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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.
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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.
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Dietvorst M, van der Steen MCM, van den Besselaar M, Janssen RP. Height is a predictor of hamstring tendon length and ACL graft characteristics in adolescents. BMC Musculoskelet Disord 2023; 24:563. [PMID: 37434191 DOI: 10.1186/s12891-023-06705-2] [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] [Received: 09/10/2022] [Accepted: 07/07/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Knowing the potential hamstring tendon length is relevant for planning ligament reconstructions in children and adolescents, as it is not uncommon to encounter small hamstring tendons intraoperatively. The aim of this study is to predict semitendinosus and gracilis tendon length based on anthropometric values in children and adolescents. The secondary aim is to analyse hamstring tendon autograft characteristics in a closed socket anterior cruciate ligament reconstructions and to evaluate the relationship with anthropometric variables. The hypothesis of this study was that height is predictor of hamstring tendon length and thereby graft characteristics. METHODS This observational study included two cohorts of adolescents undergoing ligament reconstructions between 2007-2014 and 2017-2020. Age, sex, height and weight were recorded preoperatively. Semitendinosus and gracilis tendon length and graft characteristics were measured intraoperatively. Regression analysis was performed on tendon length and anthropometric values. Subgroup analyses of the closed socket ACL reconstruction were performed and the relation between anthropometric values and graft characteristics were analysed. RESULTS The population consisted of 171 adolescents from 13 to 17 years of age, with a median age of 16 years [IQR 16-17]. The median semitendinosus tendon length was 29 cm [IQR 26-30] and gracilis tendon length was 27 cm [IQR 25-29]. Height was a significant predictor of semitendinosus and gracilis tendon length. Subgroup analysis of the closed socket ACL reconstructions showed that in 75% of the procedure, the semitendinosus tendon alone was sufficient to create a graft with a minimum diameter of 8.0 mm. CONCLUSIONS Height is a significant predictor of semitendinosus and gracilis tendon length in adolescents between 13 and 17 years of age and outcomes are similar to data in adults. In 75% of the closed socket ACL reconstructions, the semitendinosus tendon alone is sufficient to create an adequate graft with a minimum diameter of 8 mm. Additional use of the gracilis tendon is more often necessary in females and shorter patients. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Martijn Dietvorst
- Department of Orthopaedic Surgery and Trauma, Máxima MC, Eindhoven, the Netherlands.
| | - M C Marieke van der Steen
- Department of Orthopaedic Surgery and Trauma, Máxima MC, Eindhoven, the Netherlands
- Department of Orthopaedic Surgery and Trauma, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | | | - Rob Pa Janssen
- Department of Orthopaedic Surgery and Trauma, Máxima MC, Eindhoven, the Netherlands
- Dept. of Paramedical Sciences, Chair Value-Based Health Care, Fontys University of Applied Sciences, Eindhoven, the Netherlands
- Department of Biomedical Engineering, Orthopaedic Biomechanics, Eindhoven University of Technology, Eindhoven, the Netherlands
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Dietvorst M, van der Steen MCM, Reijman M, Janssen RPA. Diagnostic values of history taking, physical examination and KT-1000 arthrometer for suspect anterior cruciate ligament injuries in children and adolescents: a prospective diagnostic study. BMC Musculoskelet Disord 2022; 23:710. [PMID: 35883084 PMCID: PMC9317060 DOI: 10.1186/s12891-022-05659-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 07/12/2022] [Indexed: 11/22/2022] Open
Abstract
Background Diagnosing anterior cruciate ligament (ACL) injuries in children and adolescents are more challenging compared to adults. Delayed diagnosis may result in meniscal or chondral injuries. The aim of this study was to determine the diagnostic values of history taking, physical examination and KT-1000 arthrometer for suspect ACL injuries in children and adolescents. Methods In this prospective diagnostic study, all children and adolescents (< 18 years) with post-traumatic knee complaints presenting at the out-patient department of the Máxima MC were eligible for inclusion. One experienced knee specialised orthopaedic surgeon was blinded and performed history taking, physical examination and KT-1000 arthrometer measurement. All patients had a magnetic resonance imaging (MRI) for the final diagnosis. Diagnostic values of interest were sensitivity, specificity, positive and negative predictive values (PPV and NPV). The outcomes of the KT-1000 arthrometer were drafted in a relative operating characteristics (ROC) curve to determine the optimal cut-off points. Results Sixty-six patients were included, of which 50 had an ACL rupture and 16 had no ACL rupture on MRI. Report of a popping sensation during trauma had a specificity and PPV of 100% for diagnosing ACL injuries. The PPV and NPV of the Lachman test (in case of describing end-feel) were 95 and 82%, of the anterior drawer test 87 and 90% and of the pivot shift test 95 and 81% respectively. The optimal cut-off point of the KT-1000 arthrometer at 133 N force was an absolute translation of ≥7 mm with a PPV and NPV of 97 and 88% respectively. Conclusions Report of a popping sensation during trauma has a specificity and PPV of 100% for diagnosing ACL injuries in children and adolescents. Although potentially difficult in children, the Lachman test, anterior drawer test and pivot shift test have a high PPV and NPV when performed by an experienced orthopaedic surgeon. An absolute anterior translation of ≥7 mm of the injured knee in the KT-1000 arthrometer at 133 N has the highest diagnostic values of all tests for diagnosing ACL injuries. Level of evidence 3
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Affiliation(s)
- Martijn Dietvorst
- Department of Orthopedic Surgery and Trauma, Máxima MC, Eindhoven, the Netherlands.
| | - M C Marieke van der Steen
- Department of Orthopedic Surgery and Trauma, Máxima MC, Eindhoven, the Netherlands.,Department of Orthopedic Surgery and Trauma, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Max Reijman
- Department of Orthopedic Surgery, Erasmus University MC, Rotterdam, the Netherlands
| | - Rob P A Janssen
- Department of Orthopedic Surgery and Trauma, Máxima MC, Eindhoven, the Netherlands.,Department of Biomedical Engineering, Orthopedic Biomechanics, Eindhoven University of Technology, Eindhoven, the Netherlands.,Department of Paramedical Sciences, Chair Value-Based Health Care, Fontys University of Applied Sciences, Eindhoven, the Netherlands
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Mouton C, Moksnes H, Janssen R, Fink C, Zaffagnini S, Monllau JC, Ekås G, Engebretsen L, Seil R. Preliminary experience of an international orthopaedic registry: the ESSKA Paediatric Anterior Cruciate Ligament Initiative (PAMI) registry. J Exp Orthop 2021; 8:45. [PMID: 34173077 PMCID: PMC8233435 DOI: 10.1186/s40634-021-00366-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/15/2021] [Indexed: 01/14/2023] Open
Abstract
Paediatric and adolescent ACL injuries are an emerging health burden, increasing at a higher rate than in adults. They compromise quality of life, affect knee structure and function, lead to the early development of osteoarthritis and are a serious economic burden due to shortened professional careers and subsequent surgeries. Up to 35% of children and adolescents will experience a second ACL injury and this population particularly at high risk of secondary intraarticular soft tissue degeneration and growth abnormalities. However, there is still a lack of high-quality outcome studies on this specific population and many knowledge gaps persist in the current treatment guidelines. It is currently unknown whether ACL reconstruction in this young population decreases the risk of irreversible secondary intraarticular soft tissue degeneration. Furthermore, it is not known whether return to high or elite level sports after paediatric ACL injury or reconstruction should be recommended. The relatively low number of paediatric ACL injuries seen in each hospital makes it necessary to conduct international multi-centre studies to collect robust data to provide evidence-based guidelines for the treatment of these injuries. The Paediatric Anterior Cruciate Ligament Initiative (PAMI) was thus started by the European Society of Sports Traumatology, Knee Surgery & Arthroscopy and opened for patient inclusion in 2018. This comprehensive overview of the first 2 years of the PAMI registry shows that the project is now well consolidated and accepted by the European orthopaedic community. Future challenges include ensuring additional external funding to ascertain long term sustainability and continuous dissemination of the knowledge acquired in scientific journals.
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Affiliation(s)
- Caroline Mouton
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg - Clinique d'Eich, 78 Rue d'Eich, L-1460, Luxembourg, Luxembourg.,Luxembourg Institute of Research in Orthopaedics, Sports Medicine and Science (LIROMS), Luxembourg, Luxembourg
| | - Håvard Moksnes
- Oslo Sports Trauma Research Centre (OSTRC), Norwegian School of Sports Sciences, Oslo, Norway
| | - Rob Janssen
- Department of Orthopaedic Surgery & Trauma, Máxima Medical Center, Eindhoven-Veldhoven, The Netherlands.,Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.,Value-Based Health Care, Department of Paramedical Sciences, Fontys University of Applied Sciences, Eindhoven, The Netherlands
| | - Christian Fink
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria.,Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), UMIT Tirol, Hall, Austria
| | - Stefano Zaffagnini
- IIa Clinica Ortopedica E Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Juan Carlos Monllau
- Hospital del Mar / Hospital Universitari Dexeus, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Guri Ekås
- Oslo Sports Trauma Research Centre (OSTRC), Norwegian School of Sports Sciences, Oslo, Norway.,Department of Orthopedic Surgery, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Lars Engebretsen
- Oslo Sports Trauma Research Centre (OSTRC), Norwegian School of Sports Sciences, Oslo, Norway.,Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Romain Seil
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg - Clinique d'Eich, 78 Rue d'Eich, L-1460, Luxembourg, Luxembourg. .,Luxembourg Institute of Research in Orthopaedics, Sports Medicine and Science (LIROMS), Luxembourg, Luxembourg. .,Human Motion, Orthopaedics, Sports Medicine and Digital Methods, Luxembourg Institute of Health, Luxembourg, Luxembourg.
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