Concurrent Meniscal and Chondral Injuries in Pediatric and Adolescent Patients Undergoing ACL Reconstruction

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.

Social deprivation index affects time to MRI after knee injury in pediatric patients and is predicted by patient demographics

OBJECTIVES

This study aims to characterize the association between the timing of MRI ordering and completion for pediatric knee injuries and Social Deprivation Index (SDI), which is a comprehensive, validated, county-level, measure of socioeconomic variation in health outcomes based upon combining geography, income, education, employment, housing, household characteristics, and access to transportation.

METHODS

A retrospective chart review was completed of patients 21 years old and younger from our institution with a history of knee sports injury (ligamentous/soft tissue injury, structural abnormality, instability, inflammation) evaluated with MRI between 5/26/2017 and 12/28/2020. Patients were from three states and attended to by physicians associated with an urban academic institution. Patients were assigned SDI scores based on their ZIP code. Excluded from the study were patients with a non-knee related diagnosis (hip, foot, or ankle), patients from ZIP codes with unknown SDI, and non-sports medicine diagnoses (tumor, infection, fracture).

RESULTS

In a multivariate regression analysis of 355 patients, increased SDI was independently associated with increased time from clinic visit to MRI order (p = 0.044) and from clinic visit to MRI completion (p = 0.047). Each 10-point increase in SDI (0-100) was associated with a delay of 7.2 days on average. SDI itself was found to be associated with a patient's race (p < 0.001), ethnicity (p < 0.001), and insurance category (p < 0.001).

CONCLUSION

Increased SDI is independently associated with longer time from clinic visit to knee MRI order and longer time from clinic visit to knee MRI completion in our pediatric population. Recognizing potential barriers to orthopedic care can help create the change necessary to provide the best possible care for all individual patients.

Prevalence and Predictors of Concomitant Meniscal Surgery During Pediatric and Adolescent ACL Reconstruction: Analysis of 4729 Patients Over 20 Years at a Tertiary-Care Regional Children's Hospital

Background

The rate of concomitant meniscal procedures performed in conjunction with anterior cruciate ligament (ACL) reconstruction is increasing. Few studies have examined these procedures in high-risk pediatric cohorts.

Hypotheses

That (1) the rates of meniscal repair compared with meniscectomy would increase throughout the study period and (2) patient-related factors would be able to predict the type of meniscal operation, which would differ according to age.

Study Design

Cohort study (prevalence); Level of evidence, 2.

Methods

Natural language processing was used to extract clinical variables from notes of patients who underwent ACL reconstruction between 2000 and 2020 at a single institution. Patients were stratified to pediatric (5-13 years) and adolescent (14-19 years) cohorts. Linear regression was used to evaluate changes in the prevalence of concomitant meniscal surgery during the study period. Logistic regression was used to determine predictors of the need for and type of meniscal procedure.

Results

Of 4729 patients (mean age, 16 ± 2 years; 54.7% female) identified, 2458 patients (52%) underwent concomitant meniscal procedures (55% repair rate). The prevalence of lateral meniscal (LM) procedures increased in both pediatric and adolescent cohorts, whereas the prevalence of medial meniscal (MM) repair increased in the adolescent cohort (P = .02). In the adolescent cohort, older age was predictive of concomitant medial meniscectomy (P = .031). In the pediatric cohort, female sex was predictive of concomitant MM surgery and of undergoing lateral meniscectomy versus repair (P≤ .029). Female sex was associated with decreased odds of concomitant LM surgery in both cohorts (P≤ .018). Revision ACLR was predictive of concomitant MM surgery and of meniscectomy (medial and lateral) in the adolescent cohort (P < .001). Higher body mass index was associated with increased odds of undergoing medial meniscectomy versus repair in the pediatric cohort (P = .03).

Conclusion

More than half of the young patients who underwent ACLR had meniscal pathology warranting surgical intervention. The prevalence of MM repair compared with meniscectomy in adolescents increased throughout the study period. Patients who underwent revision ACLR were more likely to undergo concomitant meniscal surgeries, which were more often meniscectomy. Female sex had mixed effects in both the pediatric and adolescent cohorts.

Skeletal Maturity Is Associated With Increased Meniscal and Chondral Pathology in Patients Under 21 Years of Age Undergoing Primary Anterior Cruciate Ligament Reconstruction Within 6 Months of Injury

PURPOSE

To compare injury profiles of meniscal and/or chondral injury in skeletally mature (SM) with immature (SI) patients undergoing primary anterior cruciate ligament reconstruction (ACLR).

METHODS

Current Procedural Terminology code 29888 was queried from January 2012 to April 2020. Patients younger than 22 years who underwent primary ACLR within 6 months of injury were included. Exclusion criteria included age older than 22 years, treatment after 6 months, revision ACLR, concurrent osteotomy, or multiligamentous injury. All patients required a minimum 1-year follow-up. Demographics and intraoperative pathology were recorded. Data were analyzed for factors affecting intra-articular injury and stratified by sport.

RESULTS

Of 927 patients (739 SM, 188 SI), the mean age was 16.63 and 14.00 years for the SM and SI cohorts, respectively (P < .001). There were more SM males (51.4%) compared to SI males (81.9%) (P < .001); however, in univariate analysis, sex did not significantly affect the rates of meniscal (P = .519) or chondral injury (P = .961). In total, 887 meniscal injuries were recorded (344 medial, 543 lateral) in 659 patients. SM sustained greater rates of medial meniscal tear (MMT) (P < .001) and underwent higher rates of partial meniscectomy (P = .022). Male sex conferred meniscal injury (95% confidence interval [CI], 0.43-0.81; P = .001). Body mass index prognosticated medial meniscal (95% CI, 1.01-1.06; P = .002) and medial chondral injuries (95% CI, 1.02-1.09; P < .001). Skeletal maturity was a superior predictor of intra-articular pathology than age for all outcomes: MMT (95% CI, 0.00-0.06; P = .002), lateral meniscal tear (95% CI, 0.00-0.75; P = .034), and chondral injury (95% CI, 0.00-0.49; P = .049). In sport subanalysis, soccer anterior cruciate ligament (ACL) injuries were most common (32.6%). Soccer and basketball athletes were more likely SM (P = .016, P = .003 respectively) with increased medial compartment pathology. Football ACL injuries occurred significantly in SI athletes (P = .001) via contact mechanisms (P = .025).

CONCLUSIONS

Skeletal maturity affects the meniscal and chondral injury profile in ACL-injured patients. SM patients have greater risk of sustaining concomitant meniscal injury, while chondral injury profile depends more on the mechanism of injury. Mechanism of injury and skeletal maturity status affect risk of sports-related ACL rupture and ACL-concurrent pathology in young patients. Patient-specific variables influence injury profiles within each sport. Skeletal maturity rather than age predicts concomitant intra-articular injury risk.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Prevalence and Predictors of Concomitant Meniscal and Ligamentous Injuries Associated With ACL Surgery: An Analysis of 20 Years of ACL Reconstruction at a Tertiary Care Children's Hospital

BACKGROUND

There is an increasing rate of procedures being performed for concomitant injuries during anterior cruciate ligament (ACL) surgery. Few studies have examined risk factors for these associated injuries in young patients.

HYPOTHESIS

There are patient-related factors predictive of concomitant knee pathology that differ between age-based cohorts.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Natural language processing was used to extract clinical variables from available notes of patients undergoing ACL surgery between 2000 and 2020 at a single institution (5174 ACL surgeries; mean age, 17 ± 4 years; 53.1% female; accuracy, >98%). Patients were stratified to pediatric (5-13 years), adolescent (14-19 years), and young adult (20-35 years) cohorts. Logistic regression was used to determine predictors of concomitant injury to the menisci, medial collateral ligament (MCL), posterolateral corner (PLC), and posterior cruciate ligament (PCL).

RESULTS

Between 2000 and 2020, 54% of pediatric, 71% of adolescent, and 70% of adult patients had ≥1 concomitant soft tissue injury. In children and adolescents, increased age was consistently predictive of sustaining a concomitant injury (P < .02). Female children had increased odds of concomitant medial meniscal injury, while female adults had decreased odds (P≤ .046). Adolescent and adult female patients had decreased odds of concomitant lateral meniscal injury (P≤ .027). Female children had increased odds of injury to the MCL (P = .015), whereas female children and adolescents had decreased odds of PCL injury (P≤ .044). Adolescents undergoing revision ACL surgery had increased odds of meniscal injury (P≤ .001) and decreased odds of concomitant MCL injury (P = .028). Increased body mass index (BMI) was associated with increased odds of concomitant medial meniscal injury in all cohorts (P≤ .041), lateral meniscal injury in adults (P = .045), and PLC injury in children (P = .016). Contact injuries were associated with increased odds of MCL injury in adolescents (P = .017) and PLC injury in adolescents and adults (P < .014).

CONCLUSION

These findings support the hypothesis, as there were multiple factors that significantly affected the risk of concomitant injuries that differed between cohorts. Increased age, BMI, and contact injury history were generally associated with increased odds of sustaining a concomitant injury, whereas female sex and revision ACL surgery had mixed effects. Further studies are essential to investigate the sex-based differences in risk for concomitant injuries and to develop tailored treatment plans that minimize the risk of secondary ACL injury.

Causal relationship between dried fruit intake and meniscal injuries: Two-sample Mendelian randomization

To investigate the causal relationship between dried fruit intake and meniscal injuries using Mendelian randomization (MR). Data were pooled from large-scale genome wide association studies (GWAS), and genetic loci independently associated with dry fruit intake and meniscal injuries in populations of European origin were selected as instrumental variables. Three MR analyses, inverse variance weighting (IVW), weighted median (WME) and MR-Egger, were used to investigate the causal relationship between dried fruit intake and meniscal injuries. The results were tested for robustness by heterogeneity and multiplicity tests, and sensitivity analyses were performed using the "leave-one-out" method. The IVW results showed an OR (95 % CI) of 0.47 (0.28-0.78), P = .003, indicating a causal relationship between dried fruit intake and meniscus injury. And no heterogeneity and multiplicity were found by the test and sensitivity analysis also showed robust results. The present study used a 2-sample MR analysis, and by analyzing and exploring the genetic data, the study showed that too little intake of dry fruits is a risk factor for meniscal injuries.

Functional Rehabilitation of Anterior Cruciate Ligament Tear in the Pediatric Population: A Comprehensive Review

Pediatric sports injuries are a growing concern due to increased youth participation in sports. Effective rehabilitation strategies are essential for ensuring optimal recovery, restoring knee function, and preventing long-term consequences. This research aims to explore and evaluate various functional rehabilitation approaches tailored to pediatric anterior cruciate ligament (ACL) tear injuries. Functional rehabilitation of ACL tears in pediatric sports injuries is an important area of research due to the unique considerations and challenges that arise when treating ACL injuries in young athletes. Over the last 20 years, there has been a well-documented uptick in ACL injuries among pediatric populations. This rise can be attributed to the growing involvement of the younger population in competitive sports, as well as heightened awareness regarding sports-linked injuries. This study highlights the importance of early surgical reconstruction in children to enable a quick return to sports and prevent long-term cartilage and meniscal damage resulting from instability. The use of physeal-sparing ACL reconstruction techniques, particularly hamstring autografts, is recommended for favorable clinical outcomes while minimizing growth disturbances. This study offers valuable insights for healthcare professionals and researchers, serving as a reference to guide optimal approaches in managing pediatric ACL injuries and achieving successful results in this field.

Analysis of Growth After Transphyseal Anterior Cruciate Ligament Reconstruction in Children

BACKGROUND

Pediatric transphyseal anterior cruciate ligament reconstruction (ACLR) bears several advantages and is widely used. The main concern is the risk of growth disturbance. Our purpose was to investigate the incidence and risk factors of growth disturbance in skeletally immature patients who underwent transphyseal ACLR. We hypothesized that this procedure would generate neither clinically relevant limb length discrepancy (LLD) nor axis deviation.

METHODS

This prospective, consecutive, single-center series included skeletally immature patients who underwent primary transphyseal ACLR using semitendinosus tendon autograft, with a 2-year follow-up bone length standing radiograph of both lower limbs from pelvis to ankle in anterior posterior view. Lower limb length, mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA) were measured. The definition of postoperative growth disturbance was defined as ≥10 mm for LLD or ≥3 degrees for axis deviation in comparison to the contralateral lower limb. Predictive variables included age at surgery, gender, side, and diameter of bone tunnels. Student or Mann-Whitney test was used for numerical variables, and Chi-square test or Fisher exact test was used for categorical variables. P values <0.05 were considered statistically significant.

RESULTS

Fifty consecutively treated patients were included. Forty-seven patients (31 boys, 16 girls) with a mean age of 13.2 years (range, 9 to 16) at the time of surgery were available for analysis. Six patients had an LLD of at least 10 mm. Twenty-five patients had a difference in MPTA of a least 3 degrees (range, 5 to 8). Sixteen patients had a difference in LDFA of a least 3 degrees (range, 4 to 9). No patients presented with a clinical deformity or related symptoms. Regarding coronal alignment, there was no statistical difference in mechanical axis deviation, LDFA, or MPTA. Gender, side, age, and bone tunnel diameter did not influence growth disturbance.

CONCLUSIONS

Transphyseal pediatric ACLR generated a high rate of growth disturbances (leg length discrepancy and axis deviation) although none clinically relevant. Mild proximal tibial axis deviation in patients operated on near skeletal maturity should be further investigated.

LEVEL OF EVIDENCE

Level III.

STUDY DESIGN

Case-control study.

Is Delayed Anterior Cruciate Ligament Reconstruction Associated With a Risk of New Meniscal Tears? Reevaluating a Longstanding Paradigm

Background

Delayed anterior cruciate ligament (ACL) reconstruction has been associated with an increased risk of meniscal tears. However, studies comparing early versus delayed ACL reconstruction have not clearly demonstrated that meniscal tears diagnosed arthroscopically are new injuries as opposed to concomitant injuries sustained during ACL rupture.

Purpose

To determine whether and how delay of ACL reconstruction is associated with risk of "new" meniscal tears (defined as those visualized arthroscopically that had not been detected on magnetic resonance imaging [MRI]) in adult and pediatric patients.

Study Design

Cohort study; Level of evidence, 3.

Methods

We retrospectively identified patients who underwent primary ACL reconstruction between 2013 and 2022 at our institution. To ensure that MRI reflected initial intra-articular pathology, we included only patients who had an MRI scan within 3 weeks after injury (173 pediatric and 369 adult patients). Multivariate Poisson regression was performed to calculate the adjusted relative risk (ARR) of new meniscal tears after delayed (≥8 weeks from injury) operative treatment.

Results

The mean (± SD) time from injury to MRI was 1.0 ± 0.8 weeks for pediatric patients and 1.1 ± 0.7 weeks for adults. Less than half of the meniscal tears observed arthroscopically had been absent on initial MRI. New medial meniscal tears occurred in 15% of pediatric patients and 16% of adults. New lateral meniscal tears occurred in 48% of pediatric patients and 34% of adults. Among pediatric patients, delayed ACL reconstruction was associated with higher risk of new medial tears (ARR, 3.9; 95% CI, 1.5-10) but not lateral tears (ARR, 0.8; 95% CI, 0.4-1.5). In contrast, adults had no significant increase in risk of meniscal tears associated with operative delay.

Conclusion

Delayed ACL reconstruction may be acceptable in adults, who may be less active and less injury-prone than children and adolescents.

Meniscal repair failure following concurrent primary anterior cruciate ligament reconstruction: results from the New Zealand ACL Registry

PURPOSE

This study aimed to identify the risk factors for meniscal repair failure following concurrent primary anterior cruciate ligament (ACL) reconstruction.

METHODS

Prospective data recorded by the New Zealand ACL Registry and the Accident Compensation Corporation were reviewed. Meniscal repairs performed during concurrent primary ACL reconstruction were included. Repair failure was defined as a subsequent reoperation involving meniscectomy of the repaired meniscus. Multivariate survival analysis was performed to identify the risk factors for failure.

RESULTS

A total of 3,024 meniscal repairs were analysed with an overall failure rate of 6.6% (n = 201) at a mean follow-up of 2.9 years (SD 1.5). The risk of medial meniscal repair failure was higher with hamstring tendon autografts (adjusted HR [aHR] = 2.20, 95% CI 1.36-3.56, p = 0.001), patients aged 21-30 years (aHR = 1.60, 95% CI 1.30-2.48, p = 0.037) and in patients with cartilage injury in the medial compartment (aHR = 1.75, 95% CI 1.23-2.48, p = 0.002). The risk of lateral meniscal repair failure was higher in patients aged ≤ 20 years (aHR = 2.79, 95% CI 1.17-6.67, p = 0.021), when the procedure was performed by a low case volume surgeon (aHR = 1.84, 95% CI 1.08-3.13, p = 0.026) and when a transtibial technique was used to drill the femoral graft tunnel (aHR = 2.30, 95% CI 1.03-5.15, p = 0.042).

CONCLUSION

The use of a hamstring tendon autograft, younger age and the presence of medial compartment cartilage injury are risk factors for medial meniscal repair failure, whereas younger age, low surgeon volume and a transtibial drilling technique are risk factors for lateral meniscal repair failure.

LEVEL OF EVIDENCE

Level II.

Delaying anterior cruciate ligament reconstruction increases the rate and severity of medial chondral injuries

Aims

The aim of this study was to evaluate the association between chondral injury and interval from anterior cruciate ligament (ACL) tear to surgical reconstruction (ACLr).

Methods

Between January 2012 and January 2022, 1,840 consecutive ACLrs were performed and included in a single-centre retrospective cohort. Exclusion criteria were partial tears, multiligament knee injuries, prior ipsilateral knee surgery, concomitant unicompartmental knee arthroplasty or high tibial osteotomy, ACL agenesis, and unknown date of tear. A total of 1,317 patients were included in the final analysis, with a median age of 29 years (interquartile range (IQR) 23 to 38). The median preoperative Tegner Activity Score (TAS) was 6 (IQR 6 to 7). Patients were categorized into four groups according to the delay to ACLr: < three months (427; 32%), three to six months (388; 29%), > six to 12 months (248; 19%), and > 12 months (254; 19%). Chondral injury was assessed during arthroscopy using the International Cartilage Regeneration and Joint Preservation Society classification, and its association with delay to ACLr was analyzed using multivariable analysis.

Results

In the medial compartment, delaying ACLr for more than 12 months was associated with an increased rate (odds ratio (OR) 1.93 (95% confidence interval (CI) 1.27 to 2.95); p = 0.002) and severity (OR 1.23 (95% CI 1.08 to 1.40); p = 0.002) of chondral injuries, compared with < three months, with no association in patients aged > 50 years old. No association was found for shorter delays, but the overall dose-effect analysis was significant for the rate (p = 0.015) and severity (p = 0.026) of medial chondral injuries. Increased TAS was associated with a significantly reduced rate (OR 0.88 (95% CI 0.78 to 0.99); p = 0.036) and severity (OR 0.96 (95% CI 0.92 to 0.99); p = 0.017) of medial chondral injuries. In the lateral compartment, no association was found between delay and chondral injuries.

Conclusion

Delay was associated with an increased rate and severity of medial chondral injuries in a dose-effect fashion, in particular for delays > 12 months. Younger patients seem to be at higher risk of chondral injury when delaying surgery. The timing of ACLr should be optimally reduced in this population.

Effect of Delayed Anterior Cruciate Ligament Reconstruction on Repair of Concomitant Medial Meniscus Tears in Young Athletes

BACKGROUND

Delayed anterior cruciate ligament (ACL) reconstruction (ACLR) is associated with an increased risk of meniscal injury. Limited data are available regarding the relationship between surgical delay and meniscal repairability in the setting of ACLR in young patients.

PURPOSE

To determine whether time from ACL injury to primary ACLR was associated with the incidence of medial and/or lateral meniscal repair in young athletes who underwent meniscal treatment at the time of ACLR.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Records were retrospectively reviewed for patients aged 13 to 25 years who underwent primary ACLR between January 2017 and June 2020 by surgeons from a single academic orthopaedic surgery department. Demographic data were collected, and operative reports were reviewed to document all concomitant pathologies and procedures. Univariable and multivariable logistic regression analyses were used to determine factors associated with meniscal repair, including time elapsed from ACL injury to surgery.

RESULTS

Concomitant meniscal tears were identified and treated in 243 of 427 patients; their mean age was 17.9 ± 3.3 years, and approximately half (47.7%) of patients were female. There were 144 (59.3%) medial tears treated and 164 (67.5%) lateral tears treated; 65 (26.7%) patients had both medial and lateral tears treated. Median time from ACL injury to ACLR was 2.4 months (interquartile range, 1.4-4.7 months). Adjusted univariate analysis showed a statistically significant correlation between medial meniscal repair and time to surgery, with a 7% decreased incidence of medial meniscal repair per month elapsed between injury and surgery (odds ratio, 0.93 per month; 95% CI, 0.89-0.98; P = .006). No similar relationship was found between lateral meniscal repair and time to surgery (odds ratio, 1.02; 95% CI, 0.99-1.06; P = .24).

CONCLUSION

In the setting of concomitant ACL and meniscal injuries, surgical delay decreased the incidence of medial meniscal repair in young athletes by 7% per month from time of injury.

Increased Risk of Concomitant Meniscal Injuries in Adolescents With Elevated Body Mass Index After Anterior Cruciate Ligament Tear: A Systematic Review

PURPOSE

To investigate existing studies examining the association between body mass index (BMI) and outcomes of anterior cruciate ligament reconstruction (ACLR) in adolescent patients.

METHODS

A literature search was conducted on PubMed and Embase. Studies examining associations between BMI and outcomes after ACLR in adolescents were included. Quality assessment was performed. Data on patient age, sex, study design, time of follow-up, sample size, graft type, concomitant injuries (meniscal injury, surgical procedures), clinical outcomes (revision ACLR, postoperative weight gain, post-traumatic osteoarthritis [PTOA], range of motion [ROM]), and functional outcome (muscle strength) were extracted.

RESULTS

Eleven papers of Levels II-IV evidence were included. Five studies found positive correlations between BMI and risk of concomitant meniscal injuries. Two of them reported young patients with elevated BMI having 1.6 times greater odds of requiring meniscectomy (P < .01) and 1.031 times greater odds of requiring concomitant surgeries (P = .011). One study showed significant positive association of postoperative weight gain by time (r = 0.28, P < .01), with smaller increase in the overweight and obese groups compared with the normal-weight group. One study demonstrated greater cartilage breakdown in young patients with overweight and obesity postsurgery, contributing to PTOA (r = 0.42, P = .009). There was no clinically important difference in postoperative ROM and muscle strength. Four studies reviewed the association between BMI and revision ACLR risk, but results were heterogeneous and a firm conclusion cannot be drawn.

CONCLUSIONS

Adolescents with elevated BMI are more likely to have concomitant meniscal injuries and surgical procedures after ACL tear. There is some weak evidence of the association of elevated BMI with PTOA and slight postoperative weight gain post-ACLR. There may not be any clinically significant association of obesity with post-operative muscle strength and ROM, and current studies are inconclusive regarding the impact of BMI on revision ACLR risk.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

Reliability of MRI Detection of Kaplan Fiber Injury in Pediatric and Adolescent Patients with ACL Tears

Background:

While studies have described Kaplan fiber (KF) injury in up to 60% of adults with anterior cruciate ligament (ACL) tears, the incidence of KF injury in the pediatric and adolescent population remains unknown.

Purpose:

To (1) determine the reliability of using magnetic resonance imaging (MRI) to identify KF injury in the pediatric and adolescent population and (2) define the incidence of KF injury in these patients with acute ACL injuries.

Study Design:

Cohort study (diagnosis); Level of evidence, 3.

Methods:

The authors retrospectively identified patients ≤18 years of age who underwent ACL reconstruction for acute tears between 2013 and 2020. All preoperative MRI scans were reviewed independently and in a blinded fashion by 2 musculoskeletal radiologists, who noted the presence of the KF complex and any evidence of injury; interrater reliability was assessed. Patient characteristics, time from injury to MRI, laterality, and concomitant ligamentous or meniscal injuries were recorded, and associations between patient or injury characteristics and KF integrity on MRI were assessed.

Results:

In total, 51 patients (mean age, 14.9 years) met the inclusion criteria. Of these, 27 patients were female and 31 sustained an injury to the right knee. With respect to KF integrity, radiologist 1 visualized KF injury in 29% of patients, while radiologist 2 visualized KF injury in 35% of patients. In 12% of cases for radiologist 1 and 6% of cases for radiologist 2, KFs were unable to be visualized at all. The overall percentage agreement between the 2 radiologists was 76.5% with a kappa statistic of 0.57 (moderate agreement). There were no significant associations found between the presence of KF injury and patient age, sex, laterality, body mass index, concomitant ligamentous injury, or meniscal injury. However, visualization of KF injury on MRI was associated with a shorter time from index injury to MRI (15 days vs 23 days; P = .044).

Conclusion:

Approximately one-third of pediatric and adolescent patients who underwent ACL reconstruction were found to have KF injuries. Standard preoperative MRI scans can reliably be used to visualize KF injury in the majority of pediatric and adolescent patients with ACL tears, especially when the MRI is performed in the acute setting.

The Insidious Effects of Childhood Obesity on Orthopedic Injuries and Deformities

The current childhood obesity epidemic, affecting approximately 20% of American children and adolescents, is accompanied by unique orthopedic manifestations. The growing musculoskeletal system is susceptible to the endocrine effects of obesity, resulting in decreased bone mass and quality. As a result, obese children are at increased risk of musculoskeletal injury, fracture, and lower extremity deformities. The efficacy of nonoperative treatment such as casting or bracing may be limited by body habitus and surgical treatment is accompanied by increased risk of perioperative complications.

Validity of the McMurray Test for Meniscal Tear in Pediatric and Adolescent Patients

OBJECTIVE

The aim of this study was to identify the accuracy of the McMurray test in the adolescent and pediatric population.

DESIGN

Retrospective case series.

SETTING

Tertiary care, institutional.

PATIENTS

Inclusion criteria included patients who presented with unilateral knee pain and were seen by pediatric sports medicine physicians. Patients were excluded if their knee pain was related to any underlying conditions. Three hundred patient charts were reviewed, and 183 patients (age range: 8-18 years, mean: 14 years; 74 male) met the inclusion criteria.

INTERVENTIONS

Symptoms at initial visit (knee pain).

MAIN OUTCOME MEASURES

Presence of a meniscal tear using the McMurray test.

RESULTS

Eighty-four percent (160/191) of patients had a McMurray test documented as performed by the physician, and 17% (27/160) elucidated a positive response. Of 26 patients who had a positive McMurray and underwent magnetic resonance imaging (MRI), 16 (62%) showed a meniscal tear on their MRI. However, of the 87 patients who had a negative McMurray and still underwent MRI, 25 (29%) had a positive meniscal tear. The sensitivity, specificity, positive predictive value, and negative predictive value were 39%, 86%, 62%, and 71%, respectively.

CONCLUSION

In a pediatric and adolescent population, the McMurray test was negative for 61% (23/38) of meniscal tears identified on MRI.

CLINICAL RELEVANCE

Although the test can be a useful tool as a part of a thorough evaluation, combining it with mechanical symptoms, patient history and imaging may be more helpful to diagnose a meniscus tear.

Influence of Sex, Race/Ethnicity, and Socioeconomic Factors on Meniscal Treatment With Pediatric and Adolescent ACL Reconstruction

BACKGROUND

The rate of anterior cruciate ligament (ACL) reconstruction is increasing over time in pediatric/adolescent populations, but there is less evidence to support how concomitant meniscal procedures are changing over time. There are also less data to suggest which characteristics are associated with meniscectomy versus meniscal repair treatment.

HYPOTHESIS

Age, sex, race/ethnicity, income, and insurance type may independently affect the rate of concomitant meniscal procedures and treatment modalities in pediatric patients with ACL reconstruction.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

The Pediatric Health Information System database was queried for all patients aged ≤18 years who underwent ACL reconstruction with or without concomitant meniscal procedures from 2015 to 2019. Basic demographic data including age, sex, self-identified race/ethnicity, rural-urban commuting area code, predicted median income, and insurance status were collected. Linear regression was used to model trends and multiple logistic regression modeling was used to test for associations.

RESULTS

A total of 14,398 patients aged ≤18 years underwent ACL reconstruction during the study period, with 8337 patients (58%) having concomitant meniscal procedures with a 1.24-fold increase over 5 years. Of the concomitant meniscal treatment cohort, 41% had a meniscectomy and 59% had meniscal repair. There was a 0.82-fold change in meniscectomy and a 1.67-fold increase in meniscal repair during the study period. Male patients, older patients, Black race, living in an urban area, and those with nonprivate insurance had increased odds of undergoing a concomitant meniscal procedure (all P < .05). Patients of non-White race and those with nonprivate insurance had increased odds of having a meniscectomy versus meniscal repair (all P < .05). There were no associations detected between income bracket and the outcomes in this study.

CONCLUSION

This study shows that in pediatric and adolescent patients undergoing ACL reconstruction, there was a rise in concomitant meniscal procedures from 2015 to 2019. In addition, patients of non-White race and those with nonprivate insurance have increased odds of undergoing meniscectomy versus meniscal repair.

Treatment Trends in Meniscal Pathology in the Setting of Concomitant ACL Injuries in Pediatric and Young Adult Patients: An Insurance Database Study

BACKGROUND

Meniscal pathology is commonly encountered in the setting of anterior cruciate ligament (ACL) rupture and is increasingly common in the pediatric and adolescent population. Studies have shown that over half of individuals presenting with ACL rupture will have concurrent meniscal pathology.

PURPOSE

To define trends in the utilization of meniscal procedures (ie, meniscus repair vs partial meniscectomy) and short-term complications in pediatric and young adult patients with meniscal pathology in the setting of a concurrent ACL reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The IBM MarketScan Commercial Database was utilized to identify ACL reconstruction procedures performed between 2006 and 2018 for individuals aged 5 to 30 years. Annual proportions of meniscectomy and meniscal repair were analyzed, and short-term complications were compared between pediatric/adolescent patients (aged 5-17 years) and young adults (aged 18-30 years).

RESULTS

An overall 40,736 records of individuals <18 years old with ACL tears were included. The pediatric/adolescent population had a significantly lower proportion of concomitant meniscal procedures (56.8%; 23,149/40,736) than the young adult population (59.7%; 33,764/56,515; P < .01). From 2006 to 2018, utilization of meniscal repair in the setting of ACL reconstruction steadily increased (20.1% to 35.1% [+15 percentage points], P < .01), while the proportion with meniscectomy decreased (34.4% to 21.3% [-13.1 percentage points], P < .01). There was no difference in rate of reoperation for repeat meniscal repair or meniscectomy in the pediatric/adolescent population for those undergoing meniscal repair versus meniscectomy within 180 days of primary surgery (1.7% [188/10,766] vs 1.5% [186/12,383]; P = .14).

CONCLUSION

From 2006 to 2018, the proportion of patients receiving ACL reconstruction with concomitant meniscal repair increased (20.1% to 35.1%) while the proportion with meniscectomy decreased (34.4% to 21.3%) in the pediatric/adolescent population. Meniscal repair was not associated with a higher 180-day rate of reoperation for repeat meniscal repair or meniscectomy than meniscectomy in the setting of ACL reconstruction.

Age- and sex-specific differences in ACL and ACL bundle size during adolescent growth

Anterior cruciate ligament (ACL) injuries are increasingly common in adolescents, and injuries in this age-group are associated with many unique challenges. Recent large animal studies suggest that the size and function of the major bundles of the ACL change differently throughout skeletal growth. To better aid clinical treatment of pediatric partial ACL tears and better predict outcomes from age-specific treatments, there is a need to measure changes in ACL bundle size in humans during growth. As such, the objective of this study was to compare changes in the length and cross-sectional area (CSA) of the ACL and its primary bundles in adolescent human subjects. Magnetic resonance imaging (MRI) scans were analyzed to determine the visibility and integrity of the ACL and its anteromedial and posterolateral bundles. MRI scans were considered from a retrospective database of subjects ranging from 10 to 18 years of age. The ACL and its anteromedial and posterolateral bundles were segmented and reconstructed into 3D models, and length and CSA were calculated. Total ACL length and CSA were greater in males compared with females, with a statistically significant interaction between age and sex for CSA. Sex had a significant effect on the CSA of both bundles. These sex-dependent differences emerge with moderate to large effect sizes (range: d = 0.50 to d = 1.23) beginning around 13 years of age. Along with ACL bundle structure-function relationships previously established in preclinical animal models, these findings may point toward biomechanical changes in the adolescent human ACL.

Paediatric Anterior Cruciate Ligament (ACL) Injuries: Current Concepts Review

BACKGROUND

Over the past two decades, there has been a documented increase in paediatric ACL injuries because of a rise in younger age sports participation at the competitive level, awareness about sports-related injuries, and advanced imaging modalities.

METHODS

A PubMed electronic database search was done, which revealed 1366 hits over the last five years (2016 - 2020). Finally, 37 articles that contributed to new findings were included. This review was conducted based on predefined research questions.

RESULTS AND CONCLUSION

Early surgical reconstruction is recommended in children due to the increasing demand for early return to sports and to prevent the instability that can lead to progressive cartilage and meniscal damage. With the evolution of several "physeal sparing" ACL reconstruction (ACLR) techniques, a favorable clinical outcome with less growth disturbance is achievable. Although different autograft options are available, hamstring autografts are most commonly preferred. A specific pattern of a bone bruise not extending into the metaphysis, and lateral meniscus tears are the most common associated injuries. Following paediatric ACLR, complications like graft rupture and contralateral ACL injuries are two to three folds higher than with adult ACLR. Unprepared early return to sports is one of the reasons for increased complication rates in children; thus, clearance criteria for return to sports need to be standardized, and early return to sports (< 9 months post ACLR) should be avoided. Neuromuscular training protocols are recommended to minimize complications like graft ruptures.

Graft Choice for Anterior Cruciate Ligament Reconstruction in Women Aged 25 Years and Younger: A Systematic Review

CONTEXT

Although anterior cruciate ligament (ACL) tears are relatively common in athletic populations, few studies have systematically reviewed graft choice in young women.

OBJECTIVE

To quantitatively and qualitatively examine reported outcomes for graft choice in women aged 25 years and younger undergoing primary ACL reconstruction.

DATA SOURCE

A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. An electronic search in the PubMed (includes MEDLINE) and EMBASE databases was completed using a combination of key terms.

STUDY SELECTION

Studies were included if they reported graft choice outcomes in women aged 25 years and younger.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

The following information was extracted: title, author, year of publication, number of female patients and age, graft type, follow-up, and patient-reported outcome measures. The following outcome scores were identified as being reported or not reported by each study: graft failure, contralateral ACL (CACL) rupture, IKDC (International Knee Documentation Committee), graft survival (Kaplan-Meier), Lysholm, Tegner, KT-1000, kneeling pain, return to sport, and Lachman.

RESULTS

Of 1170 identified articles, 16 met inclusion criteria, reporting on 1385 female patients aged 25 years and younger. Comparison of 655 bone-patellar tendon-bone (BPTB) versus 525 hamstring tendon (HT) autografts showed significant differences in mean failure rate between BPTB autografts (6.13% ± 2.58%) and HT autografts (17.35% ± 8.19%), P = 0.001. No statistically significant differences in CACL failure rates were found between BPTB autografts and HT autografts (P = 0.25). Pooled results for IKDC were possible in 3 of the HT autograft studies, showing a mean score of 88.31 (95% CI 83.53-93.08). Pooled Lysholm score results were possible in 2 of the HT autograft studies, showing a mean score of 93.46 (95% CI 91.90-95.01).

CONCLUSION

In female patients aged 25 years and younger, BPTB autografts showed significantly less graft failure compared with HT autografts. However, BPTB autografts had comparable patient-reported outcomes compared with HT autografts with the available data. The overall state of evidence for graft choice in female patients aged 25 years and younger is low. Future studies should report statistics by age and sex to allow for further analysis of graft choice for this specific population that is known to be more vulnerable to ACL injury.

Outcomes of pediatric anterior cruciate ligament reconstructions in patients with and without bucket handle meniscus repairs

The purpose of this study was to report the outcomes of concomitant bucket handle meniscal tear (BHMT) repair and anterior cruciate ligament (ACL) reconstruction and to compare the outcomes with those after isolated ACL reconstruction in patients aged ≤16 years. Patients in our database from 2013 to 2017 were retrospectively analyzed. Patients were assigned to one of two treatment groups based on the presence of BHMTs: no meniscal tear group (group A) and BHMT group (group B). All BHMTs were repaired using the combined inside-out with all-inside technique. This study included 64 knees divided into two groups: 47 knees in group A and 17 knees in group B. There was a significant difference in the interval between ACL injury and surgery between groups A and B (69 vs. 150 days, respectively; P < 0.001). Mean postoperative International Knee Documentation Committee and Lysholm scores in group A were slightly, although significantly, improved compared to those in group B (96.5 vs. 92.6, respectively; P < 0.05, and 98 vs. 95, respectively; P < 0.05). There were no significant differences in postoperative anteroposterior laxity and graft failure rate between the groups. In group B, four patients (23.5%) required surgery for incomplete meniscal healing. Postoperative International Knee Documentation Committee and Lysholm scores of patients with BHMTs were significantly lower than those of patients without any meniscal tear, although with significant improvement in the amount of instability. Level of evidence was Level III.

Long-term evaluation of pediatric ACL reconstruction: high risk of further surgery but a restrictive postoperative management was related to a lower revision rate

INTRODUCTION

The guidelines regarding rehabilitation after pediatric anterior cruciate ligament reconstruction (ACLR) are sparse. The aim of the study was to retrospectively describe the long-term outcome regarding further surgery and with special emphasis on the revision rate after two different postoperative rehabilitation programs following pediatric ACLR.

MATERIAL AND METHODS

193 consecutive patients < 15 years of age who had undergone ACLR at two centers, A (n = 116) and B (n = 77), in 2006-2010 were identified. Postoperative rehabilitation protocol at A: a brace locked in 30° of flexion with partial weight bearing for 3 weeks followed by another 3 weeks in the brace with limited range of motion 10°-90° and full weight bearing; return to sports after a minimum of 9 months. B: immediate free range of motion and weight bearing as tolerated; return to sports after a minimum of 6 months. The mean follow-up time was 6.9 (range 5-9) years. The mean age at ACLR was 13.2 years (range 7-14) years. The primary outcome measurement in the statistical analysis was the occurrence of revision. Multivariable logistic regression analysis was performed to investigate five potential risk factors: surgical center, sex, age at ACLR, time from injury to ACLR and graft diameter.

RESULTS

Thirty-three percent had further surgery in the operated knee including a revision rate of 12%. Twelve percent underwent ACLR in the contralateral knee. The only significant variable in the statistical analysis according to the multivariable logistic regression analysis was surgical center (p = 0.019). Eight percent of the patients at center A and 19% of the patients at B underwent ACL revision.

CONCLUSIONS

Further surgery in the operated knee could be expected in one third of the cases including a revision rate of 12%. The study also disclosed a similar rate of contralateral ACLR at 12%. The revision rate following pediatric ACLR was lower in a center which applied a more restrictive rehabilitation protocol.

LEVEL OF EVIDENCE

Case-control study, Level III.

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.

Elevated BMI increases concurrent pathology and operative time in adolescent ACL reconstruction

PURPOSE

The purpose of this study was to (1) report on the incidence of concurrent surgical pathology at the time of adolescent ACL reconstruction, (2) evaluate patient risk factors for concurrent pathology, and (3) measure the effect of BMI on operating room (OR) time.

METHODS

A retrospective analysis of the NSQIP database for the years 2005-2017 was conducted. Nine-hundred and seventeen patients 18 years of age and younger who underwent ACL reconstruction (ACLR) were identified using CPT code 29888 and patients undergoing surgery for multi-ligamentous knee injuries were excluded. The mean patient age was 17.6 years (range 14-18, standard deviation 0.52) and consisted of 546 males (59.5%) and 371 females (40.5%). Logistic regression was used to assess the relationship between BMI and additional CPT codes for internal derangement at the time of surgery. Internal derangement was defined as any procedure for the treatment of a meniscal tear, chondral lesion, or loose body removal. Linear regression analysis was then performed to evaluate the effect of BMI on operative time.

RESULTS

43.7% of patients undergoing ACLR required an associated procedure for internal derangement. Additionally, the risk of requiring additional procedures for internal derangement increased by 3.1% per BMI point. BMI was also predictive of operative time, independent of the number of additional procedures. Specifically, the operative time increased by nearly one minute for every point increase in BMI (58.0 s).

CONCLUSIONS

Adolescent patients with an elevated BMI were much more likely to require additional surgical procedures for internal derangement at the time of ACL reconstruction. Additionally, BMI was a significant predictor for longer operative times.

LEVEL OF EVIDENCE

Level III.

Association Between Knee Alignment and Meniscal Tear in Pediatric Patients with Anterior Cruciate Ligament Injury

BACKGROUND

The present study aimed to evaluate the association between elapsed time from anterior cruciate ligament (ACL) injury to surgical treatment and the incidence of meniscal tears in a cohort of patients ≤16 years old with varus-aligned and non-varus-aligned knees.

METHODS

The study cohort included 123 patients ≤16 years old who underwent primary ACL reconstruction between January 2016 and March 2020. Knee alignment was expressed as the hip-knee-ankle angle (HKAA), as measured preoperatively on an anteroposterior view of 3-dimensional computed tomography of the full length of the lower limb. Varus alignment was defined as an HKAA ≥181.0°, and non-varus alignment was defined as an HKAA <181.0°. Patients were divided into groups according to knee alignment and the elapsed time from injury to surgical treatment: early-treatment group (<60 days) and delayed-treatment group (≥60 days).

RESULTS

A total of 64 varus-aligned and 59 non-varus-aligned knees were identified. Among patients with varus-aligned knees, those in the delayed-treatment group showed a significantly lower rate of lateral meniscal tears (6 of 30, 20%) compared with those in the early-treatment group (17 of 34, 50%; p = 0.015). Among patients with non-varus-aligned knees, there was no significant difference in meniscal tears of any type between the early and delayed-treatment groups. Among patients without medial meniscal injury identified on initial magnetic resonance imaging, those with varus-aligned knees in the delayed-treatment group showed a significantly higher rate of medial meniscal tears at the time of the surgical procedure (8 of 20, 40%) compared with those with non-varus-aligned knees (1 of 18, 6%; p = 0.015).

CONCLUSIONS

Delayed ACL reconstruction in patients ≤16 years old with varus-aligned knees might be associated with an increased incidence of secondary medial meniscal tears. Accordingly, earlier ACL reconstruction in patients with varus-aligned knees should be considered.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Failure After Anterior Cruciate Ligament Reconstruction in a Pediatric Population: A Prediction Algorithm

Background:

Anterior cruciate ligament reconstruction (ACLR) in pediatric patients is becoming increasingly common. There is growing yet limited literature on the risk factors for revision in this demographic.

Purpose:

To (1) determine the rate of pediatric revision ACLR in a nationally representative sample, (2) ascertain the associated patient- and injury-specific risk factors for revision ACLR, and (3) examine the differences in the rate and risks of revision ACLR between pediatric and adult patients.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

The PearlDiver patient record database was used to identify adult patients (age ≥20 years) and pediatric patients (age <20 years) who underwent primary ACLR between 2010 and 2015. At 5 years postoperatively, the risk of revision ACLR was compared between the adult and pediatric groups. ACLR to the contralateral side was also compared. Multivariate logistic regression was used to determine the significant risk factors for revision ACLR and the overall reoperation rates in pediatric and adult patients; from these risk factors, an algorithm was developed to predict the risk of revision ACLR in pediatric patients.

Results:

Included were 2055 pediatric patients, 1778 adult patients aged 20 to 29 years, and 1646 adult patients aged 30 to 39 years who underwent ACLR. At 5 years postoperatively, pediatric patients faced a higher risk of revision surgery when compared with adults (18.0 % vs 9.2% [adults 20-29 years] and 7.1% [adults 30-39 years]; P < .0001), with significantly decreased survivorship of the index ACLR (P < .0001; log-rank test). Pediatric patients were also at higher risk of undergoing contralateral ACLR as compared with adults (5.8% vs 1.6% [adults 20-29 years] and 1.9% [adults 30-39 years]; P < .0001). Among the pediatric cohort, boys (odds ratio [OR], 0.78; 95% CI, 0.63-0.96; P = .0204) and patients >14 years old (OR, 0.62; 95% CI, 0.45-0.86; P = .0035) had a decreased risk of overall reoperation; patients undergoing concurrent meniscal repair (OR, 1.84; 95% CI, 1.43-2.38; P < .0001) or meniscectomy (OR, 2.20; 95% CI, 1.72-2.82; P < .0001) had an increased risk of revision surgery. According to the risk algorithm, the highest probability for revision ACLR was in girls <15 years old with concomitant meniscal and medial collateral ligament injury (36% risk of revision).

Conclusion:

As compared with adults, pediatric patients had an increased likelihood of revision ACLR, contralateral ACLR, and meniscal reoperation within 5 years of an index ACLR. Families of pediatric patients—especially female patients, younger patients, and those with concomitant medial collateral ligament and meniscal injuries—should be counseled on such risks.

Rates of Concomitant Meniscal Tears in Pediatric Patients With Anterior Cruciate Ligament Injuries Increase With Age and Body Mass Index

Background

Anterior cruciate ligament (ACL) tears are frequently associated with meniscal injury. Risk factors for concomitant meniscal injuries have been studied in the adult population but less so in pediatric patients.

Purpose

To evaluate the relationship between age and body mass index (BMI) and the presence of a concomitant meniscal tear at the time of ACL reconstruction (ACLR) in pediatric patients.

Study Design

Case-control study; Level of evidence, 3.

Methods

A single-institution retrospective review was performed of patients aged <19 years who underwent primary ACLR over a 3.5-year period. Revision ACLR and multiligament knee reconstructions were excluded. Logistic regression was used to identify risk factors associated with having a meniscal tear at the time of surgery. Subgroup analysis was performed for medial and lateral meniscal tears.

Results

Included in this study were 453 patients (230 males, 223 females; median age, 15 years). Of these, 265 patients (58%) had a meniscal tear, including 150 isolated lateral meniscal tears, 53 isolated medial meniscal tears, and 62 patients with both lateral and medial meniscal tears. Median time from injury to surgery was 48 days. For every 1-year increase in age, there was a 16% increase in the adjusted odds of having any meniscal tear (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.05-1.27; P = .002), with a 20% increase in the odds of having a medial meniscal tear (OR, 1.20; 95% CI, 1.07-1.35; P = .002) and a 16% increase in the odds of having a lateral meniscal tear (OR, 1.16; 95% CI, 1.05-1.27; P = .003). For every 2-point increase in BMI, there was a 12% increase in the odds of having any meniscal tear (OR, 1.12; 95% CI, 1.02-1.22; P = .016) and a 10% increase in the odds of having a lateral meniscal tear (OR, 1.10; 95% CI, 1.01-1.19; P = .028).

Conclusion

Pediatric patients undergoing ACLR had a 58% incidence of concomitant meniscal pathology. Increasing age and BMI were independent risk factors for these injuries, while no association was found between time to surgery and meniscal pathology.

Age, rehabilitation and surgery characteristics are re-injury risk factors for adolescents following anterior cruciate ligament reconstruction

OBJECTIVES

To examine the effect of age on post-ACLR rehabilitative outcomes and identify surgical/rehabilitative characteristics as ACL re-injury risk factors in adolescents.

DESIGN

Cohort study.

SETTING

Children's hospital.

PARTICIPANTS

273 adolescents with first-time ACLR.

MAIN OUTCOME MEASURES

Demographics, injury history, surgery, and outcomes documented during post-ACLR physical therapy (PT) sessions were extracted from medical records. Effects of age on outcomes were examined using multivariate regression. ACL re-injury risk factors were identified using survival analysis with Cox regression.

RESULTS

Re-injury was recorded in 47 patients (17.2%) with a median follow-up time of 3.1 years and median re-injury time of 13.4 months post-surgery. Younger age (Hazard-Ratio, HR = 1.264 per year decrease; P = 0.005), receiving surgery within 1 month post-injury (HR = 3.378 vs. >3 months; P = 0.012), starting PT within 3 days post-surgery (HR = 3.068; P = 0.022), and decreased number of PT sessions (HR = 1.118 per 3-session decrease; P = 0.010) increased re-injury risk. Although age was associated with re-injury risk, age was not associated with any outcome (P > 0.059).

CONCLUSION

Adolescents who are younger, receive surgery and post-surgery PT sooner, or attend fewer PT sessions may be at an increased re-injury risk. Younger patients achieved similar outcomes despite elevated re-injury risk. Current discharge criteria are inadequate in identifying high re-injury risk patients.

Towards Standardization in the Diagnostic Evaluation of ACL Injuries in Skeletally Immature Patients

The purpose of this study was to establish consensus regarding a standardized approach to the diagnostic evaluation of ACL tears in pediatric/adolescent patients. Despite an abundance of literature evaluating management techniques, no standardized consensus exists regarding evaluation in these patients. A three-step classic Delphi technique was employed. The panel included 12 Orthopaedic Sports Medicine specialists from across the United States with training in pediatric and adult ACL injuries. Panelists were presented with four clinical vignettes. Consensus was established if ≥66% of respondents reached agreement. Across all four rounds of this study, 100% participation was achieved, and consensus was reached for a majority of diagnostic domains. For history, previous injuries, sports participation, and current symptoms were endorsed for all vignettes. The consensus radiographic sequences across all four vignettes included: standing AP, flexion (tunnel or notch view), lateral, long-leg alignment, and bone age (left hand) views. Radiographic interpretation responses met consensus with interpretations were split by gender. Cross-sectional imaging met consensus with 100% support for MRI. In this Delphi study, we identified a standardized diagnostic treatment approach derived from expert opinion applicable to all skeletally immature patients with ACL tears, which can serve as a framework for evaluation to aid clinical decision making.

Incidence of Medial and Lateral Meniscal Tears After Delayed Anterior Cruciate Ligament Reconstruction in Pediatric Patients

Background:

The treatment of pediatric anterior cruciate ligament (ACL) injuries is controversial, and no clear management guidelines have been established.

Purpose:

To evaluate the association between elapsed time from ACL injury to surgery and the incidence of meniscal tears and chondral injuries in patients aged ≤16 years.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Between December 2012 and April 2019, a total of 207 consecutive knees in 207 patients aged ≤16 years underwent primary ACL reconstruction and were included in this study. Patients were divided into 1 of 2 groups (early group [≤150 days] and delayed group [>150 days]) based on the time between injury and surgery. Patient records, including arthroscopic findings identified by 2 experienced knee surgeons at the time of surgery, were reviewed for demographic information, incidence and types of medial and lateral meniscal tears, and chondral injuries and their locations in each group.

Results:

There were 180 knees in the early group and 27 knees in the delayed group. The delayed group showed a significantly higher rate of medial meniscal tears than the early group: 16 of 27 (59.2%) and 46 of 180 (25.6%), respectively (odds ratio [OR], 4.24 [95% CI, 1.83-9.33]; P = .0011). The delayed group had a significantly lower rate of lateral meniscal tears than the early group: 6 of 27 (22.2%) and 90 of 180 (50.0%), respectively (OR, 0.29 [95% CI, 0.11-0.70]; P = .007). The delayed group had significantly higher rates of chondral injuries in the medial femoral condyle and the medial tibial plateau than the early group: 8 of 27 (29.6%) and 25 of 180 (13.9%), respectively (OR, 2.61 [95% CI, 1.03-6.62]; P = .049), and 2 of 27 (7.4%) and 1 of 180 (0.6%), respectively (OR, 14.32 [95% CI, 1.58-208.10]; P = .045).

Conclusion:

Delayed ACL reconstruction was associated with an increased incidence of medial chondral injuries and medial meniscal tears but with a decreased incidence of lateral meniscal tears.

One in 5 Athletes Sustain Reinjury Upon Return to High-Risk Sports After ACL Reconstruction: A Systematic Review in 1239 Athletes Younger Than 20 Years

CONTEXT

Anterior cruciate ligament (ACL) reconstruction (ACLR) is frequently performed in patients younger than 20 years whose goal is to return to sport (RTS). Varying reinjury rates have been reported, and the factors responsible are unclear. Studies differ with regard to age, graft type, surgical techniques, postoperative rehabilitation, RTS guidelines, and methods used to determine ACL failures.

OBJECTIVE

To determine RTS rates; the effect of participation in high-risk sports, sex, and graft type on ACL reinjury rates; and whether objective test criteria before RTS correlate with lower reinjury rates.

DATA SOURCES

A systematic review of the literature from inception to May 31, 2019, was conducted using the PubMed and Cochrane databases.

STUDY SELECTION

Studies on transphyseal ACLR in athletes <20 years old with a minimum mean follow-up of 2 years that reported reinjury rates, the number that RTS, and detailed the type of sport were included.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

A total of 1239 patients in 8 studies were included; 87% returned to sport and 80% resumed high-risk activities. Of the patients, 18% reinjured the ACL graft and/or the contralateral ACL. Nine percent of patellar tendon autografts and 15% of hamstring autografts failed (odds ratio [OR], 0.52; P = 0.002). Of reinjuries, 90% occurred during high-risk sports. Male patients had a significantly higher rate of ACL graft failure than female patients (OR, 1.64; P = 0.01). There was no sex-based effect on contralateral ACL injuries. Only 1 study cited objective criteria for RTS.

CONCLUSION

A high percentage of athletes returned to sport, but 1 in 5 suffered reinjuries to either knee. Male patients were more likely to reinjure the ACL graft. Objective criteria for RTS were rarely mentioned or not detailed. The need for testing of knee stability, strength, neuromuscular control, agility, and psychological measures before RTS remains paramount in young athletes.

Inside-Out Repair of the Meniscus in Concomitant Anterior Cruciate Ligament Reconstruction: Absorbable Versus Nonabsorbable Sutures

PURPOSE

To compare the clinical and magnetic resonance imaging (MRI) outcomes of meniscal repair using absorbable versus nonabsorbable sutures in patients undergoing concomitant anterior cruciate ligament reconstruction.

METHODS

Data of 142 patients who underwent meniscal repair with concomitant anterior cruciate ligament reconstruction using either absorbable or nonabsorbable sutures for longitudinal meniscal tear were retrospectively reviewed. Inside-out suture technique was used for all meniscal repairs. Weight bearing and flexion (>90°) were allowed after 6 weeks postoperatively. Clinical evaluations were assessed by the International Knee Documentation Committee subjective score, Lysholm score, and Tegner activity score preoperatively and at 2-year follow-up. MRI outcomes at 1-year follow-up were compared to identify the successful healing (complete or partial healing) rate and incidence of additional meniscal tears. Subgroup analysis was performed to evaluate the results of medial or lateral meniscus.

RESULTS

Eighty patients underwent meniscal repair using absorbable sutures (mean age, 26.3 ± 11.9 years) and 62 patients with nonabsorbable sutures (mean age, 27.2 ± 10.0 years). There were no differences in zone and length of meniscal tears and stability tests between the groups. At a 2-year follow-up, all clinical scores had improved in both groups but did not differ significantly between the groups. Successful healing rate based on 1-year postoperative MRI was not significantly different between the absorbable and nonabsorbable sutures (93.7% vs 96.8%, P = .469). However, the absorbable sutures showed a lower additional tear incidence than the nonabsorbable sutures (2.5% vs 9.6%, P = .031). Subgroup analysis showed that the successful healing rate was not significantly different between the suture materials in both the medial and lateral menisci.

CONCLUSIONS

The use of absorbable sutures leads to comparable healing rates to and lower incidence of additional tears than nonabsorbable sutures in patients undergoing meniscal repair with anterior cruciate ligament reconstruction.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Evidence too weak to guide surgical treatment decisions for anterior cruciate ligament injury: a systematic review of the risk of new meniscal tears after anterior cruciate ligament injury

OBJECTIVE

To investigate the risk of new meniscal tears after treatment for anterior cruciate ligament (ACL) injury, in children and adults with and without ACL reconstruction.

DESIGN

Prognosis systematic review (PROSPERO registration number CRD42016036788).

METHODS

We searched Embase, Ovid Medline, Cochrane, CINAHL, SPORTDiscus, PEDro and Google Scholar from inception to 3rd May 2018. Eligible articles included patients with ACL injury (diagnosis confirmed by MRI and/or diagnostic arthroscopy), reported the number of meniscal tears at the time of ACL injury diagnosis/start of treatment and reported the number of new meniscal tears that subsequently occurred. Articles with fewer than 20 patients at follow-up, and articles limited to ACL revision surgery or multi-ligament knee injuries were excluded. Two independent reviewers screened articles, assessed eligibility, assessed risk of bias and extracted data. We judged the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation (GRADE) working group methodology.

RESULTS

Of 75 studies included in the systematic review, 54 studies with 9624 patients and 501 new meniscal tears were appropriate for quantitative analysis. Heterogeneity precluded data pooling. The risk of new meniscal tears was 0%-21% when follow-up was <2 years, 0%-29% when follow-up was 2 to 5 years, 5%-52% when follow-up was 5 to 10 years and 4%-31% when follow-up was longer than 10 years. The proportion of studies with high risk of selection, misclassification and detection bias was 84%, 69% and 68%, respectively. Certainty of evidence was very low.

CONCLUSION

New meniscal tears occurred in 0%-52% of patients between 4 months and 20 years (mean 4.9±4.4 years) following treatment for ACL injury. The certainty of evidence was too low to guide surgical treatment decisions. This review cannot conclude that the incidence of new meniscal tears is lower if ACL injury is treated with surgery compared with treatment with rehabilitation only.

Epidemiology, Injury Patterns, and Treatment of Meniscal Tears in Pediatric Patients: A 16-Year Experience of a Single Center

Background:

Meniscal injuries in children continue to increase, which may be attributable to increasing levels of athletic participation and may be associated with additional injuries or need for additional surgeries.

Purpose:

To better understand the patterns of pediatric meniscal injuries by analyzing tear location, morphologic features, and associated injury patterns over a 16-year period.

Study Design:

Case series; Level of evidence, 4.

Methods:

Pediatric patients were identified and were included in the study if age at the time of initial surgery for meniscal tear was between 5 and 14 years for female patients and 5 and 16 years for male patients. Patients were observed until age 18, and any subsequent surgeries were noted. Demographic factors, tear type and location, associated injuries, and treatment type were analyzed.

Results:

Mean patient age at surgery was 13.3 years, and 37% of patients were female. A total of 1040 arthroscopic meniscal surgeries in 880 pediatric patients were evaluated. There were 160 reoperations in 138 patients, representing a reoperation rate of 15%. These included 98 reoperations on the ipsilateral knee in 88 patients and 62 operations for injuries to the contralateral knee in 50 patients; 53% of surgeries were meniscal repair, as opposed to partial meniscectomy, and the most common technique was an all-inside repair (91%). Significant differences were identified between male and female patients. Male patients were more likely to have lateral meniscus (74% vs 65%), posterior horn (71% vs 60%), peripheral (45% vs 30%), and vertical tears (31% vs 21%); concomitant ACL injury (50% vs 40%); and an associated osteochondritis dissecans lesion (7% vs 4%). Female patients were more likely to have medial meniscus (24% vs 17%), anterior horn (25% vs 15%), and degenerative tears (34% vs 26%); discoid meniscus (33% vs 24%); and isolated meniscal tears (47% vs 33%).

Conclusion:

This evaluation of a large series of patients has helped characterize injury patterns associated with pediatric meniscal surgeries. Most meniscal tears were repaired (53%) and were associated with additional injuries (62%), especially anterior cruciate ligament injuries (48%). More than 25% of patients had a discoid meniscus. Injury patterns differed significantly between male and female patients.

Variability in rehabilitation protocols following pediatric anterior cruciate ligament (ACL) reconstruction

Objectives: The objective of this study was to assess the variability of publicly available pediatric anterior cruciate ligament (ACL) reconstruction rehabilitation protocols produced by academic orthopedic surgery departments and children's hospitals.Methods: A web-based search was performed to identify rehabilitation protocols. Protocol and literature review guided the development of a comprehensive scoring rubric that was used to assess protocols for the presence and timing of postoperative adjunctive therapy and physical therapy recommendations.Results: A search of 180 academic orthopedic surgery programs and 250 children's hospitals identified 21 rehabilitation protocols. A majority of these protocols (90%) recommended postoperative adjunctive therapies such as bracing (81%), cryotherapy (43%), electrical muscle stimulation (24%), and/or continuous passive motion (14%). Several protocols (57%) recommended a specific weight-bearing status in the immediate postoperative period, but there was minimal consensus on that status. Conversely, there was more agreement amongst protocols that recommended strength exercises (52%); a majority of protocols suggested quad sets (91%), ankle pumps (73%), leg press (64%), and/or double-leg squats (55%). Ten protocols (48%) recommended initiation of stretches in the first week following surgery, and most commonly suggested patella mobilizations start at an average of 1.9 weeks postop (range 0-8 weeks). Twelve protocols (57%) discussed return to play, with an average recommended return to play at 7.5 months (range 3-11 months) postoperatively. However, few protocols recommended that patients get approval from their surgeon (19%) or pass specific tests (24%) prior to return to play.Conclusion: Few academic departments of orthopedic surgery or children's hospitals publish pediatric ACL reconstruction protocols online. Given the substantial variability observed amongst these protocols and recent findings that patients increasingly turn to the internet for medical information, this study suggests that standardization of pediatric ACL reconstruction rehabilitation has the potential to further optimize patient care.

Paediatric anterior cruciate ligament tears: management and growth disturbances. A survey of EPOS and POSNA membership

PURPOSE

The therapeutic algorithm of paediatric anterior cruciate ligament (ACL) tears remains controversial. The primary aim of the study was to describe variations in practice patterns among European Paediatric Orthopaedic Society (EPOS) and Pediatric Orthopaedic Society of North America (POSNA) members with respect to management of ACL tears in skeletally immature patients. The secondary objective was to determine the number, type and severity of growth disturbances associated with ACL reconstruction (ACLR).

METHODS

An email invitation to complete a 52-question survey was sent to all members of POSNA and EPOS. Data were collected automatically. Descriptive statistics were applied.

RESULTS

In all, 305 (25.4%) surgeon members responded. Only 182 (60%) of the participants treated ACL injuries in skeletally immature patients and completed the survey. A total of 17% of EPOS and 70% of POSNA members recommended ACLR within three months for a prepubescent paediatric ACL tear. In total, 61% of POSNA and 83% of EPOS members recommended ACLR within three months for a pubescent paediatric ACL tear. Epiphyseal tunnels were the preferred technique in prepubescent children (43% at the tibia and 49% at the femur), while transphyseal tunnels were recommended preferentially in pubescent children (85% at the tibia and 63% at the femur). In all, 5.5% of participants reported growth disturbances after ACLR.

CONCLUSION

Current practice patterns across the Atlantic remain varied and controversial. Consensus remains elusive; as such, research collaboration among societies will be important to develop an evidence-based treatment algorithm. The use of transphyseal tunnels has been reinforced. The number of cases of significant growth disturbance is minimal, yet worrisome.

LEVEL OF EVIDENCE

II.

Higher BMI predicts additional surgery at the time of ACL reconstruction

PURPOSE

Despite public recognition, obesity is a growing epidemic affecting an estimated 34% of adults and 20% of children in the U.S.

POPULATION

As such, the number of ACL reconstructions performed in this population is likely to increase. The goal of this study is to evaluate the risk that increasing BMI poses for additional surgery at the time of ACL reconstruction.

METHODS

A retrospective analysis of the American College of Surgeons' National Surgical Quality Improvement Program's (ACS-NSQIP) database for the years 2005-2015 was conducted. Logistic regressions were used to assess the relationship between BMI and additional CPT codes for internal derangement at the time of ACL reconstruction. Internal derangement was defined as any CPT code for treatment of a meniscus tear, chondral lesion, or loose body removal. Surgeries for multi-ligamentous knee injuries were excluded.

RESULTS

A total of 11,403 patients undergoing ACL reconstruction were identified. 41.9% of patients had an associated CPT code for internal derangement. As BMI increased, there was a corresponding increase in the odds of additional surgery. Specifically, for every 1.0 increase in BMI, the risk of additional surgery increased by 1.6% (p < 0.001). Compared to patients with a BMI of 18.5-24.9, those with a BMI 25-29.9 had an odds ratio (OR) of 1.112, BMI 30-34.9 had an OR of 1.137, BMI 35-39.9 had an OR of 1.249, and those ≥ 40 had an OR of 1.442 for additional surgery (p < 0.001).

CONCLUSIONS

This nationally-representative, population-based study demonstrates that patients with elevated BMI are much more likely to require additional surgery in the setting of primary ACL reconstruction. This risk correlates with increasing BMI. Surgeons should keep these risks in mind when evaluating and counseling patients for surgery in the setting of ACL reconstruction.

LEVEL OF EVIDENCE

Case-control study, Level III.

Outcome Measures After ACL Injury in Pediatric Patients: A Scoping Review

Background

The incidence of anterior cruciate ligament (ACL) injuries in children is increasing. However, no standardized core set of outcome measures exists for evaluating pediatric ACL injuries.

Purpose

To perform a scoping review of the literature to identify patient-reported outcome measures (PROMs) and objective outcome measures used to evaluate pediatric patients after ACL injury and to classify these in accordance with the International Classification of Functioning, Disability, and Health (ICF) domains.

Study Design

Systematic review; Level of evidence, 4.

Methods

The literature was systematically searched with the PubMed, EMBASE, CINAHL, and PEDro databases. The inclusion criteria were Danish, Norwegian, Swedish, German, or English language; publication between 2010 and 2018; pediatric ACL injury (patients ≤15 years old); and outcome measures. The selected papers were screened for title, abstract, and full text in accordance with predefined inclusion and exclusion criteria.

Results

A total of 68 papers (4286 patients; mean ± SD age, 12.2 ± 2.3 years) were included. Nineteen PROMs and 11 objective outcome measures were identified. The most frequently reported PROMs were the International Knee Documentation Committee (IKDC) Subjective Knee Form (51% of studies), Lysholm scoring scale (46% of studies) and Tegner activity rating scale (37% of studies). Additionally, return to sport was reported in 41% of studies. The most frequent objective measures were knee laxity (76% of studies), growth disturbances (69% of studies), range of motion (41% of studies), and muscle strength (21% of studies). With respect to the ICF domains, the IKDC covered all 3 ICF health domains, the Lysholm score covered the Body Structure and Function and the Activity Limitation domains, while the Tegner score covered the Participation Restriction domain. Objectively measured knee joint laxity, range of motion, and muscle strength covered 1 domain (Body Structure and Function).

Conclusion

Pediatric patients with ACL injury were mainly evaluated subjectively with the IKDC and objectively by knee joint laxity. No consensus exists in the evaluation of children after ACL injury. The majority of applied outcome measures are developed for adults. To cover the ICF health domains, future research needs to consider reliable and valid outcome measures relevant for pediatric patients with ACL injury.

The Safe Distance to the Popliteal Neurovascular Bundle in Pediatric Knee Arthroscopic Surgery: An Age-Based Magnetic Resonance Imaging Anatomic Study

Background:

The close proximity of the popliteal neurovascular bundle to the posterior horn of the lateral meniscus puts it at risk of compromise during lateral meniscal repair. This is particularly important in smaller pediatric patients, who are commonly treated for lateral meniscal abnormalities in isolation (discoid meniscus) or concomitantly with anterior cruciate ligament reconstruction.

Purpose:

To quantify the distance between the posterior horn of the lateral meniscus and the popliteal neurovascular bundle along the path of meniscal repair and to investigate for associations with age, sex, height, weight, body mass index (BMI), and skeletal maturity.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 144 magnetic resonance imaging scans were evaluated in a cohort of patients aged 10 to 18 years without meniscal or ligament abnormalities. Measurements were made along a line from the anterolateral portal between the popliteal neurovascular bundle and the free edge, midpoint, and meniscocapsular junctions of the posterior horn of the lateral meniscus. In addition to descriptive statistics of these distances by age and sex, analyses of variance and linear regression analyses were performed to investigate for associations with age, sex, height, weight, BMI, and skeletal maturity.

Results:

Male participants had a significantly larger mean free edge distance (14.4 ± 2.5 vs 13.1 ± 2.5 mm, respectively; P = .005) and midpoint distance (9.6 ± 2.2 vs 8.9 ± 1.8 mm, respectively; P = .011) than female participants but not a significantly larger meniscocapsular distance (5.2 ± 1.6 vs 4.6 ± 1.4 mm, respectively; P = .096). Linear regression analyses revealed significant associations between these distances and age, height, weight, and BMI (P < .001 for all). There were statistically significant pairwise differences for free edge and midpoint distances to the neurovascular bundle between patients with open and closed physes.

Conclusion:

The distance between the posterior horn of the lateral meniscus and the popliteal vasculature along a trajectory from the standard anterolateral arthroscopic portal increases linearly throughout development between the ages of 10 and 18 years. There were also significant associations between height, weight, BMI, and skeletal maturity and these anatomic distances. Knowing the safe distance to the popliteal vasculature will increase the safety of arthroscopic lateral meniscal repair in children, especially with all-inside devices that require setting the penetration depth for the advancement of a sharp delivery device beyond the posterior capsule.

Delayed reconstruction and high BMI z score increase the risk of meniscal tear in paediatric and adolescent anterior cruciate ligament injury

PURPOSE

The purpose of this study was to identify epidemiologic risk factors for secondary meniscal tears in paediatric and adolescent patients who sustain an anterior cruciate ligament (ACL) tear. The hypothesis was that delayed reconstruction and elevated BMI z score, increase the risk for secondary meniscal tears.

METHODS

A prospective, descriptive and analytical study of consecutively accrued children and adolescents with an ACL tear was performed. One hundred and sixty subjects (114 males and 46 females) were identified between 2006 and 2015 at one institution. The age range was between 7 and 19 years. Fifteen parameters were recorded and analysed: age at initial trauma, initial trauma circumstance, sex, BMI z score, affected side, type of sport, Tegner score, athletic level, time to MRI, time to first referral, time to surgery, age at surgery, attempted non-operative treatment, operative report and associated meniscal tear. These meniscal lesions could be diagnosed by an MRI and / or during surgery.

RESULTS

Out of the 160 cases, 143 were treated surgically and 17 cases non-operatively. Median corrected BMI z score was 0.5 (range - 1.8 to 4.7). 41.9% had one or more meniscal lesions. 55 patients were initially treated non-operatively, of which 39 patients were secondarily operated. There was a positive relationship between meniscal lesion and: BMI z score (p = 0.0364), attempted non-operative treatment (p = 0.001) and time to surgery (p = 0.002). The median time to ACL reconstruction was 229 days for patients with secondary meniscal lesions.

CONCLUSIONS

Patients with ACL tears treated non-operatively developed secondary meniscal lesions requiring delayed surgical management. There was a positive correlation between BMI z score and secondary meniscal lesions. Thus, early ACL reconstruction is advocated in young athletes.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

Anterior cruciate ligament reconstruction with an all-epiphyseal "over-the-top" technique is safe and shows low rate of failure in skeletally immature athletes

PURPOSE

The aim of this study was to follow up, clinically and radiographically, skeletally immature patients who underwent ACL reconstruction with an all-epiphyseal "over-the-top" technique.

METHODS

Twenty athletes aged between 8 and 13 years were enrolled and retrospectively evaluated. The subjects underwent surgical ACL reconstruction between 2009 and 2013. The surgical technique consisted of a single-bundle all-epiphyseal ACL reconstruction with an extra-articular lateral tenodesis. The mean follow-up was 54 months [34-123] after surgery. Clinically, the patients were evaluated pre- and post-operatively with Lysholm and KOOS scores; sport activity level was evaluated using the pre-injury, pre-operative and post-operative Tegner scores. Objective IKDC was calculated post-operatively. The joint laxity was evaluated by KT1000 and Rolimeter arthrometers. Panoramic AP standing radiographs of the lower limbs and lateral knee radiographs were also taken at the follow-up to evaluate limb length discrepancies (LLD) and axial malalignment. Normally distributed parameters were presented as mean ± standard deviation, while the non-normally distributed parameters were presented as median [25° percentile, 75° percentile].

RESULTS

Clinical scores showed significant (P < 0.01) improvement: Lysholm and KOOS scores improved from 40 [22; 65] and 59 [42, 73], respectively, to 100 [95; 100] and 99 [97;100] after surgery. Tegner score improved from 2 [2; 2] pre-operatively to 7 [3; 9] at follow-up (P < 0.01). At follow-up, IKDC score was A for 19 patients and one who scored B. All patients returned to sport activity and had good stability at follow-up: the KT1000 showed a median side-to-side difference of 0.0 mm [- 0.4; 1.0] for the standard force evaluation and 0.0 mm [- 1.0; 0.8] for manual-maximum test. The Rolimeter showed median side-to-site difference of 0.0 mm [- 1.0; 0.8]. Three minor leg length discrepancies and axial deviations were observed at the radiograph: one patient had 0.6 cm lengthening and 4° of varus, one had 1 cm lengthening, and one had 3° of varus (in comparison with the non-operated limb). No re-injury was observed.

CONCLUSION

This study demonstrates that the modified all-epiphyseal single-bundle "over-the-top" technique is a viable and safe option for ACL reconstruction in pediatric subjects. These results support once more that not only ACL reconstruction is a safe procedure in skeletally immature patients, but also it is highly recommended for those who want to pursue an active and sportive life.

LEVEL OF EVIDENCE

Case series, IV.

How Does Obesity Impact Pediatric Anterior Cruciate Ligament Reconstruction?

PURPOSE

To assess the relationship of elevated body mass index (BMI) on postoperative outcomes, including graft rupture, contralateral anterior cruciate ligament (ACL) tear, new meniscus injuries, isokinetic strength testing, and range of motion (ROM) in a large group of pediatric patients. We also sought to calculate the risk of graft rupture in overweight patients with small femoral or tibial tunnels. The secondary objective was to evaluate the association between BMI and concurrent meniscus tears and the need for meniscectomy at the time of primary ACL reconstruction.

METHODS

We retrospectively reviewed all pediatric patients undergoing primary ACL reconstruction at our institution. BMI percentile for age was used to categorize children as having normal BMI or being overweight or obese per Centers for Disease Control and Prevention guidelines. Demographic data, intraoperative findings and techniques, postoperative complications (including graft rupture, contralateral ACL tear, and meniscus injuries), ROM, and isokinetic strength testing were recorded. Univariate analysis was followed by stepwise, logistic regression to control for confounders.

RESULTS

Of the 1,056 patients included, 535 (50.7%) were male and 521 were (49.3%) female, with a mean age of 15.1 ± 2.4 years. The average BMI was 23.1 ± 4.7. There were 675 (63.9%) children with normal BMI, 228 (21.6%) who were overweight, and 153 (14.5%) who were obese. In multivariate analysis, children with elevated BMI had a higher rate of concurrent meniscus tears compared with those with normal BMI (76.3% vs 70.2%; P = .02) and 1.6 times higher odds of requiring a meniscectomy (95% confidence interval, 1.2-2.2; P < .01). The 723 patients included in the analysis of postoperative complications had a mean follow-up duration of 26.2 ± 3.3 months Postoperatively, BMI did not impact the rate of graft rupture, contralateral ACL injury, or new meniscus tears. There was no increased risk of graft failure in overweight children with smaller graft size (≤8 mm). There was no clinically relevant difference in postoperative ROM or isokinetic strength testing.

CONCLUSIONS

After ACL rupture, overweight and obese children sustained more overall meniscus tears and more irreparable meniscus tears than those with normal BMI. Graft size did not impact the risk of early graft failure in overweight patients. With an appropriate rehabilitation protocol, there was no increased risk of graft rupture, contralateral ACL injury, or new meniscus tear in early follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Earlier anterior cruciate ligament reconstruction is associated with a decreased risk of medial meniscal and articular cartilage damage in children and adolescents: a systematic review and meta-analysis

PURPOSE

To evaluate the association between surgical timing and the incidence of secondary meniscal or chondral damage in children and adolescents with anterior cruciate ligament (ACL) ruptures.

METHODS

Three electronic databases, PubMed, MEDLINE, and EMBASE, were systematically searched from database inception until October 16, 2017 by two reviewers independently and in duplicate. The inclusion criteria were English language studies that reported the incidence of meniscal and articular cartilage damage in children or adolescent athletes with ACL injuries as well as the timing of their ACL reconstruction (ACLR). Risk ratios were combined in a meta-analysis using a random effects model.

RESULTS

A total of nine studies including 1353 children and adolescents met the inclusion criteria. The mean age of patients included was 14.2 years (range 6-19), and 45% were female. There was a significantly decreased risk of concomitant medial meniscal injury in those reconstructed early (26%) compared to those with delayed reconstruction (47%) [pooled risk ratio (RR) = 0.49, 95% CI 0.36-0.65, p < 0.00001]. There was also a significantly reduced risk of medial femoral chondral (RR = 0.48, 95% CI 0.31-0.75, p = 0.001), lateral femoral chondral (RR = 0.38, 95% CI 0.20-0.75, p = 0.005), tibial chondral (RR = 0.45, 95% CI 0.27-0.75, p = 0.002), and patellofemoral chondral (RR = 0.41, 95% CI 0.20-0.82, p = 0.01) damage in the early reconstruction group in comparison to the delayed group.

CONCLUSION

Pooled results from observational studies suggest that early ACLR results in a significantly decreased risk of secondary medial meniscal injury, as well as secondary medial, lateral, and patellofemoral compartment chondral damage in children and adolescents. This study provides clinicians with valuable information regarding the benefits of early ACL reconstruction in children and adolescents, and can be used in the decision making for athletes in this population.

LEVEL OF EVIDENCE

IV.

Seventeen-Year Follow-up After Meniscal Repair With Concomitant Anterior Cruciate Ligament Reconstruction in a Pediatric and Adolescent Population

BACKGROUND

Studies have shown good and excellent clinical and radiographic results after meniscal repair. Limited published information exists on the long-term outcomes, however, especially in a pediatric and adolescent population.

PURPOSE

To determine long-term results of meniscal repair and concomitant anterior cruciate ligament (ACL) reconstruction in a pediatric and adolescent population. Specifically, the aims were to determine the clinical success rate of meniscal repair with concomitant ACL reconstruction, compare results with midterm outcomes, and analyze risk factors for failure.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Cases of meniscal repair with concomitant ACL reconstruction between 1990 and 2005 were reviewed among patients aged ≤18 years. Patient demographics, injury history, and surgical details were recorded, and risk factors for failure were analyzed. Physical examination findings and clinical outcomes at latest available follow-up were collected. Subjective knee outcomes were compared with midterm results. Descriptive statistics and univariate analysis were used to evaluate the available data.

RESULTS

Forty-seven patients (30 females, 17 males) with a mean age of 16 years (SD, 1.37) and a mean follow-up of 16.6 years (SD, 3.57) were included in this study. Overall, 13 patients (28%) failed meniscal repair and required repeat surgery at the time of final follow-up. Of the 13 failures, 9 underwent a subsequent meniscectomy; 2, meniscectomy and revision ACL reconstruction; 1, meniscal repair and revision ACL reconstruction; and 1, meniscal repair and subsequent meniscectomy. Mean International Knee Documentation Committee scores improved from 47.9 preoperatively to 87.7 postoperatively ( P < .01), and the mean score at long-term follow-up (87.7) did not significantly differ from that at the midterm follow-up (88.5) at a mean 7.4 years ( P = .97). Mean Tegner Activity Scale scores improved from 1.9 preoperatively to 6.3 postoperatively ( P < .01) and decreased from 8.3 at preinjury to 6.3 at final long-term follow-up ( P < .01).

CONCLUSION

In conclusion, the long-term overall clinical success rate (failure-free survival) was 72% for repair of pediatric and adolescent meniscal tears in the setting of concomitant ACL reconstruction. Patients reported excellent knee subjective outcome scores that remained favorable when compared with midterm follow-up.

Outcomes of Physeal-Sparing ACL Reconstruction with Iliotibial Band Autograft in Skeletally Immature Prepubescent Children

BACKGROUND

Anterior cruciate ligament (ACL) tears are occurring in youth athletes with increasing frequency. Many ACL reconstruction procedures designed to allow for continued growth in patients with open physes have been described, but large series with mid- to long-term outcomes data are lacking. The purpose of the current study was to assess the clinical outcomes of a large cohort of prepubescent children who underwent a physeal-sparing, combined intra- and extra-articular ACL reconstruction with iliotibial (IT) band autograft over a 23-year period.

METHODS

Included in our analysis were 237 patients (240 knees) who underwent ACL reconstruction using IT band autograft at Tanner stage 1 or 2 (mean age of 11.2 ± 1.7 years). Physical examination data were analyzed for 225 of the 240 knees (mean follow-up, 25.8 months), and 137 (57%) of the knees had corresponding patient-reported clinical outcomes (patient-reported graft rupture and Pediatric International Knee Documentation Committee [Pedi-IKDC], Tegner activity scale, and Lysholm scores; mean follow-up, 6.2 years). Rates of growth arrest, IT band graft-harvest morbidity, and return to sports were analyzed.

RESULTS

Physical examination revealed that 96.8% of the knees were grade A on the Lachman test and 98.8% were grade A on the pivot-shift test. Graft rupture occurred in 9 (6.6%) of 137 knees, at an average of 33.5 months (range, 8.2 months to 8.0 years) postoperatively. For patients who did not sustain a graft rupture, the mean Pedi-IKDC score was 93.3 ± 11.0, the mean Lysholm score was 93.4 ± 9.9, and the mean score on the Tegner activity scale was 7.8 (mode, 7). While lateral thigh asymmetry at the IT band harvest site was noted by 48% of the subjects, only 1.6% reported associated pain. No cases of limb-length discrepancy or angular deformity were observed.

CONCLUSIONS

This procedure was associated with excellent functional outcomes, minimal risk of growth disturbance, and a low graft-rupture rate in skeletally immature prepubescent children. These results appear durable at mid- to long-term follow-up, at an average of >6 years postoperatively.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Operative Treatment of Isolated Meniscus Injuries in Adolescent Patients: A Meta-Analysis and Review

Context:

With the rise in sports participation and increased athleticism in the adolescent population, there is an ever-growing need to better understand adolescent meniscus pathology and treatment.

Objective:

To better understand the operative management of meniscus tears in the adolescent population.

Data Sources:

A systematic review of PubMed (MEDLINE) and Google Scholar was performed for all archived years.

Study Selection:

Studies that reported on isolated meniscus tears in adolescent patients (age, 10-19 years) were included.

Study Design:

Systematic review and meta-analysis.

Level of Evidence:

Level 4.

Data Extraction:

Two authors reviewed and extracted data from studies that fulfilled all inclusion criteria.

Results:

Nine studies on isolated meniscus tears in adolescent patients were found, with level of evidence ranging from 3 to 4. These studies evaluated a total of 373 patients (248 males, 125 females) and 390 knees. Seven studies were published between 1979 and 2000, all of which discuss meniscectomy as the primary treatment. Two studies were published after 2000 and report on meniscus repair surgery. The mean patient age was 14.4 years. A total of 308 meniscectomies and 64 meniscus repairs were performed. Follow-up ranged from 1.8 to 30 years (mean, 10.8 years). A 37% retear rate was reported for patients undergoing meniscus repair. Different outcome measures were used for meniscectomy versus meniscus repair. Three studies evaluating meniscectomy reported Tapper-Hoover scores, showing 54 patients with an excellent result, 58 with good, 57 with fair, and 23 with poor results.

Conclusion:

A shift in the management of isolated adolescent meniscal tears is reflected in the literature, with a recent increase in operative repair. This is likely secondary to poor outcomes after meniscectomy reflected in long-term follow-up studies. The current literature highlights the need for improved description of tear patterns, standardized reporting of outcome measures, and improved study methodologies to help guide orthopaedic surgeons on operative treatment of meniscal tears in adolescent patients.

Revision Anterior Cruciate Ligament Reconstruction Outcomes in Younger Patients: Medial Meniscal Pathology and High Rates of Return to Sport Are Associated With Third ACL Injuries

BACKGROUND

There are limited data evaluating the outcomes of revision anterior cruciate ligament (ACL) reconstruction surgery in younger patients despite recent reports that the rates of graft rupture are higher in young cohorts.

PURPOSE

To explore the outcomes of revision ACL reconstruction surgery in younger patients with the specific aims of determining the rates of third ACL injury and whether knee pathology at the time of revision surgery and return to sport were associated with further injury.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

The study cohort consisted of 151 consecutive patients who were aged 25 years or younger at the time of their first revision ACL reconstruction. The number of subsequent ACL injuries (graft rerupture or contralateral injury to the native ACL) was determined at a mean follow-up time of 4.5 years (range, 2-9 years). Surgical details were recorded, along with a range of sport participation outcomes. Contingency tables were used to assess the associations between subsequent ACL injury and return to sport, knee pathology, and the drilling of new femoral or tibial tunnels at revision surgery.

RESULTS

The follow-up rate was 85% (128/151). Graft reruptures occurred in 20 patients (16%) at a mean time of 2 years after revision surgery. Contralateral ACL injuries occurred in 15 patients (12%) at a mean time of 3.9 years. The total number of patients who had a third ACL injury was 35 (27%). There was a significant association between having medial meniscal pathology and sustaining a graft rerupture ( P = .03), but there was no association between graft rerupture and using the same tunnels from the primary procedure at revision surgery. After revision reconstruction, 68% of patients (95% CI, 55%-71%) returned to their preinjury level of sport, compared with 83% (95% CI, 69%-84%) after primary reconstruction in the same patients. Those who had a third ACL injury had a significantly higher rate of return to preinjury sport (83%) after the revision procedure than did the group that did not have further ACL injuries (62%, P = .02).

CONCLUSION

Younger patients are at significant risk of having multiple ACL injuries. The high rate of third ACL injuries presents a significant issue for future knee health in these young athletes. Medial meniscal pathology and returning to high-risk sport are factors that are significantly associated with the high multiple ACL injury rate in the young.

Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Early Results Using a Hybrid Physeal-Sparing Technique

Background:

Reconstruction of the anterior cruciate ligament (ACL) in the skeletally immature patient is frequently performed in hopes of preventing new or additional chondral damage and meniscal injuries. Patients within a few years of skeletal maturity are more at risk for ACL injuries than prepubescent patients, about whom several physeal-sparing techniques have been described. Reconstruction techniques in the former higher risk group need to be better understood.

Purpose:

To review a series of adolescent patients with ACL injuries surgically treated with the hybrid physeal-sparing technique.

Study Design:

Case series; Level of evidence, 4.

Methods:

Surgical logs of ACL reconstructions (ACLRs) performed at a single pediatric/adolescent sports medicine center over a 6-year period were reviewed. Patients with open physes who had undergone ACLR with a femoral physeal-sparing tunnel and transphyseal tibial tunnel were identified. Their demographics, operative reports, rehabilitative course, time to return to play, outcome scores, and postoperative radiographs were collected and analyzed.

Results:

Twenty-three patients with a mean chronological age and bone age of 13.0 and 13.6 years, respectively, were identified. Examination and subjective outcome scores were obtained at a mean of 19 months and overall demonstrated positive results, with a mean Pediatric International Knee Documentation Committee (Pedi-IKDC) score of 96.0 and a mean Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) score of 89.1. Full-length mechanical axis films obtained at a mean 21 months postoperatively demonstrated no leg-length discrepancies or angular deformities in 21 of 23 patients. Two patients had an identified growth disturbance in the form of femoral and tibial growth acceleration on the ACL-reconstructed limb.

Conclusion:

The femoral physeal-sparing with transphyseal tibial drilling “hybrid” technique in skeletally maturing patients appears to have a high rate of success with low morbidity. However, the possibility of physeal abnormalities does exist, which demonstrates the importance of a close postoperative follow-up and evaluation until skeletal maturity is achieved. ACLR in skeletally immature patients is performed on an increasingly regular basis. Establishing the best and safest technique to do so is therefore important.

The frequency of cartilage lesions in non-injured knees with symptomatic meniscus tears: results from an arthroscopic and NIR- (near-infrared) spectroscopic investigation

INTRODUCTION

Are symptomatic tear injuries to the menisci of the knee frequently or always associated with cartilage damage to the corresponding articular surfaces and other joint surfaces, respectively?

METHODS

A total of 137 patients (medial n = 127; lateral n = 10) underwent a meniscus resection. These patients showed no signs of a clear radiographic arthrosis and no MRI-detectable cartilage lesions > grade II. Traumatic injury was ruled out with a thorough medical history. The indication for operation was made exclusively on the basis of distinct, clinically apparent meniscus signs. In addition to the ICRS classification, all articular surfaces were examined spectroscopically (NIRS, near-infrared spectroscopy).

RESULTS

In 76.6% (n = 105) of all knees examined, clear cartilage damage (ICRS-grade III/IV) was found. For 43.8%, these were in the area of the patella, while for 34.3% they were in the area of the medial femur, and for 17.5%, in the area of the medial tibial plateau. More rarely, this damage was localized to the area of the trochlea (8.8%) or the lateral joint compartment (femoral 2.2%, tibial 15.3%). There were no significant differences between patients with medial or lateral meniscus lesions with respect to the distribution pattern of the joint injuries. During spectroscopic examination, pathological values were demonstrated (objective evidence of cartilage degeneration) in at least one of the examined articular surfaces (media n = 6, range 1-6).

CONCLUSION

Through our investigations, a high, if not complete, concomitance of degenerative cartilage lesions and degenerative meniscus damage was demonstrated. From this it can be concluded that the entity of "isolated degenerative meniscus damage" clearly does not exist in practice. It is therefore highly probable that degenerative meniscus lesions, as a part of general joint degeneration, are to be interpreted in the context of the development of arthrosis. The practical consequences still are unclear. Patients after partial meniscectomy need a longer follow-up to detect potential cartilage lesions as well as an OA progression.