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Migliorini F, Pilone M, Memminger MK, Eschweiler J, Giorgino R, Maffulli N. All-epiphyseal anterior cruciate ligament reconstruction yields superior sports performances than the trans-epiphyseal technique in skeletally immature patients: a systematic review. J Orthop Traumatol 2024; 25:7. [PMID: 38376718 PMCID: PMC10879072 DOI: 10.1186/s10195-024-00751-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/13/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Anterior cruciate ligament (ACL) tears in skeletally immature patients are increasingly common. Evidence comparing the outcomes of all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients is limited, and the current literature could benefit from a comprehensive systematic review. The present study compared all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients. The outcomes of interest were to compare joint laxity, patient-reported outcome measures (PROMs), return to sport, and complications. METHODS This study was conducted according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. In November 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. No additional filters were used in the database search. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles that clearly stated the surgical technique (all- or trans-epiphyseal) were eligible. Only articles with a minimum of 6 months of follow-up were included. Only articles that clearly stated that surgeries were conducted in children with open physis were eligible. RESULTS Data from 1489 patients (1493 procedures) were collected, of which 32% (490 of 1489 patients) were female. The mean length of follow-up was 46.6 months. The mean age of the patients was 12.7 years. No difference was found in joint laxity (Table 3): positive pivot shift (P = 0.4), positive Lachman test (P = 0.3), and mean arthrometer laxity (P = 0.1). No difference was found in PROMs (Table 4): International Knee Documentation Committee (IKDC) (P = 0.3), Lysholm (P = 0.4), and Tegner (P = 0.7). The trans-epiphyseal technique was associated with a greater rate of patients unable to return to sports (1% versus 7%, P = 0.0001) and with a longer time to return to sports (7.7 versus 8.6 months, P = 0.01). Though the trans-epiphyseal technique was associated with a lower rate of return to sport, this difference was not statistically significant (P = 0.8). No difference was evidenced in the rate of patients who had reduced their league or level of sports activity (P = 0.6) or in the rate of patients who had returned to their previous league or level of sports activity (P = 0.7). No difference was found in the rate of complication: re-tear (P = 0.8), reoperation (P = 0.7), increased laxity (P = 0.9), and persistent instability sensation (P = 0.3). CONCLUSION Trans-epiphyseal ACL reconstruction was associated with a greater rate of patients unable to return to sport and with a longer time to return to sport compared with the all-epiphyseal technique in skeletally immature patients. Level of evidence Level III, systematic review.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopaedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy.
| | - Marco Pilone
- Residency Program in Orthopedics and Traumatology, University of Milan, Milan, Italy
| | - Michael Kurt Memminger
- Department of Orthopaedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy
| | - Jörg Eschweiler
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
- Department of Trauma and Reconstructive Surgery, BG Hospital Bergmannstrost, Halle, Germany
| | - Riccardo Giorgino
- Residency Program in Orthopedics and Traumatology, University of Milan, Milan, Italy
| | - Nicola Maffulli
- Department of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, ST4 7QB, Stoke on Trent, England
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, E1 4DG, London, England
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Migliorini F, Cocconi F, Schäfer L, Memminger MK, Giorgino R, Maffulli N. Anterior cruciate ligament reconstruction in skeletally immature patients is effective: A systematic review. Knee Surg Sports Traumatol Arthrosc 2024; 32:418-431. [PMID: 38258963 DOI: 10.1002/ksa.12048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024]
Abstract
PURPOSE The present study evaluated the outcomes of anterior cruciate ligament (ACL) reconstruction in children with open physes. The outcomes of interest were to compare the increase in joint laxity and PROMs from baseline to the last follow-up, the rate and features of the return to sport and the rate of complications. METHODS This study was conducted according to the 2020 PRISMA guidelines. In October 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles which clearly stated that surgeries were conducted in children with open physis were eligible. RESULTS Data from 53 studies (1691 procedures) were collected. 35% (597 out of 1691 patients) were women. The mean length of the follow-up was 44.7 ± 31.3 months. The mean age of the patients was 12.7 ± 1.1 years old. All PROMs significantly improved from the baseline values to those at the last follow-up. The mean time to return to sport was 8.3 ± 1.9 months. 89% (690 out of 771 patients) returned to sports, 15% (109 out of 721 patients) reduced their level of sports activity or league, and 84% (651 out of 771 patients) returned to their previous level of sport. 9% (112 out of 1213) of patients experienced re-tear of the reconstructed ACL, and 11% (75 out of 660) of patients underwent a further ACL reoperation. No patients (0 out of 83) demonstrated increased laxity at the last follow-up, and persistent sensation of instability was reported by 5% (11 out of 235) of patients. CONCLUSION ACL reconstruction in skeletally immature patients is effective and safe, and is associated with fast recovery and a high rate of return to sport. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Aachen, Germany
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Bolzano, Italy
| | - Federico Cocconi
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Bolzano, Italy
| | - Luise Schäfer
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Aachen, Germany
| | - Michael Kurt Memminger
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Bolzano, Italy
| | - Riccardo Giorgino
- Residency Program in Orthopaedic and Traumatology, University of Milan, Milan, Italy
| | - Nicola Maffulli
- Department of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke-on-Trent, UK
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, UK
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Cai Q, Wang, D, Yan L, Kuang H, Tang W, Min Z, Wang, X. Abnormal femoral trochlea morphology is a risk factor for secondary injury of anterior cruciate ligament after reconstruction. Medicine (Baltimore) 2024; 103:e36786. [PMID: 38181284 PMCID: PMC10766302 DOI: 10.1097/md.0000000000036786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/05/2023] [Indexed: 01/07/2024] Open
Abstract
Secondary injury of the anterior cruciate ligament (ACL) is a common concern after anterior cruciate ligament (ACL) reconstruction, and identification of morphological risk factors is essential to prevent these injuries. We hypothesized that abnormal femoral trochlea morphology is associated with secondary ACL injuries after reconstruction. This study aimed to investigate the relationship between femoral trochlear morphology and secondary ACL injuries after reconstruction. A retrospective analysis was conducted on 20 patients who experienced secondary ACL injuries after reconstruction in our hospital between 2017 and 2022 (experimental group), and 40 patients were included in the control group. The following femoral trochlear characteristics were compared between the 2 groups: medial condylar height (MCH), trochlear sulcus height (TSH), lateral condylar height (LCH), trochlear sulcus depth (TSD), trochlear sulcus angle (TSA), medial trochlear inclination (MTI), and lateral trochlear inclination (LTI). The study found that patients in the secondary ACL injury after reconstruction group exhibited the following differences when compared to the control group: decreased MCH (56.33 ± 3.52 vs 59.93 ± 3.24, P value = .015), decreased TSD (4.89 ± 1.56 vs 6.98 ± 1.23, P value ˂ .001), decreased MTI (12.54 ± 6.57 vs 19.45 ± 6.35, P value ˂ .001), and increased TSA (145.23 ± 9.76 vs 139.25 ± 8.42, P value ˂ .001). This study demonstrated a significant correlation between abnormal femoral trochlear morphological characteristics and secondary ACL injuries after reconstruction. Decreased MCH, TSD, and MTI along with increased TSA are associated with a higher risk of secondary ACL injury. These data could thus help identify individuals susceptible to secondary ACL injuries after reconstruction.
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Affiliation(s)
- Qiangqiang Cai
- The Third Hospital of Nanchang, Nanchang, Jiangxi, People’s Republic of China
| | - Dongqin Wang,
- The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China
| | - Liang Yan
- The Third Hospital of Nanchang, Nanchang, Jiangxi, People’s Republic of China
| | - Hailin Kuang
- The Third Hospital of Nanchang, Nanchang, Jiangxi, People’s Republic of China
| | - Wubing Tang
- The Third Hospital of Nanchang, Nanchang, Jiangxi, People’s Republic of China
| | - Zhihai Min
- The Third Hospital of Nanchang, Nanchang, Jiangxi, People’s Republic of China
| | - Xin Wang,
- Hebei Medical University Third Hospital, Shijiazhuang, Hebei, People’s Republic of China
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Patil V, Rajan P, Hayter E, Bartlett J, Symons S. Growth Disturbances Following Paediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review. Cureus 2023; 15:e40455. [PMID: 37456432 PMCID: PMC10349531 DOI: 10.7759/cureus.40455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
Growth disturbances after transphyseal paediatric anterior cruciate ligament (ACL) reconstruction have led to the development of physeal-sparing techniques. The aim of this study is to investigate growth disturbances following paediatric ACL reconstruction and identify associated risk factors. A systematic search on PubMed, Scopus and Web of Science databases was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify case series reporting paediatric ACL reconstructions. Of 518 articles, 78 met the inclusion criteria, and data related to growth disturbances and graft failures were extracted. A total of 2,693 paediatric ACL reconstructions resulted in 70 growth disturbances (2.6%): 17 were varus, 26 were valgus, 13 were shortening, 14 were lengthening and five patients had reduced tibial slope. Some patients showed deformities in more than one plane. Coronal plane deformities were seen more frequently with eccentric physeal arrest and lengthening with intraepiphyseal tunnelling. Shortening and reduced tibial slope were related to large central physeal arrest and anterior tibial physeal arrest, respectively. Sixty-two studies documented 166 graft failures in 2,120 reconstructions (7.8%). The extraphyseal technique was least likely to result in growth disturbances and graft failure. Paediatric ACL reconstruction is a safe and effective treatment of rupture. Growth disturbances are least likely following extraphyseal tunnelling, and those resulting from transphyseal techniques can be minimised by reducing drill size, drilling steep and avoiding the physeal periphery. The insertion of hardware, synthetic material, or a bone plug through the drilled physis should be avoided. There is a greater need for robust long-term data collection, such as national ligament registries, to standardise practice and evaluate the risk of growth disturbance and re-ruptures in this treatment.
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Affiliation(s)
- Vijay Patil
- Trauma and Orthopaedics, Basildon University Hospital, Basildon, GBR
| | - Praveen Rajan
- Trauma and Orthopaedics, Basildon University Hospital, Basildon, GBR
| | - Edward Hayter
- Trauma and Orthopaedics, Basildon University Hospital, Basildon, GBR
| | | | - Sean Symons
- Trauma and Orthopaedics, Basildon University Hospital, Basildon, GBR
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Marx RG, Hsu J, Fink C, Eriksson K, Vincent A, van der Merwe WM. Graft choices for paediatric anterior cruciate ligament reconstruction: State of the art. J ISAKOS 2023; 8:145-152. [PMID: 36646171 DOI: 10.1016/j.jisako.2023.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/15/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
The paediatric population is at particularly high risk for anterior cruciate ligament (ACL) injuries due to high rates of sports participation. Other risk factors for ACL injuries in children include but are not limited to being female, generalised ligamentous laxity, a high body mass index (BMI), and poor neuromuscular control. ACL reconstruction (ACLR) is commonly done to treat ACL injuries and allow for return to sports and daily activities. ACL repair is another option with ongoing techniques being developed. The high rates of graft failure in children reported in recent publications on ACL repair are very concerning. Special consideration must be taken in ACLR in the skeletally immature patient due to the risk of growth-related complications, such as limb deformity or growth arrest, that can arise from drilling across or disrupting the physis. Graft choices for paediatric ACLR include iliotibial band (ITB) over the top and over the front, hamstring autograft, bone patellar tendon bone (BTB) autograft, quadriceps tendon autograft, and allograft. Factors for each graft choice to consider include graft size, graft failure rates, donor site morbidity, requirement for bony tunnels, the post-op rehabilitation process, and return to sport outcomes. Each graft has its benefits and disadvantages for the individual patient, depending on age, skeletal maturity, and goals for recovery. Lateral extra-articular tenodesis (LET) is another option to consider with paediatric ACLR because LET has been shown to decrease the re-rupture rate in adult ACLR. After surgery, patient follow-up until at least the growth plates are closed is important. This article aims to provide an overview and comparison of the various graft types to aid in the graft choice decision making process for paediatric ACLR.
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Affiliation(s)
- Robert G Marx
- Sports Medicine Institute, Hospital for Special Surgery, New York, 10021, USA; Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, 10021, USA.
| | - Janet Hsu
- Sports Medicine Institute, Hospital for Special Surgery, New York, 10021, USA
| | - Christian Fink
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, 6020, Austria; Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), UMIT, Hall in Tirol, 6060, Austria
| | - Karl Eriksson
- Orthopaedic Surgery, Stockholm South Hospital, Karolinska Institutet, Stockholm, 17177, Sweden
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