1
|
Bixby EC, Heyworth BE. Management of Anterior Cruciate Ligament Tears in Skeletally Immature Patients. Curr Rev Musculoskelet Med 2024; 17:258-272. [PMID: 38639870 PMCID: PMC11156825 DOI: 10.1007/s12178-024-09897-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2024] [Indexed: 04/20/2024]
Abstract
PURPOSE OF REVIEW Anterior cruciate ligament (ALC) tears are increasingly common in skeletally immature patients, as more children and adolescents participate in intensive sports training and specialization at increasingly younger ages. These injuries were historically treated nonoperatively, given concerns for physeal damage and subsequent growth disturbances after traditional ACL reconstruction techniques. However, there is now sufficient data to suggest superior outcomes with operative treatment, specifically with physeal-sparing and physeal-respecting techniques. This article reviews considerations of skeletal maturity in patients with ACL tears, then discusses surgical techniques, with a focus on their unique indications and outcomes. Additional surgical adjuncts and components of postoperative rehabilitation, which may reduce retear rates, are also considered. RECENT FINDINGS Current research shows favorable patient-reported outcomes and high return-to-sport rates after ACL reconstruction in skeletally immature patients. Graft rupture (ACL retear) rates are low, but notably higher than in most adult populations. Historically, there has been insufficient research to comprehensively compare reconstruction techniques used in this patient population. However, thoughtful systematic reviews and multicenter prospective studies are emerging to address this deficit. Also, more recent data suggests the addition of lateral extra-articular procedures and stringent return-to-sports testing may lower retear rates. Physeal-sparing and physeal-respecting ACL reconstructions result in stabilization of the knee, while respecting the growth remaining in children or skeletally immature adolescents. Future research will be essential to compare these techniques, given that more than one may be appropriate for patients of a specific age and skeletal maturity.
Collapse
Affiliation(s)
- Elise C Bixby
- Department of Sports Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Benton E Heyworth
- Department of Sports Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
| |
Collapse
|
2
|
Glover MA, St Jeor JD, Parikh N, Rider DE, Bullock GS, Trasolini NA, Waterman BR. Previous Knee Surgery, Anteromedial Portal Drilling, Quadriceps Tendon Autograft, and Meniscal Involvement Associated With Delayed Return to Sport After Anterior Cruciate Ligament Reconstruction in Amateur Athletes. Arthrosc Sports Med Rehabil 2024; 6:100911. [PMID: 39006786 PMCID: PMC11240041 DOI: 10.1016/j.asmr.2024.100911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 02/07/2024] [Indexed: 07/16/2024] Open
Abstract
Purpose To identify prognostic factors associated with a delayed return-to-sport (RTS) time in amateur athletes who return to full participation after a primary isolated anterior cruciate ligament (ACL) reconstruction. Methods A retrospective review was performed among athletes who underwent ACL reconstruction between October 2014 and October 2021. Inclusion criteria were any amateur athletes with an ACL reconstruction who had a documented RTS and greater than 1-year follow-up. Nonathletes, those with multiligamentous knee injury, and those missing documented RTS timelines were excluded. RTS was defined as participation in athletics at a level equivalent to or greater than the preinjury level participation. Demographic and prognostic factors, including previous knee surgery, meniscal involvement, level of participation, surgical approach, and graft type, were recorded along with RTS time and analyzed via Poisson regression. Results In total, 91 athletes, average age 18.8 (± 6.7) years, who underwent ACL reconstruction at a single institution from 2014 to 2021 were identified with an average follow-up time of 4.6 (± 2.5) years (range 1.1, 9.0). Meniscal involvement (1.11; 95% confidence interval [CI] 1.08-1.15, P < .001) and previous knee surgery (1.43; 95% CI 1.29-1.58; P < .001) were related to a delayed RTS. Quadriceps tendon and bone-patellar tendon-bone autografts, as well as allograft, showed a significant association with a longer RTS time when compared with hamstring autograft (1.16, 95% CI 1.13-1.20, P < .001; 1.04, 95% CI 1.01-1.07, P = .020; 1.11, 95% CI 1.03-1.19, P = .004, respectively), as did anteromedial portal drilling, when compared with the outside in approach for femoral drilling (1.19, 95% CI 1.16-1.23, P < .001). Conclusions Previous knee surgery, anteromedial femoral drilling, quadriceps tendon autograft, and meniscus tear were most associated with a delayed timeline for RTS among young athletes who were able to return. Level of Evidence Level IV, prognostic case series.
Collapse
Affiliation(s)
- Mark A Glover
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Jeffery D St Jeor
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Nihir Parikh
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Danielle E Rider
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia, U.S.A
| | - Garrett S Bullock
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Nicholas A Trasolini
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Brian R Waterman
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A
| |
Collapse
|
3
|
Pediatric Revision Anterior Cruciate Ligament Reconstruction: Current Concepts Review. Clin J Sport Med 2022; 32:139-144. [PMID: 34173782 DOI: 10.1097/jsm.0000000000000953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/05/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE We present a review of revision anterior cruciate ligament (ACL) reconstruction in pediatric patients, discussing risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes. DATA SOURCES PubMed, Cochrane, and Embase databases were queried for relevant articles about revision ACL topics. All types of manuscripts, including clinical studies, basic science studies, case series, current concepts reviews, and systematic reviews were analyzed for relevant information. Current concepts on risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes were synthesized. MAIN RESULTS Surgical treatment should be individualized, and the graft type, fixation devices, tunnel placement, and complementary procedures (eg, extra-articular tenodesis) should be tailored to the patient's needs and previous surgeries. Rehabilitation programs should also be centered around eccentric strengthening, isometric quadriceps strengthening, active flexion range of motion of the knee, and an emphasis on closed chain exercises. Despite adherence to strict surgical and postoperative rehabilitation principles, graft refailure rate is high, and return to sports rate is low. CONCLUSION Rerupture of the ACL in the pediatric population is a challenging complication that requires special attention. Diagnostic evaluation of repeat ACL ruptures is similar to primary injuries. Although outcomes after revision ACL reconstruction are expectedly worse than after primary reconstruction, athletes do return to sport after proper rehabilitation. Further research is needed to continue to improve outcomes in this high-risk population, aimed at continued knee stability, graft survivorship, and improved quality of life.
Collapse
|
4
|
Knapik DM, Singh H, Gursoy S, Trasolini NA, Perry AK, Chahla J. Functional Bracing Following Anterior Cruciate Ligament Reconstruction: A Critical Analysis Review. JBJS Rev 2021; 9:01874474-202109000-00001. [PMID: 35417443 DOI: 10.2106/jbjs.rvw.21.00056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
» Anterior cruciate ligament (ACL) injuries remain common among athletes; these injuries require reconstruction to restore stability and enable successful return to sport. » The role of postoperative dynamic knee bracing following ACL reconstruction in protecting graft integrity and promoting return to sport remains largely unknown. » Limited biomechanical studies on functional bracing have reported decreased strain across the ACL with increasing anterior shear loading. » Investigations evaluating functional brace use in clinical studies have not yet demonstrated consistent improvement in clinical outcomes, reduced graft retear rates, or improved return-to-sport rates in sports other than skiing. » Additional investigation examining athletes of various ages participating in different sporting activities is necessary to better understand the role of functional bracing following ACL reconstruction.
Collapse
Affiliation(s)
| | - Harsh Singh
- Midwest Orthopaedics at Rush University, Chicago, Illinois
| | - Safa Gursoy
- Midwest Orthopaedics at Rush University, Chicago, Illinois
| | | | | | - Jorge Chahla
- Midwest Orthopaedics at Rush University, Chicago, Illinois
- Department of Orthopaedic Surgery, Rush University School of Medicine, Rush University Medical Center, Chicago, Illinois
| |
Collapse
|
5
|
Ithurburn MP, Paljieg A, Thomas S, Hewett TE, Paterno MV, Schmitt LC. Strength and Function Across Maturational Levels in Young Athletes at the Time of Return to Sport After ACL Reconstruction. Sports Health 2019; 11:324-331. [PMID: 31173697 DOI: 10.1177/1941738119849070] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The impact of maturation on lower extremity strength and function after anterior cruciate ligament reconstruction (ACLR) may help guide future studies of age-specific rehabilitation. HYPOTHESIS Pediatric ACLR patients would demonstrate higher thigh strength symmetry and knee-related function at return to sport (RTS) compared with adolescent and young adult participants who underwent traditional ACLR. STUDY DESIGN Prospective cohort study. LEVEL OF EVIDENCE Level 2. METHODS A total of 144 young athletes at the time of RTS clearance post-ACLR were classified into 3 maturational groups (pediatric, n = 16 with physeal-sparing ACLR [mean age = 12.3 years; range = 9.2-14.6 years]; adolescent, n = 113 [mean age = 16.5 years; range = 14.1-19.8 years]; young adult, n = 15 [mean age = 22.0 years; range = 20.5-24.9 years]). Quadriceps and hamstring strength were measured using an electromechanical dynamometer. Knee-related function was measured using the International Knee Documentation Committee (IKDC) subjective form and single-leg hop tests. The Limb symmetry Index (LSI) was used in calculations for hop and strength tests. Group differences were compared with Kruskal-Wallis tests and Mann-Whitney U post hoc tests. Proportions of participants meeting literature-recommended RTS criterion cutoffs were compared among the groups using chi-square tests. RESULTS The pediatric group demonstrated higher quadriceps LSI (P = 0.01), IKDC scores (P < 0.01), single-hop LSI (P < 0.01), and crossover-hop LSI (P = 0.02) compared with the young adult group. In addition, the pediatric group demonstrated higher IKDC scores (P < 0.01) and single-hop LSI (P = 0.02) compared with the adolescent group. The adolescent group demonstrated higher IKDC scores (P < 0.01), single-hop LSI (P = 0.02), and crossover-hop LSI (P = 0.03) compared with the young adult group. The proportions of participants meeting all RTS criterion cutoffs were highest in the pediatric group and lowest in the young adult group (P = 0.03). CONCLUSION Young athletes at RTS clearance after pediatric ACLR demonstrated higher quadriceps strength symmetry and knee-related function than adolescents and young adults after traditional ACLR. CLINICAL RELEVANCE These findings demonstrate the need for further study regarding the impact of these group differences on longitudinal outcomes after ACLR, including successful RTS and risk of second ACL injury.
Collapse
Affiliation(s)
- Matthew P Ithurburn
- Department of Physical Therapy and Center for Exercise Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Adam Paljieg
- Doctor of Physical Therapy Program, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio
| | - Staci Thomas
- Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Timothy E Hewett
- Biomechanics Laboratories and Sports Medicine, Departments of Orthopedic Surgery, Physical Medicine, and Physiology and Biomedical Engineering, Mayo Clinic, Rochester and Minneapolis, Minnesota
| | - Mark V Paterno
- Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Laura C Schmitt
- Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| |
Collapse
|
6
|
Tibial tunnel widening following anterior cruciate ligament reconstruction: A retrospective seven-year study evaluating the effects of initial graft tensioning and graft selection. Knee 2018; 25:1107-1114. [PMID: 30414786 PMCID: PMC6286238 DOI: 10.1016/j.knee.2018.08.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/09/2018] [Accepted: 08/11/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate tibial tunnel widening in ACL reconstruction patients over seven years to establish the effects of initial graft tension on tibial widening and clinical outcomes when using both patellar tendon (BTB) and hamstring tendon (HS) grafts. METHODS Ninety patients, who were reconstructed with BTB or HS autografts, were randomized using one of two initial graft tension protocols; 1) tensioned to restore normal anteroposterior laxity ("low-tension"; n = 46) and 2) tensioned to over-constrain anteroposterior (AP) laxity by two millimeters ("high-tension"; n = 44). Seventy patients had post-surgical data with 45 available for review at seven years. Tunnel widening was assessed via radiographs at one-, three-, and seven-year follow-up. Patient-reported outcomes were compared. RESULTS The mean ± 95% confidence intervals of the initial diameters for the BTB autografts were 10.3 ± 0.5 mm (Low-tension) and 10.2 ± 0.6 mm (High-tension) with final diameters of 10.8 ± 0.6 mm (Low-tension) and 9.9 ± 0.6 mm (High-tension). The initial diameters for HS autografts were 8.1 ± 0.9 mm (Low-tension) and 8.4 ± 0.7 mm (High-tension) with final diameters of 11.5 ± 1.1 mm (Low-tension) and 11.1 ± 0.9 mm (High-tension). For subjects with HS autografts, mean tunnel diameters significantly changed over time (p < .001); no significant changes were observed in BTB autografts (p = .29). Change in diameter of the HS autograft group remained significantly greater than the BTB group at all time points for both tension groups (p < .05). No differences in patient-reported outcomes were found between tension groups or graft types. CONCLUSIONS Patients who underwent ACL-R with HS autograft exhibited tibial tunnel widening over seven years. Patients with BTB autografts did not experience widening, regardless of initial graft tension. Patient-reported outcomes were equivalent.
Collapse
|
7
|
Perioperative Interdisciplinary Intervention Contributes to Improved Outcomes of Adolescents Treated With Hip Preservation Surgery. J Pediatr Orthop 2018; 38:254-259. [PMID: 27328119 DOI: 10.1097/bpo.0000000000000816] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Adolescent hip preservation surgery (HPS) candidates typically present with chronic pain, which can negatively affect psychological function and surgical outcomes. A previous study demonstrated high rates of psychological symptoms and maladaptive behaviors in this population. This study quantified psychological and functional improvements in these patients from preoperative presentation to postoperative follow-up. An integrated interdisciplinary approach is also described. METHODS A total of 67 patients undergoing HPS were evaluated preoperatively and postoperatively at 1 year by staff psychologists. Perioperative psychological intervention consisted of education, counseling, and administration of self-report measures. Self-report measure scores were compared preoperatively and postoperatively, grouped by orthopaedic diagnoses. Frequency analysis, correlational analysis, and analysis of variance were conducted. RESULTS Psychological function improved significantly at follow-up: decreased emotional symptomatology (46.1 to 43.6, P=0.013), anxiety (49.6 to 45.8, P<0.001), school problems (46.6 to 44.7, P=0.035), internalizing problems (46.3 to 44.1, P=0.015), social stress (44.5 to 42.3, P=0.024), sense of inadequacy (49.0 to 46.0, P=0.004), and increased self-concept (51.1 to 54.1, P=0.003). Resiliency factors also significantly improved: increased mastery (50.3 to 52.9, P=0.001) and resourcefulness (49.7 to 52.0, P=0.046), decreased emotional reactivity (46.3 to 42.9, P=0.001), and vulnerability (47.7 to 44.7, P=0.011). Physical function and return to activity also significantly improved (University of California-Los Angeles: 7.1 to 8.7, P=0.017; modified Harris Hip Score: 67.3 to 83.8, P<0.001). Return to activity positively correlated with optimism and self-efficacy (P=0.041). Femoroacetabular impingement and hip dysplasia patients consistently reported feeling less depressed (P=0.036), having fewer somatic complaints (P=0.023), fewer internalized problems (P=0.037), and exhibiting fewer atypical behaviors (P=0.036) at follow-up. Slipped capital femoral epiphysis patients did not demonstrate improvements in psychological functioning postoperatively. CONCLUSIONS Perioperative psychological education and counseling, in combination with HPS, improved postoperative psychological and physical function. Patients reported reduced anxiety, school problems, and social stress, with marked increase in resilience. Increased mobility and return to activity significantly correlated with improved optimism and self-efficacy. LEVEL OF EVIDENCE Level II-therapeutic studies-investigating the results of treatment.
Collapse
|
8
|
Yellin JL, Fabricant PD, Gornitzky A, Greenberg EM, Conrad S, Dyke JA, Ganley TJ. Rehabilitation Following Anterior Cruciate Ligament Tears in Children: A Systematic Review. JBJS Rev 2018; 4:01874474-201601000-00004. [PMID: 27490007 DOI: 10.2106/jbjs.rvw.o.00001] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) tears are increasingly prevalent in the pediatric population. ACL rehabilitation is an essential component of recovery following injury and reconstruction, yet there are few explicit descriptions of pediatric-specific ACL rehabilitation protocols in the literature, especially in the context of varying treatment interventions. Our aim was to systematically review the literature on rehabilitation following ACL tears in children in order to describe common principles among different treatment options and areas of future research. METHODS Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we performed a systematic review of the PubMed, EMBASE, and Cochrane databases (for the past five years) to identify detailed rehabilitation protocols described in the pediatric population following ACL rupture. When available, the following aspects of rehabilitation were extracted: "prehabilitation" (exercises prior to surgery), bracing, weight-bearing status, range of motion, strength, modalities (ice, heat, electrical stimulation, etc.), plyometrics/proprioceptive exercises, return-to-sport criteria, and suggested ACL injury-prevention programs. RESULTS Two hundred and two unique articles were identified. Twenty-seven articles meeting inclusion criteria with extractible rehabilitation data were included. A table, categorized by differing orthopaedic intervention, was designed to detail the components and duration of the different aspects of rehabilitation. While there are substantial differences across protocols, several trends emerged, particularly regarding weight-bearing, bracing, range of motion, and strength training. Interestingly, we found that many current protocols are based on time frame alone rather than on functional milestones; of the fourteen unique articles that addressed return-to-sport criteria by specific orthopaedic intervention, seven were based on temporal progression whereas seven also involved achievement of physical milestones. In addition, only three of the eight articles that mentioned a future ACL injury-prevention plan described a formal prevention program. CONCLUSION We systematically identified, and subsequently outlined and compared, the current trends of the various components of pediatric-specific ACL rehabilitation protocols, categorized by orthopaedic intervention. Several protocols are based on time frames rather than milestones achieved, with newer protocols involving milestone-based progression. Newer protocols are also incorporating formal prevention programs. Just as skeletally immature patients require unique methods of operative fixation, so too do they require catered rehabilitation protocols. To effectively prevent re-rupture or contralateral injury, future research should focus on prospectively evaluating each component of the rehabilitation protocols described and return-to-sport criteria for young patients.
Collapse
Affiliation(s)
- Joseph L Yellin
- The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Richard D. Wood Ambulatory Care Building, Second Floor, Philadelphia, PA 19104
| | | | | | | | | | | | | |
Collapse
|
9
|
McGowan J, Reid DA, Caldwell J. Post-operative rehabilitation of anterior cruciate ligament reconstruction in the skeletally immature child: a systematic review of the literature. PHYSICAL THERAPY REVIEWS 2017. [DOI: 10.1080/10833196.2017.1364541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - Duncan A. Reid
- School of Sport and Recreation, Auckland University of Technology , Auckland, New Zealand
| | - Jill Caldwell
- School of Physiotherapy, Auckland University of Technology , Auckland, New Zealand
| |
Collapse
|
10
|
Abstract
There are various treatments for musculoskeletal-related conditions, including the use of durable medical equipment (DME). Numerous DME devices are currently available. This article addresses several of the common DME devices used for treating upper and lower extremity orthopedic conditions.
Collapse
Affiliation(s)
- Bret C Jacobs
- Department of Family & Community Medicine, Penn State Milton S. Hershey Medical Center, 500 University Drive, Mail Code HP 06, Hershey, PA 17033, USA; Department of Orthopaedics & Rehabilitation, Penn State Milton S. Hershey Medical Center, 500 University Drive, Mail Code HP 06, Hershey, PA 17033, USA.
| | - Justin A Lee
- Department of Family Medicine, Brody School of Medicine, East Carolina University, 101 Heart Drive, Mail Stop 654, Greenville, NC 27834, USA
| |
Collapse
|