Rehabilitation Following Anterior Cruciate Ligament Tears in Children: A Systematic Review

Effect of Age and Sex on Anterior Cruciate Ligament Functional Tests Approximately 6 Months After Anterior Cruciate Ligament Reconstruction

Purpose

To examine age- and sex-related differences in postoperative functional outcomes at approximately 6 months after anterior cruciate ligament reconstruction (ACLR).

Methods

In this study, patients who underwent primary ACLR performed a series of return-to-sport functional tests at 5 to 8 months after surgery. Functional tests included strength tests (knee extensors, knee flexors, hip abductors, and hip extensors), a balance test (Y-balance composite score), and hop tests (single, triple, crossover, and 6-m timed hop tests). Limb symmetry was calculated to compare the reconstructed limb with the uninvolved limb. A 2-way multivariate analysis of covariance was used, and effect size was calculated for data analysis.

Results

A total of 176 subjects were included in this study. There were no significant interaction between age and sex on return-to-sport functional tests after ACLR. Also, no main effects of age and sex on return-to-sport functional tests were found in our data.

Conclusions

Age and sex do not significantly affect functional test performance after ACLR 6 months postoperatively.

Level of Evidence

Level III, retrospective review of prospective cohort study.

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

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.

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.

Return to Sport After Pediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review of the Criteria

BACKGROUND

Postoperative rehabilitation is an important component of recovery after anterior cruciate ligament (ACL) reconstruction (ACLR), facilitating successful return to sport (RTS) by reducing risk factors for repeat injury.

PURPOSE

This systematic review aimed to determine the best protocol for RTS after ACLR in children.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

PubMed, Embase, PEDro, SPORTDiscus, and Web of Science databases were searched from October 3, 2014, to November 3, 2022. The inclusion criteria were the pediatric population (<18 years old) after ACLR with clear RTS criteria and/or mean/median time to RTS. Multiligament knee injuries were excluded from this study. The methodologic quality of the included articles was assessed using the methodological index for non-randomized studies (MINORS). The highest possible score was 24 points for comparative studies (ie, a study comparing 2 protocols or more). Noncomparative studies or studies with a single protocol could score a maximum of 16 points as assessed by the MINORS score.

RESULTS

The search yielded 1816 titles, and 24 were retained based on the inclusion and exclusion criteria. Every study was published between 2015 and 2022. Among the 24 studies included, 13 were retrospective and 11 were prospective. The mean MINORS score for the noncomparative studies was 13 of 16 (n = 23) and 23 of 24 for the comparative study (n = 1). The studies were categorized into unspecified clearance (n = 10), milestone based (n = 13), and combined time and milestone (n = 1). A total of 1978 patients (57% female) were included in the review. The mean age at ACLR was 14.7 years. The most common endpoint used was graft rupture (0% to 35%). In the unspecified group, the quickest RTS was 5.8 months and the longest was 9.6 months. Statistically significant risk factors for ACL reinjury included younger age and earlier RTS. The latter was a significant contributor to graft failure for combined time-based and milestone-based RTS. In the milestone-based group, the most common criteria were ≥90% limb symmetry measured using hamstring strength, quadriceps strength, and/or hop tests. The mean RTS time was 6.8 to 13.5 months.

CONCLUSION

RTS should be delayed, when possible, especially in the younger population. A combination of quantitative tests and qualitative tests is also recommended. However, optimal RTS criteria have yet to be determined. Future prospective studies should focus on comparing the different times and milestones currently available.

Criteria Used to Determine Unrestricted Return to Activity After ACL Reconstruction in Pediatric and Adolescent Patients: A Systematic Review

Background

The rates of anterior cruciate ligament (ACL) graft failure or contralateral ACL rupture range from 17% to 30% in pediatric patients after ACL reconstruction (ACLR). A contributing factor to the high reinjury rate in this population may be the limited evidence regarding appropriate criteria for allowing unrestricted return to activity (RTA) postoperatively.

Purpose

To review the literature and identify the most commonly used criteria when determining unrestricted RTA after ACLR in pediatric patients.

Study Design

Systematic review; Level of evidence, 4.

Methods

A search was performed of the Medline/PubMed, Cochrane Central Register of Controlled Trials, Embase, CINAHL, and SPORTDiscus databases using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The authors identified studies that included pediatric patients (<19 years of age) and specified the criteria used to determine RTA after ACLR.

Results

A total of 27 articles met all criteria for review, of which 13 studies only used 1 criterion when determining RTA. Objective criteria were the most common type of criteria for RTA (17 studies). Strength tests (15 studies) and hop tests (10 studies) were the most commonly used tasks when deriving RTA criteria. Only 2 studies used validated questionnaires to assess the patient's physiological readiness for RTA, and only 2 studies used an objective assessment of movement quality before RTA.

Conclusion

Only 14 of the 27 reviewed studies reported using >1 criterion when determining RTA. Furthermore, few studies used patient-reported outcome measures or lower limb kinematics as RTA criteria, indicating that more research is needed to validate these metrics in the pediatric population.

Age- and Sex-Specific Joint Biomechanics in Response to Partial and Complete Anterior Cruciate Ligament Injury in the Porcine Model

CONTEXT

Pediatric anterior cruciate ligament (ACL) injury rates are increasing and are highest in female adolescents. Complete ACL tears are typically surgically reconstructed, but few guidelines and very limited data exist regarding the need for surgical reconstruction or rehabilitation for partial ACL tears in skeletally immature patients.

OBJECTIVE

To evaluate the effects of partial (anteromedial bundle) and complete ACL transection on joint laxity and tissue forces under anterior and rotational loads in male and female stifle joints throughout skeletal growth in the porcine model.

DESIGN

Descriptive laboratory study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

We studied 60 male and female Yorkshire crossbreed pigs aged 1.5, 3, 4.5, 6, and 18 months (n = 6 pigs per age per sex).

MAIN OUTCOME MEASURE(S)

Joint laxity was measured in intact, anteromedial bundle-transected, and ACL-transected joints under applied anterior-posterior drawer and varus-valgus torque using a robotic testing system. Loading of the soft tissues in the stifle joint was measured under each condition.

RESULTS

Anterior-posterior joint laxity increased by 13% to 50% (P < .05) after anteromedial bundle transection and 75% to 178% (P < .05) after ACL transection. Destabilization after anteromedial bundle transection increased with age (P < .05) and was greater in late female than late male adolescents (P < .05). In anteromedial bundle-transected joints, the posterolateral bundle resisted the anterior load. In ACL-transected joints, the medial collateral ligament (MCL) contribution was largest, followed by the medial meniscus. The MCL contribution was larger and the medial meniscus contribution was smaller in male versus female specimens.

CONCLUSIONS

Partial ACL transection resulted in moderate increases in joint laxity, with the remaining bundle performing the primary ACL function. Destabilization due to partial ACL transection (anteromedial bundle) was largest in late adolescent joints, indicating that operative treatment should be considered in active, late-adolescent patients with this injury. Increased forces on the MCL and medial meniscus after ACL transection suggested that rehabilitation protocols may need to focus on protecting these tissues.

Risk of reoperation after primary anterior cruciate ligament reconstruction in children and adolescents

OBJECTIVE

To examine the incidence and risk factors of any-cause reoperation after primary ACLR in children and adolescents.

DESIGN

Retrospective Cohort.

SETTING

Electronic medical records from a large tertiary care, single institution integrated healthcare delivery system.

PATIENTS

Patients were under the age of 18 years and had anterior cruciate ligament reconstruction. They were excluded if they had a multi-ligamentous knee injury or <1 year follow-up.

INTERVENTIONS

Patients were further identified to have undergone a subsequent knee operation ipsilaterally or contralateral ACLR.

MAIN OUTCOME MEASURES

The rate of any-cause reoperation was our primary outcome measure.

RESULTS

The median age was 16. There were 208 females (53.9%) and 178 males (46.1%) included. The median follow-up was 25 months with a minimum of 12 months (interquartile range: 16.0, 46.0). The rate of any-cause reoperation was 34.7%. There was no statistically significant difference between those who underwent reoperation versus those who did not undergo reoperation relative to age, sex, BMI, graft type, or the presence of concomitant meniscal injury. The rates of ipsilateral ACLR and contralateral ACLR at any time during the study period was 8.0% and 10.9% respectively. There was no statistically significant difference for rate of reoperation between graft types, between various concomitant injuries, between those who underwent meniscus repair or no repair.

CONCLUSIONS

This study reflects a 34.7% rate of a subsequent knee operation after ACLR in patients younger than 18 years. These findings can be used to inform pediatric patients undergoing primary ACLR on their risk of returning to the operating room.

Protocol for the systematic review of return-to-activity criteria in adolescent patients following an anterior cruciate ligament reconstruction

BACKGROUND

Anterior cruciate ligament (ACL) rupture is a debilitating knee injury associated with sequela such as joint instability and progressive degeneration. Unfortunately, following surgical ACL reconstruction in adolescents, the rates of ACL graft failure range from 17 to 19%. A contributing factor to the high reinjury rate in this population may be the limited evidence regarding appropriate criteria for allowing unrestricted return-to-activities (RTA) postoperatively. Several systematic reviews have already sought to develop a consensus on what criteria should be utilized for releasing patients to unrestricted sports activities; however, these reviews have focused on adult populations, a group at much lower risk for reinjury. Our objective is to systematically examine the literature and identify the criteria used when determining unrestricted RTA following an ACL reconstruction in an adolescent population.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search will be performed of the MEDLINE/PubMed, Cochrane, Embase, CINAHL, and SPORTDiscus electronic databases. Searches will be conducted from January 1, 2000, until submission of the final review. Studies will be identified that include adolescent patients (10-18 years old) undergoing a primary ACL reconstruction and which have specified the criteria used to determine RTA. Each article will be independently screened by two reviewers. To supplement the electronic database search, citations within all included studies will be manually reviewed. Reviewers will record the RTA assessment utilized and the rates of ACL reinjury through a standardized data extraction sheet. Reviewers will resolve full-text screening and data extraction disagreements through discussion. Synthesis of the collected data will focus on compiling and mapping the most commonly used types of RTA criteria.

DISCUSSION

This systematic review will determine the most commonly used RTA criteria in adolescent patients post-ACL reconstruction. This will help future interventions build more effective adolescent-specific RTA assessments through the validation of current RTA criteria as well as the implementation of new criteria according to the identified literature gaps.

Anterior Cruciate Ligament Rupture in Skeletally Immature Patients

In the past 20 years, sports injuries in pediatric and adolescent athletes have increased dramatically, with anterior cruciate ligament (ACL) injuries accounting for more than 25% of all knee injuries at this age. Diagnosis is based on detailed clinical history, physical examination, and imaging assessment, where magnetic resonance imaging plays a central role. The growing immature skeleton presents specific characteristics, which require unique methods for surgical reconstruction, ideally avoiding the physes or minimizing the risk of damaging them. Specific rehabilitation protocols are needed, and these patients face a higher risk of recurrent and contralateral ACL injury. Nonsurgical treatment or delayed reconstruction has been associated with persistent instability, activity modifications, worst functional outcomes, and increased risk of irreparable injuries to menisci and articular cartilage. Consequently, surgical stabilization is the preferred treatment for most patients, despite the eventual risk of angular deformities or limb-length discrepancies due to iatrogenic physeal injury. A variety of surgical techniques have been described, depending on the skeletal maturity and growth remaining. Targeted prevention programs play a key role in reducing the risk of ACL injury, are easy to implement, and require no additional equipment. High-quality evidence supports its use in all pediatric athletes.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Case-control study, Level III.

Unique Considerations for the Pediatric Athlete During Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction

Level of Evidence

Vertical Drop Jump Biomechanics of Patients With a 3- to 10-Year History of Youth Sport-Related Anterior Cruciate Ligament Reconstruction

Background

A better understanding of movement biomechanics after anterior cruciate ligament reconstruction (ACLR) could inform injury prevention, knee injury rehabilitation, and osteoarthritis prevention strategies.

Purpose

To investigate differences in vertical drop jump (VDJ) biomechanics between patients with a 3- to 10-year history of youth sport-related ACLR and uninjured peers of a similar age, sex, and sport.

Study Design

Cross-sectional study. Level of evidence III.

Methods

Lower limb kinematics and bilateral ground-reaction forces (GRFs) were recorded for participants performing 10 VDJs. Joint angles and GRF data were analyzed, and statistical analysis was performed using 2 multivariate models. Dependent variables included sagittal (ankle, knee, and hip) and coronal (knee and hip) angles at initial contact and maximum knee flexion, the rate of change of coronal knee angles (35%-90% of the support phase; ie, slopes of linear regression lines), and vertical and mediolateral GRFs (normalized to body weight [BW]). Fixed effects included group, sex, and time since injury. Participant clusters, defined by sex and sport, were considered as random effects.

Results

Participants included 48 patients with a history of ACLR and 48 uninjured age-, sex-, and sport-matched controls (median age, 22 years [range, 18-26 years]; 67% female). Patients with ACLR demonstrated steeper negative coronal knee angle slopes (β = -0.04 deg/% [95% CI, -0.07 to -0.00 deg/%]; P = .025). A longer time since injury was associated with reduced knee flexion (β = -0.2° [95% CI, -0.3° to -0.0°]; P = .014) and hip flexion (β = -0.1° [95% CI, -0.2° to -0.0°]; P = .018). Regardless of ACLR history, women displayed greater knee valgus at initial contact (β = 2.1° [95% CI, 0.4° to 3.8°]; P = .017), greater coronal knee angle slopes (β = 0.05 deg/% [95% CI, 0.02 to 0.09 deg/%]; P = .004), and larger vertical GRFs (landing: β = -0.34 BW [95% CI, -0.61 to -0.07 BW]; P = .014) (pushoff: β = -0.20 BW [95% CI, -0.32 to -0.08 BW]; P = .001).

Conclusion

Women and patients with a 3- to 10-year history of ACLR demonstrated VDJ biomechanics that may be associated with knee motion control challenges.

Clinical Relevance

It is important to consider knee motion control during activities such as VDJs when developing injury prevention and rehabilitation interventions aimed at improving joint health after youth sport-related ACLR.

Anatomic all-epiphyseal ACL reconstruction with "inside-out" femoral tunnel placement in immature patients yields high return to sport rates and functional outcome scores a minimum of 24 months after reconstruction

PURPOSE

To understand if anatomic physeal-sparing ACL reconstruction in the immature host preserves range of motion, permits a return to sports, and avoids limb length discrepancy and accelerated intra-articular degeneration with a cross-sectional radiographic, physical examination and patient-reported outcomes analysis.

METHODS

A cross-sectional recall study included 38 patients aged 7-15 who underwent all-epiphyseal ACL reconstruction with hamstring allograft performed by a single surgeon at a large academic medical center. All-epiphyseal reconstructions were performed using a modified Anderson physeal-sparing technique, with the femoral tunnel placed using an "inside-out" technique. Assessments consisted of a physical exam, long leg cassette radiographs, KT-1000 measurements, subjective patient metrics, and magnetic resonance imaging.

RESULTS

Thirty-eight (56.7%) of 66 eligible patients returned for in-person clinical and radiographic exams. Patients were 11.4 ± 1.8 years at the time of surgery. Five patients were females (13.2%). Mean follow-up was 5.5 ± 2.4 years. ACL re-injuries occurred in four patients (10.5%), all of whom underwent revision reconstructions. Thirty-three of the remaining 34 (97.1%) patients returned to sports following their reconstruction, and 24 (70.6%) returned to their baseline level of competition. Mean limb length discrepancy (LLD) was 0.2 ± 1.4 cm. Nine patients had an LLD of > 1 cm (26.5%), which occurred at an equivalent age as those with < 1 cm LLD (10.8 ± 2.0 vs. 11.7 ± 1.7, n.s.). Pre-operative Marx scores (13.1 ± 3.5) were not significantly different from post-operative values (12.3 ± 5.1, n.s.). Patients who required ACL revisions had significantly lower Marx scores than those with intact primary grafts (8.3 ± 7.1 vs. 13.4 ± 4.5, p = 0.047). Cohort mean International Knee Documentation Committee (IKDC) score was 89.7 ± 12.7.

CONCLUSION

Anatomic all-epiphyseal anatomic ACL reconstruction appears to be useful in patients with significant projected remaining growth, with good return-to-sport outcomes and minimal risk of clinically significant physeal complications. However, given the limited patient recall possible in the present study, further large sample size, high-quality works are necessary to validate our findings.

LEVEL OF EVIDENCE

Level IV.

Rehabilitation Following Ulnar Collateral Ligament Reconstruction in Overhead-Throwing Athletes

»

The prevalence of ulnar collateral ligament (UCL) injury and UCL reconstruction (UCL-R) continues to rise, causing morbidity in overhead-throwing athletes.

»

Postoperative rehabilitation protocols are essential for proper healing of the reconstructed ligament and safely returning athletes to competition, yet there is no uniformly accepted standard of care.

»

UCL-R rehabilitation has traditionally been guided by expert opinion and conventional wisdom rather than scientific studies, resulting in substantial variability in rehabilitation practices, time to return to play, and outcomes.

»

Current research efforts aim to closely investigate the biomechanical implications of UCL-R and overhead throwing to better guide rehabilitation and to improve competitive performance and outcomes.

»

Additional biomechanical and scientific studies on rehabilitation modalities and timing are warranted for systematic analysis, optimization, and standardization of UCL-R rehabilitation.

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

OBJECTIVES

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

DESIGN

Cohort study.

SETTING

Children's hospital.

PARTICIPANTS

273 adolescents with first-time ACLR.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Uninjured Youth Athlete Performance on Single-Leg Hop Testing: How Many Can Achieve Recommended Return-to-Sport Criterion?

BACKGROUND

Current anterior cruciate ligament reconstruction (ACLR) guidelines utilize single-leg hop tests (SLHTs) to assist in return-to-sport decision making. A limb symmetry index (LSI) of ≥90% is often required; however, after ACLR, most youth athletes cannot achieve this standard. Reporting the performance of age-matched normative controls will allow clinicians to compare post-ACLR performance with noninjured peers, improving the utility of SLHTs. The purpose of this study was to report hop test LSI within healthy youth athletes and determine whether athlete performance surpasses post-ACLR requirements.

HYPOTHESIS

The LSI for the majority of healthy youth athletes will be ≥90%.

STUDY DESIGN

Cross-sectional cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Each participant performed a single hop (SH), triple hop (TrH), crossover hop (CrH), and timed hop (TiH). A 3-trial mean was utilized to calculate an LSI (nondominant/dominant leg [self-reported kicking leg]) for each hop. The frequency of pass/fail at ≥90% LSI was calculated. Pearson correlation coefficients analyzed the relationship between the different hops, and a 2-way analysis of variance determined the effects of age and sex on LSI.

RESULTS

A total of 340 participants (54% male; mean age, 10.9 ± 1.5 years; range, 8-14 years) were included. The mean LSI was >95% for each SLHT (SH, 97.9% [SD, 0.7]; TrH, 96.6% [SD, 0.6]; CrH, 96.8% [SD, 0.8]; TiH, 96.5% [SD, 0.6]). When analyzed as a test battery, only 45% of participants achieved this standard. Significantly weak to moderate correlations existed among hop tests (P < 0.01; r = 0.342-0.520). Age and sex had no effect on LSI (P < 0.05).

CONCLUSION

While the mean LSI in our sample was >95% for each individual hop test, participant performance across all SLHT components varied, such that less than half of healthy athletes could achieve ≥90% LSI across all hops.

CLINICAL RELEVANCE

Current guidelines require ≥90% LSI on SLHTs. The majority of healthy youth athletes could not achieve this standard, which questions the validity of this LSI threshold in youth athletes after ACLR.

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

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

Confirming the Presence of Unrecognized Meniscal Injuries on Magnetic Resonance Imaging in Pediatric and Adolescent Patients With Anterior Cruciate Ligament Tears

BACKGROUND

Prior research has shown decreased accuracy of meniscal injury detection using magnetic resonance imaging (MRI) for anterior cruciate ligament (ACL)-deficient adult patients as well as ACL-deficient pediatric and adolescent patients. The objectives of this study were the following: (1) assess the diagnostic ability of MRI in detecting meniscal injuries for pediatric and adolescent patients undergoing arthroscopic ACL reconstruction and (2) characterize the unrecognized meniscal injuries.

METHODS

The sensitivity, specificity, positive predictive value, and negative predictive value of meniscal tears (medial, lateral, or both) on MRI were calculated for the 107 patients in this cohort. Fisher exact tests were used to compare event frequencies between medial meniscal (MM) and lateral meniscal (LM) tears. One-way analysis of variance tests were performed to compare event rates between the location and type of unrecognized meniscal tears.

RESULTS

The median age of the cohort was 15 (range: 7 to 18). The sensitivity, specificity, positive predictive value, and negative predictive value of MRI in detecting meniscal tears (medial, lateral, or both) in ACL-deficient pediatric and adolescent patients was 62.3%, 68.4%, 78.2%, and 50.0%, respectively. There were 26 (24.3%) cases in which a meniscal injury was not detected on MRI, but was discovered arthroscopically (MM: 5 knees, LM: 20 knees, both: 1 knee). These unrecognized meniscal injuries were more commonly the LM than the MM (77.8%, P-value=0.100), a vertical/longitudinal tear type (77.8%, P-value <0.001), and located in the posterior horn (74.1%, P-value <0.001).

CONCLUSIONS

In this ACL-deficient pediatric and adolescent cohort, there were 26 (24.3%) patients with unrecognized meniscal injuries. A vertical tear in the posterior horn was the most commonly unrecognized meniscal injury, supporting the findings of prior research postulating that the location and configuration of a tear influence the accuracy of MRI in detecting these injuries. More research is needed to investigate strategies to improve the detection of meniscal tears in pediatric and adolescent patients preoperatively. These findings have implications with regard to patient counseling, operative planning, anticipatory guidance with regard to postoperative rehabilitation, recovery expectations, and surgical outcomes.

LEVEL OF EVIDENCE

Level IV.

Patterns in Outcomes Reporting of Operatively Managed Pediatric Patellofemoral Instability: A Systematic Review and Meta-analysis

BACKGROUND

Traumatic patellofemoral dislocation is a common injury in pediatric patients, and surgical treatment is often recommended. Increasingly, it has been recognized that clinical studies need to report age-appropriate treatment outcomes. However, the variability and appropriateness of outcomes reporting in the youth patellar instability literature are unknown.

PURPOSE

To analyze the patterns of outcomes reporting in studies published in high-impact orthopaedic journals after operative management of pediatric patellar instability.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Six high-impact orthopaedic journals were searched using PubMed and EMBASE to identify studies reporting outcomes of operative management of pediatric patellar instability. Studies containing adults were excluded. Clinical and radiographic outcomes were recorded from included articles. Descriptive statistics were calculated for overall instability recurrence rates, return-to-activity rates, and changes in Kujala and Tegner scores.

RESULTS

Of 545 identified articles, 8 studies met the inclusion criteria. These studies encompassed 213 patients and 230 knees (mean age, 13.2 years; range, 4.5-18.3 years). Seven of 8 studies reported patients' physeal status, but only 4 studies limited their outcomes reporting to patients with open physes. Two studies reported postoperative radiographic measures, and 5 studies reported preoperative radiographic findings. Six studies reported patient-reported outcome measures (PROMs). Seven unique PROMs were reported. All but one study reported complication rates and types of complications. The mean postoperative change in Tegner scores was -0.07 (range, -0.6 to 1.0). Among studies examining medial patellofemoral ligament reconstruction with adequate data, the mean return-to-activity rate was 86% (range, 81%-92%), the instability recurrence rate was 3% ± 20%, and the mean improvement in Kujala scores postoperatively was 22.1 (range, 19.9-26).

CONCLUSION

There is a need for more pediatric-specific outcomes studies regarding operatively managed traumatic patellofemoral instability. Of the outcomes reported, both radiographic outcomes and PROMs should be standardized. Among radiographic outcomes, there is a need for more studies that report tibial tubercle-trochlear groove distances and use Caton-Deschamps and/or Blackburne-Peel indices to assess patellar height. Among PROMs, there is a need for studies that use PROMs validated in pediatric populations, such as the International Knee Documentation Committee Pediatric Form or the Hospital for Special Surgery Pediatric Functional Activity Brief Scale.

2018 International Olympic Committee Consensus Statement on Prevention, Diagnosis, and Management of Pediatric Anterior Cruciate Ligament Injuries

In October 2017, the International Olympic Committee hosted an international expert group of physical therapists and orthopaedic surgeons who specialize in treating and researching pediatric anterior cruciate ligament (ACL) injuries. The purpose of this meeting was to provide a comprehensive, evidence-informed summary to support the clinician and help children with ACL injury and their parents/guardians make the best possible decisions. Representatives from the following societies attended: American Orthopaedic Society for Sports Medicine; European Paediatric Orthopaedic Society; European Society for Sports Traumatology, Knee Surgery, and Arthroscopy; International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine; Pediatric Orthopaedic Society of North America; and Sociedad Latinoamericana de Artroscopia, Rodilla, y Deporte. Physical therapists and orthopaedic surgeons with clinical and research experience in the field and an ethics expert with substantial experience in the area of sports injuries also participated. This consensus statement addresses 6 fundamental clinical questions regarding the prevention, diagnosis, and management of pediatric ACL injuries. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision making with children and the potential long-term ramifications of the injury.

2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries

In October 2017, the International Olympic Committee hosted an international expert group of physiotherapists and orthopaedic surgeons who specialise in treating and researching paediatric ACL injuries. Representatives from the American Orthopaedic Society for Sports Medicine, European Paediatric Orthopaedic Society, European Society for Sports Traumatology, Knee Surgery & Arthroscopy, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Pediatric Orthopaedic Society of North America and Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte attended. Physiotherapists and orthopaedic surgeons with clinical and research experience in the field, and an ethics expert with substantial experience in the area of sports injuries also participated. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision-making with children and the potential long-term ramifications of the injury. This consensus statement addresses six fundamental clinical questions regarding the prevention, diagnosis and management of paediatric ACL injuries. The aim of this consensus statement is to provide a comprehensive, evidence-informed summary to support the clinician, and help children with ACL injury and their parents/guardians make the best possible decisions.

2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries

In October 2017, the International Olympic Committee hosted an international expert group of physiotherapists and orthopaedic surgeons who specialise in treating and researching paediatric anterior cruciate ligament (ACL) injuries. Representatives from the American Orthopaedic Society for Sports Medicine, European Paediatric Orthopaedic Society, European Society for Sports Traumatology, Knee Surgery and Arthroscopy, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Pediatric Orthopaedic Society of North America, and Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte attended. Physiotherapists and orthopaedic surgeons with clinical and research experience in the field, and an ethics expert with substantial experience in the area of sports injuries also participated. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision-making with children and the potential long-term ramifications of the injury. This consensus statement addresses six fundamental clinical questions regarding the prevention, diagnosis, and management of paediatric ACL injuries. The aim of this consensus statement is to provide a comprehensive, evidence-informed summary to support the clinician, and help children with ACL injury and their parents/guardians make the best possible decisions.

Clinical Outcome Reporting in Youth ACL Literature Is Widely Variable

Background:

Advances in anterior cruciate ligament (ACL) reconstruction procedures in pediatric and adolescent patients have resulted in an increase in recent clinical studies on this topic. However, the consistency with which outcome measures are reported in this demographic is unknown.

Purpose:

To document outcome reporting patterns of youth ACL reconstruction studies in high-impact journals.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

All articles published in 5 high-impact orthopaedic journals from 2010 to 2016 were reviewed to identify those reporting clinical outcomes of young patients who underwent ACL reconstruction. Studies that were nonclinical, reported on patients older than 18 years, or included fewer than 10 patients were excluded. Outcome measures used in all included studies were recorded.

Results:

Seventeen studies encompassing 772 subjects (mean age, 14.3 years; range, 6.3-18.0 years) were analyzed. Eight studies (47%) reported on Tanner stage of subjects, while 1 study reported skeletal age. Ten studies (59%) clearly documented the presence or absence of surgical complications. Range of motion was reported in 65% of studies. Leg-length discrepancy and angular deformity were each reported in 76% of studies, with 12% quantifying results through radiographic measurements. Ligament testing was variably defined by inclusion of instrumented testing (65%), Lachman test (53%), and pivot-shift test (53%). Fourteen studies (82%) explicitly reported on the rate of ACL rerupture, while 71% reported on the rate of revision surgery. Rate of return to preinjury activity was reported in 8 studies (47%), of which 2 defined criteria for return to sport and 3 defined the level of competitive sport. Patient-reported outcome measures (PROMs) were used variably. For the 3 most commonly reported PROMs (Lysholm, International Knee Documentation Committee, and Tegner), 24% of studies reported all 3 PROMs, 35% of studies reported 2 PROMs, and 6% of studies reported 1 PROM in isolation. A pediatric-specific PROM was reported in 1 of the 17 studies.

Conclusion:

Studies on pediatric ACL reconstruction published in high-impact journals unreliably defined subjects’ skeletal maturity, inconsistently reported on objective outcome measures, and used disparate adult-validated PROMs to assess subjective outcomes. These findings highlight the need for standardized, pediatric-specific outcome measures to be applied in future studies evaluating ACL reconstruction in children and adolescents.

Unique Issues in the Rehabilitation of the Pediatric and Adolescent Athlete After Musculoskeletal Injury

Youth sports participation is on the rise, resulting in an increase in sports-related injuries in the pediatric and adolescent population. The presentation of injury, pathology, and disease in this younger population is often unique and may require customize and novel medical and rehabilitation interventions to optimize the outcome. The purpose of this review is to highlight unique considerations in the rehabilitation management of the pediatric and adolescent athlete. General guidelines for progression of this population through a criteria-based rehabilitation program with a focus on a systematic return to sport algorithm will be reviewed.