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Jia Z, Greven J, Hildebrand F, Kobbe P, Eschweiler J. Conservative treatment versus surgical reconstruction for ACL rupture: A systemic review. J Orthop 2024; 57:8-16. [PMID: 38948499 PMCID: PMC11208802 DOI: 10.1016/j.jor.2024.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/30/2024] [Indexed: 07/02/2024] Open
Abstract
Background Anterior cruciate ligament (ACL) rupture is a prevalent sports injury with rising rates attributed to increased population participation in sports activities. ACL rupture can lead to severe knee complications including cartilage damage, torn meniscus, and osteoarthritis. Current treatment options include conservative measures and surgical interventions. However, debates persist regarding the optimal approach. Purpose This analysis intended to compare the function, knee stability, and incidence rate of secondary surgery between conservative and surgical treatments in ACL rupture patients. Methods A systematic search was performed via Embase, Ovid Medline, PubMed, Cochrane Library, Web of Science, and Google Scholar for reporting outcomes of conservative and surgical treatments after ACL rupture. The outcomes included patient-reported outcome measures (PROMs), knee stability, the need for secondary meniscal surgery, delayed ACL reconstruction surgery, and revision ACL reconstruction surgery. Outcomes were analyzed using mean differences or odd ratios (OR) with 95 % CIs. Results 11 studies were included with 1516 patients. For PROMs, our evidence indicated no differences in KOOS Pain, KOOS Symptoms, KOOS Sport/Rec, KOOS ADL, and KOOS QOL. (all p > 0.05). for knee stability, pivot shift (OR, 0.14; p < 0.001), Lachman test (OR, 0.06; p < 0.001), and tibia translation (p < 0.001) were evaluated, and the available evidence favored surgical treatment over conservative treatment. For the incidence rate of any secondary surgery after the first diagnosis, the surgical group showed a lower rate of meniscal surgery with statistical significance (OR, 0.37; p < 0.001). The average rate of revision ACL reconstruction is 5.80 %, while the rate of delayed ACL reconstruction after conservative treatment is 18.51 %. Conclusion Currently, there is insufficient empirical evidence to advocate a systematic surgical reconstruction for any patient who tore his ACL. This review found no differences in function outcomes between conservative and surgical treatments. Regarding knee stability and secondary meniscal surgery, the results prefer the surgical treatments. The occurrence rate of revision and delayed ACL reconstruction are non-negligible factors that must be fully understood by both surgeons and patients before choosing a suitable treatment.
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Affiliation(s)
- Zhongyu Jia
- Department for Orthopaedic, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Germany
| | - Johannes Greven
- Department for Thoracic Surgery, RWTH Aachen University Hospital, Germany
| | - Frank Hildebrand
- Department for Orthopaedic, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Germany
| | - Philipp Kobbe
- Department for Trauma and Reconstructive Surgery, BG Hospital Bergmannstrost Halle, Halle (Saale), Germany
- Department for Trauma and Reconstructive Surgery, University Hospital of the Martin Luther University Halle, Halle (Saale), Germany
| | - Jörg Eschweiler
- Department for Trauma and Reconstructive Surgery, BG Hospital Bergmannstrost Halle, Halle (Saale), Germany
- Department for Trauma and Reconstructive Surgery, University Hospital of the Martin Luther University Halle, Halle (Saale), Germany
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Alonso-Hernández J, Galán-Olleros M, Miranda-Gorozarri C, Cabello Blanco J, Garlito-Díaz H, Manzarbeitia-Arroba P, Araúz De Robles S. Transphyseal arthroscopic anterior cruciate ligament reconstruction in children under 12 years. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05497-x. [PMID: 39174765 DOI: 10.1007/s00402-024-05497-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 08/14/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND The incidence of anterior cruciate ligament (ACL) injuries in children is on the rise. Despite this trend, the optimal management of these injuries remains a matter of ongoing debate. In this light, our study seeks to assess the clinical, radiological, and functional outcomes of transphyseal ACL reconstruction in preadolescent patients in the medium-term. METHODS This prospective study included preadolescent patients aged up to 12 years who underwent ACL transphyseal reconstruction between 2010 and 2020 and had a minimum follow-up of 2 years. Clinical assessments encompassed joint stability and range of motion. Furthermore, leg length discrepancy (LLD) and femorotibial alignment were evaluated both clinically and radiologically using full-length lower limb standing radiographs. Pre- and postoperative functional outcomes were assessed using the International Knee Documentation Committee (IKDC) and Lysholm scales, and the return to normal sports activity was evaluated using the ACL-Return to Sport after Injury (ACL-RSI) scale. Complications and relevant follow-up data were also recorded. Statistical analyses were conducted to evaluate these outcomes. RESULTS A total of 35 preadolescent patients, consisting of 24 males and 11 females, with a mean age at surgery of 11.2 ± 0.7 years (8.7-12), were included in the study. The mean follow-up was 52.3 ± 20.7 months (24.1-95.9). No significant growth disturbances or clinically relevant LLD were evidenced. All patients demonstrated clinically stable knees with full range of motion at the 2-year follow-up. There were statistically significant improvements in pre- and postoperative IKDC (39.3 ± 13.5 vs. 99.7 ± 0.8, p < 0.005) and Lysholm scores (48.2 ± 15.1 vs. 99.6 ± 1.4, p < 0.005). All but two patients were able to return to their pre-injury level of sports activity, with a mean ACL-RSI score of 93.5 ± 1.3. The analysis revealed an 8.6% rerupture rate and an 11.4% rate of contralateral ACL injuries, with 5-year survival rates of 92.3% and 88.8%, respectively. Subgroup analyses based on age, gender, surgical delay, or associated meniscal lesions did not reveal any significant differences in functional outcomes. Additionally, there was no discernible relationship between age or timing of ACL reconstruction and the risk of meniscal injuries. CONCLUSIONS Our study reinforces the value of ACL reconstruction in skeletally immature preadolescent patients, with transphyseal technique proven to be a safe, effective, and technically simpler option, even for children under the age of 12. The findings indicate excellent functional outcomes, a high rate of successful return to sporting activities, and minimal to no incidence of growth-related complications in the medium-term. LEVEL OF EVIDENCE Level II, prospective comparative cohort study, before and after intervention.
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Affiliation(s)
- Javier Alonso-Hernández
- Pediatric Orthopaedic Unit, Clínica CEMTRO, Av. Ventisquero de la Condesa 42, Madrid, 28035, Spain
- Pediatric Orthopaedic, Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - María Galán-Olleros
- Pediatric Orthopaedic Unit, Clínica CEMTRO, Av. Ventisquero de la Condesa 42, Madrid, 28035, Spain.
- Pediatric Orthopaedic, Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain.
| | - Carlos Miranda-Gorozarri
- Pediatric Orthopaedic Unit, Clínica CEMTRO, Av. Ventisquero de la Condesa 42, Madrid, 28035, Spain
- Pediatric Orthopaedic, Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Juan Cabello Blanco
- Pediatric Orthopaedic Unit, Clínica CEMTRO, Av. Ventisquero de la Condesa 42, Madrid, 28035, Spain
- Pediatric Orthopaedic, Orthopaedic Surgery and Traumatology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Hugo Garlito-Díaz
- Pediatric Orthopaedic Unit, Clínica CEMTRO, Av. Ventisquero de la Condesa 42, Madrid, 28035, Spain
- Pediatric Orthopaedic, Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Paloma Manzarbeitia-Arroba
- Pediatric Orthopaedic Unit, Clínica CEMTRO, Av. Ventisquero de la Condesa 42, Madrid, 28035, Spain
- Pediatric Orthopaedic, Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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Yahagi Y, Iriuchishima T, Iwama G, Suruga M, Nakanishi K. Femoral Tunnel Position in Anatomical Double-bundle ACL Reconstruction is not Affected by Blumensaat's Line Morphology. J Knee Surg 2024; 37:674-679. [PMID: 38336111 DOI: 10.1055/a-2265-9586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
The aim of this study was to reveal the influence of the morphological variations of the Blumensaat's line on anteromedial (AM) and posterolateral (PL) femoral tunnel position in anatomical double-bundle anterior cruciate ligament (ACL) reconstruction.Fifty-three subjects undergoing anatomical double-bundle ACL reconstruction were included (29 female, 24 male; median age 27.4 years; range: 14-50 years). Using an inside-out transportal technique, the PL tunnel position was made on a line drawn vertically from the bottommost point of the lateral condyle at 90 degrees of knee flexion, spanning a distance of 5 to 8 mm, to the edge of the joint cartilage. AM tunnel position was made 2 mm distal to the PL tunnel position. Following Iriuchishima's classification, the morphology of the Blumensaat's line was classified into straight and hill (large and small) types. Femoral tunnel position was determined using the quadrant method. A Mann-Whitney U test was performed to compare straight and hill type knees according to AM and PL femoral tunnel position.There were 18 straight and 35 hill type knees (13 small and 22 large hill). AM and PL femoral tunnel position in straight type knees were 21.7 ± 7.0 and 33.6 ± 10.5% in the shallow-deep direction, and 42.1 ± 11.1 and 72.1 ± 8.5% in the high-low direction, respectively. In hill type knees, AM and PL femoral tunnel position were 21.3 ± 5.8 and 36.9 ± 7.1% in the shallow-deep direction, and 44.6 ± 10.7 and 72.1 ± 9.7% in the high-low direction, respectively. No significant difference in AM or PL femoral tunnel position was detected between straight and hill type knees.AM and PL femoral tunnel position in anatomical double-bundle ACL reconstruction was not affected by the morphological variations of the Blumensaat's line. Surgeons do not need to consider Blumensaat's line morphology if AM and PL femoral tunnel position is targeted at the bottommost point of the lateral condyle. This was a level of evidence III study.
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Affiliation(s)
- Yoshiyuki Yahagi
- Department of Orthopaedic Surgery, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Takanori Iriuchishima
- Department of Orthopaedic Surgery, Kamimoku Spa Hospital, Minakami, Japan
- Department of Functional Morphology, Nihon University School of Medicine, Tokyo, Japan
| | - Genki Iwama
- Department of Orthopaedic Surgery, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Makoto Suruga
- Department of Orthopaedic Surgery, Nihon University Hospital, Tokyo, Japan
| | - Kazuyoshi Nakanishi
- Department of Orthopaedic Surgery, Nihon University Itabashi Hospital, Tokyo, Japan
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Bixby EC, Heyworth BE. Management of Anterior Cruciate Ligament Tears in Skeletally Immature Patients. Curr Rev Musculoskelet Med 2024; 17:258-272. [PMID: 38639870 PMCID: PMC11156825 DOI: 10.1007/s12178-024-09897-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2024] [Indexed: 04/20/2024]
Abstract
PURPOSE OF REVIEW Anterior cruciate ligament (ALC) tears are increasingly common in skeletally immature patients, as more children and adolescents participate in intensive sports training and specialization at increasingly younger ages. These injuries were historically treated nonoperatively, given concerns for physeal damage and subsequent growth disturbances after traditional ACL reconstruction techniques. However, there is now sufficient data to suggest superior outcomes with operative treatment, specifically with physeal-sparing and physeal-respecting techniques. This article reviews considerations of skeletal maturity in patients with ACL tears, then discusses surgical techniques, with a focus on their unique indications and outcomes. Additional surgical adjuncts and components of postoperative rehabilitation, which may reduce retear rates, are also considered. RECENT FINDINGS Current research shows favorable patient-reported outcomes and high return-to-sport rates after ACL reconstruction in skeletally immature patients. Graft rupture (ACL retear) rates are low, but notably higher than in most adult populations. Historically, there has been insufficient research to comprehensively compare reconstruction techniques used in this patient population. However, thoughtful systematic reviews and multicenter prospective studies are emerging to address this deficit. Also, more recent data suggests the addition of lateral extra-articular procedures and stringent return-to-sports testing may lower retear rates. Physeal-sparing and physeal-respecting ACL reconstructions result in stabilization of the knee, while respecting the growth remaining in children or skeletally immature adolescents. Future research will be essential to compare these techniques, given that more than one may be appropriate for patients of a specific age and skeletal maturity.
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Affiliation(s)
- Elise C Bixby
- Department of Sports Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Benton E Heyworth
- Department of Sports Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
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Zsidai B, Kaarre J, Narup E, Samuelsson K. Timing of Anterior Cruciate Ligament Surgery. Clin Sports Med 2024; 43:331-341. [PMID: 38811113 DOI: 10.1016/j.csm.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
This narrative review examines the current literature for the influence of the surgical timing in the setting of anterior cruciate ligament (ACL) reconstruction on various outcomes. Although the exact definition of early and delayed ACL reconstruction (ACLR) is a subject of controversy, surgical timing influences arthrofibrosis and postoperative stiffness, quadriceps strength, postoperative knee function, and the incidence of intra-articular injuries to the menisci and cartilage. Additionally, there is a shortage of evidence regarding the role of ACLR timing in the setting of multiligament knee injury and when concurrent procedures are performed during the operative treatment of the ACL-injured knee.
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Affiliation(s)
- Bálint Zsidai
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Janina Kaarre
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA, USA
| | - Eric Narup
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedics, Sahlgrenska University Hospital, Göteborgsvägen 31, 431 30 Mölndal, Sweden
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Ebert JR, Sobhi S, Annear PT. Transphyseal ACL reconstruction and tenodesis in skeletally immature patients demonstrates encouraging clinical scores, without growth disturbance, excessive laxity or re-injury. J Orthop 2024; 52:55-60. [PMID: 38435316 PMCID: PMC10901687 DOI: 10.1016/j.jor.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/19/2024] [Indexed: 03/05/2024] Open
Abstract
Purpose Paediatric patients demonstrate high re-rupture rates after anterior cruciate ligament reconstruction (ACLR), with numerous surgical techniques proposed to deal with this challenging cohort. This study investigated the early clinical outcomes, complications, return to sport (RTS) and re-rupture rates up until 2-years post-surgery in paediatric patients presenting with open growth plates undergoing transphyseal ACLR that was combined with an extra-articular tenodesis (LET). Methods Between October 2017 and September 2020, 20 skeletally immature patients were consecutively recruited and underwent transphyseal ACLR and LET. Patient reported outcome measures (PROMs), KT-1000 laxity, knee range of motion (ROM), maximal isokinetic knee torque and a 3-hop battery were assessed at 6-, 12- and 24-months. Limb Symmetry Indices (LSIs), RTS rates, complications, re-ruptures and re-operations were reviewed. Results All PROMs improved (p < 0.05). No change (p = 0.903) in laxity between limbs was seen, while 18 patients (90%) demonstrated normal (<3 mm) or near normal (3-5 mm) laxity differences. Peak knee flexion ROM improved over time (p = 0.028), while LSIs for knee extensor strength (p < 0.001), the single (p = 0.002) and triple crossover (p = 0.038) hop tests improved. At 24 months, 18 patients (90%) were participating in their pre-injury pivoting sport activities. No complications, growth disturbances, re-injuries or subsequent surgeries were observed. Conclusions Transphyseal ACLR combined with LET, undertaken in skeletally immature paediatric patients, demonstrated high scoring PROMs, physical performance and RTS overall, without evidence of growth disturbance or excessive graft laxity. No re-injuries have been observed at this time with ongoing review required in this high-risk cohort.
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Affiliation(s)
- Jay R. Ebert
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Crawley, Western, Australia
- HFRC Rehabilitation Clinic, 117 Stirling Highway, Nedlands, Western, Australia
- Perth Orthopaedic & Sports Medicine Research Institute, West Perth, Western, Australia
| | - Salar Sobhi
- Perth Orthopaedic and Sports Medicine Centre, West Perth, Western, Australia
| | - Peter T. Annear
- Perth Orthopaedic & Sports Medicine Research Institute, West Perth, Western, Australia
- Perth Orthopaedic and Sports Medicine Centre, West Perth, Western, Australia
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Adhitya IPGS, Wibawa A, Aryana IGNW, Suprawesta L, Kurniawati I, Kamayoga IDGA, Kinandana GP. Predictors of lower knee function improvement two years after anterior cruciate ligament reconstruction. PHYSICIAN SPORTSMED 2024; 52:239-245. [PMID: 37218654 DOI: 10.1080/00913847.2023.2217877] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/22/2023] [Indexed: 05/24/2023]
Abstract
OBJECTIVES The extent to which knee functions improve after anterior cruciate ligament reconstruction (ACLR) varies. This study aimed to determine the factors that affect lower knee function improvement after two years of ACLR. METHODS The study included 159 patients who underwent ACLR in the Indonesian ACL community between August 2018 and April 2020. The concomitant injury and graft types of ACLR were determined using patients' pre-surgical MRI and medical records. The five subscales of the knee injury and osteoarthritis outcome score (KOOS) were used to evaluate the patient at baseline, first year, and second year following ACLR. A linear mixed-effect model (LMEM) was used to predict the longitudinal improvement models for the five-subscales KOOS score after ACLR. RESULTS The LMEM predicted lower KOOS subscales scores improvements by 0.5 for QOL, 0.1 for symptom, ADL, and QOL, and 0.2 for sports/recreation, respectively, for a one score increase of age and time from injury to surgery. Male patients had higher KOOS subscale scores with the improvement of pain, symptom, and ADL by 5.7, 5.9, and 6.3 compared to female patients, respectively, while patients with patellar tendon grafts had lower improvement of KOOS score pain by 6.5 compared to hamstring tendon grafts. CONCLUSION As the age and time from injury to surgery increased, the KOOS subscales scores of QOL and symptoms, ADL, sports/recreation, and QOL decreased. Male patients reported higher KOOS subscales scores for pain, symptoms, and ADL, while patients with patella tendon grafts had a lower improvement in pain score.
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Affiliation(s)
| | - Ari Wibawa
- Department of Physical Therapy, College of Medicine, Universitas Udayana, Denpasar, Indonesia
| | - I Gusti Ngurah Wien Aryana
- Department of Orthopaedic and Traumatology, College of Medicine and Sanglah General Hospital, Universitas Udayana, Denpasar, Indonesia
| | - Lalu Suprawesta
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei, Taiwan
- Department of Sport and Health Education, Faculty of Sport Science and Public Health, Universitas Pendidikan Mandalika, Mataram, Indonesia
| | - Ida Kurniawati
- Department of Histology, Faculty of Medicine and Health Sciences, Universitas Warmadewa, Bali, Indonesia
| | | | - Gede Parta Kinandana
- Department of Physical Therapy, College of Medicine, Universitas Udayana, Denpasar, Indonesia
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Kawashima T, Mutsuzaki H, Watanabe A, Ikeda K, Yamanashi Y, Kinugasa T. Impact of Surgical Timing on Functional Outcomes after Anterior Cruciate Ligament Reconstruction. J Clin Med 2024; 13:2994. [PMID: 38792535 PMCID: PMC11122620 DOI: 10.3390/jcm13102994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/02/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024] Open
Abstract
Objectives: Although acute anterior cruciate ligament reconstruction (ACLR) is often avoided because of postoperative joint stiffness, delayed ACLR can lead to a longer recovery time and can have a negative impact on physical function due to detraining. This study aimed to determine the effects of acute ACLR on postoperative outcomes, including muscle strength, performance, and return to sports. Methods: A total of 110 patients who underwent anatomical ACLR using hamstring autografts were included in this study and were divided into three groups: acute (ACLR performed within 2 weeks after ACL injury), 2-6 weeks (ACLR performed between 2 and 6 weeks after injury), and 6-12 weeks (ACLR performed between 6 and 12 weeks after injury). Several parameters were evaluated, including range of motion, knee joint stability, isokinetic knee strength, performance, and return to sports. Results: No significant differences were found in the range of motion or knee joint stability between the groups. The acute group exhibited significantly greater quadriceps strength at 3 months postoperatively than the other groups (p < 0.05). The single-leg hop test showed that 66.7%, 38.7%, and 33.3% of the patients in the acute, 2-6 weeks, and 6-12 weeks groups, respectively, recovered to an LSI of 90% or greater (p = 0.09, Cramer's V = 0.27). All patients in the acute group were able to return to sports (p = 0.14; Cramer's V = 0.28). Conclusions: Acute ACLR is advantageous for the early recovery of strength and performance without adverse events. Acute ACLR may shorten the time spent away from sports activities.
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Affiliation(s)
| | - Hirotaka Mutsuzaki
- Center for Medical Science, Ibaraki Prefectural University of Health Sciences, Ami 300-0394, Japan
- Department of Orthopedic Surgery, Ibaraki Prefectural University of Health Sciences Hospital, Ami 300-0331, Japan
| | - Arata Watanabe
- Department of Orthopedic Surgery, Ichihara Hospital, Tsukuba 300-3295, Japan
- Department of Orthopedic Surgery, University of Tsukuba, Tsukuba 305-8575, Japan
| | - Kotaro Ikeda
- Department of Orthopedic Surgery, Ichihara Hospital, Tsukuba 300-3295, Japan
| | - Yuki Yamanashi
- Department of Orthopedic Surgery, Aichi Medical University, Nagakute 480-1195, Japan
| | - Tomonori Kinugasa
- Department of Orthopedic Surgery, Ichihara Hospital, Tsukuba 300-3295, Japan
- Department of Orthopedic Surgery, University of Tsukuba, Tsukuba 305-8575, Japan
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Herdea A, Dragomirescu MC, Burcan V, Ulici A. Pediatric ACL Reconstruction in Children-An Evaluation of the Transphyseal Technique's Efficacy and Safety. CHILDREN (BASEL, SWITZERLAND) 2024; 11:545. [PMID: 38790540 PMCID: PMC11119618 DOI: 10.3390/children11050545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 04/28/2024] [Accepted: 04/30/2024] [Indexed: 05/26/2024]
Abstract
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.
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Affiliation(s)
- Alexandru Herdea
- 11th Department of Pediatric Orthopedics, “Carol Davila” University of Medicine and Pharmacy, Bd. Eroii Sanitari Nr. 8, 050474 Bucharest, Romania;
- Pediatric Orthopedics Department, “Grigore Alexandrescu” Children’s Emergency Hospital, 011743 Bucharest, Romania; (M.-C.D.); (V.B.)
| | - Mihai-Codrut Dragomirescu
- Pediatric Orthopedics Department, “Grigore Alexandrescu” Children’s Emergency Hospital, 011743 Bucharest, Romania; (M.-C.D.); (V.B.)
| | - Valentin Burcan
- Pediatric Orthopedics Department, “Grigore Alexandrescu” Children’s Emergency Hospital, 011743 Bucharest, Romania; (M.-C.D.); (V.B.)
| | - Alexandru Ulici
- 11th Department of Pediatric Orthopedics, “Carol Davila” University of Medicine and Pharmacy, Bd. Eroii Sanitari Nr. 8, 050474 Bucharest, Romania;
- Pediatric Orthopedics Department, “Grigore Alexandrescu” Children’s Emergency Hospital, 011743 Bucharest, Romania; (M.-C.D.); (V.B.)
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Ramteke SU, Jaiswal PR, Tikhile P. Nonsurgical Rehabilitation Perspectives for a Type I Salter-Harris Fracture With Lipohemarthrosis and Concomitant Grade II Anterior Cruciate Ligament (ACL) Tear in a Volleyball Athlete: A Case Report. Cureus 2024; 16:e59758. [PMID: 38846221 PMCID: PMC11153972 DOI: 10.7759/cureus.59758] [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] [Received: 04/17/2024] [Accepted: 05/06/2024] [Indexed: 06/09/2024] Open
Abstract
Anterior cruciate ligament (ACL) tears represent common occurrences in sports, particularly posing significant risks to young athletes. The diagnostic methods for ACL injury include magnetic resonance imaging (MRI), arthroscopy, and physical examination. Management of this injury can be done both operative and nonoperatively. Pediatric growth plate fractures are classified under the Salter-Harris classification. A 13-year-old male athlete sustained a knee injury during a volleyball match. While landing from a jump after a smash, the athlete directly landed on the ground on his right knee. After this, he reported discomfort and severe anterior knee pain. Due to immobility and pain, he was taken to the emergency unit. Upon radiographic examination, a Salter-Harris Classification Type I fracture was found, indicating epiphyseal slip and separation through the physis of the right proximal tibia medially. An MRI imaging was done to check the integrity of the ACL after the swelling had subsided post-15 days of injury. An MRI identified a bony contusion on the medial tibial plateau, extending to the physeal plate with a Grade II ACL tear. The concurrent occurrence of ACL injury and growth plate injury presents a significant concern. Hence, a referral for physical therapy rehabilitation was given. Our findings highlight the importance of prompt initiation of physical rehabilitation following such injuries. Where non-surgical rehabilitation strategies play a crucial role in managing these cases while focusing on restoring knee stability, promoting healing of the growth plate, and facilitating a safe return to sport. Tailored rehabilitation, including therapeutic exercises, neuromuscular training, and proprioceptive training, is essential for optimizing outcomes and preventing long-term complications. The case underscores the importance of a multidisciplinary approach in managing the complex knee injury of this young athlete.
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Affiliation(s)
- Swapnil U Ramteke
- Sports Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Pratik R Jaiswal
- Sports Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Priya Tikhile
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Gamble AR, McKay MJ, Anderson DB, Pappas E, Alvarez Cooper I, Macpherson S, Harris IA, Filbay SR, McCaffery K, Thompson R, Hoffmann TC, Maher CG, Zadro JR. Development of a patient decision aid for children and adolescents following anterior cruciate ligament rupture: an international mixed-methods study. BMJ Open 2024; 14:e081421. [PMID: 38684251 PMCID: PMC11086191 DOI: 10.1136/bmjopen-2023-081421] [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: 10/27/2023] [Accepted: 04/08/2024] [Indexed: 05/02/2024] Open
Abstract
AIM To develop and user test an evidence-based patient decision aid for children and adolescents who are considering anterior cruciate ligament (ACL) reconstruction. DESIGN Mixed-methods study describing the development of a patient decision aid. SETTING A draft decision aid was developed by a multidisciplinary steering group (including various types of health professionals and researchers, and consumers) informed by the best available evidence and existing patient decision aids. PARTICIPANTS People who ruptured their ACL when they were under 18 years old (ie, adolescents), their parents, and health professionals who manage these patients. Participants were recruited through social media and the network outreach of the steering group. PRIMARY AND SECONDARY OUTCOMES Semistructured interviews and questionnaires were used to gather feedback on the decision aid. The feedback was used to refine the decision aid and assess acceptability. An iterative cycle of interviews, refining the aid according to feedback and further interviews, was used. Interviews were analysed using reflexive thematic analysis. RESULTS We conducted 32 interviews; 16 health professionals (12 physiotherapists, 4 orthopaedic surgeons) and 16 people who ruptured their ACL when they were under 18 years old (7 were adolescents and 9 were adults at the time of the interview). Parents participated in 8 interviews. Most health professionals, patients and parents rated the aid's acceptability as good-to-excellent. Health professionals and patients agreed on most aspects of the decision aid, but some health professionals had differing views on non-surgical management, risk of harms, treatment protocols and evidence on benefits and harms. CONCLUSION Our patient decision aid is an acceptable tool to help children and adolescents choose an appropriate management option following ACL rupture with their parents and health professionals. A clinical trial evaluating the potential benefit of this tool for children and adolescents considering ACL reconstruction is warranted.
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Affiliation(s)
- Andrew R Gamble
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Marnee J McKay
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David B Anderson
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Evangelos Pappas
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | | | - Sophie Macpherson
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ian A Harris
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW, Sydney, New South Wales, Australia
| | - Stephanie R Filbay
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rachel Thompson
- Discipline of Behavioural and Social Sciences in Health, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Tammy C Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Christopher G Maher
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Joshua R Zadro
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
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Herring SA, Kibler WB, Putukian M, Boyajian-O'Neill LA, Chang CJ, Franks RR, Hutchinson M, Indelicato PA, O'Connor FG, Powell A, Roach R, Safran M, Statuta SM, Sutton K. Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement. Med Sci Sports Exerc 2024; 56:385-401. [PMID: 37847756 DOI: 10.1249/mss.0000000000003324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
ABSTRACT Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.
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Herring SA, Kibler WB, Putukian M, Boyajian-O'Neill LA, Chang CJ, Franks RR, Hutchinson M, Indelicato PA, O'Connor FG, Powell A, Roach R, Safran M, Statuta SM, Sutton K. Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement. Curr Sports Med Rep 2024; 23:86-104. [PMID: 38437494 DOI: 10.1249/jsr.0000000000001151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
ABSTRACT Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.
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14
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Tang H, Xiao YF, Wu YM, Xiong YL, Gao SG. Physeal-Sparing, All-Inside Anterior Cruciate Ligament Reconstruction Using Quadrupled Semitendinosus Autograft and Suture Tape Augmentation for Skeletally Immature Patients. Arthrosc Tech 2024; 13:102889. [PMID: 38584626 PMCID: PMC10995729 DOI: 10.1016/j.eats.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/04/2023] [Indexed: 04/09/2024] Open
Abstract
The anterior cruciate ligament (ACL) is the primary soft-tissue structure for anterior stabilization of the knee and is one of the most frequently injured structures. The incidence of ACL injuries in children and adolescents ranges from 92 to 151 per 100,000 person-years. The choice of surgical treatment for this population group is controversial, with a widespread concern that adult reconstruction techniques may damage the epiphyseal plate, compromise growth, or cause deformity. In this article, we describe a physeal-sparing, all-inside ACL reconstruction technique for skeletally immature patients. This technique is supported by retrograde drilling of the femoral tunnel and retrograde drilling of the tibial tunnel, both of which are able to avoid the epiphyseal growth line. Fixation of the quadrupled semitendinosus autograft and suture tape augmentation are achieved by soft-tissue buttons on the femur and tibia. The surgical details of this reproducible reconstruction technique are elaborated.
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Affiliation(s)
- Hang Tang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yi-Fan Xiao
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yu-Mei Wu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yi-Lin Xiong
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Shu-Guang Gao
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan, China
- Hunan Engineering Research Center of Osteoarthritis, Changsha, Hunan, China
- National Clinical Research Center of Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
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15
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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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Monaco E, Cantagalli MR, Daggett M, Carrozzo A, Annibaldi A, Criseo N, Labianca L, Ferretti A. Arthroscopic Physeal Sparing Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis With Semitendinosus and Gracilis Tendons. Arthrosc Tech 2024; 13:102843. [PMID: 38435246 PMCID: PMC10907894 DOI: 10.1016/j.eats.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/20/2023] [Indexed: 03/05/2024] Open
Abstract
Anterior cruciate ligament (ACL) injuries among young patients have increased in recent years. The purpose of this study was to present a physeal-sparing intra- and extra-articular reconstruction using semitendinosus and gracilis tendons autograft. In recent years, the management of these injuries in the pediatric population has become increasingly surgical to restore knee function and reduce the risk of meniscal and chondral injury due to persistent knee instability. However, this is a population at high risk for ACL graft rupture, but it can be lowered by an addition of lateral extra-articular tenodesis (LET). This study shows the pearls and pitfalls of an arthroscopic physeal-sparing ACL reconstruction combined with a concomitant LET using hamstrings autograft.
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Affiliation(s)
- Edoardo Monaco
- Sant’Andrea University Hospital, La Sapienza University of Rome, Rome, Italy
| | | | - Matt Daggett
- Sant’Andrea University Hospital, La Sapienza University of Rome, Rome, Italy
| | - Alessandro Carrozzo
- Sant’Andrea University Hospital, La Sapienza University of Rome, Rome, Italy
| | | | - Natale Criseo
- Sant’Andrea University Hospital, La Sapienza University of Rome, Rome, Italy
| | - Luca Labianca
- Sant’Andrea University Hospital, La Sapienza University of Rome, Rome, Italy
| | - Andrea Ferretti
- Sant’Andrea University Hospital, La Sapienza University of Rome, Rome, Italy
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17
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Madsen MØ, Warming S, Rathcke MW, Faunø P, Nielsen TG, Herzog RB, Lundgaard-Nielsen M, Kourakis AH, Lind M, Krogsgaard MR. Similar outcomes after anterior cruciate ligament reconstruction in paediatric and adult populations: a 1-year follow-up of 506 paediatric operations in Denmark. Knee Surg Sports Traumatol Arthrosc 2023; 31:4871-4877. [PMID: 37573265 PMCID: PMC10598128 DOI: 10.1007/s00167-023-07530-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/26/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE To present 1-year results after all paediatric anterior cruciate ligament (ACL) reconstructions in Denmark (5.9 M inhabitants) for the 10½ year period, 1 July 2011 to 31 December 2021. METHODS All children who had an ACL reconstruction were enrolled. They were asked to complete Pedi-IKDC preoperatively and at 1-year follow-up. Independent observers performed pivot shift test and instrumented laxity assessment preoperatively and at 1-year follow-up. RESULTS The median age of the 506 children (47.2% girls) was 14.3 years (9.3-15.9). The Pedi-IKDC score increased from preoperatively 61.6 ± 15.8 (mean ± SD) to 85.9 ± 13.0 at 1-year follow-up (p < 0.0001). There were concomitant injuries (to meniscus and/or cartilage) in 49.9%, but these children had preoperative and follow-up Pedi-IKDC scores similar to the scores for children with isolated injury to ACL (n. s.). Instrumented anterior laxity was 4.3 ± 1.4 (mean ± SD) mm preoperatively and 1.4 ± 1.4 mm at follow-up (p < 0.0001). Preoperatively, 3% had no pivot shift whilst this was the case for 68% postoperatively (p < 0.0001). Twenty-five children (5.6%) had 4 mm instrumented laxity or more relative to the unoperated knee at follow-up. Two patients (0.4%) had an operatively treated deep infection, three (0.5%) were operated on for reduced range of motion and two (0.4%) had a revision ACL reconstruction. CONCLUSION ACL reconstruction resulted in a clinically meaningful increase in Pedi-IKDC, an improved instrumented stability, a reduction in the grade of pivot shift and the complication rate was low at 1-year follow-up. The risk of graft insufficiency at 1-year follow-up was the same as in an adult population. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Maria Østergaard Madsen
- Section for Sports Traumatology M51, Bispebjerg and Frederiksberg University Hospital, (A Part of Copenhagen IOC Research Center), Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark
| | - Susan Warming
- Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Martin Wyman Rathcke
- Section for Sports Traumatology M51, Bispebjerg and Frederiksberg University Hospital, (A Part of Copenhagen IOC Research Center), Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark
| | - Peter Faunø
- Sector for Sports Traumatology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | | | - Robert Bennike Herzog
- Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Mathilde Lundgaard-Nielsen
- Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg University Hospital, Copenhagen, Denmark
| | - Anette Holm Kourakis
- Section for Sports Traumatology M51, Bispebjerg and Frederiksberg University Hospital, (A Part of Copenhagen IOC Research Center), Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark
| | - Martin Lind
- Sector for Sports Traumatology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Michael Rindom Krogsgaard
- Section for Sports Traumatology M51, Bispebjerg and Frederiksberg University Hospital, (A Part of Copenhagen IOC Research Center), Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark.
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18
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Kay J, Liotta ES, Sugimoto D, Heyworth BE. Assessment of Return to Sport After ACL Reconstruction With Soft Tissue Autograft in Adolescent Athletes: Quadriceps Versus Hamstring Tendon. Orthop J Sports Med 2023; 11:23259671231207113. [PMID: 38021299 PMCID: PMC10676070 DOI: 10.1177/23259671231207113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/19/2023] [Indexed: 12/01/2023] Open
Abstract
Background Quadriceps tendon soft tissue autograft represents an increasingly popular graft option for anterior cruciate ligament reconstruction (ACLR), particularly for adolescents, some of whom have an open physis, precluding use of graft options with bone plugs. Purpose/Hypothesis The purpose of this study was to quantify return-to-sport performance assessments in adolescents at 6 months after ACLR with all-soft tissue quadriceps tendon autograft (ACLR-Q) versus hamstring tendon autograft (ACLR-HS). It was hypothesized that ACLR-Q would be associated with improved hamstring strength and hamstring-to-quadriceps (HS:Q) ratios compared with ACLR-HS, albeit with decreased quadriceps strength. Study Design Cross-sectional study; Level of evidence, 3. Methods Included were patients aged 12 to 19 years who underwent primary ACLR by a single surgeon and who completed a return-to-sport performance assessment between 5 and 9 months postoperatively. The performance assessment included manual muscle strength tests (hamstring, quadriceps, hip abductor and adductor), dynamic balance test (Y-balance), and functional hop tests (single hop, triple hop, crossover hop, 6-m timed hop). Data were converted to limb symmetry indices, and limb symmetry index deficits were compared between the ACLR-Q and ACLR-HS cohorts using the Student t test or Wilcoxon-Mann-Whitney test. Results An initial cohort of 90 ACLR-Q patients was compared with 54 ACLR-HS patients, with no significant differences in patient characteristics. Differences in meniscal repair rates, however, prompted use of propensity score matching on age, sex, body mass index, meniscectomy, and meniscal repair to produce comparable subcohorts. The matching resulted in 67 ACLR-Q and 52 ACLR-HS patients. Hamstring strength deficits were significantly greater in ACLR-HS versus ACLR-Q patients (-40.5% vs -5.7%; P < .001). Quadriceps strength deficits were significantly greater in ACLR-Q versus ACLR-HS patients (-12.8% vs -0.4%; P < .001). ACLR-Q patients had a significantly greater HS:Q ratio on the operative knee (P < .001) and significantly higher Y-balance composite score deficits (-2.9% vs -0.4%; P = .01) than ACLR-HS patients. There were no significant differences in hop test performance between groups. Conclusion Adolescent athletes who underwent ACLR-Q showed significantly greater quadriceps strength deficits but significantly smaller hamstring strength deficits than those who underwent ACLR-HS, leading to more favorable HS:Q ratios in ACLR-Q patients at 6 months postoperatively.
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Affiliation(s)
- Jeffrey Kay
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Division of Sports Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Elizabeth S. Liotta
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Dai Sugimoto
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA
- Faculty of Sport Sciences, Waseda University, Tokyo, Japan
| | - Benton E. Heyworth
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
- Division of Sports Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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19
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Jildeh TR, Bowen E, Bedi A. Revision Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients. J Am Acad Orthop Surg 2023; 31:e920-e929. [PMID: 37364250 DOI: 10.5435/jaaos-d-23-00288] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 05/27/2023] [Indexed: 06/28/2023] Open
Abstract
Revision anterior cruciate ligament (ACL) reconstruction in the skeletally immature patient is a challenging procedure for pediatric patients with recurrent instability after primary ACL reconstruction. The pediatric population presents unique technical challenges and complications secondary to open physes compared with the adult population. Complications can include growth disturbances, recurrent graft failure, instability, and secondary chondral and/or meniscal injury. Moreover, identifying the etiology of graft failure is critical for a successful revision. Patients should undergo a complete history and physical examination with a focus on patient physiologic age, physeal status, mechanical axis, tibial slope, collagen status, injury mechanism, concomitant injuries, and previous surgical procedures. The surgeon must be adept at reconstruction with various grafts as well as socket or tunnel preparation and fixation, including over-the-top, all-epiphyseal, transphyseal, extra-articular augmentation, and staging approaches. Reported rates of return to sport are lower than those of primary reconstruction, with higher rates of cartilage and meniscal degeneration. Future research should focus on optimizing surgical outcomes and graft survivorship after primary ACL reconstruction with minimized trauma to the physis.
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Affiliation(s)
- Toufic R Jildeh
- From the Department of Orthopaedics, Michigan State University, East Lansing, MI (Jildeh), the Weill Cornell Medical College, New York, NY (Bowen), and the NorthShore Medical Group, Skokie, IL (Bedi)
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20
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Huang SG, Wilson PL, Worrall HM, Ramo BA, Kapadia A, Ellis HB. Elective musculoskeletal surgery is associated with postoperative weight changes in pediatric and adolescent patients. J Child Orthop 2023; 17:489-496. [PMID: 37799309 PMCID: PMC10549699 DOI: 10.1177/18632521231198250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 08/15/2023] [Indexed: 10/07/2023] Open
Abstract
Purpose Patients of elective orthopedic surgeries often reduce activity levels during postoperative recovery. It is unclear whether these extended periods of modified activities lead to weight changes. The purpose of this study was to evaluate changes in body mass index percentile in pediatric patients over 2.5 years following primary musculoskeletal surgeries. Methods Institutional records for utilized current procedural terminology codes were used to identify patients aged 21 years or younger who underwent elective surgery at a single pediatric orthopedic institution between October 2016 and December 2018. Non-primary surgeries and patients without preoperative body mass index measurements were excluded. Demographic characteristics, height, weight, and body mass index within 30 months of surgery were collected. Body mass index relative to age was calculated. Analysis of body mass index changes at follow-up intervals of 3-7, 9-18, and 24-30 months after surgery was performed for the overall sample, within surgical categories, and within preoperative weight classifications. Results A total of 1566 patients (53.1% female, average age 12.4 years) were included. Over one-third of patients were overweight or obese at presentation. The average change in body mass index percentile relative to baseline was increased at all follow-up intervals. Values reached significance at 9-18 months (p = .002) and 24-30 months (p = .001). While underweight and normal-weight patients had increased body mass index at all three timepoints, overweight or obese patients decreased. Conclusions Patients undergoing elective orthopedic procedures may experience significant changes in body mass index percentile postoperatively. At extremes of weight, patients experience improvement toward the mean, but most patients may undergo body mass index increases beyond what would be expected during normal growth. Level of evidence Retrospective level III.
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Affiliation(s)
- Sharon G Huang
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Philip L Wilson
- University of Texas Southwestern Medical Center, Dallas, TX, USA
- Scottish Rite for Children, Dallas, TX, USA
- Children’s Medical Center Dallas, Dallas, TX, USA
| | | | - Brandon A Ramo
- University of Texas Southwestern Medical Center, Dallas, TX, USA
- Scottish Rite for Children, Dallas, TX, USA
- Children’s Medical Center Dallas, Dallas, TX, USA
| | - Ami Kapadia
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Henry B Ellis
- University of Texas Southwestern Medical Center, Dallas, TX, USA
- Scottish Rite for Children, Dallas, TX, USA
- Children’s Medical Center Dallas, Dallas, TX, USA
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21
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Kiani SN, England P, Gornitzky AL, Renjilian CB, Williams BA, Ganley TJ. Disparate Impact: How Does Social Deprivation Affect Patient-reported Outcomes After ACL Reconstruction in Children and Adolescents? J Pediatr Orthop 2023; 43:543-548. [PMID: 37694606 DOI: 10.1097/bpo.0000000000002491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
BACKGROUND Research has indicated that lower socioeconomic status is associated with delays in the treatment of anterior cruciate ligament (ACL) injuries; however, there is a paucity of literature evaluating its association with patient-reported outcomes (PROs). Using the Area Deprivation Index (ADI), a validated proxy for socioeconomic status, the study aimed to determine how relative socioeconomic disadvantage is related to PROs after primary ACL reconstruction (ACLR) in pediatric patients. METHODS This retrospective cohort study included all patients 18 years old or above who underwent primary ACLR at an academic institution between 2018 and 2021. Exclusion criteria included multiligament injury, congenital ACL absence, and absent outcomes data. The minimum follow-up was 6 months. A Patient-reported Outcomes Measurement Information System (PROMIS) 50 Pediatric self-report questionnaire was completed at postoperative visits, and domain scores for pain, physical function/mobility, fatigue, anxiety, depression, and peer relationships were generated. The National ADI percentile was calculated using the patients' addresses. Patients were divided into quartiles (low, moderate, moderate-severe, and severe ADI), and comparative analyses were performed to determine the relationship between ADI and PROMIS. RESULTS A total of 413 patients were identified, including 49% (n=207), 33% (n=139), 11% (n=48), and 7% (n=30) from the low, moderate, moderate-severe, and severe deprivation areas, respectively. As compared with those in the low-deprivation quartile, patients in the severe deprivation quartile had delayed time to the first clinic visit (11 vs. 16.5 d, P=0.044) and surgery (51 vs. 80 d, P=0.004). There were no differences in the number of additional procedures required at index surgery. All quartiles had progressive improvements in physical function/mobility and pain scores throughout recovery, but at 9 months, there was significantly more pain in the severe deprivation cohort, despite no difference in self-reported physical function and mobility. Those with severe socioeconomic disadvantage had worse psychosocial outcomes, including significantly increased depression, fatigue, and anxiety and decreased peer relationship scores. CONCLUSIONS Although there were no differences in preoperative PROMIS scores, pediatric patients living in areas with higher levels of socioeconomic deprivation/disadvantage had worse psychosocial PROs after ACLR. LEVEL OF EVIDENCE Level III-retrospective comparative study.
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Affiliation(s)
- Sara N Kiani
- Department of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, PA
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Cronström A, Häger CK, Thorborg K, Ageberg E. Factors Associated With Sports Function and Psychological Readiness to Return to Sports at 12 Months After Anterior Cruciate Ligament Reconstruction: A Cross-sectional Study. Am J Sports Med 2023; 51:3112-3120. [PMID: 37681565 PMCID: PMC10543957 DOI: 10.1177/03635465231192983] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/05/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Sports function and psychological readiness to return to sports (RTS) are important outcomes when evaluating rehabilitation after anterior cruciate ligament reconstruction (ACLR). It is, however, unclear which specific factors contribute most to these outcomes. PURPOSE To determine associations between demographic characteristics, objective measurements of physical function, patient-reported outcome measure scores, sports-related function assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS) Sport and Recreation subscale, and psychological readiness to RTS assessed with the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale at 1 year after ACLR. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS At a mean of 12.5 ± 2.0 months after ACLR, 143 participants (50.3% female), with a mean age of 25.0 ± 5.7 years, were assessed for demographic characteristics, physical factors (hop performance, muscle strength, ankle and hip range of motion), and psychological factors (KOOS Pain and Symptoms subscales, Perceived Stress Scale, fear of reinjury) as well as the KOOS Sport and Recreation subscale and ACL-RSI scale. Backward linear regression models were used to evaluate factors associated with sports function and psychological readiness to RTS. RESULTS Lower isokinetic knee extension peak torque (limb symmetry index) (B = 18.38 [95% CI, 3.01-33.75]), lower preinjury activity level (B = 2.00 [95% CI, 0.87-3.14]), greater knee pain (B = 0.90 [95% CI, 0.70-1.10]), shorter time between injury and reconstruction (B = 0.16 [95% CI, 0.05-0.26]), and greater fear of reinjury (B = 0.11 [95% CI, 0.01-0.20]) were associated with a worse KOOS Sport and Recreation subscore (R2 = 0.683). A shorter hop distance (B = 0.15 [95% CI, 0.00-0.29]) was associated with a lower ACL-RSI score (R2 = 0.245). CONCLUSION A combination of knee muscle strength, activity level, knee pain, timing of surgery, and fear of reinjury accounted for approximately 70% of the variation in sports function at 1 year after ACLR. In contrast, there was only 1 weak association between physical function and psychological readiness to RTS at this time point. Thus, factors associated with current sports function are much better known than features related to psychological readiness to RTS.
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Affiliation(s)
- Anna Cronström
- Department of Health Sciences, Lund University, Lund, Sweden
- Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden
| | - Charlotte K. Häger
- Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden
| | - Kristian Thorborg
- Department of Health Sciences, Lund University, Lund, Sweden
- Department of Orthopaedic Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eva Ageberg
- Department of Health Sciences, Lund University, Lund, Sweden
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Erard J, Cance N, Shatrov J, Fournier G, Gunst S, Ciolli G, Porcelli P, Lustig S, Servien E. Delaying ACL reconstruction is associated with increased rates of medial meniscal tear. Knee Surg Sports Traumatol Arthrosc 2023; 31:4458-4466. [PMID: 37486367 DOI: 10.1007/s00167-023-07516-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
PURPOSE The aim of this study was to evaluate the relationship between the time from injury to ACL reconstruction (ACLR) and the rate as well as repairability of meniscal tears. Secondary aims were to evaluate the relationship between meniscal injury and Tegner Activity Scale, age, BMI, and gender. METHODS Between 2012 and 2022, 1,840 consecutive ACLRs were performed. A total of 1,317 ACLRs were included with a mean patient age of 31.2 years ± 10.5 [16-60]. Meniscal tear was assessed during arthroscopy using the ISAKOS classification. Time from injury to ACLR, Tegner Activity Scale, age, BMI and gender were analysed in uni- and then in multivariate analyses. Patients were divided into four groups according to the time from injury to surgery: < 3 months (427; 32%), 3-6 months (388; 29%), 6-12 months (248; 19%) and > 12 months (254; 19%). RESULTS Delaying ACLR > 12 months significantly increased the rate of medial meniscal (MM) injury (OR 1.14; p < 0.001). No correlation was found between a 3- or 6-month time from injury to surgery and MM tear. Performing ACLR > 3, 6, or 12 months after injury did not significantly increase the rate of lateral meniscal (LM) injury. Increasing Tegner activity scale was significantly associated with a lower rate of MM injury (OR 0.90; p = 0.020). An age > 30 years (OR 1.07; p = 0.025) and male gender (OR 1.13; p < 0.0001) was also associated with an increased rate of MM injury. Age > 30 years decreased the rate of MM repair (OR 0.85; p < 0.001). Male gender increased the rate of LM tear (OR 1.10; p = 0.001). CONCLUSION Performing ACLR more than 12 months after injury was associated with increased rates of MM injury but not with lower rates of repairable lesions. An increased pre-injury Tegner activity score was associated with a decreased rate of MM tear. Age > 30 years was associated with an increased rate of MM tear with concomitant ACL injury and a decreased rate of repairability of MM tear. ACLR should be performed within 12 months from injury to prevent from the risk of MM injury. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Julien Erard
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de La Croix Rousse, 69004, Lyon, France.
| | - Nicolas Cance
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de La Croix Rousse, 69004, Lyon, France
| | - Jobe Shatrov
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de La Croix Rousse, 69004, Lyon, France
- Sydney Orthopaedic Research Institute, University of Notre Dame Australia, Hornsby and Ku-Ring Hospital, Sydney, Australia
| | - Gaspard Fournier
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de La Croix Rousse, 69004, Lyon, France
| | - Stanislas Gunst
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de La Croix Rousse, 69004, Lyon, France
| | - Gianluca Ciolli
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de La Croix Rousse, 69004, Lyon, France
- Department of Orthopaedics, A. Gemelli University Hospital Foundation IRCCS, Catholic University, Via Della Pineta Sacchetti, 217, 00168, Rome, Italy
| | - Pasquale Porcelli
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de La Croix Rousse, 69004, Lyon, France
- Orthopaedic and Traumatology Department, Centro Traumatologico Ortopedico, Via Gianfranco Zuretti, 29, 10126, Turin, TO, Italy
| | - Sébastien Lustig
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de La Croix Rousse, 69004, Lyon, France
- IFSTTAR, Univ Lyon, Claude Bernard Lyon 1 University, LBMC UMR_T9406, F69622, Lyon, France
| | - Elvire Servien
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande Rue de La Croix Rousse, 69004, Lyon, France
- LIBM-EA 7424, Interuniversity Laboratory of Human Movement Science, Université Lyon 1, Lyon, France
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Kooy CEVW, Jakobsen RB, Fenstad AM, Persson A, Visnes H, Engebretsen L, Ekås GR. Major Increase in Incidence of Pediatric ACL Reconstructions From 2005 to 2021: A Study From the Norwegian Knee Ligament Register. Am J Sports Med 2023; 51:2891-2899. [PMID: 37497771 PMCID: PMC10478322 DOI: 10.1177/03635465231185742] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/15/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND The incidence of pediatric and adolescent anterior cruciate ligament reconstruction (ACLR) is increasing in several countries. It is uncertain whether this trend applies to countries that traditionally prefer an initial nonoperative treatment approach whenever possible, like Norway. Nationwide, long-term patient-reported outcomes and revision rates after ACLR in the pediatric population are also lacking. PURPOSE To determine the incidence of pediatric ACLR in Norway since 2005, as well as to detect trends in surgical details and describe patient-reported outcomes up to 10 years after ACLR. STUDY DESIGN Descriptive cohort study. METHODS This study is based on prospectively collected data on girls ≤14 years and boys ≤16 years, registered in the Norwegian Knee Ligament Register at the time of their primary ACLR, between 2005 and 2021. The main outcome was the incidence of ACLR, adjusted to the corresponding population numbers for each year. The time trend was analyzed by comparing the mean of the first and last 3-year period (2005-2007 and 2019-2021). Patient-reported outcomes were assessed using the Knee injury and Osteoarthritis Outcome Score preoperatively and at 2, 5, and 10 years postoperatively. RESULTS A total of 1476 patients (1484 cases) were included, with a mean follow-up of 8.1 years (range, 1-17). The incidence of pediatric ACLRs per 100,000 population increased from 18 to 26, which corresponds to an increase of 40% for boys and 55% for girls. Concurrent meniscal procedures increased significantly from 45% to 62%, and the proportion of meniscal repairs increased from 19% to 43% when comparing the first and last time period. The mean Knee injury and Osteoarthritis Outcome Score values for the Sport and Recreation and Quality of Life subscales were between 72 and 75 at the 2-, 5- and 10-year follow-up. The 5-year revision rate was 9.9%. CONCLUSION There was a major increase in incidence of pediatric ACLR in Norway during the study period. There was a shift in the approach to concomitant meniscal procedures from resection to repair, with more than a doubling of the proportion of meniscal repairs. Patient-reported outcomes revealed long-lasting reduced knee function.
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Affiliation(s)
- Caroline E. v. W. Kooy
- Oslo Sports Trauma Research, Norwegian School of Sports Science, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Orthopedic Surgery, Akershus University Hospital, Oslo, Norway
| | - Rune B. Jakobsen
- Oslo Sports Trauma Research, Norwegian School of Sports Science, Oslo, Norway
- Department of Orthopedic Surgery, Akershus University Hospital, Oslo, Norway
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Anne M. Fenstad
- The Norwegian Knee Ligament Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Andreas Persson
- Oslo Sports Trauma Research, Norwegian School of Sports Science, Oslo, Norway
- The Norwegian Knee Ligament Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Håvard Visnes
- Oslo Sports Trauma Research, Norwegian School of Sports Science, Oslo, Norway
- The Norwegian Knee Ligament Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Orthopedic Surgery, Sorlandet Hospital Kristiansand, Kristiansand, Norway
| | - Lars Engebretsen
- Oslo Sports Trauma Research, Norwegian School of Sports Science, Oslo, Norway
- Department of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway
| | - Guri R. Ekås
- Oslo Sports Trauma Research, Norwegian School of Sports Science, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Orthopedic Surgery, Akershus University Hospital, Oslo, Norway
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Ellis HB, Zak TK, Jamnik A, Lind DRG, Dabis J, Losito M, Wilson P, Moatshe G. Management of Pediatric Anterior Cruciate Ligament Injuries: A Critical Analysis. JBJS Rev 2023; 11:01874474-202308000-00001. [PMID: 37535763 DOI: 10.2106/jbjs.rvw.22.00223] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
» Overall evidence for the treatment of an anterior cruciate ligament (ACL) injury in a pediatric or skeletally immature patient remains lows.» An ACL reconstruction is recommended with concomitant repairable chondral and meniscus injury or with symptoms of persistent instability despite high-quality rehabilitation.» Treatment decision for pediatric ACL reconstruction should use a shared decision-making model weighing the risks and benefits of both a nonoperative vs. surgical treatment.
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Affiliation(s)
- Henry B Ellis
- Scottish Rite for Children, Dallas, Texas
- University of Texas Southwestern, Dallas, Texas
| | | | | | - Dane R G Lind
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Philip Wilson
- Scottish Rite for Children, Dallas, Texas
- University of Texas Southwestern, Dallas, Texas
| | - Gilbert Moatshe
- Department of Sports Medicine, Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
- Department of Orthopedics, Oslo University Hospital, Oslo, Norway
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Iwaasa T, Takahashi T, Tensho K, Koyama S, Takeshita K, Takahashi J. Suture Augmentation Does Not Change Biomechanical Properties and Histological Remodeling of Tendon Graft in Anterior Cruciate Ligament Reconstruction: A Study in a Porcine Model. Arthroscopy 2023; 39:1014-1024. [PMID: 36634741 DOI: 10.1016/j.arthro.2022.10.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 10/05/2022] [Accepted: 10/20/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE To evaluate the initial safety of the combined use of ultra-high molecular weight polyethylene (UHMWPE) sutures for suture augmentation (SA) in a porcine ACL reconstruction model and examine whether the procedure can affect the anterior knee laxity and structural properties of the tendon graft itself, influence histological remodeling, and cause a foreign body-induced inflammation. METHODS Ten pigs were divided into SA and non-SA Groups to undergo ACL reconstruction using an autologous semitendinosus tendon with and without SA, respectively. At 12 weeks postoperatively, the tibial fixation of the grafted tendon and SA was removed, and the anterior knee laxity and structural characteristics of the grafted tendon were evaluated for mechanical testing. Histological evaluation, including the ligament tissue maturation index (LTMI) score and the presence or absence of foreign-body reaction, was evaluated. RESULTS There was no significant difference in anterior laxity between the two groups (SA Group, 1.19 ± 0.78 mm; non-SA Group, 1.08 ± 0.42 mm; P = 1). There were no significant differences in maximum load failure, yield strength, stiffness, elongation at failure, and the LTMI score between the two groups (P = 0.31, 1, 1, 1, and 0.24, respectively). All grafted tendons showed no foreign-body reactions. CONCLUSION Suture augmentation did not have significant effect on the anterior knee laxity and the structural properties of the grafted tendon, interfere with histological remodeling, or cause foreign body-induced reactions. CLINICAL RELEVANCE The results of our study may lay the foundation for further clinical studies to verify the usefulness of ACL reconstruction with SA.
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Affiliation(s)
- Tomoya Iwaasa
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Tsuneari Takahashi
- Department of Orthopedic Surgery, Ishibashi General Hospital, Tochigi, Japan.
| | - Keiji Tensho
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Suguru Koyama
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Katsushi Takeshita
- Department of Orthopedic Surgery, Jichi Medical University, Tochigi, Japan
| | - Jun Takahashi
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
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Rosenberg SI, Ouweleen AJ, Hall TB, Patel NM. Are Neighborhood Conditions Associated With Surgical Delays and Meniscus Tears in Children and Adolescents Undergoing ACL Reconstruction? Clin Orthop Relat Res 2023; 481:281-288. [PMID: 36103207 PMCID: PMC9831176 DOI: 10.1097/corr.0000000000002368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Markers of a patient's social determinants of health, including healthcare insurance and median household income based on ZIP Code, have been associated with the interval between injury and ACL reconstruction (ACLR) as well as the presence of concomitant meniscus tears in children and adolescents. However, the aforementioned surrogate indicators of a patient's social determinants of health may not reflect all socioeconomic and healthcare resources affecting the care of ACL injuries in children and adolescents. The use of multivariate indices such as the Child Opportunity Index (COI) may help to better identify patients at risk for increased risk for delay between ACL injury and surgery, as well as the incidence of meniscus tears at the time of surgery. The COI is a summative measure of 29 indicators that reflect neighborhood opportunities across three domains: education, health and environment, and social and economic factors. COI scores range from 0 to 100 (100 being the highest possible score), as well as five categorical scores (very low, low, moderate, high, and very high) based on quintile rankings. QUESTIONS/PURPOSES To investigate the relationship between neighborhood conditions and the treatment of ACL injuries in children and adolescents via the COI, we asked: (1) Is a lower COI score associated with a longer delay between ACL injury and surgery? (2) Does a higher proportion of patients with lower COI scores have meniscus tears at the time of ACLR? METHODS In this retrospective, comparative study, we considered data from 565 patients, 18 years or younger, who underwent primary ACLR at an urban, tertiary children's hospital between 2011 and 2021. Of these patients, 5% (31 of 565) did not have a clearly documented date of injury, 2% (11 of 565) underwent revision reconstructions, and 1% (5 of 565) underwent intentionally delayed or staged procedures. Because we specifically sought to compare patients who had low or very low COI scores (lowest two quintiles) with those who had high or very high scores (highest two quintiles), we excluded 18% (103 of 565) of patients with moderate scores. Ultimately, 73% (415 of 565) of patients with COI scores in either the top or bottom two quintiles were included. Patient addresses at the time of surgery were used to determine the COI score. There were no differences between the groups in terms of gender. However, patients with high or very high COI scores had a lower median (IQR) age (15 years [2.6] versus 17 years [1.8]; p < 0.001) and BMI (23 kg/m 2 [6.1] versus 25 kg/m 2 [8.8]; p < 0.001), were more commonly privately insured (62% [117 of 188] versus 22% [51 of 227]; p < 0.001), and had a higher proportion of patients identifying as White (67% [126 of 188] versus 6.2% [14 of 227]; p < 0.001) compared with patients with low or very low COI scores. Medical records were reviewed for demographic, preoperative, and intraoperative data. Univariate analyses focused on the relationship of the COI and interval between injury and surgery, frequency of concomitant meniscus tears, and frequency of irreparable meniscus tears treated with partial meniscectomy. Multivariable regression analyses were used to determine factors that were independently associated with delayed surgery (longer than 60 and 90 days after injury), presence of concomitant meniscal injuries, and performance of meniscectomy. Multivariable models included insurance and race or ethnicity to determine whether COI was independently associative after accounting for these variables. RESULTS Patients with a high or very high COI score had surgery earlier than those with a low or very low COI score (median [IQR] 53 days [53] versus 97 days [104]; p < 0.001). After adjusting for insurance and race/ethnicity, we found that patients with a low or very low COI score were more likely than patients with a high or very high COI score to have surgery more than 60 days after injury (OR 2.1 [95% CI 1.1 to 4.0]; p = 0.02) or more than 90 days after injury (OR 1.8 [95% CI 1.1 to 3.4]; p = 0.04). Furthermore, patients with low or very low COI scores were more likely to have concomitant meniscus tears (OR 1.6 [95% CI 1.1 to 2.5]; p = 0.04) compared with patients with high or very high COI scores. After controlling for insurance, race/ethnicity, time to surgery, and other variables, there was no association between COI and meniscectomy (OR 1.6 [95% CI 0.9 to 2.8]; p = 0.12) or presence of a chondral injury (OR 1.7 [95% CI 0.7 to 3.9]; p = 0.20). CONCLUSION As the COI score is independently associated with a delay between ACL injury and surgery as well as the incidence of meniscus tears at the time of surgery, this score can be useful in identifying patients and communities at risk for disparate care after ACL injury. The COI score or similar metrics can be incorporated into medical records to identify at-risk patients and dedicate appropriate resources for efficient care. Additionally, neighborhoods with a low COI score may benefit from improvements in the availability of additional and/or improved resources. Future studies should focus on the relationship between the COI score and long-term patient-reported functional outcomes after ACL injury, identification of the specific timepoints in care that lead to delayed surgery for those with lower COI scores, and the impact of community-based interventions in improving health equity in children with ACL injury. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
| | | | - Tyler B. Hall
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Neeraj M. Patel
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Orthopaedic Surgery and Sports Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Rosenberg SI, Chu Y, Ouweleen AJ, Hall TB, Patel NM. Is Preferred Language Other Than English Associated With Delayed Surgery After ACL Injury in Children and Adolescents? Clin Orthop Relat Res 2023; 481:292-298. [PMID: 36073983 PMCID: PMC9831159 DOI: 10.1097/corr.0000000000002359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/19/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Previous studies have investigated the impact of social determinants of health, such as the type of healthcare insurance and household income, on children and adolescents with ACL tears. However, despite the increasing incidence of ACL injury in young patients and a substantial proportion of families who may prefer languages other than English, the relationship between language and clinical care remains unclear. QUESTIONS/PURPOSES To investigate the relationship between language and the care of children and adolescents with ACL tears, we asked: (1) Is a preferred language other than English (PLOE) associated with a delay between ACL injury and surgery? (2) Is a PLOE associated with a greater odds of a patient experiencing a meniscal tear and undergoing a meniscectomy than in those who prefer English? METHODS We treated 591 patients surgically for ACL injuries between 2011 and 2021. Of those, we considered patients aged 18 years or younger who underwent primary ACL reconstruction for this retrospective, comparative study. Five percent (31 of 591) of patients were excluded because the date of injury was not clearly documented, 2% (11 of 591) were revision reconstructions, and 1% (6 of 591) underwent procedures that were intentionally delayed or staged, leaving 92% (543 of 591) for analysis. The mean age was 16 ± 2 years, and 51% (276 of 543) of patients were boys. The family's preferred language was noted, as were demographic data, time between injury and surgery, and intraoperative findings. A language other than English was preferred by 21% (113 of 543) of patients. Of these, 94% (106 of 113) preferred Spanish. In a univariate analysis, we used independent-samples t-tests, Mann-Whitney U-tests, and Fisher exact tests, as appropriate. Purposeful-entry multivariable regression analyses were used to determine whether PLOE was associated with increased time to surgery, concomitant meniscus injury, or performance of meniscectomy while adjusting for confounding variables. Variables were included in multivariable models if they met the threshold for statistical significance in univariate testing (p < 0.05). RESULTS The median time between injury and ACL reconstruction was shorter in families who preferred English compared with those with a PLOE (69 days [IQR 80] versus 103 days [IQR 107)]; p < 0.001). After controlling for potentially confounding variables like insurance and age, we found that patients whose families had a PLOE had greater odds of undergoing surgery more than 60 days after injury (OR 2.2 [95% CI 1.3 to 3.8]; p = 0.005) and more than 90 days after injury (OR 1.8 [95% CI 1.1 to 2.8]; p = 0.02). After controlling for insurance, age, and other factors, PLOE was not associated with surgical delay beyond 180 days, concomitant meniscal tears, or performance of meniscectomy. CONCLUSION In this study of children and adolescents undergoing primary ACL reconstruction, patients whose families prefer a language other than English experienced a longer delay between injury and surgery. In areas with a large proportion of families with a PLOE, partnerships with primary care clinicians, emergency departments, schools, athletic teams, and community organizations may improve efficiency in the care of children with ACL injuries. Clinicians proficient in other languages, reliable interpreter services, and translated references and resources may also be impactful. Our results suggest a need for further research on the experiences, needs, and long-term outcomes of these patients, as well as the association of preferred language with results after surgery. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
| | - Yuyang Chu
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Tyler B. Hall
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Neeraj M. Patel
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Division of Orthopaedic Surgery and Sports Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Wang X, Qi Y, Bao H, Xu Y. Application of the 3D-MRI on post-operative graft assessment in adolescent patients with ACL reconstruction: A minimal 2-year follow-up. Front Surg 2023; 9:1070324. [PMID: 36684206 PMCID: PMC9852513 DOI: 10.3389/fsurg.2022.1070324] [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] [Received: 10/14/2022] [Accepted: 11/07/2022] [Indexed: 01/09/2023] Open
Abstract
Background The purpose of the present study was to assess the prognostic morphological changes of the reconstructed hamstring auto-grafts by using reconstructed three-dimensional MRI (3D-MRI) in adolescent patients with ACLR. Methods 22 adolescent patients (less than 17 years old) were retrospective included between January 1, 2018, and October 31, 2020, in our department. The patients were divided into 2 subgroups: subgroup A (<14 years old) and subgroup B (≥14 years old). 3D-MRI was used to detect the total cross-sectional area (TCA) and long-to-short axis (LSA) ratio of the reconstructed ACL graft at the proximal, mid-point, and distal regions. The minimal follow-up was 2 years. Results The averaged follow-up of subgroup A and B was 37.8 ± 5.6 and 37.6 ± 6.5 months, respectively. Comparing to the initial graft (ACLR operation), the TCA of reconstructed ACL was increased by 30.6% on average, and the TCAs at proximal, mid-point, and distal regions were increased by 56.4%, 50.0%, and 17.7%, respectively, inner-group comparisons showed that the TCAs of the 3 region in subgroup A were all increased at the follow-up (P = 0.002) (P < 0.001) (P < 0.001), however, only increased mid-point (P = 0.024) and distal TCAs (P < 0.001) were found in subgroup B. Comparing to the native ACL, the proximal LSA ratio in subgroup A was comparable, while it was lower in subgroup B than the native ACL (P = 0.004), the distal LSA ratios in the 2 subgroups were both lower than the native ACL (P = 0.004) (P = 0.006). Conclusions 3D-MRI assessment can exactly identify the morphological changes of the graft in adolescent patients with ACLR, the TCA of the constructed ACL was increased compared to the initial graft, however, the LSA ratio was still lower than the native ACL. Younger adolescent patients may have a better potential on the ligamentization after ACLR than the older adolescent patients.
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Affiliation(s)
- Xiaona Wang
- Department of Imaging Medicine, Inner Mongolia People's Hospital, Hohhot, China
| | - Yansong Qi
- Department of Orthopedics (Sports Medicine Center), Inner Mongolia People's Hospital, Hohhot, China,Correspondence: Yongsheng Xu Yansong Qi
| | - Huricha Bao
- Department of Orthopedics (Sports Medicine Center), Inner Mongolia People's Hospital, Hohhot, China
| | - Yongsheng Xu
- Department of Orthopedics (Sports Medicine Center), Inner Mongolia People's Hospital, Hohhot, China,Correspondence: Yongsheng Xu Yansong Qi
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Deviandri R, van der Veen HC, Lubis AMT, van den Akker-Scheek I, Postma MJ. "Cost-effectiveness of ACL treatment is dependent on age and activity level: a systematic review". Knee Surg Sports Traumatol Arthrosc 2023; 31:530-541. [PMID: 35997799 PMCID: PMC9898360 DOI: 10.1007/s00167-022-07087-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/25/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE To systematically review the literature on health-economic evaluations of anterior cruciate ligament (ACL) injury between reconstruction surgery (ACLR) and non-operative treatment (NO) and suggest the most cost-effective strategy between the two. METHODS All economic studies related to ACLR versus NO post-ACL injury, either trial based or model based, published until April 2022, were identified using PubMed and Embase. The methodology of the health-economic analysis for each included study was categorized according to the four approaches: cost-minimization analysis (CMA), cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), and cost-utility analysis (CUA). The quality of each included study was assessed using the Consensus on Health Economic Criteria (CHEC) list. RESULTS Of the seven included studies, two compared the strategies of early ACLR and NO alone, and five compared early ACLR and NO with optional delayed ACLR. All studies performed a CUA, and one study performed a CBA additionally. The CHEC scores of the included studies can be considered good, ranging from 15 to 18 from a maximum of 19. Applying the common standard threshold of $50,000 per QALY, six studies in young people with high-activity levels or athletes showed that early ACLR would be preferred over either NO alone or delayed ACLR. Of six studies, two even showed early ACLR to be the dominant strategy over either NO alone or delayed ACLR, with per-patient cost savings of $5,164 and $1,803 and incremental per-patient QALY gains of 0.18 and 0.28, respectively. The one study in the middle-aged people with a moderate activity level showed that early ACLR was not more cost-effective than delayed ACLR, with ICER $101,939/QALY using the societal perspective and ICER $63,188/QALY using the healthcare system perspective. CONCLUSION Early ACLR is likely the more cost-effective strategy for ACL injury cases in athletes and young populations with high-activity levels. On the other hand, non-operative treatment with optional delayed ACLR may be the more cost-effective strategy in the middle age population with moderate activity levels. LEVEL OF EVIDENCE Systematic review of level III studies.
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Affiliation(s)
- R. Deviandri
- grid.4494.d0000 0000 9558 4598Department of Orthopedics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands ,grid.444161.20000 0000 8951 2213Department of Physiology, Faculty of Medicine, Universitas Riau, Pekanbaru, Indonesia ,Division of Orthopedics, Arifin Achmad Hospital, Pekanbaru, Indonesia
| | - H. C. van der Veen
- grid.4494.d0000 0000 9558 4598Department of Orthopedics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - A. M. T. Lubis
- grid.9581.50000000120191471Department of Orthopedics-Faculty of Medicine, Universitas Indonesia/Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - I. van den Akker-Scheek
- grid.4494.d0000 0000 9558 4598Department of Orthopedics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - M. J. Postma
- grid.4494.d0000 0000 9558 4598Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands ,grid.4830.f0000 0004 0407 1981Department of Economics, Econometrics & Finance, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands ,grid.440745.60000 0001 0152 762XDepartment of Pharmacology & Therapy, Universitas Airlangga, Surabaya, Indonesia ,grid.11553.330000 0004 1796 1481Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
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Freshman RD, Truong NM, Cevallos N, Lansdown DA, Feeley BT, Ma CB, Zhang AL. Delayed ACL reconstruction increases rates of concomitant procedures and risk of subsequent surgery. Knee Surg Sports Traumatol Arthrosc 2022:10.1007/s00167-022-07249-z. [PMID: 36459171 DOI: 10.1007/s00167-022-07249-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE To utilise a large cross-sectional database to analyse the effects of time duration between diagnosis of anterior cruciate ligament (ACL) tear and ACL reconstruction (ACLR) on concomitant procedures performed and subsequent surgery within 2 years. METHODS An analysis from 2015 to 2018 was performed using the Mariner PearlDiver Patient Records Database. Current Procedural Terminology (CPT), and International Classification of Diseases (ICD-10) codes identified patients with a diagnosis of ACL tear who underwent subsequent ACLR. Patients were stratified in biweekly and bimonthly increments based on the time duration between initial diagnosis of ACL tear and surgical treatment. Chi-squared analysis was used to compare categorical variables, and trend analysis was performed with Cochran-Armitage independence testing. RESULTS Of 11,867 patients who underwent ACLR, 76.1% underwent surgery within 2 months of injury diagnosis. Patients aged 10-19 were most likely to undergo surgery within 2 months of injury diagnosis (83.5%, P < 0.0001). As duration from injury diagnosis to ACLR increased from < 2 months to > 6 months, rates of concomitant meniscectomy increased from 9.1% to 20.5% (P < 0.0001). The overall 2-year subsequent surgery rate was 5.3%. The incidence of revision ACLR was highest for patients who underwent surgery > 6 months after diagnosis (P < 0.0001), whilst the incidence of ipsilateral lysis of adhesions and manipulation under anaesthesia (MUA) was highest for patients who underwent surgery < 2 months after diagnosis (P < 0.0001). ACLR at 6-8 weeks after diagnosis demonstrated the lowest risk for concomitant procedures as well as 2-year subsequent surgery. CONCLUSION The majority of patients undergo ACL reconstruction within 2 months of initial ACL tear diagnosis. Delayed surgery greater than 6 months after the diagnosis of an ACL rupture leads to increased need for concomitant meniscectomy as well as higher risk for revision ACLR within 2 years, but immediate surgery may increase risk for knee arthrofibrosis. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Ryan D Freshman
- Department of Orthopaedic Surgery, University of California-San Francisco, 500 Parnassus Avenue, MU West 320, San Francisco, CA, 94143, USA.
| | - Nicole M Truong
- Department of Orthopaedic Surgery, University of California-San Francisco, 500 Parnassus Avenue, MU West 320, San Francisco, CA, 94143, USA
| | - Nicolas Cevallos
- Department of Orthopaedic Surgery, University of California-San Francisco, 500 Parnassus Avenue, MU West 320, San Francisco, CA, 94143, USA
| | - Drew A Lansdown
- Department of Orthopaedic Surgery, University of California-San Francisco, 500 Parnassus Avenue, MU West 320, San Francisco, CA, 94143, USA
| | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California-San Francisco, 500 Parnassus Avenue, MU West 320, San Francisco, CA, 94143, USA
| | - C Benjamin Ma
- Department of Orthopaedic Surgery, University of California-San Francisco, 500 Parnassus Avenue, MU West 320, San Francisco, CA, 94143, USA
| | - Alan L Zhang
- Department of Orthopaedic Surgery, University of California-San Francisco, 500 Parnassus Avenue, MU West 320, San Francisco, CA, 94143, USA
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Foissey C, Thaunat M, Caron E, Haidar I, Vieira TD, Gomes L, Freychet B, Sonnery-Cottet B, Fayard JM. Combining Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Procedures in Skeletally Immature Patients Is Safe and Associated With a Low Failure Rate. Arthrosc Sports Med Rehabil 2022; 4:e1941-e1951. [PMID: 36579042 PMCID: PMC9791843 DOI: 10.1016/j.asmr.2022.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 08/01/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose To analyze the rates of graft ruptures and growth disorders, the level of return to sport, and the clinical results of 2 lateral extra-articular procedures in growing children. Methods This study was a retrospective, single-center study of patients undergoing anterior cruciate ligament (ACL) surgery combined with 2 different lateral extra-articular procedures (anatomic reconstruction with a gracilis graft or modified Lemaire technique with a strip of fascia lata). The measurements of side-to-side anterior laxity and pivot shift were performed preoperatively and at the last follow-up. The sports level and the complications rate were assessed. The minimal clinically important differences (MCID) and patient acceptable symptoms state threshold scores were calculated. Results Thirty-nine patients (40 ACLs) were included (20 anatomic and 20 modified Lemaire) at an average follow-up of 57 months ± 10 [42-74]. One patient (2.5%) was lost to follow-up. The mean age at surgery was 13.8 ± 1.4 years old [9.8; 16.5]. One graft failure was reported (2.6% [0.06-13.5]) at 35.6 months after surgery. Two cases (5.4%) of femoral overgrowth were observed, and one of them required distal femoral epiphysiodesis. Ninety-two percent of the patients returned to sports. At the final follow-up, side-to-side anterior laxity was significantly improved, and no residual pivot shift was recorded in 95% of patients. Eighty-nine percent of the patients presented a Pedi-International Knee Documentation Committee score greater than the MCID postoperatively, and 77% presented a Lysholm score greater than the MCID. Conclusions This series of ACL reconstructions combined with 2 different lateral extra-articular procedures in skeletally immature patients demonstrated promising findings. The low rate of observed complications, including graft rupture and growth disturbance, is encouraging, but the small study population and lack of comparative group precludes reliable conclusions. Level of Evidence IV, therapeutic case series.
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Affiliation(s)
| | | | | | | | - Thais Dutra Vieira
- Address correspondence to Thais Dutra Vieira, M.D., Centre Orthopédique Santy, 24 avenue Paul Santy, 69008 Lyon, France.
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Patel NM, Edison BR, Carter CW, Pandya NK. The Impact of Race, Insurance, and Socioeconomic Factors on Pediatric Knee Injuries. Clin Sports Med 2022; 41:789-798. [DOI: 10.1016/j.csm.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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[Research progress of anterior cruciate ligament reconstruction with over-the-top technique]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:1166-1171. [PMID: 36111481 PMCID: PMC9626294 DOI: 10.7507/1002-1892.202203097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To review the research progress regarding the over-the-top technique for anterior cruciate ligament (ACL) reconstruction. METHODS The relevant literature on ACL reconstruction using the over-the-top technique was analyzed for its evolution, clinical application, advantages, and limitations. RESULTS Over-the-top technique for ACL reconstruction is a combined intra- and extra-articular technique. Because it avoids drilling the femoral tunnel, its advantages are mainly highlighted in the protection of the femur. Therefore, it is widely used in children and adolescents with epiphyseal occlusion and in patients with revision reconstruction. In addition, significant improvements in postoperative joint stability, functional scores, and return to exercise rates are found in long-term follow-up studies of patients with primary ACL reconstruction and combined anterolateral tenodesis. However, the technique also has some limitations, such as poor stability of knee flexion after operation, high requirement for graft length, and easy impact of graft in the intercondylar fossa. CONCLUSION The current research results show the effectiveness and safety of the over-the-top technique for primary and revision ACL reconstruction, with the advantages of wide application, simple operation, and quick recovery; however, more researches are needed to further optimize the selection of grafts and femoral condyle management problems, and to clarify the long-term effectiveness.
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35
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Rohde MS, Cinque ME, LaPrade CM, Ganley TJ, Shea KG. The Spectrum of Anterior Cruciate Ligament Reconstruction Options for the Pediatric and Adolescent Patient: A Narrative Review. J Athl Train 2022; 57:961-971. [PMID: 35380680 PMCID: PMC9842125 DOI: 10.4085/1062-6050-0542.21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
As youth sports participation has increased in recent years, injuries to the anterior cruciate ligament (ACL) have become increasingly common in pediatric patients. Historically, ACL reconstruction was delayed in pediatric patients to avoid physeal damage with the potential for leg-length discrepancy or angular deformity. Current research shows that delaying reconstruction or choosing nonoperative management is associated with increased rates of meniscal and chondral injuries, persistent knee instability, and low rates of return to previous activity. Early ACL reconstruction using techniques to avoid physeal growth disturbance is now widely accepted among physicians. The purpose of this review was to describe the pediatric ACL in terms of the relevant anatomy and biomechanics, physical examination, and diagnostic imaging. In addition, the importance of skeletal age and possible physeal injury is discussed in the context of ACL reconstruction options by skeletal age and remaining growth potential.
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Affiliation(s)
- Matthew S. Rohde
- Department of Orthopaedics, Stanford University School of Medicine, CA
| | - Mark E. Cinque
- Department of Orthopaedics, Stanford University School of Medicine, CA
| | | | | | - Kevin G. Shea
- Department of Orthopaedics, Stanford University School of Medicine, CA
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36
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Bade D, Malayko G, Johnson L, Bradford K, Reddan T, Stockton C, Frawley K, Phillips T, Saxby D, Ware RS, Byrnes J, Carty CP. Single versus double hamstring tendon graft in anterior cruciate ligament reconstruction in the paediatric patient: a single-blind randomised controlled trial study protocol. BMJ Open 2022; 12:e057465. [PMID: 35985784 PMCID: PMC9396117 DOI: 10.1136/bmjopen-2021-057465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION There is currently no clear indication in the literature regarding a single or double hamstring tendon (single bundle) autograft for anterior cruciate ligament (ACL) reconstruction in the paediatric patient. The primary aim of this single blind randomised controlled trial is to determine whether a single or double hamstring tendon graft ACLR leads to superior clinical outcomes postsurgery in paediatric patients with ACL injury. METHODS AND ANALYSIS Single site, prospective, single blind, randomised controlled trial with two parallel treatment arms. 100 patients aged 10-18 years who present with an isolated ACL tear±meniscal injury, verified on MRI, will be randomly allocated to one of the two surgical groups. The primary outcomes will be side-to-side difference in anterior tibial translation and graft failure incidence 12 months postsurgery. Primary and secondary outcomes will also be assessed at 2-year and 5-year postsurgery. ETHICS AND DISSEMINATION Results will be presented in peer-reviewed journals and at international conferences and disseminated to participants and healthcare professionals via newsletters and hospital presentations. This study is approved by the Children's Health Queensland Hospital and Health Service Human Research Ethics committee. TRIAL REGISTRATION NUMBER ACTRN12620001170910p; Australian New Zealand Clinical Trials Registry.
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Affiliation(s)
- David Bade
- Department of Orthopaedics, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
- Griffith Centre of Biomedical and Rehabilitation Engineering, Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Garrett Malayko
- Department of Orthopaedics, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Liam Johnson
- Department of Orthopaedics, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Kylie Bradford
- Department of Orthopaedics, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Tristan Reddan
- Department of Medical Imaging and Nuclear Medicine, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Chris Stockton
- Department of Medical Imaging and Nuclear Medicine, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Kieran Frawley
- Department of Medical Imaging and Nuclear Medicine, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Teresa Phillips
- Department of Orthopaedics, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - David Saxby
- Griffith Centre of Biomedical and Rehabilitation Engineering, Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Robert S Ware
- Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia
| | - Christopher P Carty
- Department of Orthopaedics, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
- Griffith Centre of Biomedical and Rehabilitation Engineering, Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
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Allahabadi S, Mittal A, Coughlan MJ, Kim AE, Hung NJ, Pandya NK. Outcomes, Including Graft Tears, Contralateral Anterior Cruciate Ligament Tears, and All-Cause Ipsilateral Knee Operations, are Similar for Adult-type, Transphyseal, and Partial Transphyseal Anterior Cruciate Ligament Reconstruction Using Hamstring Autograft in Pediatric and Adolescent Patients. Arthrosc Sports Med Rehabil 2022; 4:e1465-e1474. [PMID: 36033172 PMCID: PMC9402463 DOI: 10.1016/j.asmr.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 05/22/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco
| | - Ashish Mittal
- San Francisco Orthopedic Residency Program, St. Mary’s Medical Center, San Francisco
| | - Monica J. Coughlan
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco
| | - Arin E. Kim
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco
| | - Nicole J. Hung
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles
| | - Nirav K. Pandya
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco
- Benioff Children’s Hospital Oakland, University of California, San Francisco, Oakland, California, U.S.A
- Address correspondence to Nirav K. Pandya, M.D., Department of Orthopaedic Surgery, Benioff Children’s Hospital Oakland, University of California, San Francisco, 747 52nd St., Oakland, CA 94609.
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38
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Frank RM, Bradsell H, Thompson SR. What's New in Sports Medicine. J Bone Joint Surg Am 2022; 104:667-674. [PMID: 35202043 DOI: 10.2106/jbjs.22.00089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Rachel M Frank
- University of Colorado School of Medicine, Aurora, Colorado
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Madhan AS, Ganley TJ, McKay SD, Pandya NK, Patel NM. Trends in Anterolateral Ligament Reconstruction and Lateral Extra-articular Tenodesis With ACL Reconstruction in Children and Adolescents. Orthop J Sports Med 2022; 10:23259671221088049. [PMID: 35400143 PMCID: PMC8990701 DOI: 10.1177/23259671221088049] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/21/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Anterolateral ligament reconstruction (ALLR) and lateral extra-articular
tenodesis (LET) show promise in lowering the risk of rerupture after
anterior cruciate ligament reconstruction (ACLR), but there are little data
on surgeon practices and preferences in children and adolescents. Purpose: To quantify surgeon practices regarding ALLR and LET in the pediatric
population. Study Design: Cross-sectional study. Methods: An electronic survey was administered to 87 surgeons in the Pediatric
Research in Sports Medicine society. The questionnaire asked several
questions about surgeon and practice characteristics as well as indications,
preferences, and techniques for ALLR or LET in the context of primary and
revision pediatric ACLR. Chi-square and Fisher exact tests were used to
evaluate factors that affect surgical preferences. Results: A total of 63 surgeons completed the survey, of whom 62% performed ≥50
pediatric ACLRs annually; 56% sometimes performed anterolateral augmentation
with primary ACLR, and 79% with revision ACLR. The most common indications
for ALLR or LET in the primary setting were high-grade pivot shift, knee
hyperextension, generalized laxity, and type of sports participation.
Surgeons whose practice was >75% sports medicine were more likely to
perform ALLR or LET with both primary and revision ACLR (P
= .005 and P < .001, respectively). Those who had
completed a sports medicine fellowship were more likely to perform these
procedures than those with only pediatric orthopaedic training, in both
primary (68% vs 36%; P = .01) and revision scenarios (92%
vs 60%; P = .002). Of the 28 respondents who did not
perform ALLR or LET with primary ACLR, 75% cited insufficient evidence as
the reason. However, 96% of surgeons who did perform these procedures
expressed interest in studying them prospectively, and 87% were willing to
randomize patients. Conclusion: Findings indicated that 56% of pediatric sports surgeons sometimes perform
anterolateral augmentation with primary ACLR and 79% with revision ACLR.
Surgeons with sports medicine fellowship training or a mostly sports
practice were more likely to perform these procedures. Insufficient evidence
was the most common reason given by surgeons who did not perform
anterolateral augmentation. However, there was substantial willingness to
prospectively study and even randomize pediatric patients to assess the
impact of ALLR or LET in this population.
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Affiliation(s)
- Ashwin S. Madhan
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | | | | | - Nirav K. Pandya
- University of California, San Francisco, Benioff Children’s Hospital, San Francisco, California, USA
| | - Neeraj M. Patel
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
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40
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Brodeur PG, Licht AH, Modest JM, Testa EJ, Gil JA, Cruz AI. Epidemiology and Revision Rates of Pediatric ACL Reconstruction in New York State. Am J Sports Med 2022; 50:1222-1228. [PMID: 35234535 DOI: 10.1177/03635465221074694] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are limited epidemiologic data examining the incidence of pediatric anterior cruciate ligament reconstruction (ACLR) over the past decade. PURPOSE To examine statewide population trends in the incidence of ACLR in a pediatric population. STUDY DESIGN Descriptive epidemiology study. METHODS Inpatient and outpatient claims for pediatric patients who underwent ACLR between 2009 and 2017 were identified in the New York Statewide Planning and Research Cooperative System database via International Classification of Diseases (ICD), Revision 9, Clinical Modification; ICD, Revision 10, Clinical Modification and Procedural Classification System; or Current Procedural Terminology codes. New York population data for each year between 2009 and 2017 were used from the New York State Department of Health to calculate the rates of ACLR per 100,000 people aged 3 to 19 years and determine the 95% confidence limits. The rates were then stratified by age, sex, and insurance. Two-year rates of revision and contralateral ACLR were also analyzed by sex. RESULTS Between 2009 and 2017, 20,170 pediatric ACLRs were identified. The rates of pediatric ACLR increased steadily from 49.3 per 100,000 in 2009 (95% CI, 47.2-51.4) to a peak of 61.0 (95% CI, 58.6-63.4) in 2014 and decreased to 51.8 (95% CI, 49.6-54.1) by 2017. The age group 15 to 17 years had the highest rates of ACLR of all age groups, peaking at 198.5 (95% CI, 188.3-208.7) per 100,000. Analysis by sex showed that ACLR rates between males and females were not different. Males had a 2-year ipsilateral revision rate of 4.3%, while females had a rate of 3.3% (P = .0001). Females had a contralateral ACLR rate of 4.0%, while males had a rate of 2.6% (P = .0002). CONCLUSION Pediatric ACLR rates continued to rise until 2014, but there was a demonstrable decrease in rates after 2014. This decline in pediatric ACLR may point to the efficacy of injury prevention programs or changes in practice management. The high revision rate in males and high contralateral surgery rate in females can help guide patient counseling for return to play and complication risk. CLINICAL RELEVANCE This study showed that ACLR in pediatric patients may be decreasing in recent years. There were differences in revision and contralateral ACLR by sex.
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Affiliation(s)
- Peter G Brodeur
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Aron H Licht
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Jacob M Modest
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Edward J Testa
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Joseph A Gil
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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41
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Dawkins BJ, Kolin DA, Park J, Fabricant PD, Gilmore A, Seeley M, Mistovich RJ. Sensitivity and Specificity of MRI in Diagnosing Concomitant Meniscal Injuries With Pediatric and Adolescent Acute ACL Tears. Orthop J Sports Med 2022; 10:23259671221079338. [PMID: 35295551 PMCID: PMC8918745 DOI: 10.1177/23259671221079338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/29/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Preoperative diagnosis of concomitant meniscal tears in pediatric and adolescent patients with acute anterior cruciate ligament (ACL) deficiency is challenging. Purpose: To investigate the diagnostic performance of magnetic resonance imaging (MRI) in detecting meniscal injuries for pediatric and adolescent patients with acute ACL tears. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The authors retrospectively identified patients aged ≤18 years who underwent acute ACL reconstruction between 2006 and 2018 at 2 tertiary academic hospitals. The primary outcomes were arthroscopically confirmed medial, lateral, or any (defined as medial and/or lateral) meniscal tears. To control for chronically deficient knees, patients must have received their MRI study within 4 weeks of injury and must have undergone surgery no more than 8 weeks after their MRI study. Preoperative MRI reports were compared with the gold standard of arthroscopically confirmed tears to calculate sensitivity, specificity, positive predictive value, and negative predictive value. In a secondary analysis, patients were stratified by age into 2 groups (≤13 or ≥14 years), body mass index-for-age data from the Centers for Disease Control were used to classify patients as obese or nonobese, and differences between sensitivity and specificity proportions were analyzed using chi-square test for homogeneity. Results: Overall, 406 patients with a mean age of 15.4 years (range, 10-18 years) were identified. The sensitivity, specificity, positive predictive value, and negative predictive value were as follows: for lateral meniscal (LM) tears, 51.0%, 86.5%, 78.3%, and 65.0%; for medial meniscal tears, 83.2%, 80.6%, 62.3%, and 92.5%; and for any meniscal tear, 75.0%, 72.1%, 81.5%, and 63.8%, respectively. In the stratified analysis, MRI was less specific for the following diagnoses: any meniscal tear in patients aged ≤13 years (P = .048) and LM tears in obese patients (P = .020). Conclusion: The diagnostic ability of MRI to predict meniscal injuries present at acute ACL reconstruction was moderate. Performance was poorest at the lateral meniscus, where MRI failed to detect 97 tears that were found arthroscopically. Specificity was significantly lower in younger patients for any meniscal tear and in obese patients for LM tears.
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Affiliation(s)
- Brody J. Dawkins
- SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - David A. Kolin
- Weill Cornell Graduate School of Medical Sciences, New York, New York, USA
| | - Joshua Park
- MetroHealth Medical Center, Cleveland, Ohio, USA
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | | | - Allison Gilmore
- Rainbow Babies and Children’s Hospital, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Mark Seeley
- Geisinger Medical Center, Danville, Pennsylvania, USA
| | - R. Justin Mistovich
- Rainbow Babies and Children’s Hospital, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- R. Justin Mistovich, MD, MBA, Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children’s Hospital, University Hospitals Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH 44106, USA () (Twitter: @JustinMistovich)
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Moreno Mateo F, Perea SH, Green DW. Lateral-extra articular tenodesis vs. anterolateral ligament reconstruction in skeletally immature patients undergoing anterior cruciate ligament reconstruction. Curr Opin Pediatr 2022; 34:71-75. [PMID: 34845153 DOI: 10.1097/mop.0000000000001084] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to review the most recent available evidence about lateral-extra articular tenodesis (LET) and anterolateral ligament (ALL) reconstruction in young patients treated for anterior cruciate ligament (ACL) injury. RECENT FINDINGS The ALL of the knee acts as a secondary stabilizer of the knee preventing anterior translation and internal rotation. In vitro and in vivo biomechanical studies as well as prospective clinical trials have shown the importance of the ALL in knee biomechanics. The ALL injury has a synergetic impact on the knee stability in patients with acute ACL injury. ALL augmentation of ACL provides reduction of knee instability and graft failure and higher return to sport rates in high-risk patients. It has not been demonstrated that extra-articular procedures increase the risk of knee osteoarthritis secondary to knee over-constriction. Both Iliotibial band (ITB) ALL reconstruction and modified Lemaire LET have been shown safe and effective. Minimal biomechanical or clinical differences have been found between the two reconstruction methods. SUMMARY Young patients with ACL tears and risk factors such as laxity or pivot shift willing to return to sports may benefit from ALL augmentation. Therefore, it is essential to identify these high-risk patients to individualize treatment.
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Affiliation(s)
- Fernando Moreno Mateo
- Division of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Hansson F, Moström EB, Forssblad M, Stålman A, Janarv PM. Long-term evaluation of pediatric ACL reconstruction: high risk of further surgery but a restrictive postoperative management was related to a lower revision rate. Arch Orthop Trauma Surg 2022; 142:1951-1961. [PMID: 34459955 PMCID: PMC9296415 DOI: 10.1007/s00402-021-04135-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 08/20/2021] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Frida Hansson
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden.
- Capio Artro Clinic, FIFA Medical Centre of Excellence, Sophiahemmet Hospital, Valhallavägen 91, 11486, Stockholm, Sweden.
| | - Eva Bengtsson Moström
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
- Capio Artro Clinic, FIFA Medical Centre of Excellence, Sophiahemmet Hospital, Valhallavägen 91, 11486, Stockholm, Sweden
| | - Magnus Forssblad
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
| | - Anders Stålman
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
- Capio Artro Clinic, FIFA Medical Centre of Excellence, Sophiahemmet Hospital, Valhallavägen 91, 11486, Stockholm, Sweden
| | - Per-Mats Janarv
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
- Capio Artro Clinic, FIFA Medical Centre of Excellence, Sophiahemmet Hospital, Valhallavägen 91, 11486, Stockholm, Sweden
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Matsuzaki Y, Chipman DE, Hidalgo Perea S, Green DW. Unique Considerations for the Pediatric Athlete During Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2022; 4:e221-e230. [PMID: 35141555 PMCID: PMC8811511 DOI: 10.1016/j.asmr.2021.09.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/27/2021] [Indexed: 11/03/2022] Open
Abstract
Anterior cruciate ligament (ACL) injuries and surgical intervention in the pediatric population have increased in the recent years. Although surgical techniques have advanced, evidence-based rehabilitation guidelines that consider all aspects of the youth athlete are currently lacking. The purpose of this commentary is to review the current evidence on unique considerations for the pediatric and adolescent population during rehabilitation and return to sport after ACL reconstruction (ACLR), with a focus on children under 18 years of age. This review revealed that returning a youth athlete to sport after ACLR requires knowledge and appreciation of various aspects of the growing athlete different from adults. In addition to postoperative precautions that contribute to a slow rehabilitation process, young athletes need additional time for strength gains. Address risk of reinjury and for contralateral injury by using neuromuscular training and rigorous return-to-sport training programs. Consider return to sport after 9 months because the reinjury rate is high in this population. A combination of time and objective measures, both quantitative and qualitative criteria, and psychological readiness should be used to assess readiness to return to sport and decrease risk of future injury. Healthcare providers should be aware of the psychosocial impact of injury on the youth athletes and refer to sport psychology when necessary. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Yukiko Matsuzaki
- Department of Pediatric Rehabilitation, Department of Sports Rehabilitation and Performance, Hospital for Special Surgery, New York, New York, U.S.A
| | - Danielle E. Chipman
- Department of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Sofia Hidalgo Perea
- Department of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Daniel W. Green
- Department of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
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Wide Variability of Pediatric Knee Arthroscopy Case Volume in Orthopaedic Surgery Residency. Arthrosc Sports Med Rehabil 2021; 3:e1769-e1773. [PMID: 34977632 PMCID: PMC8689256 DOI: 10.1016/j.asmr.2021.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/17/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose The purpose of this study was to evaluate orthopaedic surgery resident case volume and variability for adult and pediatric knee arthroscopy from 2016 to 2020. Methods The Accreditation Council for Graduate Medical Education surgical case log data from 2016 to 2020 for graduating United States orthopaedic surgery residents were analyzed. The average number of total (adult and pediatric), adult, and pediatric knee arthroscopy cases were compared from 2016 to 2020. The 10th and 90th percentiles of case volumes for adult and pediatric knee arthroscopy procedures were compared from 2016 to 2020 to determine caseload variability. Results There was an 18% increase in pediatric knee arthroscopy cases between 2016 and 2020 (average: 13.9 ± 10 to 16.4 ± 13; P < .005), a 5.4% decrease in adult knee arthroscopy cases (100 ± 45 to 94.6 ± 47; P < .027), and a 2.6% decrease in total knee arthroscopy (113.9 ± 47 to 111 ± 51; P = .264) cases. There was an 11-fold difference in the number of pediatric knee arthroscopy cases performed between the 10th and 90th percentile of residents in 2020 (3 vs 33 cases, respectively), a 3.28-fold difference for adult knee arthroscopy (47 vs 154, respectively), and a 2.98-fold difference for total knee arthroscopy (59 vs 176, respectively). Conclusions Pediatric knee arthroscopy comprises a small yet growing percentage of total knee arthroscopy case volume of graduating orthopaedic surgery residents. However, wide variability in resident exposure is present and likely masked by the abundance of adult cases performed each year. Clinical Relevance The findings presented in this study may assist in optimizing arthroscopy resident education. Existing ACL reconstruction and knee arthroscopy case minimum requirements could be updated to include a set number of pediatric cases. These changes might help reduce case volume variability and discrepancies in resident education.
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