Management of anterior cruciate ligament tears in skeletally immature athletes

Effect of Hip-Focused Injury Prevention Training for Anterior Cruciate Ligament Injury Reduction in Female Basketball Players: A 12-Year Prospective Intervention Study

BACKGROUND

Programs to prevent anterior cruciate ligament (ACL) injuries in female basketball players are scarce. Also, ACL injury prevention training that focuses on hip joint function has not been reported.

PURPOSE

To determine the effectiveness of a hip-focused ACL injury prevention program in female basketball players.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A prospective intervention study was conducted for 12 years. Incidence rates of ACL injuries were collected in the first 4 years (observation period) from college female basketball players. After the observation period, a hip-focused ACL injury prevention program was implemented for 8 years (intervention period). A total of 309 players (mean ± SD age, 19.6 ± 1.2 years; height, 163.7 ± 5.6 cm; weight, 59.1 ± 5.1 kg; body mass index, 22.0 ± 1.4) were tracked in the observation period and compared with 448 players (age, 19.6 ± 1.1 years; height, 162.6 ± 5.8 cm; weight, 58.0 ± 5.7 kg; body mass index, 21.9 ± 1.5) who participated in the intervention period. Athlete-exposures (AEs), ACL numbers and mechanisms of injury (MOIs), relative risk (RR), absolute risk reduction (ARR), numbers needed to treat (NNT), and compliance were analyzed.

RESULTS

There were 16 ACL injuries (13 noncontact MOIs) in the 4-year observation period, whereas 9 ACL injuries (8 noncontact MOIs) were recorded in the 8-year intervention period. The overall ACL injury incidence was 0.25/1000 AEs in the 4-year observation period compared with 0.10/1000 AEs in the 8-year intervention period, respectively. Compared with the 4-year observation period, significant RR reduction was observed (0.38; 95% CI, 0.17-0.87; P = .017) with ARR and NNT of 0.032 (95% CI, 0.027-0.037) and 31.6 (95% CI, 27.1-37.7), respectively, in the 8-year intervention period. The noncontact ACL injury incidence was 0.21 per 1000 AEs during the 4-year observation period compared with 0.08/1000 AEs in the 8-year intervention period, which also showed significant RR reduction (0.37; 95% CI, 0.15-0.92; P = .026), with ARR and NNT of 0.024 (95% CI, 0.020-0.029) and 41.3 (95% CI, 34.6-51.3), respectively. The mean compliance rate during the intervention periods (8 years) was 89%.

CONCLUSION

A hip-focused injury prevention program demonstrated significant reduction in the incidence of ACL injury in female collegiate basketball players.

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

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

Intraarticular hamstring graft diameter decreases with continuing knee growth after ACL reconstruction with open physes

PURPOSE

To evaluate the graft diameter size after one-year follow-up or more of patients Tanner II, III, and IV who were submitted to anterior cruciate ligament reconstruction.

METHODS

Ten patients [five males (mean age: 14.4 years) and five females (mean age: 13.6 years)] with open physis and anterior cruciate ligament tear were submitted to transphyseal anterior cruciate ligament reconstruction with quadruple hamstrings graft. During the procedure, graft and tunnel size were recorded. After last clinical follow-up (range 1-11 years), an MRI study was requested and their measurements near the tibial tunnel were compared with the graft diameter measured and used during primary procedure.

RESULTS

Four patients had Tanner stage II, four patients Tanner stage III, and two Tanner IV. There were statistically significant decreases in the quadruple hamstrings graft diameter size (average of 25.3%). Mean size at time of surgery was 7.9 mm (±0.87), and mean size measured at different points of follow-up evaluation was 5.9 mm (±0.65).

CONCLUSION

Diameter size of hamstring graft in skeletally immature patients is smaller in most cases. If there is a decrease in the diameter of the graft along postoperative time, the risk of a re-rupture is theoretically further increased. Quadruple hamstring graft decreases a mean 25.3% in diameter from time of anterior cruciate ligament reconstruction surgery until reassessment period in skeletally immature patients.

LEVEL OF EVIDENCE

IV.