Anterior cruciate ligament injuries in children and adolescents

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.

Anterior Cruciate Ligament Injuries in Skeletally Immature Patients: A Meta-analysis Comparing Repair Versus Reconstruction Techniques

BACKGROUND

Anterior cruciate ligament (ACL) surgery remains challenging in the skeletally immature patient. Despite the widespread use of physeal-sparing reconstruction techniques, there has been renewed interest in the ACL repair. The purpose of this study was to systematically review the literature to better understand outcomes following all-epiphyseal (AE) reconstruction to extraphyseal reconstruction, while also evaluating ACL repair outcomes in skeletally immature patients.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, all studies in the literature from January 1970 to August 2019 reporting on skeletally immature patients undergoing ACL surgery were identified. Inclusion criteria were pediatric patients with open physes indicative of skeletal immaturity sustaining complete ACL ruptures treated with AE reconstruction, extraphyseal reconstruction or ACL repair. Chronologic age, bone age, postoperative outcomes scores, return to sport rate, and the incidence of complications, namely reruptures, were analyzed.

RESULTS

A total of 14 studies comprising 443 patients were identified. No significant difference in chronologic age or postoperative outcome scores at final follow-up were appreciated between patients undergoing AE versus extraphyseal reconstruction. Return to activity rate was significant greater following extraphyseal reconstruction when compared with AE reconstruction. The incidence of any limb-length discrepancies and limb discrepancies measuring ≥10 mm were significant higher following AE reconstruction, while rerupture rates were more common following AE reconstruction.

CONCLUSIONS

Patients undergoing AE reconstruction possessed significantly lower return to activity rates, higher incidences of limb-length discrepancies and more commonly experienced ACL reruptures when compared with patients undergoing extraphyseal reconstruction. Further investigations analyzing results following ACL repair in skeletally immature patients are warranted to allow for the comparison of outcomes with current physeal-sparing reconstruction techniques.

LEVEL OF EVIDENCE

Level IV-systematic review-therapeutic study.

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.