconstruction techniques have been developed to prevent physeal injury in skeletally immature patients. The surgical treatment of skeletally immature patients with an ACL rupture may differ from that of adults with an ACL rupture and presents unique challenges with regard to reconstruction technique selection, graft preparation, rehabilitation, and return to sports activity. Orthopaedic surgeons should understand various physeal-sparing ACL reconstruction techniques and the general challenges associated with the surgical management of ACL ruptures in pediatric patients.

2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries

In October 2017, the International Olympic Committee hosted an international expert group of physiotherapists and orthopaedic surgeons who specialise in treating and researching paediatric anterior cruciate ligament (ACL) injuries. Representatives from the American Orthopaedic Society for Sports Medicine, European Paediatric Orthopaedic Society, European Society for Sports Traumatology, Knee Surgery and Arthroscopy, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Pediatric Orthopaedic Society of North America, and Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte attended. Physiotherapists and orthopaedic surgeons with clinical and research experience in the field, and an ethics expert with substantial experience in the area of sports injuries also participated. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision-making with children and the potential long-term ramifications of the injury. This consensus statement addresses six fundamental clinical questions regarding the prevention, diagnosis, and management of paediatric ACL injuries. The aim of this consensus statement is to provide a comprehensive, evidence-informed summary to support the clinician, and help children with ACL injury and their parents/guardians make the best possible decisions.

Revision pediatric anterior cruciate ligament reconstruction after failure of iliotibial band technique treated with all-epiphyseal technique in a prepubescent with Ehlers-Danlos syndrome: a case report

The increasing number of pediatric anterior cruciate ligament (ACL) injuries and the failure of nonoperative management of these patients has elicited a concordant response in the surgical community to devise reconstruction techniques that stabilize the knee joint without causing iatrogenic growth disturbances. Likewise, the rise in pediatric ACL reconstructions forecasts a consequent rise in revision ACL reconstructions in patients with open physes. In this case report, we describe a prepubescent with Ehlers-Danlos syndrome and congenital ACL deficiency, who underwent physeal-sparing iliotibial band ACL reconstruction and revision to an all-epiphyseal ACL reconstruction with allograft. We also underscore the lack of evidence addressing graft choice and outcomes for ACL reconstructions in patients with connective tissue disorders.

Effect of limb dominance and sex on neuromuscular activation patterns in athletes under 12 performing unanticipated side-cuts

Non-contact ACL injuries are one of the most common injuries to the knee joint among adolescent/collegiate athletes, with sex and limb dominance being identified as risk factors. In children under 12years of age (U12), these injuries occur less often and there is no sex-bias present. This study set out to explore if sex and/or limb dominance differences exist in neuromuscular activations in U12 athletes. Thirty-four U12 males and females had six bilateral muscles analyzed during unanticipated side-cuts. Principal component analysis was performed, capturing differences in overall magnitudes and timing of peak magnitudes. Two-way mixed-model ANOVAs determined significant limb effects with both sexes displaying (i) greater magnitudes in the lateral gastrocnemius and both hamstrings in the dominant limb and (ii) earlier timing of peak magnitudes in both gastrocnemii, both hamstrings and vastus medialis in the non-dominant limb, while no sex differences were identified. This study demonstrated that limb dominance, not sex, affects neuromuscular activation strategies in U12 athletes during unanticipated side-cuts. When developing injury prevention programs for younger athletes, an increased focus on balancing neuromuscular activations in both limbs could be beneficial in reducing the likelihood of ACL injuries in these athletes as they mature through puberty.

A 10-year Retrospective Review of Functional Outcomes of Adolescent Anterior Cruciate Ligament Reconstruction

BACKGROUND

Rupture of the anterior cruciate ligament (ACL) is an increasingly prevalent sporting injury in adolescents. Surgical reconstruction of the ACL in adolescents has been controversial and there has been little reported on functional outcomes after surgery.The aim of this study was to undertake a retrospective notes review and questionnaire survey of a group of adolescents who had their ACL surgically reconstructed over the previous 10 years, assessing delay to surgery, levels of meniscal damage, reoperation rates, and functional outcomes.

METHODS

A retrospective chart review was performed on 100 adolescent patients who underwent arthroscopic ACL reconstruction using a transphyseal technique. These patients were also contacted and completed the Knee Osteoarthritis Outcome Score (KOOS).

RESULTS

One hundred patients had their records reviewed. The average age at follow-up was 20.5 (SD, 2.4) years. There were 49 females and 51 males. Meniscal tears were present in 76% of patients at the time of surgery. The rate of medial meniscal tears increased with delay to surgical intervention beyond 3 months. Reoperation rate for these patients was 24%.Eighty patients completed the KOOS questionnaire. Patients were a mean of 4 (SD, 2.2) years postsurgery. The main findings indicate that in the 5 key KOOS domains patients scored a mean of 60 (SD, 13) for symptoms, 65 (SD, 10) for pain, 70 (SD, 6.4) for activities of daily living, 54 (SD, 17.6) for sport and recreation, and 47.2 (SD, 20.1) for quality of life.

CONCLUSIONS

This study demonstrates that young people with ACL injuries have a very high associated incidence of meniscal pathology at the time of surgery. There is a high reoperation rate for meniscal surgery and graft failure. Four years post-ACL reconstruction many have not yet returned to a fully functional state.Further research to understand why functional outcomes are modest is required.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

Impact of surgical timing on the outcome of anterior cruciate ligament reconstruction

PURPOSE

The purpose of the present study is the comparison of acute ACL reconstruction with or without meniscus repair within 48 h after injury and a delayed surgery during the inflammation-free interval. It was hypothesized that acute ACL reconstruction results in inferior patient reported outcomes and higher frequency of range of motion deficits.

METHODS

The effect of acute (within 48 h) and delayed (during the inflammation-free interval) ACL surgery was prospectively studied on 160 consecutive patients with ACL injury between January 2010 and December 2011. Subgroup analyses were performed to evaluate patients with an additional meniscus repair separately from isolated ACL surgeries. During the study period, partial meniscectomies were recorded to evaluate time dependent meniscus reparability. Patient reported outcomes, objective IKDC and manual stability measurements were documented during the 24-month follow-up period. The Pearson Chi-squared test was used to evaluate objective outcome measures. The Mann-Whitney U test was performed to analyse the results of patient reported outcomes. Statistical significance was set at p < 0.05.

RESULTS

For patients who underwent isolated ACL reconstruction, no statistical significant difference was observed at any time point regarding objective and subjective outcome measures. Significantly fewer patients who underwent acute combined ACL reconstruction and meniscus repair had an extension deficit between 3° and 5° at 12 months following surgery (3.7 vs. 22.2 %, p < 0.05). No difference regarding cyclops removal, re-injury of ACL or meniscus was found between the two surgical timing groups. Further, surgical timing did not influence the reparability of the meniscus.

CONCLUSION

An acute ACL reconstruction within 48 h is preferable in highly active patients or competitive athletes.

LEVEL OF EVIDENCE

Prospective cohort study, Level II.

Anterior cruciate ligament reconstruction in skeletally immature patients

The management of pediatric patients with an anterior cruciate ligament (ACL) tear can be a challenging endeavor for physicians, athletic trainers, coaches, and parents alike. In particular, the significant longitudinal growth that arises from the physes about the knee creates a unique set of circumstances that must be considered in this patient population. The purpose of this review is to provide a summary of the most recent current literature for the management of skeletally immature patients with an ACL tear.

Meniscal tears associated with anterior cruciate ligament injury

PURPOSE

To investigate the frequency of meniscal tear and the location of tear associated with anterior cruciate ligament (ACL) injury.

SUBJECTS AND METHODS

We studied 549 patients (552 knees) who were diagnosed with ACL injury by arthroscopy at our center between January 2006 and March 2014 (8 years and 3 months). The subjects comprised 289 males and 263 females ranging in age from 13 to 66 (mean 26.1) years. The cause of injury was sports-related in 89.1 %, and the mean interval from injury to initial arthroscopy was 23 months. The patients were divided into two groups: arthroscopy performed within 8 weeks after injury (acute group; 256 knees) and more than 8 weeks after injury (chronic group; 296 knees). Frequency of meniscal tear and location of tear were compared between two groups.

RESULTS

The incidence of meniscal tear diagnosed by arthroscopic examination was 79.2 % (437 of 552 knees) in all subjects; 72.7 % (186 of 256 knees) in acute group and 84.8 % (251 of 296 knees) in chronic group, and was significantly higher in chronic group. Regarding the locations of meniscal tears, in acute group (186 knees), medial meniscal tear only was found in 20 knees (10.8 %), lateral meniscal tear only in 129 knees (69.4 %), and bilateral (including medial and lateral) meniscal tears in 37 knees (19.9 %). In chronic group (251 knees), medial meniscal tear only was found in 62 knees (24.7 %), lateral meniscal tear only in 85 knees (33.9 %), and bilateral meniscal tears in 104 knees (41.4 %). Lateral meniscal tear was commonly associated with acute ACL injury, while medial meniscal tear with chronic ACL injury. Bucket handle tear was observed in 25 knees (medial: 17 knees, lateral: 8 knees) in acute group, and 81 knees (medial: 69 knees, lateral: 12 knees) in chronic group, and was more common in the chronic group.

CONCLUSION

The incidence of meniscal tear associated with ACL injury is higher in chronic cases; the number of medial meniscal tears is particularly high, many of which require meniscectomy. Early ACL reconstruction is recommended also for the prevention of secondary meniscal tear.

Clinical outcome of simultaneous high tibial osteotomy and anterior cruciate ligament reconstruction for medial compartment osteoarthritis in young patients with anterior cruciate ligament-deficient knees: a systematic review

PURPOSE

High tibial osteotomy (HTO) has been a well-established procedure addressing tibiofemoral osteoarthritis in young patients. However, for physically active patients with concomitant anterior cruciate ligament (ACL) injury, simultaneous HTO and ACL reconstruction is considered a salvage procedure. Controversy exists regarding the subjective and objective evaluations and the prevalence of complications.

METHODS

A search in the Medline database and of major orthopaedic journals was performed. Articles were included if they met the specific inclusion and exclusion criteria. Anterior knee laxity, osteoarthritis, subjective outcomes, sagittal and coronal alignment, and complications were analyzed.

RESULTS

A total of 721 articles were retrieved from the search, and 11 eligible studies (218 knees) were included for evaluation. Postoperatively, the mean side-to-side difference measured by KT-1000 (MEDmetric, San Diego, CA) was 2.4 mm, and 85.7% of patients gained grade A or B stability according to International Knee Documentation Committee evaluation. Medial compartment osteoarthritis showed a tendency of alleviation. Regardless of the scoring system, all subjective evaluations showed improvement and most of the participants returned to recreational sports. All cases of varus malalignment were corrected, with a mean value of 7.13°. The most prevalent complication was deep venous thrombosis (7.7%).

CONCLUSIONS

Simultaneous HTO and ACL reconstruction was a salvage procedure for physically active young patients because it provided satisfactory restoration of anterior stability, alleviation of medial compartment osteoarthritis, improvement of subjective evaluations, and a predictable return to recreational sports.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Correlation of meniscal and articular cartilage injuries in children and adolescents with timing of anterior cruciate ligament reconstruction

BACKGROUND

In pediatric patients, anterior cruciate ligament (ACL) reconstruction is controversial; however, delaying surgery until skeletal maturity is complete may increase the risk of secondary meniscal and articular cartilage injury.

PURPOSE

To assess the risk of meniscal and chondral injuries with delay of ACL reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Records were reviewed in patients younger than 17 years (median age, 14 years) who had ACL reconstruction. Patients were consecutively enrolled and assigned to 1 of 3 surgical groups based on timing of surgery: acute (<6 weeks after surgery), subacute (6-12 weeks), or chronic (>3 months). The type and grade of meniscal injuries was documented according to the International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine (ISAKOS) meniscal classification criteria. International Cartilage Repair Society (ICRS) criteria were used to document location and grade of chondral injuries. Associations between patient characteristics and meniscal injury were tested using rank sum and chi-square tests. Regression analyses were conducted to model incidence and severity of lateral and medial meniscal tears. There were 130 patients who had 135 ACL reconstructions between the years of 2000 and 2012.

RESULTS

Sixty-two ACL injuries were treated acutely, 37 were subacute, and 36 were chronic. Meniscal injuries (n = 112) included 70 lateral and 42 medial tears. Time to surgery had bivariate association with lateral and medial meniscal tears (P = .016 and .007, respectively). Independent risk factors for incidence of lateral meniscal tears were younger age (P = .028) and return to sports activities before surgery (P = .007). Patients with 1 episode of instability had 3-fold higher odds of higher grade lateral meniscal tear (95% CI, 1.30-7.60). Compared with acute reconstruction, subacute and chronic reconstruction patients had 1.45 and 2.82 times higher odds, respectively, of lateral meniscal tear severity (P = .12). Independent risk factors for incidence of medial meniscal tears were female sex (P = .03), older age (P = .01), and any episode of instability (P = .01). Adjusted odds ratio for medial meniscal tear was 4.7 for an instability episode (vs no episode; P = .01). Adjusted odds ratio for increased severity of medial meniscal tears included any instability episode, 5.6 (P < .01); playing sports before reconstruction, 15.2 (P < .01); and time to surgery greater than 3 months, 4.3 (P = .046). Seventeen patients had 23 chondral injuries. The risk factors for chondral injury included increased time to surgery (P = .005) and any instability episode (P = .001). For increased grade of chondral injury, risk factors were time to surgery (P ≤ .001) and any instability episode (P = .003).

CONCLUSION

Delayed ACL reconstruction increased the risks of secondary meniscal and chondral injuries in this population of pediatric patients.