Complication rates following all-epiphyseal ACL reconstructions in skeletally immature patients: A retrospective case series study

All-epiphyseal anterior cruciate ligament reconstruction yields superior sports performances than the trans-epiphyseal technique in skeletally immature patients: a systematic review

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.

Anterior cruciate ligament reconstruction in skeletally immature patients is effective: A systematic review

PURPOSE

The present study evaluated the outcomes of anterior cruciate ligament (ACL) reconstruction in children with open physes. The outcomes of interest were to compare the increase in joint laxity and PROMs from baseline to the last follow-up, the rate and features of the return to sport and the rate of complications.

METHODS

This study was conducted according to the 2020 PRISMA guidelines. In October 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles which clearly stated that surgeries were conducted in children with open physis were eligible.

RESULTS

Data from 53 studies (1691 procedures) were collected. 35% (597 out of 1691 patients) were women. The mean length of the follow-up was 44.7 ± 31.3 months. The mean age of the patients was 12.7 ± 1.1 years old. All PROMs significantly improved from the baseline values to those at the last follow-up. The mean time to return to sport was 8.3 ± 1.9 months. 89% (690 out of 771 patients) returned to sports, 15% (109 out of 721 patients) reduced their level of sports activity or league, and 84% (651 out of 771 patients) returned to their previous level of sport. 9% (112 out of 1213) of patients experienced re-tear of the reconstructed ACL, and 11% (75 out of 660) of patients underwent a further ACL reoperation. No patients (0 out of 83) demonstrated increased laxity at the last follow-up, and persistent sensation of instability was reported by 5% (11 out of 235) of patients.

CONCLUSION

ACL reconstruction in skeletally immature patients is effective and safe, and is associated with fast recovery and a high rate of return to sport.

LEVEL OF EVIDENCE

Level IV.

Abnormal femoral trochlea morphology is a risk factor for secondary injury of anterior cruciate ligament after reconstruction

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.

Growth Disturbances Following Paediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review

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.

Graft choices for paediatric anterior cruciate ligament reconstruction: State of the art

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.