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

Transphyseal arthroscopic anterior cruciate ligament reconstruction in children under 12 years

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.

Use of cryotherapy in the postoperative management of paediatric anterior cruciate ligament reconstruction: a prospective randomised controlled trial

To investigate the efficacy of cryotherapy in relieving postoperative pain and restoring knee range-of-motion (ROM) after paediatric anterior cruciate ligament reconstruction (ACLR). Patients undergoing primary ACLR were randomised into cryotherapy or non-cryotherapy groups. Those receiving cryotherapy were subjected to a standardised icing protocol. Icing schedules were used to assess compliance. Standard postoperative rehabilitation protocol was followed for both groups. Outcome measurements were visual analogue scale at rest and movement and knee ROM. Patients were assessed on postoperative day 1 (POD1), 1, 4 and 6 weeks. Twenty-one out of 42 patients received cryotherapy. Both groups were similar in demographics, surgical technique and use of intraoperative anaesthesia. Patients in the cryotherapy group reported lower overall mean pain scores throughout the study duration at rest (0.61 ± 1.70, 95% CI = 0.23-0.99 vs. 1.06 ± 2.03, 95% CI = 0.60-1.53) and on movement (2.19 ± 2.68, 95% CI = 1.59-2.79 vs. 3.13 ± 2.75, 95% CI = 2.51-3.75; P  = 0.032). Knee flexion in the cryotherapy group showed better recovery of knee flexion from week 4 onwards. Improvement of knee flexion from POD1 is statistically significant at week 6 (98.7 ± 19.1°, 95% CI = 89.5-107.9 vs. 65.4 ± 49.9°, 95% CI = 42.7-88.1; P  = 0.010) and overall mean (71.2 ± 35.9°, 95% CI = 61.2-81.1 vs. 45.3 ± 55.5°, 95% CI = 30.4-60.2; P  = 0.005). The cryotherapy group reported statistically significant better degree of overall mean knee extension (1.2 ± 3.3°, 95% CI = 0.5-2.0 vs. 2.6 ± 4.6°, 95% CI = 1.6-3.7; P  = 0.032). The use of cryotherapy in postoperative ACLR recovery in paediatrics is a simple yet effective measure resulting in short-term pain relief and improvement in knee flexion.

Maturation-dependent patterns of knee injuries among symptomatic pediatric soccer players on MRI

OBJECTIVE

To systematically investigate the prevalence of knee MRI findings among symptomatic pediatric soccer players with respect to skeletal maturity and to identify predictors of surgery.

METHODS

This IRB-approved, HIPAA-compliant retrospective study included soccer players (< 18 years of age) who underwent MRI examinations in the past 5 years (2018-2023). Two radiologists retrospectively and independently reviewed all examinations to categorize skeletal maturity and to identify osseous and soft tissue findings. Findings were compared between maturation groups, and logistic regression models were used to identify predictors of surgery.

RESULTS

Ninety-seven players (45 boys, 52 girls) included 39 skeletally immature, 21 maturing, and 37 mature knees. Kappa coefficient for interobserver reliability ranged between 0.65 and 1.00. Osgood-Schlatter disease (OSD) was more common among immature than maturing and mature knees (25% vs 14% and 5%, p = 0.04); anterior cruciate ligament (ACL) injury was more common among maturing and mature than immature knees (59% and 48%, vs 15%, p < 0.01); and meniscal tears were more common among mature than immature and maturing knees (medial, 41% vs 18% and 14%, p = 0.03; lateral, 43% vs 21% and 19%, p = 0.04). Players in the mature group were more likely to undergo surgery (p = 0.01). The presence of an effusion (OR = 19.5, 95% CI 2.8-240.9, p = 0.01), ACL injury (OR = 170.0, 95% CI 1.3-6996.9, p < 0.01), and lateral meniscal tears (OR = 10.8, 95% CI 1.8-106.1, p = 0.02) were independent predictors of surgery.

CONCLUSION

Differential patterns of injury were found among symptomatic pediatric soccer players; the presence of an effusion, ACL injury, and lateral meniscal tears were independent predictors of surgery, likely contributing to the higher rates of surgery among skeletally mature players.

Growth progression of anterior cruciate ligament bone grafts in a pediatric population: magnetic resonance imaging analysis

BACKGROUND

In children, the incidence of anterior cruciate ligament (ACL) ruptures and reconstructions has significantly risen. Unfortunately, re-rupture rates following surgery are substantially higher in children than adults. Previous research suggests that smaller graft diameters are predictive of re-rupture.

OBJECTIVE

This study aimed to investigate the growth progression of the ACL bone graft, specifically in terms of width and length, within the intra-articular portion and tunnels, using successive magnetic resonance imaging (MRI) scans. The hypothesis was that the ACL grafts would undergo thinning during growth.

MATERIALS AND METHODS

The cohort comprised 100 patients who underwent ACL reconstruction. Among them, 37 patients with significant residual growth were selected for analysis. Of these, 4 patients experienced graft rupture, 5 had "over-the-top" techniques, 12 had missing MRI scans and 5 were lost to follow-up. Each included patient underwent two MRI scans; the analyses of which were conducted in a double-masked manner.

RESULTS

A total of 13 knees (and patients) were analyzed, with a mean ± SD (range) delay of residual growth between the two MRI scans of 3.3 + / - 1.4 (1.2-5.2) years. The graft exhibited elongation, thinning and eventual integration with the surrounding bone in the tunnels. Within the intra-articular portion, the mean [95% CI] increase in graft size between the two MRI scans was 30.8% in length and 14.8% in width. The width/length ratio in the intra-articular part was 20.4% on the first MRI and 20.8% on the second MRI. Since this difference in the ratio (+ 0.4%) was not statistically significant (P=0.425), our results indicate that the grafts remained stable in terms of proportions without thinning or thickening. Therefore, the initial hypothesis was validated for the tunnel portion but not the intra-articular portion of the grafts.

CONCLUSION

In children with open physes, ACL grafts demonstrate smooth growth progression in all dimensions. However, this finding does not fully explain the high rate of re-rupture observed in children. Further research is needed to elucidate the underlying factors contributing to re-rupture in this population.

Analysis of Growth After Transphyseal Anterior Cruciate Ligament Reconstruction in Children

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III.

STUDY DESIGN

Case-control study.

Surgical techniques in the management of pediatric anterior cruciate ligament tears: Current concepts

Background

Anterior cruciate ligament injury in the child and adolescent patient remains a controversial topic when considering management, especially regarding surgical choices. Treatment variations are seen not just when comparing different countries but also within nations. This arises partly as contemporary treatment is mostly inferred from the adult population who physiologically and in terms of outcomes differ significantly from children. There is an increasing body of evidence for this cohort of patients who have specific challenges and difficulties when determining the optimum treatment.

Methods

Within this article, we will summarize the current evidence for surgical management of anterior cruciate ligament injury for the pediatric patient.

Results and Conclusions

There remain many controversies and gaps inthe treatment of Paediatric Anterior cruciate ligament reconstruction and this high risk cohort continues to cause difficulty in identifying the best mode of surgical management.

Level of evidence

level IV.

Single versus double hamstring tendon graft in anterior cruciate ligament reconstruction in the paediatric patient: a single-blind randomised controlled trial study protocol

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.

Current trends in the treatment of supracondylar fractures of the humerus in children: Results of a survey of the members of European Paediatric Orthopaedic Society

PURPOSE

The purpose of this study was to evaluate the current trends in the treatment of supracondylar humerus fractures as well as the preferred post-operative follow-up protocol among members of the European Paediatric Orthopaedic Society.

METHODS

The survey was composed by four main domains and 26 items: (1) surgeon information (3 items); (2) treatment (8 items); (3) post-operative treatment (3 items); and (4) factors influencing the outcome (12 items). All active members of European Paediatric Orthopaedic Society were invited by email to answer an electronic questionnaire.

RESULTS

The survey was submitted to 397 European Paediatric Orthopaedic Society active members; 184 members answered (46.3%) the questionnaire. Among respondents, 64.1% declared >10 years of experience and 55.4% declared to treat >20 supracondylar humerus fractures per year. Closed reduction, percutaneous pinning, and supine position were the preferred treatment option for Gartland type II and III supracondylar humerus fractures by 79.9%, 95.5%, and 84.8% of respondents, respectively. Supracondylar humerus fractures are treated within 24 h from trauma by 33.2% of respondents. Pins are removed 4 weeks from index procedure by 58.2% of respondents. Fracture type (72.3%), surgeon experience, and (71.2%) are of "crucial importance" for expected outcome of supracondylar humerus fractures treatment.

CONCLUSION

Surgeon experience, type of fracture, treatment modality, and pins configuration were considered the main factors potentially influencing the outcome of supracondylar humerus fractures. European Paediatric Orthopaedic Society members agreed on the treatment modality of Gartland type II and III supracondylar humerus fractures, patient positioning, and timing of hardware removal. Other important issues such as timing of surgery, pins configuration, surgical approach, and post-operative protocol are still debated.

LEVEL OF EVIDENCE

level II.

Does harvesting of the semitendinosus tendon really spare the gracilis in pediatric anterior cruciate ligament reconstruction?

PURPOSE

The use of isolated semitendinosus tendon for Anterior Cruciate Ligament Reconstruction bears several advantages and is popular worldwide. It assumes that the gracilis tendon is spared. The aim of the study was to measure the surface area of the gracilis tendon in children who had undergone arthroscopic reconstruction of the anterior cruciate ligament using a semitendinosus tendon graft. Our hypothesis was that the gracilis tendon may be unintentionally and iatrogenically sectioned due to the anatomical proximity and the small size of the patients.

METHODS

Fifty patients who had undergone a magnetic resonance imaging preoperatively and postoperatively at 1 year from the surgery and who had been operated between January 2017 and March 2019 were included in this prospective series. The surface area of the gracilis tendon was measured on fat-saturated T2-weighted axial views at the widest point of the medial epicondyle of the femur. Age, sex, body weight, and height were documented.

RESULTS

One hundred magnetic resonance imaging of 50 knees were reviewed, from 34 boys (68%) and 16 girls (32%). The mean age was 14.5 years (10-18). The gracilis was visualized in all cases at 1 year postoperatively. The average tendinous surface area of the gracilis before the surgical procedure was 7.13 mm² versus 8.73 mm² at 1 year, representing an increase of 1.6 mm² (p = 0.0003).

CONCLUSIONS

This study demonstrated that harvesting of the semitendinosus for the purpose of Anterior Cruciate Ligament Reconstruction was a safe technique that preserves the gracilis.

LEVEL OF EVIDENCE

III.

Results of the Italian Pediatric Orthopedics Society juvenile flexible flatfoot survey: diagnosis and treatment options

The objectives of this study were to collect and analyze current diagnosis and treatment options of symptomatic flexible flatfoot (FFF), as well as to identify treatment expectations, among the members of the Italian Pediatric Orthopedics Society (SITOP). Diagnosis and treatment preferences were recorded according to a web-based survey. The survey was divided into six main sections: (1) general clinical parameters; (2) foot aspects; (3) X-ray angles (or lines); (4) expectations; (5) standard clinical assessment; (6) treatment options. One hundred and ten out of 248 SITOP members answered to the questionnaire. Age (85.5%), pain at the level of the plantar arch or fascia (61.8%), fatigue (59.1%) were the clinical parameters of crucial importance. Heel valgus (85.4%), flexibility (61.8%) and forefoot supination (47.3%) were identified as the most important foot aspects. Ninety-two responders (83.6%) identified the 'improved ability to walk longer without symptoms or discomfort' as the principal treatment expectation. Pain evaluated through the visual analog scale (VAS) was considered crucial in 31.8% of cases. All respondents confirmed they also treat patients with FFF surgically; in particular, 97.3% of SITOP affiliates declare to perform arthroereisis followed by lateral column lengthening (29.1%) and medializing calcaneal osteotomy (9.1%). Although in this survey heterogeneous findings for diagnosis and treatment of patients with symptomatic FFF within SITOP members were found, a large preference for age, heel valgus, flexibility as clinical aspects and parameters, as well as nonoperative treatment and arthroereisis, was reported.

Diagnosis and treatment of flexible flatfoot: results of 2019 flexible flatfoot survey from the European Paediatric Orthopedic Society

The aim of the study was to evaluate flexible flatfoot (FFF) diagnostic and current therapeutic modalities, as well as treatment expectations, among members of the European Paediatric Orthopaedic Society (EPOS). A 59-questions survey on FFF diagnosis and treatment preferences was distributed to EPOS members. The survey consisted of six sections (1) general clinical parameters; (2) foot aspects; (3) X-ray angles (or lines); (4) expectations; (5) standard clinical assessment; and (6) management options. Descriptive statistics were performed. A total of 93 responses were analysed. In general, clinical parameters, age (91.4% of cases), laxity (81.7%), diffuse pain (84.9%), and pain at the ankle joint (81.7%) were rated as 'average' and 'crucial importance' by the vast majority of respondents. Meary's angle (47.3% of cases), talonavicular coverage (35.5%), and lateral talocalcaneal angle (35.5%) were assessed as main radiological tools in the FFF evaluation. Among respondents, 61.3% rated 'improved ability to walk longer without symptoms' as of 'crucial importance'. Eighty-two percent of the respondents felt less than 10% of patients with FFF are candidates for corrective surgery. Arthroereisis (29.3%) was the most common surgical procedure (16.4% for subtalar and 12.9% for extra-articular arthroereisis, respectively), followed by lateral column lengthening (17.9%) and medializing calcaneal osteotomy (12.3%). There is great variation among respondents in diagnostic and treatment preferences in the management of children with FFF. The results of the EPOS 2019 FFF survey clearly show that large-scale, multicentric, international studies are necessary to elucidate which diagnostic and treatment practices lead to the best outcomes.

Physeal-Sparing Anterior Cruciate Ligament Reconstruction for Skeletally Immature Patients: All-Epiphyseal Technique Using Quadricep Tendon Autograft

The anterior cruciate ligament (ACL) is a major stabilizing structure of the knee and one of the most common injured structures. The true incidence of ACL injury in children and adolescents is unknown, but recent studies suggest increased ACL injury rates, especially in the sports-participating population. The mechanism of injury, clinical examination, and diagnosis of ACL injury in children is the same as in adults. The main concerns in the management of pediatric ACL injuries are the open physes and the eventual long-term consequences of the ACL deficient knee. The ideal treatment strategy of pediatric ACL injuries is still controversial, because there is still no universal consensus for techniques, graft choices, and postoperative rehabilitation. We present a case of a 12-year-old male patient who underwent ACL reconstruction using an all-inside, physeal-sparing technique with a quadriceps tendon autograft and discuss the current treatment strategies.

Understanding the undulating pattern of the distal femoral growth plate: Implications for surgical procedures involving the pediatric knee: A descriptive MRI study

INTRODUCTION

Operative procedures near the distal femoral physis can result in iatrogenic damage if one is not familiar with the complex anatomy of the growth plate. The purpose of this study was to use physeal-specific MRI sequences to delineate the anatomic dimensions of the distal femoral physis.

MATERIALS AND METHODS

Sixty patients underwent physeal-specific spoiled gradient 3-D fat saturated (SPGR) MRI analysis of a single knee. Three age groups (eight to 10, 11-13, and 14-16 years) comprised of equal numbers (n = 20) of boys and girls were evaluated. Using the SPGR coronal sequence, the distance of the physis to the femoral articular cartilage was recorded at the medial, mid-medial, notch, mid-lateral and lateral margins of the knee. Coronal measurements were recorded at four locations along the sagittal sequence, as the anteroposterior dimension of the knee was divided into equal quartiles.

RESULTS

While little variation in shape was observed in the anterior quartile, the remaining quartiles demonstrated significant variability that increased moving posteriorly (p < .001), therefore reflecting a more concave shape in the posterior aspect of the femur. These observations were statistically significant for age at the posterior two quartiles.

CONCLUSION

These MRI data suggest that while the physis is linear in the anterior part of the femur, it possesses a more concave shape in the posterior aspect of the medial and lateral condyles. Findings were preserved across gender and age. Ultimately, these data can aid in preoperative planning and should be considered when performing operative procedures in the skeletally immature knee.