Pediatric Anterior Cruciate Ligament Reconstruction

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.

Reliability and Validity of an MRI-Based Knee Sagittal Alignment Measure in a Pediatric Cohort

BACKGROUND

Magnetic resonance imaging (MRI) sagittal alignment is a measure that has been described and validated in the adult population as a means of distinguishing normal knees from those with anterior cruciate ligament (ACL) injury, but this measure has not been formally assessed among pediatric patients. The purpose of this study was to (1) assess the reliability of this MRI-based measure in a pediatric cohort, and (2) validate its ability to distinguish between ACL and non-ACL-injured knees in this population.

METHODS

A consecutive series of knee MRI examinations performed at our center were reviewed to identify studies of pediatric patients (1) with ACL injury, and (2) without significant pathology. Patient age, sex, physeal status (open, closing, or closed), knee laterality, and magnet strength (1.5 or 3-Tesla) were collected. The sagittal alignment was measured in both medial and lateral tibiofemoral compartments using a previously described method. Mean anterior tibial translation was then calculated for each study. Inter-rater and intrarater reliability testing was performed on a subset of randomly-selected patients from each cohort by three raters by calculating intraclass correlation coefficients. Sagittal alignment measurements of all patients were then completed by a single author after reliability was confirmed. The medial and lateral compartment translation and mean anterior tibial translation measurements of normal and ACL-injured knees were compared.

RESULTS

Inclusion criteria were met by 131 studies: 86 from uninjured knees (normal cohort) and 45 knees with ACL injury (ACL cohort). Studies were performed at a mean age of 13.4 with a near equivalent sex distribution. Inter-rater and intrarater reliability were good to excellent for all measures for patients in both normal and ACL cohorts. Normal and ACL-injured knees demonstrated a significant difference in anterior tibial translation in all measured regions. The mean anterior tibia translation for ACL-injured knees was 2.01 mm (95% confidence interval: 1.03-2.98) versus -0.44 mm (95% confidence interval: -0.89-0.014).

CONCLUSION

This study identified good to excellent inter-rater and intrarater reliability of knee sagittal alignment measurements among pediatric patients. It also demonstrated a significant difference in medial compartment, lateral compartment, and mean tibial translation in patients with and without ACL injury, validating previous findings demonstrated in adult cohorts. These findings may be useful in assisting providers in the confirmation of suspected ACL injury and insufficiency and guide operative management in cases of clinical uncertainty.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

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.

Patient expectations and perceived social support related to return to sport after anterior cruciate ligament reconstruction in adolescent athletes

OBJECTIVE

Examine the relationship between pre-operative competitive status and return to sport expectations post-operatively among adolescents undergoing ACL reconstruction. Assess the association between perceived levels of social support and doubts in returning to sport after ACL reconstruction.

DESIGN

Cross-sectional.

SETTING

Outpatient sports medicine clinic at a single institution.

PARTICIPANTS

12-18 years old with an ACL tear who were planning to undergo ACL reconstruction.

MAIN OUTCOME MEASURES

Psychovitality questionnaire responses and Multidimensional Scale of Perceived Social Support (MSPSS) questionnaire scores.

RESULTS

86% of participants expected to return to sports in six months or less after surgery; there was no significant difference in expected time to return to sport between competitive vs. recreational athletes. Competitive athletes were less likely to be content returning to a lower activity level after surgery compared to recreational athletes. There were no significant differences in MSPSS scores between those who did and did not report doubts in their ability to return to their previous sports.

CONCLUSION

Most of our adolescent athlete population expected to return to sport after ACL reconstruction within six months of surgery. Those with and without doubts in their ability to return to sports did not significantly differ in levels of perceived social support.