Pediatric Anterior Cruciate Ligament Reconstruction

Bone-patellar tendon-bone, hamstring, and quadriceps tendon autografts for anterior cruciate ligament reconstruction in skeletally immature patients: a systematic review

INTRODUCTION

Historically, anterior cruciate ligament (ACL) ruptures in the paediatric age group were managed conservatively with bracing, casting, activity modification, and physical therapy. However, most of these patients had to reduce their sports activities, and secondary damages to the affected knee were prevalent.

SOURCE OF DATA

Published scientific literature in Embase, Web of Science, PubMed, and Google Scholar databases.

AREAS OF AGREEMENT

ACL reconstruction in children with open physes patients is debated. Any damage to the physes around the knee could lead to growth abnormalities and axial deviation of the knee.

AREAS OF CONTROVERSY

Different grafts are available and suitable for ACL reconstruction in skeletally immature patients; however, which graft performs better remains unclear.

GROWING POINTS

This systematic review compared bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and quadriceps tendon (QT) autografts for ACL reconstruction in skeletally immature patients. The joint laxity, Patient-reported outcome measures (PROMs), return to sport, and complications were compared.

AREAS TIMELY FOR DEVELOPING RESEARCH

In skeletally immature patients, HT, BPTB, and QT autografts for ACL reconstruction yielded good outcomes. Comparative studies are strongly required to establish the most suitable autograft.

Insurance Status, Language, and Access to Care for Pediatric Anterior Cruciate Ligament Injury

Background

Patients with public insurance (PUBs) face more difficulty obtaining orthopaedic appointments and have longer wait times than privately insured patients (PVTs). These delays are associated with greater injury severity at the time of surgery, which affects sports injuries such as anterior cruciate ligament tears where early surgical stabilization leads to better outcomes. Additionally, previous evidence showed that patients with limited English proficiency often must rely on informal translation services, such as family members or friends, to communicate with their orthopaedic surgeons, which may represent a disparity in the care provided.

Hypothesis

It was hypothesized that PUBs would be less likely to obtain an appointment compared with PVTs and that most providers would not offer professional translation services to Spanish-speaking patients.

Study Design

Cross-sectional study.

Methods

The authors called 50 randomly selected orthopaedic surgeons' offices in California specializing in sports medicine to request an appointment. Each office was called 4 times in random order for the hypothetical patient having either private or public insurance and speaking either Spanish or English.

Results

The hypothetical PUB had significantly decreased access to an appointment (19% of offices offered an appointment) when compared to the PVT (73.8% offered an appointment). Independent private practice (IPP) offices were less likely to accept public insurance (13.3%) compared with offices at academic medical centers (57.1%). There was no difference in access to an appointment for the Spanish- versus English-speaking patient. Translation services were offered at 73.8% of the orthopaedic offices.

Conclusion

Overall, the data illustrated disparities in access to pediatric orthopaedic care for PUBs compared to those with private insurance. Disparities were most prominent in IPP settings, which were less likely than academic offices to accept public insurance. Additionally, it was found that 73.8% of the offices the authors contacted offered Spanish translation services. Interventions should focus on increasing acceptance of public insurance and translation services in IPP settings. Future studies should expand this analysis to other languages and investigate the potential impacts of language on the quality of care provided.

Predictors of Anterior Cruciate Ligament Tears in Adolescents and Young Adults

Background

Anterior cruciate ligament (ACL) injury in youth can lead to expensive treatment, lengthy rehabilitation, and long-term impairment. Injuries to the ACL are more common in adolescents who participate in organized sports.

Purpose

To examine whether there is an association between age, physical activity patterns, pubertal timing (Tanner stage), or body mass index (obesity/overweight status) and the risk of developing an ACL injury in youth.

Study Design

Cohort study; Level of evidence, 2.

Methods

Data from the Growing Up Today Study (GUTS), a prospective cohort study of youth throughout the United States, were used in this study. From 1996 to 2003, questionnaires were sent to GUTS participants every 12 to 18 months to assess a variety of self-reported factors; in a related 2004 questionnaire, ACL tears and other diagnoses among the participants were reported. Cox proportional hazard models were run to determine the sex-specific association of activity patterns and pubertal timing with risk of developing an ACL tear.

Results

A total of 4519 boys and 5622 girls (age: 9-15 years) were included, with 2.4% and 2.0% sustaining an ACL injury, respectively. Age was found to be a significant risk factor for ACL injury in both sexes (male: hazard ratio [HR] = 1.30 [95% CI, 1.14-1.48]; female: HR = 1.23 [95% CI, 1.10-1.38]). Mean hours per week engaged in vigorous activity was also predictive of a higher risk of ACL injury (male: HR = 1.04 [95% CI, 1.01-1.08]; female: HR = 1.10 [95% CI, 1.07-1.14]). The sports that were the most predictive of injury were running, basketball, soccer, and cheerleading/gymnastics in girls and running, football, and karate/martial arts in boys. Additionally, in boys, overweight/obese status was found to be a significant predictor of ACL injury (HR = 2.61 [95% CI, 1.60-4.26]). Furthermore, among 9- to 13-year-old girls, advanced Tanner stage was a strong predictor of injury risk (HR = 2.43 [95% CI, 1.10-5.36]).

Conclusion

Age, time engaged in vigorous activity, overweight/obese status, and advanced Tanner stage were associated with an increased risk of ACL injury in young adults and adolescents. Further research with follow-up data will help complement this study and continue to highlight the risk factors associated with ACL reconstruction in adolescents and young adults.

Decreasing Incidence of Anterior Cruciate Ligament Tears, Increasing Utilization of Anterior Cruciate Ligament Reconstruction in the United States from 2010-2020

PURPOSE

The present study aimed to characterize the incidence of anterior cruciate ligament (ACL) tears, ACL reconstruction (ACLR), and ACL non-operative management from 2010-2020, stratifying by age, biological sex, and Charlson Comorbidity Index (CCI) score.

METHODS

A retrospective cohort analysis was performed using the PearlDiver national insurance claims database. Cohorts of patients with ACL tears, ACLR, and non-operative management were identified using ICD-9/10, and CPT codes between 2010-2020. All patients with ACL tears were included. Patients were stratified by age, sex, and CCI. Compound Annual Growth Rate (CAGR) analysis, T tests, and Cohen's d tests were performed to analyze trends and demographic variables.

RESULTS

Of 931,186 ACL tears during the study period, 196,589 were managed with ACLR and 734,597 were managed non-operatively. The cumulative incidence of ACL tears was 75.19 tears per 100,000 person-years. There was a modest decrease in the incidence of ACL tears, ACLR, and non-operative management from 2010-2020, with CAGRs of -3.43%, -3.55%, and -5.35%, respectively. The relative utilization of ACLR compared to non-operative management increased from 2010-2020 (CAGR 2.15%). Patients aged 10-19 accounted for the majority of ACL tears (22.31%) and ACLRs (30.97%). A slight majority of ACL tears (51.2%, p<0.001), ACLR (50.7%, p<0.001), and ACL tears with non-operative management (51.6%, p<0.001) occurred in female patients. The mean CCI of patients who underwent ACLR (mean=0.32; SD=0.77) was significantly lower than that of the general ACL tear cohort (mean=0.54; SD=1.19; p=0.005), and the non-operative management cohort (mean=0.64; SD 1.32; p=0.0004).

CONCLUSION

The overall decrease in ACL tears, ACLR, and non-operative management found in this study is a reversal from trends reported in the literature from previous decades.

LEVEL OF EVIDENCE

4 (Retrospective Case Series).

Management of Anterior Cruciate Ligament Tears in Skeletally Immature Patients

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.

Pediatric ACL Reconstruction in Children-An Evaluation of the Transphyseal Technique's Efficacy and Safety

INTRODUCTION

Injuries of the anterior cruciate ligament (ACL) are commonly found in the general population, both among adult and pediatric patients, and their incidence has been increasing in recent years. Most of the late literature agrees that surgical reconstruction of the ACL is effective in improving long-term outcomes in pediatric patients, while others in the past have pleaded for non-surgical management.

PURPOSE/HYPOTHESIS

Our study aims to verify if ACL reconstruction (ACLR) using transphyseal technique in skeletally immature patients will provide angular deviations or growth restrictions.

STUDY DESIGN

Retrospective cohort study; Level of evidence 4.

METHODS

We perfomed a retrospective study to verify if transphyseal ACLR in children with less than or equal to 2 years of remaining growth leads to either limb length discrepancies or axis deviations.

RESULTS

Most patients who were treated using transphyseal technique showed significant improvements in their functional scores. There were statistically significant differences in lateral distal femoral angles (LDFA) and medial proximal tibial angles (MPTA), with no clinical impact. There was no significant limb length discrepancy (LLD) during the 2-year follow-up.

CONCLUSIONS

Transphyseal ACLR is safe among children who have less than or equal to 2 years of remaining growth and brings no risk of axis deviations or limb length discrepancy.

Editorial Commentary: Promising Short-Term Results of Adolescent Transphyseal Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft Warrant Long-Term Follow-Up Study

Several graft choices have been described for surgeons performing anterior cruciate ligament reconstruction. Bone-patellar tendon-bone autograft has been referred to as the gold standard with which other grafts are compared. Hamstring autograft has been widely used when a soft-tissue graft is desired, such as when physes are open with significant growth remaining, but with greater revision rate than bone-patella tendon-bone in young athletes. Allograft tissue is discouraged in younger patients due to increased re-rupture rate. More recently, quadriceps autograft has been described as another soft tissue graft. Quadriceps tendon grafts do show promise as a soft-tissue graft alternative with a potential drawback of decreased knee extension strength, although longer-term follow-up studies are necessary to evaluate its use in the pediatric population.

Development of a patient decision aid for children and adolescents following anterior cruciate ligament rupture: an international mixed-methods study

AIM

To develop and user test an evidence-based patient decision aid for children and adolescents who are considering anterior cruciate ligament (ACL) reconstruction.

DESIGN

Mixed-methods study describing the development of a patient decision aid.

SETTING

A draft decision aid was developed by a multidisciplinary steering group (including various types of health professionals and researchers, and consumers) informed by the best available evidence and existing patient decision aids.

PARTICIPANTS

People who ruptured their ACL when they were under 18 years old (ie, adolescents), their parents, and health professionals who manage these patients. Participants were recruited through social media and the network outreach of the steering group.

PRIMARY AND SECONDARY OUTCOMES

Semistructured interviews and questionnaires were used to gather feedback on the decision aid. The feedback was used to refine the decision aid and assess acceptability. An iterative cycle of interviews, refining the aid according to feedback and further interviews, was used. Interviews were analysed using reflexive thematic analysis.

RESULTS

We conducted 32 interviews; 16 health professionals (12 physiotherapists, 4 orthopaedic surgeons) and 16 people who ruptured their ACL when they were under 18 years old (7 were adolescents and 9 were adults at the time of the interview). Parents participated in 8 interviews. Most health professionals, patients and parents rated the aid's acceptability as good-to-excellent. Health professionals and patients agreed on most aspects of the decision aid, but some health professionals had differing views on non-surgical management, risk of harms, treatment protocols and evidence on benefits and harms.

CONCLUSION

Our patient decision aid is an acceptable tool to help children and adolescents choose an appropriate management option following ACL rupture with their parents and health professionals. A clinical trial evaluating the potential benefit of this tool for children and adolescents considering ACL reconstruction is warranted.

All-epiphyseal anterior cruciate ligament reconstruction yields superior sports performances than the trans-epiphyseal technique in skeletally immature patients: a systematic review

BACKGROUND

Anterior cruciate ligament (ACL) tears in skeletally immature patients are increasingly common. Evidence comparing the outcomes of all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients is limited, and the current literature could benefit from a comprehensive systematic review. The present study compared all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients. The outcomes of interest were to compare joint laxity, patient-reported outcome measures (PROMs), return to sport, and complications.

METHODS

This study was conducted according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. In November 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. No additional filters were used in the database search. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles that clearly stated the surgical technique (all- or trans-epiphyseal) were eligible. Only articles with a minimum of 6 months of follow-up were included. Only articles that clearly stated that surgeries were conducted in children with open physis were eligible.

RESULTS

Data from 1489 patients (1493 procedures) were collected, of which 32% (490 of 1489 patients) were female. The mean length of follow-up was 46.6 months. The mean age of the patients was 12.7 years. No difference was found in joint laxity (Table 3): positive pivot shift (P = 0.4), positive Lachman test (P = 0.3), and mean arthrometer laxity (P = 0.1). No difference was found in PROMs (Table 4): International Knee Documentation Committee (IKDC) (P = 0.3), Lysholm (P = 0.4), and Tegner (P = 0.7). The trans-epiphyseal technique was associated with a greater rate of patients unable to return to sports (1% versus 7%, P = 0.0001) and with a longer time to return to sports (7.7 versus 8.6 months, P = 0.01). Though the trans-epiphyseal technique was associated with a lower rate of return to sport, this difference was not statistically significant (P = 0.8). No difference was evidenced in the rate of patients who had reduced their league or level of sports activity (P = 0.6) or in the rate of patients who had returned to their previous league or level of sports activity (P = 0.7). No difference was found in the rate of complication: re-tear (P = 0.8), reoperation (P = 0.7), increased laxity (P = 0.9), and persistent instability sensation (P = 0.3).

CONCLUSION

Trans-epiphyseal ACL reconstruction was associated with a greater rate of patients unable to return to sport and with a longer time to return to sport compared with the all-epiphyseal technique in skeletally immature patients. Level of evidence Level III, systematic review.

Arthroscopic Transphyseal ACL Reconstruction With Lateral Extraarticular Tenodesis With Unusual Arthroscopic Meniscal Findings in a Case of an Adolescent Girl Previously Diagnosed With Amniotic Band Syndrome

Amniotic band syndrome (ABS) constriction rings in the lower limb are common. Despite this, there is insufficient literature on anatomical abnormalities in the knee joints of children with ABS. There is an increasing incidence of paediatric anterior cruciate ligament (ACL) injuries recently. ACL reconstruction in this population has an extra dilemma of sparing the physis to prevent growth disturbances. Treating both these conditions simultaneously is a challenge that is rarely encountered. In our literature review, we found no case such as this. As such a case is being described for the first time, we also found certain meniscal anatomical variations on diagnostic arthroscopy. A 12-year-old adolescent Indian girl presented with an ACL tear in her left leg after a school sports injury. She had a known case of ABS constriction bands in both her lower limbs. Her distal femoral and proximal femoral physis was fused on radiographs, so we went ahead with a transphyseal ACL soft-tissue graft reconstruction. On the diagnostic round, we found an anatomical variation of the menisci, which was previously not described since arthroscopy of the knee in an adolescent kid with ABS has not been published in the literature as of yet. These kinds of clinical presentations can become common in the future as more and more kids with ABS take part in recreational sports. In such a scenario, having knowledge about common anatomical variations in the knee of such syndromic patients is essential. While performing ACL reconstructions in this population, we have to be aware of the risk of growth deformities along with vascular and neurological complications, which are added risks with constriction bands around the lower limb.

Anterior cruciate ligament reconstruction in skeletally immature patients is effective: A systematic review

PURPOSE

The present study evaluated the outcomes of anterior cruciate ligament (ACL) reconstruction in children with open physes. The outcomes of interest were to compare the increase in joint laxity and PROMs from baseline to the last follow-up, the rate and features of the return to sport and the rate of complications.

METHODS

This study was conducted according to the 2020 PRISMA guidelines. In October 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles which clearly stated that surgeries were conducted in children with open physis were eligible.

RESULTS

Data from 53 studies (1691 procedures) were collected. 35% (597 out of 1691 patients) were women. The mean length of the follow-up was 44.7 ± 31.3 months. The mean age of the patients was 12.7 ± 1.1 years old. All PROMs significantly improved from the baseline values to those at the last follow-up. The mean time to return to sport was 8.3 ± 1.9 months. 89% (690 out of 771 patients) returned to sports, 15% (109 out of 721 patients) reduced their level of sports activity or league, and 84% (651 out of 771 patients) returned to their previous level of sport. 9% (112 out of 1213) of patients experienced re-tear of the reconstructed ACL, and 11% (75 out of 660) of patients underwent a further ACL reoperation. No patients (0 out of 83) demonstrated increased laxity at the last follow-up, and persistent sensation of instability was reported by 5% (11 out of 235) of patients.

CONCLUSION

ACL reconstruction in skeletally immature patients is effective and safe, and is associated with fast recovery and a high rate of return to sport.

LEVEL OF EVIDENCE

Level IV.

Arthroscopic Physeal Sparing Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis With Semitendinosus and Gracilis Tendons

Anterior cruciate ligament (ACL) injuries among young patients have increased in recent years. The purpose of this study was to present a physeal-sparing intra- and extra-articular reconstruction using semitendinosus and gracilis tendons autograft. In recent years, the management of these injuries in the pediatric population has become increasingly surgical to restore knee function and reduce the risk of meniscal and chondral injury due to persistent knee instability. However, this is a population at high risk for ACL graft rupture, but it can be lowered by an addition of lateral extra-articular tenodesis (LET). This study shows the pearls and pitfalls of an arthroscopic physeal-sparing ACL reconstruction combined with a concomitant LET using hamstrings autograft.

Time to return to school following ACL reconstruction: influence of the COVID-19 pandemic

INTRODUCTION

ACL reconstruction is commonly performed in school-aged patients for whom missed time from school can have an impact on their education. Additionally, the COVID-19 pandemic has led to different ways of accessing school content. We sought to determine how many days of school school-aged patients should expect to miss following ACL reconstruction and how the availability of remote learning during the COVID-19 pandemic affected this.

METHODS

We evaluated 53 ACL reconstruction patients in grades 7-12 undergoing surgery during the school year. Demographic, medical, and educational information were collected. Patients were placed into 1 of 2 cohorts: Group A (surgery before the COVID-19 pandemic) or Group B (surgery during the COVID-19 pandemic). We calculated days missed from school after surgery until return to either virtual or in-person school.

RESULTS

Overall, patients returned to school after missing an average of 4.4 (SD, 3.0) days of school after ACL reconstruction surgery. Patients in Group A missed an average of 5.5 (SD, 2.9) school days, while patients in Group B missed an average of 2.3 (SD, 1.4) school days (p <.001). Eighty-nine percent of Group B patients first returned to school utilizing a virtual option. Among those returning virtually, these patients missed an average of 1.9 (SD, 0.9) school days.

CONCLUSIONS

A virtual distance learning option results in fewer missed days of school post ACL reconstruction. When given this option, school-aged patients can expect to return to school within two days post-op. Otherwise, patients should expect to miss about one week of in-person schooling. In this regard, the COVID-19 pandemic has positively impacted educational opportunities for students post-surgery, and physicians should advocate for continuing virtual options for students receiving medical treatment.

Clinical outcomes of different autografts used for all-epiphyseal, partial epiphyseal or transphyseal anterior cruciate ligament reconstruction in skeletally immature patients - a systematic review

BACKGROUND

Different types of grafts can be used for anterior cruciate ligament reconstruction (ACLR). There is little published data regarding skeletally immature patients. The purpose of this systematic review was to assess the clinical outcomes and complications for different autograft types used in all-epiphyseal, transphyseal and partial epiphyseal/hybrid ACLR in skeletally immature children and adolescents.

METHODS

PubMed, Embase and Cochrane databases were systematically searched for literature regarding ACLR using hamstrings, quadriceps or bone-patellar-tendon-bone (BPTB) autografts in skeletally immature patients. Studies were included if they examined at least one of the following outcomes: graft failure, return to sport(s), growth disturbance, arthrofibrosis or patient reported outcomes and had a minimum follow-up of 1 year. Case reports, conference abstracts and studies examining allografts and extra-articular or over-the-top ACL reconstruction techniques were excluded. Graft failure rates were pooled for each graft type using the quality effects model of MetaXL. A qualitative synthesis of secondary outcomes was performed.

RESULTS

The database search identified 242 studies. In total 31 studies were included in this review, comprising of 1358 patients. Most patients (81%) were treated using hamstring autograft. The most common used surgical technique was transphyseal. The weighted, pooled failure rate for each graft type was 12% for hamstring tendon autografts, 8% for quadriceps tendon autografts and 6% for BPTB autografts. Confidence intervals were overlapping. The variability in time to graft failure was high. The qualitative analysis of the secondary outcomes showed similar results with good clinical outcomes and low complication rates across all graft types.

CONCLUSIONS

Based on this review it is not possible to determine a superior graft type for ACLR in skeletally immature. Of the included studies, the most common graft type used was the hamstring tendon. Overall, graft failure rates are low, and most studies show good clinical outcomes with high return to sports rates.

Fixation Strategy Does Not Affect Risk of Growth Disturbance After Surgical Treatment of Pediatric Tibial Spine Fracture

Purpose

To characterize growth abnormalities after surgical treatment of tibial spine fractures and to investigate risk factors for these abnormalities.

Methods

A retrospective analysis of children who underwent treatment of tibial spine fractures between January 2000 and January 2019 was performed, drawing from a multicenter cohort among 10 tertiary care children's hospitals. The entire cohort of surgically treated tibial spine fractures was analyzed for incidence and risk factors of growth disturbance. The cohort was stratified into those who were younger than the age of 13 years at the time of treatment in order to evaluate the risk of growth disturbance in those with substantial growth remaining. Patients with growth disturbance in this cohort were further analyzed based on age, sex, surgical repair technique, implant type, and preoperative radiographic measurements with χ2, t-tests, and multivariate logistic regression.

Results

Nine patients of 645 (1.4%) were found to have growth disturbance, all of whom were younger than 13 years old. Patients who developed growth disturbance were younger than those without (9.7 years vs 11.9 years, P = .019.) There was no association with demographic factors, fracture characteristics, surgical technique, hardware type, or anatomic placement (i.e., transphyseal vs physeal-sparing fixation) and growth disturbance.

Conclusions

In this study, we found an overall low incidence of growth disturbance after surgical treatment of tibial spine fractures. There was no association with surgical technique and risk of growth disturbance.

Level of Evidence

Level III, retrospective comparative study.

Imaging the pediatric anterior cruciate ligament: not little adults

An increased incidence of anterior cruciate ligament (ACL) injuries in children over the last few decades has led to a corresponding increase in ACL reconstruction procedures in children. In this review, we will illustrate unique features seen when imaging the ACL in children versus adults. After briefly reviewing relevant normal ACL anatomy, we will review imaging findings of congenital ACL dysplasia. This is followed by a discussion of imaging ACL avulsions. Lastly, we will review the different types of ACL reconstruction procedures performed in skeletally immature children and their post-operative appearances.

Variability in Pain Management Practices for Pediatric Anterior Cruciate Ligament Reconstruction

BACKGROUND

The opioid epidemic in the United States is a public health crisis. Pediatric orthopaedic surgeons must balance adequate pain management with minimizing the risk of opioid misuse or dependence. There is limited data available to guide pain management for anterior cruciate ligament reconstruction (ACLR) in the pediatric population. The purpose of this study was to survey current pain management practices for ACLR among pediatric orthopaedic surgeons.

METHODS

A cross-sectional survey study was conducted, in which orthopaedic surgeons were asked about their pain management practices for pediatric ACLR. The voluntary survey was sent to members of the Pediatric Orthopaedic Society of North America. Inclusion criteria required that the surgeon perform anterior cruciate ligament repair or reconstruction on patients under age 18. Responses were anonymous and consisted of surgeon demographics, training, practice, and pain management strategies. Survey data were assessed using descriptive statistics.

RESULTS

Of 64 included responses, the average age of the survey respondent was 48.9 years, 84.4% were males, and 31.3% practiced in the southern region of the United States. Preoperative analgesia was utilized by 39.1%, 90.6% utilized perioperative blocks, and 89.1% prescribed opioid medication postoperatively. For scheduled non-narcotic medications postoperatively 82.8% routinely advocated and 93.8% recommended cryotherapy postoperatively.Acetaminophen was the most used preoperative medication (31.3%), the most common perioperative block was an adductor canal block (81.0%), and the most common postoperative analgesic medication was ibuprofen (60.9%). Prior training or experience was more frequently reported than published research as a primary factor influencing pain management protocols.

CONCLUSIONS

Substantial variability exists in pain management practices in pediatric ACLR. There is a need for more evidence-based practice guidelines regarding pain management.

LEVEL OF EVIDENCE

Level V.

"Over-the-Top" Anterior Cruciate Ligament Reconstruction Associated With a Lateral Extra-Articular Tenodesis in Children

Anterior cruciate ligament (ACL) tears are one of the most frequent injuries in growing children, and they are often associated with other injuries such as meniscal and chondral injuries. In the past, treatment of ACL tears in growing patients relied on activity modification and bracing. However, surgical treatment has prevailed over conservative treatment in recent years. A surgical technique is presented for ACL reconstruction using an "over-the-top" technique associated with a lateral extra-articular tenodesis procedure in children. An extra-articular lateral tenodesis is done first. The gracilis and semitendinous tendons are then extracted using a tenotome without releasing their distal desinsertions. The tibial guide is then centered over the ACL tibial footprint under arthroscopic vision and an image intensifier, proximal to the physis. Then, a Kocher-type forceps is used to pass a suture "over the top" from the posterolateral window to the tibial tunnel. The double-bundle graft and iliotibial tract graft are fixed within the tunnel in full extension and neutral rotation with an interference screw.

The incidence of anterior cruciate ligament injury in youth and male soccer athletes: an evaluation of 17,108 players over two consecutive seasons with an age-based sub-analysis

PURPOSE

To evaluate the incidence of anterior cruciate ligament (ACL) injuries in male athletes from professional soccer clubs over two consecutive seasons (2018-2019) with a sub-analysis based on age category: under-13 (U-13), under-15 (U-15), under-17 (U-17), and under-20 (U-20) years.

METHODS

A total of 17,108 young male soccer players were retrospectively reviewed from sixty-three professional clubs in the four highest Brazilian soccer divisions. Data regarding the number of athletes and the number of ACL injuries confirmed by magnetic resonance imaging (MRI) exams in the 2018 and 2019 seasons were collected. Incidence of ACL injury were compared by season, age category (under-13; under-15; under 17; and under-20), demographic region, and club division.

RESULTS

Clubs from all regions of Brazil participated in the study. A total of 336 primary ACL injuries were diagnosed over the two seasons (8,167 athletes during the 2018 season and 8,941 athletes during the 2019 season) among all athletes, which corresponds to 2% of the included athletes. There were 11 cases (0.3%) in the under-13, 53 cases (1.3%) in the under-15, 107 cases (2.5%) in the under-17, and 165 cases (3.8%) in the under-20 age category. There was a higher incidence of ACL injury in the older age groups (p < 0.001).

CONCLUSION

A total of 336 ACL injuries were identified in 17,108 youth soccer players from 63 professional clubs with an overall incidence of 2% over 2 seasons of competition. ACL injury rate ranged from 0.3% to 3.8% and was higher in the older and more competitive club divisions.

LEVEL OF EVIDENCE

IV.

Surgical techniques in the management of pediatric anterior cruciate ligament tears: Current concepts

Background

Anterior cruciate ligament injury in the child and adolescent patient remains a controversial topic when considering management, especially regarding surgical choices. Treatment variations are seen not just when comparing different countries but also within nations. This arises partly as contemporary treatment is mostly inferred from the adult population who physiologically and in terms of outcomes differ significantly from children. There is an increasing body of evidence for this cohort of patients who have specific challenges and difficulties when determining the optimum treatment.

Methods

Within this article, we will summarize the current evidence for surgical management of anterior cruciate ligament injury for the pediatric patient.

Results and Conclusions

There remain many controversies and gaps inthe treatment of Paediatric Anterior cruciate ligament reconstruction and this high risk cohort continues to cause difficulty in identifying the best mode of surgical management.

Level of evidence

level IV.

Robot-assisted all-epiphyseal anterior cruciate ligament reconstruction in skeletally immature patients: a retrospective study

PURPOSE

To review a series of adolescent patients with anterior cruciate ligament (ACL) injuries surgically treated with robot-assisted all-epiphyseal ACL reconstruction (ACLR), and to compare with the traditional freehand group.

METHODS

This retrospective clinical study included 16 patients with ACL injuries who underwent ACLR by robot-assisted technique or traditional freehand method from June 2018 to March 2020. All patients were divided into the robot-assisted group (6 patients) or the traditional surgery group (10 patients). The number of intra-operative fluoroscopies, operation time, accuracy of bone tunnel insertions, International Knee Documentation Committee (IKDC) subjective score and ligament laxity testing were recorded in the two groups.

RESULTS

All patients returned for follow-up, at a mean of 31.6 ± 4.5 months after surgery. The average age of the robot-assisted group was 12.2 ± 1.3 years. The number of intra-operative fluoroscopies was 10.9 ± 2.8 in the traditional freehand group, whereas it was only 3.0 ± 0.6 in the robot-assisted group, which was significantly lower (P < 0.05). The operative time in the robot-assisted group was shorter than that in the traditional freehand group (87 ± 10.7 min vs. 126 ± 12.1 min, P < 0.05). The distance between the center of actual insertion and the center of the idea insertion on both femoral and tibial intra-articular bone tunnel were 1.5 ± 0.3 mm and 1.6 ± 0.3 mm for the robot-assisted group and 2.7 mm ± 0.4 mm and 2.4 ± 0.4 mm for the traditional freehand group (P < 0.05). There were no significant differences between the two groups in function recovery at the last follow-up.

CONCLUSIONS

All-epiphyseal ACLR is a technically demanding procedure with a small margin of error. Robot-assisted treatment of ACL injuries in skeletally immature patients is more accurate than traditional freehand method, with shorter operation time and fewer intra-operative fluoroscopies.

Age, Sex, and BMI Differences Related to Repairable Meniscal Tears in Pediatric and Adolescent Patients

BACKGROUND

The incidence of meniscus tears and ACL tears in pediatric patients continues to rise, bringing to question the risk factors associated with these injuries. As meniscus tears are commonly repaired in pediatric populations, the epidemiology of repairable meniscus tears is an important for consideration for surgeons evaluating treatment options.

PURPOSE

To describe meniscal tear patterns in pediatric and adolescent patients who underwent meniscal repair across multiple institutions and surgeons, as well as to evaluate the relationship between age, sex, and body mass index (BMI) and their effect on the prevalence, type, and displacement of repaired pediatric meniscal tears.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data within a prospective multicenter cohort registry for quality improvement, Sport Cohort Outcome Registry (SCORE), were reviewed to describe repaired meniscal tear patterns. All consecutive arthroscopic meniscal repairs from participating surgeons in patients aged <19 years were analyzed. Tear pattern, location, and displacement were evaluated by patient age, sex, and BMI. A subanalysis was also performed to investigate whether meniscal tear patterns differed between those occurring in isolation or those occurring with a concomitant anterior cruciate ligament (ACL) injury. Analysis of variance was used to generate a multivariate analysis of specified variables. Sex, age, and BMI results were compared across the cohort.

RESULTS

There were 1185 total meniscal repairs evaluated in as many patients, which included 656 (55.4%) male and 529 (44.6%) female patients. Patients underwent surgery at a mean age of 15.3 years (range, 5-19 years), with a mean BMI of 24.9 (range, 12.3-46.42). Of the 1185 patients, 816 (68.9%) had ACL + meniscal repair and 369 (31.1%) had isolated meniscal repair. The male patients underwent more lateral tear repairs than the female patients (54.3% to 40.9%; P < .001) and had a lower incidence of medial tear repair (32.1% vs 41.4%; P < .001). Patients with repaired lateral tears had a mean age of 15.0 years, compared with a mean age of 15.4 years for patients with repaired medial or bilateral tears (P = .001). Higher BMI was associated with "complex" and "radial" tear repairs of the lateral meniscus (P < .001) but was variable with regard to medial tear repairs.

CONCLUSION

In pediatric and adolescent populations, the data suggest that the surgical team treating knees with potential meniscal injury should be prepared to encounter more complex meniscal tears, commonly indicated in those with higher BMI, while higher rates of lateral meniscal tears were seen in male and younger patients. Future studies should analyze correlates for meniscal repair survival and outcomes in this pediatric cohort undergoing knee surgery.

Kindliche vordere Kreuzbandruptur mit komplexer Außenmeniskusverletzung und Knorpelfragmentablösung der posterolateralen Tibia

Ein 11-jähriger Junge erleidet ein Distorsionstrauma des Kniegelenks mit einer Ruptur des vorderen Kreuzbands (VKB), Läsion des Außenmeniskus und Ablösung eines Knorpelfragments am posterolateralen Tibiaplateau. Aufgrund der konträren Nachbehandlungsschemata dieser schwerwiegenden Kombinationsverletzung erfolgt eine zweizeitige operative Versorgung. In einem ersten arthroskopischen Eingriff werden die Meniskus- und Knorpelverletzung behandelt. Nach stattgefundener Knorpeleinheilung erfolgt eine epiphysenschonende Rekonstruktion des vorderen Kreuzbands.

Combined Anterior Cruciate Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis Better Restores Knee Stability and Reduces Failure Rates Than Isolated Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

BACKGROUND

The increase in anterior cruciate ligament (ACL) injuries in pediatric patients and the high failure rate reported in the literature in this population are driving surgeons to search for specific techniques to better restore knee stability. Recent literature has reported that the combination of lateral extra-articular tenodesis (LET) and ACL reconstruction improves outcomes in high-risk patients. However, such advantages in pediatric patients have been infrequently evaluated.

PURPOSE

To assess whether adding LET to ACL reconstruction can significantly improve knee stability, clinical outcomes, and failure rates in pediatric patients.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A multicentric study involving 3 orthopaedic teaching centers was conducted to evaluate pediatric patients aged between 12 and 16 years who had undergone primary ACL reconstruction using a physeal-sparing femoral tunnel drilling technique. A minimum 2-year follow-up evaluation was required. Based on the surgical technique performed, the patients were divided into 2 group. The patients in group 1 underwent an isolated arthroscopic ACL reconstruction, while the patients in group 2 had an arthroscopic ACL reconstruction in combination with a modified Lemaire LET procedure. Group 1 was a historical control cohort of patients, whereas group 2 was prospectively enrolled. All the patients included in the present study were clinically evaluated using the Pediatric International Knee Documentation Committee (Pedi-IKDC) subjective score and the Pediatric Functional Activity Brief Scale (Pedi-FABS) score. Anteroposterior knee stability was measured using the KT-1000 knee ligament arthrometer, and the objective pivot-shift evaluation was documented using a triaxial accelerometer (Kinematic Rapid Assessment [KiRA]). The included patients also underwent a standardized radiological protocol to evaluate leg-length discrepancies, axial deviation, and degenerative signs preoperatively and at last follow-up.

RESULTS

This study included 66 pediatric patients with an anatomic hybrid ACL reconstruction using an autologous 4-strand hamstring graft. In group 1, there were 34 patients (mean age, 13.5 ± 1.2 years), while 32 patients (mean age, 13.8 ± 1.4 years) were included in group 2. The clinical outcome scores showed no difference between the 2 groups (Pedi-IKDC, P = .072; Pedi-FABS, P = .180). Nevertheless, the patients in group 2 had better anteroposterior stability measured using a KT-1000 arthrometer (1.9 ± 1.1 mm in group 1 vs 0.8 ± 0.8 mm in group 2; P = .031), as well as better rotational stability measured using the KiRA (-0.59 ± 1.05 m/s² in group 2 vs 0.98 ± 1.12 m/s² in group 1; P = .012). The patients in group 1 returned to sports at the same competitive level at a rate of 82.4%, while patients included in group 2 returned at the same competitive level in 90.6% of the cases without a significant difference between the 2 groups (P = .059). No leg-length discrepancies were found between the 2 groups at last follow-up (P = .881). Two patients displayed an increased valgus deformity of 3° on the operated limb at last follow-up (1 patient in group 1 and 1 patient in group 2). Group 1 had a significatively higher cumulative failure rate (14.7% vs 6.3%; P = .021). No intra- or postoperative complications was observed between the 2 groups.

CONCLUSION

Performing a modified Lemaire LET along with an ACL reconstruction with hamstring graft in pediatric patients reduced the cumulative failure rate and improved objective stability with no increase in intra- or postoperative complications. No significant difference was found between the 2 groups in terms of patient-reported outcomes or in the return-to-sports activity.

The Spectrum of Anterior Cruciate Ligament Reconstruction Options for the Pediatric and Adolescent Patient: A Narrative Review

As youth sports participation has increased in recent years, injuries to the anterior cruciate ligament (ACL) have become increasingly common in pediatric patients. Historically, ACL reconstruction was delayed in pediatric patients to avoid physeal damage with the potential for leg-length discrepancy or angular deformity. Current research shows that delaying reconstruction or choosing nonoperative management is associated with increased rates of meniscal and chondral injuries, persistent knee instability, and low rates of return to previous activity. Early ACL reconstruction using techniques to avoid physeal growth disturbance is now widely accepted among physicians. The purpose of this review was to describe the pediatric ACL in terms of the relevant anatomy and biomechanics, physical examination, and diagnostic imaging. In addition, the importance of skeletal age and possible physeal injury is discussed in the context of ACL reconstruction options by skeletal age and remaining growth potential.

Anterior Cruciate Ligament Rupture in Skeletally Immature Patients

In the past 20 years, sports injuries in pediatric and adolescent athletes have increased dramatically, with anterior cruciate ligament (ACL) injuries accounting for more than 25% of all knee injuries at this age. Diagnosis is based on detailed clinical history, physical examination, and imaging assessment, where magnetic resonance imaging plays a central role. The growing immature skeleton presents specific characteristics, which require unique methods for surgical reconstruction, ideally avoiding the physes or minimizing the risk of damaging them. Specific rehabilitation protocols are needed, and these patients face a higher risk of recurrent and contralateral ACL injury. Nonsurgical treatment or delayed reconstruction has been associated with persistent instability, activity modifications, worst functional outcomes, and increased risk of irreparable injuries to menisci and articular cartilage. Consequently, surgical stabilization is the preferred treatment for most patients, despite the eventual risk of angular deformities or limb-length discrepancies due to iatrogenic physeal injury. A variety of surgical techniques have been described, depending on the skeletal maturity and growth remaining. Targeted prevention programs play a key role in reducing the risk of ACL injury, are easy to implement, and require no additional equipment. High-quality evidence supports its use in all pediatric athletes.

Dimensions of the anterior cruciate ligament and thickness of the distal femoral growth plate in children: a MRI-based study

BACKGROUND

When determining the dimensions of an anterior cruciate ligament (ACL) graft in children, bone age should be considered in addition to the patient's age, gender, and body height.

OBJECTIVES

We aimed to determine the relationship between age, gender, and ACL dimensions as well as thickness of growth plate cartilage of the distal femur during puberty.

METHODS

We retrospectively analyzed MRI scans of the knee in 131 children (82 girls, 49 boys) aged 6-18 years (mean age: 14.9 ± 2.6 years). ACL length and width as well as thickness of the growth plate cartilage at the distal femoral epiphysis were measured.

RESULTS

Mean ACL length increased linearly up to the age of 12 years in females and 14 years in males; thereafter, mean ACL length remained constant. Mean ACL length was largest at the age of 12 to < 13 years (38.18 mm) in females and at 15 to < 16 years (39.38 mm) in males. Mean ACL width increased up to the age of 12 years in girls and 13 years in boys. After the age of 12 years, both the ACL length and width were significantly larger in boys than girls (p = 0.002 and p = 0.045, respectively). Mean thickness of the growth plate cartilage of the distal femur remained stable up to the age of 12 years in girls and 14 years in boys. Thickness of the growth plate cartilage changed most markedly between the age intervals of 11 to < 12 years and 12 to < 13 years in girls and between the age intervals of 13 to < 14 years and 14 to < 15 years in boys.

CONCLUSIONS

ACL dimensions depended on both age and gender during the growth period. Measurement of cartilage thickness of the femoral distal growth plate proved to be an objective parameter to assess the maturation stage of local bone. This may be useful for the planning and timing of orthopedic ACL procedures.

LEVEL OF EVIDENCE

III-retrospective cohort study.

[Management status of anterior cruciate ligament injury in children and adolescents]

OBJECTIVE

To summarize the current management of anterior cruciate ligament (ACL) injury in children and adolescents, in order to provide reference for the management of ACL injury in children and adolescents.

METHODS

The relevant literature at home and abroad in recent years was extensively accessed to summarize the management status of ACL injury in children and adolescent.

RESULTS

The number of ACL injury in children and adolescents is increasing every year. The diagnosis of ACL mainly depends on symptoms and signs. Rehabilitation, physeal-sparing techniques, partial transphyseal techniques, all-epiphyseal techniques, and transphyseal techniques are used to treat ACL injury in children and adolescents.

CONCLUSION

Dynamic monitoring of knee joint in children and adolescents should be strengthened. The best treatment for ACL injury in children and adolescents is selected according to the patients' actual age, bone age, Tanner stage, and physiological conditions such as menstruation, body growth speed, and other characteristics.

Limited evidence for graft selection in pediatric ACL reconstruction: a narrative review

Anterior cruciate ligament reconstruction is the preferred treatment to anterior cruciate ligament injury. With the increase in anterior cruciate ligament injuries in both adults and skeletally immature patients comes the need for individualized anterior cruciate ligament reconstruction graft selection whether it is the type of graft (auto vs. allograft) or the harvesting site (hamstrings, iliotibial band, quadriceps, patella). Several factors need to be considered preoperatively in order to optimize the patients' recovery and restore anterior cruciate ligament strength and function. These include age and bone maturity, preoperative knee flexor/extensor strength, sport participation, patient's needs and anatomical characteristics. This paper aims at bringing evidence supporting the use of a personalized approach in graft selection for faster and more efficient return to sport and propose a theoretical framework to support the approach.

The Clinical Efficacy and Risk Factors after Revision and Reconstruction of Anterior Cruciate Ligament

The aim of this study was to study the clinical efficacy and prognostic factors after revision and reconstruction of anterior cruciate ligament. All the patients who underwent the first revision of anterior cruciate ligament (ACL) reconstruction in the department of sports medicine from January 2001 to December 2015 were collected. The demographic information, the first revision and reconstruction information of ACL, and the information during the first ACL reconstruction were collected. A total of 335 cases were included. Lysholm score, Tegner activity score, and IKDC subjective score at the last follow-up were significantly higher than those before operation. Compared with graft failure caused by sports injury, the postoperative scores of patients with revision due to life accidents or initial reconstruction techniques were significantly lower (P < 0.05). The postoperative Lysholm score of patients with femoral canal drilling through the tibial canal was lower than that of patients with anterior internal approach. The postoperative IKDC score of patients who underwent medial meniscus suture at the same time was higher than that of patients without meniscus combined injury. ACL revision can improve the stability and function of knee joint. Compared with the revision caused by life accident or technical reasons of primary reconstruction surgery, the patients with graft failure caused by sports injury have better postoperative recovery. Medial meniscus suture and anterior internal approach drilling of the femoral bone canal have a statistically protective effect on the clinical function after ACL revision.

Anatomic all-epiphyseal ACL reconstruction with "inside-out" femoral tunnel placement in immature patients yields high return to sport rates and functional outcome scores a minimum of 24 months after reconstruction

PURPOSE

To understand if anatomic physeal-sparing ACL reconstruction in the immature host preserves range of motion, permits a return to sports, and avoids limb length discrepancy and accelerated intra-articular degeneration with a cross-sectional radiographic, physical examination and patient-reported outcomes analysis.

METHODS

A cross-sectional recall study included 38 patients aged 7-15 who underwent all-epiphyseal ACL reconstruction with hamstring allograft performed by a single surgeon at a large academic medical center. All-epiphyseal reconstructions were performed using a modified Anderson physeal-sparing technique, with the femoral tunnel placed using an "inside-out" technique. Assessments consisted of a physical exam, long leg cassette radiographs, KT-1000 measurements, subjective patient metrics, and magnetic resonance imaging.

RESULTS

Thirty-eight (56.7%) of 66 eligible patients returned for in-person clinical and radiographic exams. Patients were 11.4 ± 1.8 years at the time of surgery. Five patients were females (13.2%). Mean follow-up was 5.5 ± 2.4 years. ACL re-injuries occurred in four patients (10.5%), all of whom underwent revision reconstructions. Thirty-three of the remaining 34 (97.1%) patients returned to sports following their reconstruction, and 24 (70.6%) returned to their baseline level of competition. Mean limb length discrepancy (LLD) was 0.2 ± 1.4 cm. Nine patients had an LLD of > 1 cm (26.5%), which occurred at an equivalent age as those with < 1 cm LLD (10.8 ± 2.0 vs. 11.7 ± 1.7, n.s.). Pre-operative Marx scores (13.1 ± 3.5) were not significantly different from post-operative values (12.3 ± 5.1, n.s.). Patients who required ACL revisions had significantly lower Marx scores than those with intact primary grafts (8.3 ± 7.1 vs. 13.4 ± 4.5, p = 0.047). Cohort mean International Knee Documentation Committee (IKDC) score was 89.7 ± 12.7.

CONCLUSION

Anatomic all-epiphyseal anatomic ACL reconstruction appears to be useful in patients with significant projected remaining growth, with good return-to-sport outcomes and minimal risk of clinically significant physeal complications. However, given the limited patient recall possible in the present study, further large sample size, high-quality works are necessary to validate our findings.

LEVEL OF EVIDENCE

Level IV.

Hybrid Transtibial Femoral Preparation for Transphyseal Anterior Cruciate Ligament Reconstruction: A Radiographic Comparison With the Transtibial and Anteromedial Portal Techniques

Background:

Transphyseal anterior cruciate ligament (ACL) reconstruction remains the most commonly used technique for pubescent patients. The transtibial (TT) drilling technique creates vertical and central femoral tunnels to minimize the physeal area of injury at the expense of a nonanatomic femoral tunnel. The hybrid TT (HTT) technique offers the potential of an anatomic femoral position with tunnel geometry similar to that using the TT technique.

Purpose/Hypothesis:

The purpose was to perform a radiographic comparison of the HTT technique with TT and anteromedial portal (AM) techniques in adolescent patients undergoing transphyseal ACL reconstruction. It was hypothesized that femoral tunnels created during HTT would be similar to TT tunnels but significantly more vertical and central than AM tunnels.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We retrospectively screened primary transphyseal ACL reconstructions performed in adolescents at our institution between 2013 and 2019. The youngest 20 eligible patients were selected from each technique cohort: TT, AM, and HTT. Postoperative radiographs were assessed for the coronal femoral tunnel angle, as well as the location of the tunnel-physis penetration on the anteroposterior and lateral views. Physeal lesion surface area was calculated. Data were compared among the 3 groups using 1-way analysis of variance followed by pairwise comparisons.

Results:

Included were 47 patients with a mean ± SD age of 14.3 ± 1.2 years (n = 9 with TT, 18 with AM, and 20 with HTT techniques). The coronal tunnel angle was significantly more vertical in the TT (60.7° ± 7.2°) and HTT (54.4° ± 5.7) groups as compared with the AM group (48.8° ± 5.9; P = .0037 and P = .02, respectively). There was no significant difference between the TT and HTT groups (P = .066). The only significant finding regarding femoral tunnel location was that the HTT tunnels (28.9% ± 4.8%) penetrated the physis more centrally than did the AM tunnels (20.0% ± 5.1%; P = .00002) on lateral radiographs.

Conclusion:

The HTT technique presents an option for transphyseal ACL reconstruction, with femoral tunnel obliquity and estimated physeal disruption similar to that of the TT technique and significantly less than that of the AM technique. The HTT technique also results in the most central physeal perforation of all techniques, predominantly in the sagittal plane.

Tibial Spine Repair in the Pediatric Population: Outcomes and Subsequent Injury Rates

Purpose

To evaluate short- to mid-term outcomes after arthroscopic operative fixation of tibial spine fractures in pediatric patients, to determine the incidence of further ipsilateral and contralateral knee injuries, and to describe associated meniscal pathology and intraoperative findings at the time of tibial spine repair.

Methods

All patients under age 18 with a tibial spine fracture treated arthroscopically at 1 institution by 2 surgeons from 2008 through 2019 were identified by Current Procedural Terminology codes. Patients at least 1 year from their date of surgery were contacted to complete a questionnaire, which included the International Knee Documentation Committee (IKDC) form. Questions pertained to knee function, pain, and further injury or surgery on either knee. Patient charts, preoperative imaging, and operative reports were reviewed to determine demographic information, tibial spine fracture type, concomitant injuries, and intraoperative details.

Results

Sixty-six of 97 eligible patients (68%) completed questionnaires. Average age at initial surgery was 10.7 years (range, 4-17). Mean follow-up was 5.8 years (range, 1.0-11.9). Average IKDC score at follow-up was 91.4 (range, 62.1-100). Patients reported their knee as 92% of “normal” (range, 40-100). Thirty-five (53%) currently participate in sport; 6 (9%) remain limited because of instability and residual pain. Regarding pain on a visual analog scale, 94%, 95%, and 83% of patients reported less than a 3 at rest, with daily activity, and with sport, respectively. Seven patients (11%) had subsequent ACL rupture. Six patients (9%) underwent ACL reconstruction 3.1 years (range, 0.9-7) after initial repair. Fourteen patients (21%) required at least 1 additional procedure. Regarding the contralateral knee, there were no ACL or tibial spine injuries. Sixty-one (92%) patients were both satisfied and would definitely undergo the procedure again.

Conclusions

Although many pediatric patients demonstrate excellent results after tibial spine repair at mean 5.8 years follow-up, 10.6% sustained an ipsilateral ACL rupture, and 21% required an additional procedure. No patient had a contralateral tibial spine or ACL injury. This is helpful when counseling patients regarding injury risk when returning to activity after tibial spine repair.

Level of Evidence

Level IV, therapeutic case series.

Iliotibial Band Autograft Provides the Fastest Recovery of Knee Extensor Mechanism Function in Pediatric Anterior Cruciate Ligament Reconstruction

Iliotibial band autograft is an increasingly popular option for pediatric anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to compare recovery of knee extensor mechanism function among pediatric patients who underwent ACLR using iliotibial band (IT), hamstring tendon (HT), quadriceps tendon (QT), and patellar tendon (PT) autografts. One hundred forty-five pediatric athletes (76 female; age 15.0, range 7–21 years) with recent (3–18 months) unilateral ACLR performed drop-jump landing and 45° cutting with 3D motion capture. Knee extensor mechanism function (maximum knee flexion angle, maximum internal knee extensor moment, energy absorption at knee) during the loading phase (foot contact to peak knee flexion) was compared among graft types (20 IT, 29 HT, 39 QT, 57 PT) and sides (ACLR or contralateral) using linear mixed models with sex, age, and time since surgery as covariates. Overall, knee flexion was significantly lower on the operated vs. contralateral side for HT, QT, and PT during both tasks (p < 0.03). All graft types exhibited lower knee extensor moments and energy absorption on the operated side during both movements (p ≤ 0.001). Kinetic asymmetry was significantly lower for IT compared with QT and PT during both movements (p ≤ 0.005), and similar patterns were observed for HT vs. QT and PT (p ≤ 0.07). Asymmetry was similar between IT and HT and between QT and PT. This study found that knee extensor mechanism function recovers fastest in pediatric ACLR patients with IT autografts, followed by HT, in comparison to QT and PT, suggesting that IT is a viable option for returning young athletes to play after ACLR.

Intra-and interobserver reliability of determining the femoral footprint of the torn anterior cruciate ligament on MRI scans

BACKGROUND

Re-injury rates following reconstruction of the anterior cruciate ligament (ACL) are significant; in more than 20% of patients a rupture of the graft occurs. One of the main reasons for graft failure is malposition of the femoral tunnel. The femoral origin of the torn ACL can be hard to visualize during arthroscopy, plus many individual variation in femoral origin anatomy exists, which may lead to this malpositioning. To develop a patient specific guide that may resolve this problem, a preoperative MRI is needed to identify the patient specific femoral origin of the ACL. The issue here is that there may be a difference in the reliability of identification of the femoral footprint of the ACL on MRI between different observers with different backgrounds and level of experience. The purpose of this study was to determine the intra- and interobserver reliability of identifying the femoral footprint of the torn ACL on MRI and to compare this between orthopedic surgeons, residents in orthopedic surgery and MSK radiologists.

METHODS

MR images of the knee joint were collected retrospectively from 20 subjects with a confirmed rupture of the ACL. The 2D (coronal, sagittal, transversal) proton-density (PD) images were selected for the segmentation procedure to create 3D models of the femurs. The center of the femoral footprint of the ACL on 20 MRI scans, with visual feedback on 3D models (as reference) was determined twice by eight observers. The intra- and interobserver reliability of determining the center of the femoral footprint on MRI was evaluated. Intraclass correlation coefficients (ICCs) were calculated for the X, Y and Z coordinates separately and for a 3D coordinate.

RESULTS

The mean 3D distance between the first and second assessment (intraobserver reliability) was 3.82 mm. The mean 3D distance between observers (interobserver reliability) was 8.67 mm. ICCs were excellent (> 0.95), except for those between the assessments of the two MSK radiologists of the Y and Z coordinates (0.890 and 0.800 respectively). Orthopedic surgeons outscored the residents and radiologists in terms of intra- and interobserver agreement.

CONCLUSION

Excellent intraobserver reliability was demonstrated (< 4 mm). However the results of the interobserver reliability manifested remarkably less agreement between observers (> 8 mm). An orthopedic background seems to increase both intra- and interobserver reliability. Preoperative planning of the femoral tunnel position in ACL reconstruction remains a surgical decision. Experienced orthopedic surgeons should be consulted when planning for patient specific instrumentation in ACL reconstruction.