Pediatric ACL Injuries: A Review of Current Concepts

Clinical and Functional Outcomes of Suture Versus Headless Screw Fixation for Tibial Eminence Fractures in Children

BACKGROUND

Suture and screw fixations are widely used to treat tibial eminence fractures (TEFs). Although a few biomechanical and clinical studies have compared suture fixation (SF) and screw fixation in the treatment of TEFs in children, no comparative clinical studies are available regarding headless screw fixation (HSF).

PURPOSE

To evaluate the clinical and functional outcomes of children with TEF who underwent SF and HSF.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The study included 24 patients treated with either SF (11 patients) or HSF (13 patients) within 1 month of TEF (type 2 or 3) without associated ligamentous and bone injury between 2015 and 2020. All patients were evaluated at a minimum 2-year follow-up in terms of Lysholm score, Tegner activity level, International Knee Documentation Committee subjective score, and isometric strength test. Knee stability was compared based on the Lachman test, pivot-shift test, and KT-1000 arthrometer side-to-side difference.

RESULTS

No significant differences were found between the 2 groups in terms of Lysholm score, Tegner activity level, and International Knee Documentation Committee subjective score at follow-up. All patients were able to resume their daily activities within 6 months after the injury. However, flexion deficits (6°-10°) were found in 2 patients in the SF group and 1 patient in the HSF group, and extension deficits (3°-5°) were found in 3 patients in the SF group and 1 patient in the HSF group, without significant intergroup difference. Stability based on the Lachman test, pivot-shift test, and KT-1000 arthrometer side-to-side difference was also similar between the 2 groups at follow-up. No statistically significant difference was found between the 2 groups in isometric tests performed.

CONCLUSION

The present study is the first to compare the clinical and functional results of SF and HSF techniques. The HSF technique demonstrated comparable clinical and functional outcomes, suggesting its potential as an alternative to the SF technique.

Functional Rehabilitation of Anterior Cruciate Ligament Tear in the Pediatric Population: A Comprehensive Review

Pediatric sports injuries are a growing concern due to increased youth participation in sports. Effective rehabilitation strategies are essential for ensuring optimal recovery, restoring knee function, and preventing long-term consequences. This research aims to explore and evaluate various functional rehabilitation approaches tailored to pediatric anterior cruciate ligament (ACL) tear injuries. Functional rehabilitation of ACL tears in pediatric sports injuries is an important area of research due to the unique considerations and challenges that arise when treating ACL injuries in young athletes. Over the last 20 years, there has been a well-documented uptick in ACL injuries among pediatric populations. This rise can be attributed to the growing involvement of the younger population in competitive sports, as well as heightened awareness regarding sports-linked injuries. This study highlights the importance of early surgical reconstruction in children to enable a quick return to sports and prevent long-term cartilage and meniscal damage resulting from instability. The use of physeal-sparing ACL reconstruction techniques, particularly hamstring autografts, is recommended for favorable clinical outcomes while minimizing growth disturbances. This study offers valuable insights for healthcare professionals and researchers, serving as a reference to guide optimal approaches in managing pediatric ACL injuries and achieving successful results in this field.

Evaluating the Readability and Quality of Online Patient Education Materials for Pediatric ACL Tears

BACKGROUND

As the rate of anterior cruciate ligament (ACL) tears increases in children, the internet has become a major source of information and education. In the United States, the average adult reads at about an eighth grade level. The National Institutes of Health recommends that patient education materials do not exceed a sixth-grade reading level. Therefore, the most accessed resources on the internet should be created with this in mind. The purpose of this study is to assess the readability and quality of online patient resources for pediatric ACL tears.

METHODS

Google was queried using the term "Pediatric ACL Tear" on May 26, 2022. The most popular sites were identified through page one of a Google search. All content was evaluated to assure information was directed toward patients. To determine reading difficulty, the most widely accepted readability tests: Flesch Reading Ease Index, Flesch-Kincaid Grade Level, and Gunning Fog Index were calculated through plain text in Microsoft Word and URL in online readability checker Readable.io.

RESULTS

The average grade level for all resources was above the recommended reading level based on both Microsoft Word and Readable.io calculations. Each source exceeded the NIH recommendation by 2.6 grade levels on average (Mean grade level readability was 8.6 ± 1.9). Four of the 6 sites were above the average US reading level, exceeding the eighth grade by an average of 1.5 grade levels. All 6 sites analyzed had a mean DISCERN score of 61.9, meeting the 'good quality' criteria.

CONCLUSION

The most readily available online materials for Pediatric ACL tears were of 'good quality' but above both the NIH-recommended readability level and the average US adult reading level. With the increasing need for treatment of ACL tears in pediatric and adolescent patients and greater internet accessibility in these populations, it is important to consider the readability of these resources in support of increased health literacy and improved outcomes.

CLINICAL RELEVANCE

It is important for physicians treating young patients with ACL tears to be aware of all sources of information and support, including content shared online as these platforms are increasingly utilized, especially by patients and families of lower socioeconomic status.

Consensus Delphi study on guidelines for the assessment of anterior cruciate ligament injuries in children

Background: Knee examination guidelines in minors are intended to aid decision-making in the management of knee instability. Clinical question: A Delphi study was conducted with a formal consensus process using a validated methodology with sufficient scientific evidence. A group consensus meeting was held to develop recommendations and practical guidelines for use in the assessment of instability injuries in children. Key findings: there is a lack of evidence to analyse anterior cruciate ligament injuries in children and their subsequent surgical management if necessary. Diagnostic guidelines and clinical assessment of the patient based on a thorough examination of the knee are performed and a guide to anterior cruciate ligament exploration in children is developed. Clinical application: In the absence of a strong evidence base, these established guidelines are intended to assist in that decision-making process to help the clinician decide on the most optimal treatment with the aim of benefiting the patient as much as possible. Following this expert consensus, surgical treatment is advised when the patient has a subjective sensation of instability accompanied by a pivot shift test ++, and may include an anterior drawer test + and a Lachman test +. If these conditions are not present, the conservative approach should be chosen, as the anatomical and functional development of children, together with a physiotherapy programme, may improve the evolution of the injury.

Outcomes Following Primary Anterior Cruciate Ligament Reconstruction Using a Partial Transphyseal (Over-the-Top) Technique in Skeletally Immature Patients

BACKGROUND

The incidence of anterior cruciate ligament (ACL) injuries in skeletally immature patients is increasing, with ACL reconstruction preferred in this population due to reported chondroprotective benefits. Due to concerns with growth disturbance following ACL reconstruction in skeletally immature patients, various physealsparing and partial transphyseal techniques have been developed. Currently, there is no consensus on the most effective ACL reconstruction technique in skeletally immature patients. The purpose of the current study was to report the outcomes of a partial-transphyseal over-the-top (OTT) ACL reconstruction in a cohort of skeletally immature patients.

METHODS

All patients with radiographic evidence of open tibial and femoral physes that underwent primary ACL reconstruction using a partial-transphyseal OTT technique between 2009-2018 at a single tertiary-care institution with at least twelve months of clinical follow-up were retrospectively reviewed. Patient demographics, physical examination findings, graft ruptures, return to sport, and Tegner activity levels were analyzed. Statistical significance was defined as p<0.05.

RESULTS

Overall, 11 males and 1 female (12 knees) with a mean age of 12.8±1.8 (range: 10-16) years were included in the study. The mean postoperative follow-up of the cohort was 2.3±1.2 (range: 1.1-5.2) years. All ACLs were reconstructed with hamstring autograft with allograft augmentation utilized in a single patient. There were two cases of ACL graft rupture (16.7%). All patients were able to return to the same or higher level of sporting activity at an average of 7.4+2.7 months. There were no cases of clinically significant longitudinal or angular growth disturbance.

CONCLUSION

Partial transphyseal ACL reconstruction using a transphyseal tibial tunnel and an extra-articular OTT technique on the femur in skeletally immature patients affords minimal risk of growth disturbance with a graft rupture rate consistent with what has been reported in this high-risk population. All patients were able to return to sport at the same or higher level. Level of Evidence: IV.

Risk factors of young males with physically demanding occupations having accumulated damage of anterior cruciate ligament

Objective

To present the clinical characteristics of accumulated anterior cruciate ligament (ACL) damage among young male patients undergoing routine exercise, and to evaluate the related risk factors.

Methods

A retrospective study involving ACL‐accumulated damage from June 2015 to December 2019 was conducted. Baseline characteristics, such as age, body mass index (BMI), training parameters, and clinical signs, were recorded. The results of the radiologic examinations and related standardized tests were obtained to evaluate the research outcomes. These results were compared using Student's t‐test or Chi‐square test, and the impact of risk factors on the patient's injury were analyzed.

Results

A total of 86 men with accumulated ACL damage were included in this study. Exercise pain (86 [100%]), synovitis (80 [93.0%]), and intra‐articular effusion (79 [91.9%]) were the most common clinical symptoms. Loosening of ligaments, decreased tension, mild hyperplasia, and intercondylar fossa effusion were observed using radiography, magnetic resonance imaging, and arthroscopy. Age, BMI, training intensity, length of training, and knee hyperextension were identified as risk factors for accumulated ACL damage.

Conclusion

This study suggests that accumulated ACL damage has differentiated clinical symptoms, imaging features, and risk factors compared to common ACL injuries.

Paediatric Anterior Cruciate Ligament (ACL) Injuries: Current Concepts Review

BACKGROUND

Over the past two decades, there has been a documented increase in paediatric ACL injuries because of a rise in younger age sports participation at the competitive level, awareness about sports-related injuries, and advanced imaging modalities.

METHODS

A PubMed electronic database search was done, which revealed 1366 hits over the last five years (2016 - 2020). Finally, 37 articles that contributed to new findings were included. This review was conducted based on predefined research questions.

RESULTS AND CONCLUSION

Early surgical reconstruction is recommended in children due to the increasing demand for early return to sports and to prevent the instability that can lead to progressive cartilage and meniscal damage. With the evolution of several "physeal sparing" ACL reconstruction (ACLR) techniques, a favorable clinical outcome with less growth disturbance is achievable. Although different autograft options are available, hamstring autografts are most commonly preferred. A specific pattern of a bone bruise not extending into the metaphysis, and lateral meniscus tears are the most common associated injuries. Following paediatric ACLR, complications like graft rupture and contralateral ACL injuries are two to three folds higher than with adult ACLR. Unprepared early return to sports is one of the reasons for increased complication rates in children; thus, clearance criteria for return to sports need to be standardized, and early return to sports (< 9 months post ACLR) should be avoided. Neuromuscular training protocols are recommended to minimize complications like graft ruptures.

[Management status of anterior cruciate ligament injury in children and adolescents]

OBJECTIVE

To summarize the current management of anterior cruciate ligament (ACL) injury in children and adolescents, in order to provide reference for the management of ACL injury in children and adolescents.

METHODS

The relevant literature at home and abroad in recent years was extensively accessed to summarize the management status of ACL injury in children and adolescent.

RESULTS

The number of ACL injury in children and adolescents is increasing every year. The diagnosis of ACL mainly depends on symptoms and signs. Rehabilitation, physeal-sparing techniques, partial transphyseal techniques, all-epiphyseal techniques, and transphyseal techniques are used to treat ACL injury in children and adolescents.

CONCLUSION

Dynamic monitoring of knee joint in children and adolescents should be strengthened. The best treatment for ACL injury in children and adolescents is selected according to the patients' actual age, bone age, Tanner stage, and physiological conditions such as menstruation, body growth speed, and other characteristics.

Arthroscopically Assisted Cannulated Screw Fixation for Treating Type III Tibial Intercondylar Eminence Fractures: A Short-Term Retrospective Controlled Study

Background: This study presents the clinical results from 22 children who underwent minimally invasive arthroscopically assisted screw fixation for the treatment of intercondylar eminence fractures. Methods: We retrospectively analyzed the clinical data of 22 children (aged 7.5 to 13.5 years) with type III tibial intercondylar eminence fractures who were treated in our department from March 2007 to September 2019. According to the type of operation, the patients were divided into two groups: group A (n = 12) received arthroscopically assisted cannulated screw fixation, and group B (n = 10) received open reduction and cannulated screw internal fixation. Radiography scans, Lysholm scores, International Knee Documentation Committee (IKDC) 2,000 subjective scores, Tegner scores, range of motion (ROM) of the knee, the anterior drawer test (ADT), the Lachman test, and the pivot-shift test were used to evaluate the clinical efficacy. Results: All 22 children were evaluated over a 12 to 58 month follow-up period (mean: 27.5 months). At the final exam, group A was significantly superior to group B in Lysholm scores (93.33 ± 3.55 vs. 86.20 ± 4.52), IKDC scores (92.06 ± 3.55 vs. 86.07 ± 5.81), and Tegner scores (7.75 ± 0.87 vs. 6.40 ± 0.52) and presented shorter operative times (25.42 ± 3.97 vs. 35.00 ± 5.27). The differences were statistically significant (P < 0.05). All the incisions healed primarily. No complications, such as fracture fragment displacement, delayed epiphyseal growth, or knee joint dysfunction, were observed. The drawer test, Lachman test, and pivot-shift test were negative for all patients. Conclusions: Arthroscopically assisted cannulated screw fixation is effective and safe for the treatment of tibial intercondylar eminence fractures, providing excellent stability and quick recovery of joint function.

Trends of anterior cruciate ligament reconstruction in children and young adolescents in Italy show a constant increase in the last 15 years

PURPOSE

The aim of this 15-year nationwide study was to investigate the trend in ACL reconstructive surgeries in patients younger than 15 years old in Italy, as well as their social and economic impact.

MATERIALS AND METHODS

The National Hospital Discharge records (SDO) collected by the Italian Ministry of Health in the 15-year period between 2001 and 2015 were analyzed. This contains anonymous data including patients' age, gender, ICD-9-CM codes for diagnosis and intervention, census region, region of hospitalization, length of the hospitalization, and public or private reimbursement.

RESULTS

1,350 ACL reconstructions were performed in Italy in the population younger than 15 years old, with an incidence rate ranging from 0.16 to 2.04 procedures per 100,000 age-matched individuals. Similarly, the percentage of surgeries in 0-14 year old patients increased with respect to the total number of ACL reconstruction from 0.13% in 2001 to 0.95% in 2015. The age range 10-14 years is the most involved, accounting for 97.3% of surgeries recorded in the study period. The male:female ratio was 1.05 and most of these procedures were performed in the North of Italy (78.3%).

CONCLUSION

ACL reconstructions in patients aged 10-14 years are increasing constantly since 2001, and thus, specific actions aimed to define the best management strategy as well as national educational programs to prepare the future surgeons to this new reality are mandatory in the interest of the public health.

LEVEL OF EVIDENCE

Level III.

Paediatric anterior cruciate ligament injury

The number of paediatric anterior cruciate ligament injuries is rising at a greater rate than in the adult population, as a result of the increased participation of children and adolescents in sports. This review explores the key presentations, diagnostic and management plans, and prevention methods associated with paediatric anterior cruciate ligament injuries. This injury presents as an acute pop and effusion, with limitations in gait, and can be extremely debilitating. Clinical examination and magnetic resonance imaging are used to diagnose the injury. The pivot shift and Lachman test remain the most valid exams when suspecting an anterior cruciate ligament tear. Management of the injury can be surgical or non-surgical depending on the severity of the tear and associated injuries. The surgical approach chosen is determined by the patient's Tanner classification, considering potential damage to the physes of the bone. Management plans should include rehabilitation consisting of strength, proprioception and neuromuscular training, to maximise the patient's recovery. Injury prevention programmes, consisting of strength training and neuromuscular training, should be followed by young athletes to reduce anterior cruciate ligament injuries. Compliance and earlier implementation coupled with an understanding of the biomechanics of anterior cruciate ligament injuries and verbal feedback maximise the benefit of neuromuscular training.

Anterior cruciate ligament injury patterns and their relationship to fatigue and physical fitness levels - a cross-sectional study

Anterior cruciate ligament (ACL) injury is one of the most common knee injuries that leads to many consequences such as early osteoarthritis and knee joint instability.To explore the association of the types of ACL tear (complete and partial) and side of injury (dominant vs nondominate) with types of playing surfaces, sports, shoes, and mechanism of injuries as well as to determine whether higher levels of fatigue and physical fitness are risk factors for complete ACL tear.This cross-sectional study used a questionnaire to collect information from young male adults with a confirmed ACL injury who were attending rehabilitation programs. The outcomes of interest were patterns of ACL injury, levels of fatigue before the injury on a 0 to 10 scale, and levels of physical fitness (hours per week). Mann-Whitney U and Kruskal Wallis tests were used to assess the differences between groups, while the odds ratios were calculated to evaluate risk factors for complete ACL tear.One hundred thirteen young male adults with a confirmed ACL injury were enrolled. Most of the reported ACL injuries in this study were complete tear (80.5%) and occurred more frequently in the dominant leg (74.6%) due to noncontact mechanism (63.6%). More ACL injuries happened while playing soccer (97.2%) on artificial turf (53.3%). The level of fatigue before ACL injury was significantly higher in partial ACL tear injuries compared to complete ACL tear injuries (P = .014). For every 1-point increase in the level of fatigue on a 0-10 scale, there was a 25% reduction in complete ACL injury risk (P = .023).The pattern of ACL types of tear and side of injury varies in different playing surfaces and mechanisms of injuries. Higher levels of fatigue seem to be associated with a partial tear of the ACL and reduction of a complete ACL tear risk factor.

Physeal Sparing Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients Bridging the Tibial Physis With Two Divergent Tunnels

A technique for anterior cruciate ligament (ACL) reconstruction in patients with open physis is presented. The patient is positioned supine with the knee flexed 90°. After intraarticular injuries are addressed, an autologous hamstring graft is harvested and prepared using a suspension device attached in its expansion device. All-epiphyseal femoral and tibial tunnels of the same diameter of the graft are created; both of them are drilled in an outside-in direction, sparing the physis under radioscopic control. A second divergent tibial tunnel of the same diameter of the graft, distal to the physis, is created in an outside-in, mediolateral, and craniocaudal direction, leaving a 1-cm bone bridge between the 2 tibial tunnels. The graft is passed through the all-epiphyseal tunnels, from femoral to tibial, and pulled until the suspension device leans on the lateral femoral cortex. The graft is passed through the second divergent tibial tunnel and fixed in it with an interference screw to move the pressure away from the physis.

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.

The incidence of paediatric ACL injury is increasing in Finland

PURPOSE

Anterior cruciate ligament (ACL) injury is a common knee injury in paediatric and adolescent patients. The population-based incidence of paediatric ACL injury is, however, unknown. Recent studies suggest increased ACL injury rates among adolescents, especially in active, sports-participating population. The purpose of this study was to investigate the population-based incidence rates of ACL injuries and trends in paediatric ACL reconstruction surgery.

METHOD

All ACL injuries were identified (ICD-10 diagnosis code S83.5) leading to hospitalisation or surgery using validated Finnish National Hospital Discharge Register (NHDR) data from 1997 to 2014. The sample comprised 19,961,205 Finnish residents aged less than 18 years at the time of injury. Hospital admissions with the diagnosis code S83.5 were analysed more thoroughly including, sex, age and the need for surgical interventions.

RESULTS

During the 18-year study period, 4725 subjects of the study population had sustained an ACL injury. The total ACL injury incidence in study population was 23.3 per 100,000 person-years. The median age of the patients at the time of injury was 16 years (range 4-17). The incidence of ACL injury increased with age, and the highest incidence was observed among 17-year old (113.5 per 100,000 person-years). Incidence rate did not differ between genders. From the total ACL injury population of 4725 hospitalisations, 3168 (67.0%) underwent ACL reconstruction, of which 2988 (94.3%) were treated with arthroscopic reconstruction and 180 (5.6%) with open surgery. In addition, 1557 (33.0%) were treated non-operatively without ACL reconstruction. The annual incidence of ACL injuries in the Finnish paediatric population has increased during the past 15 years. The lowest incidence rate was seen in 1999 (incidence of 17.7 per 100,000 person-years, 195 ACL injuries) and the highest in 2011 (incidence of 31.5 per 100,000 person-years, 346 ACL injuries). The highest increase in ACL injuries was seen in girls aged 13-15 years, with an increase of 143%.

CONCLUSION

ACL injury is not a negligible knee injury in the paediatric population. The incidence of paediatric ACL injury has increased during the past 15 years. Moreover, a twofold increase in incidence of paediatric ACL injury was noted during the last 10 years of the study period. Incidence rates among male and female paediatric patients were comparable.

LEVEL OF EVIDENCE

III.

Implementing the Lever Sign in the Emergency Department: Does it Assist in Acute Anterior Cruciate Ligament Rupture Diagnosis? A Pilot Study

BACKGROUND

Within the emergency department (ED) setting, anterior cruciate ligament (ACL) rupture is commonly misdiagnosed, leading to improper treatment and potential meniscal injury and total joint replacement. Utilizing traditional clinical tests to diagnosis ACL rupture leads to the correct diagnosis in about 30% of cases. The lever sign is a new and effective clinical test used to diagnose ACL rupture with 100% sensitivity.

OBJECTIVE

We aim to study if the lever sign used in the ED setting is more sensitive to diagnose ACL rupture than traditional tests.

METHODS

Patients between 12 and 55 years of age were examined utilizing either traditional methods or the lever sign. Diagnostic findings in the ED were compared with those of a sports medicine specialist using magnetic resonance imaging as the diagnostic standard. A survey was given to ED providers to collect data on diagnosis and physician confidence in diagnosis.

RESULTS

The sensitivity of the lever sign was 100% (94.7% accuracy, 93.75% specificity), whereas the sensitivity of the anterior drawer/Lachman test was 40% (87.5% accuracy, 100% specificity). Physician confidence in diagnosis was higher utilizing the lever sign vs. the anterior drawer/Lachman test at 8.45 (±1.82) compared with 7.72 (±1.82) out of 10, respectively. There was no statistically significant association between diagnostic accuracy with either test and level of training of the ED provider.

CONCLUSION

Implementation of the lever sign in the ED setting resulted in a higher sensitivity, higher physician confidence in screening test diagnosis, and a decrease in the number of undiagnosed ACL ruptures.

Allograft or autograft in skeletally immature anterior cruciate ligament reconstruction: a prospective evaluation using both partial and complete transphyseal techniques

OBJECTIVE

We compared autografts and allograft using partial and complete transphyseal anterior cruciate ligament (ACL) reconstruction techniques among skeletally immature individuals.

METHODS

Male and females younger than 18 and 16 years old, respectively, diagnosed with ACL tear from April 2006 to March 2012 entered the study. One group had four-strand hamstring autograft, and the other had tibialis posterior allograft reconstruction. Those who had allografts either had hyper-laxity or recurvatum.

RESULTS

Achieved mean (± SD) 2000 International Knee Documentation Committee subjective score was not statistically different (P = 0.385) between allograft (n = 13) (84.3 ± 3.2) and autograft groups (n = 18) (85.6 ± 4.4). Mean Knee injury and Osteoarthritis Outcome Score (KOOS) subscale Knee-Related Quality of Life at 2 years was 78.0 ± 7.2 and 75 ± 7.4 for allograft and autograft groups, respectively (p = 0.261). Mean 2-year KOOS subscale Sports and Recreation was 82.1 ± 5.8 and 84.8 ± 6.6 for allograft and autograft groups, respectively (p = 0.244). No patient reported instability, giving way, or locking of the knee. Pivot shift test was negative in all patients; however, a minor positive Lachman test was found in six cases (46%) within the allograft group and seven cases (39%) in the autograft group. One postoperative septic arthritis was documented in the autograft group.

CONCLUSION

Considering existing concern that joint laxity and recurvatum are among the precursors of non-contact ACL injury in adolescents, bone-patellar-bone autografts are not applicable in this age group because of the open physis; furthermore, considering that hamstring autografts are insufficient (size thickness and stretchability), we recommend soft tissue allografts for ACL reconstruction in skeletally immature patients.

A Nationwide Follow-up Survey on the Effectiveness of an Implemented Neuromuscular Training Program to Reduce Acute Knee Injuries in Soccer Players

Background:

A cruciate ligament (CL) injury is a severe injury in soccer. Neuromuscular training programs have a well-documented preventive effect, but there are few studies on the effectiveness of such a program at a national level. The Swedish Knee Control Program (KCP) was found to be effective in preventing CL injuries in youth female soccer players. The KCP was implemented nationwide in Sweden in 2010.

Purpose:

To evaluate the effectiveness of the Swedish KCP in reducing acute knee injuries in soccer players at a nationwide level.

Study Design:

Descriptive epidemiology study.

Methods:

All licensed soccer players in Sweden are covered by the same insurance company. Using this insurance database, around 17,500 acute knee injuries that were reported to the insurance company between 2006 and 2015 were included in the study. By matching the number of licensed soccer players with the number of reported injuries each year, the annual incidence of knee and CL injuries was able to be calculated. To evaluate the spread of the KCP nationally, a questionnaire was sent to all 24 Swedish district football associations (FAs) with questions regarding KCP education. The number of downloads of the KCP mobile application (app) was obtained.

Results:

The incidence of CL injuries decreased during the study period for both male (from 2.9 to 2.4 per 1000 player-years) and female players (from 4.9 to 3.9 per 1000 player-years). The overall incidence of knee injuries decreased in both male (from 5.6 to 4.6 per 1000 player-years) and female players (from 8.7 to 6.4 per 1000 player-years). Comparing before and after the nationwide implementation of the KCP, there was a decrease in the incidence of CL injuries by 6% (rate ratio [RR], 0.94 [95% CI, 0.89-0.98]) in male players and 13% (RR, 0.87 [95% CI, 0.81-0.92]) in female players and a decrease in the incidence of knee injuries by 8% (RR, 0.92 [95% CI, 0.89-0.96]) and 21% (RR, 0.79 [95% CI, 0.75-0.83]), respectively (P < .01 for all). This trend corresponded to a reduction of approximately 100 CL injuries each year in Sweden. A total of 21 of 24 district FAs held organized KCP educational courses during the study period. The percentage of district FAs holding KCP courses was between 46% and 79% each year. There were 101,236 downloads of the KCP app.

Conclusion:

The KCP can be considered partially implemented nationwide, and the incidence of knee and CL injuries has decreased in both sexes at a nationwide level.

Conservative management of anterior cruciate ligament injury in paediatric population: About 53 patients

INTRODUCTION

The last symposium held by the French Arthroscopy Society was on anterior cruciate ligament (ACL) reconstruction on children. The first aim of this study was to analyse the tolerance of conservative management of ACL rupture in children. We also tried to find predictive factors of ACL reconstruction.

MATERIAL AND METHODS

We conducted an observational, retrospective study in an academic department of paediatric orthopaedic surgery. All patients under the age of eighteen, who were treated conservatively for an acute intra-ligamentous ACL rupture confirmed by magnetic resonance imaging (MRI) between 2007 and 2017, were included. Two groups were analysed: operated patients and conservative treatment. We also analysed population according Tanner stage.

RESULTS

Fifty-three patients were included in this study. The median length of follow-up was 31.5 months [interquartile range (IQR): 22.3-49.3]. The median age at the last follow-up was 14.4 years [IQR: 12.6-15.5]. All patients were allowed to practice activities without restrictions, including pivoting sports. Tegner activity level scale remains identical before injury and at last follow-up (p: n.s.). Nineteen patients (36%) described knee instability at last follow-up. On the last MRI, 9 (17%) patients had meniscal tears but only one patient (2%) needed a menisectomy. Twenty-one patients (40%) underwent ACL reconstruction. The 4-years successful conservative treatment rate was 92% (95% CI: 85-98%). Clinical instability at first examination was the only significant predictive factors of bad tolerance of conservative management (p=0.047).

DISCUSSION

Conservative management of ACL rupture in paediatric population is a valuable treatment which permits return to a normal life with sports activities without major increasing of meniscal tears. The rehabilitation protocol must restore full knee stability to permit a successful conservative treatment. We must study the impact of pubertal status on larger group.

LEVEL OF EVIDENCE

IV, retrospective study.