Arthroscopy in children, with special emphasis on meniscal lesions

Current Concepts of Diagnosis and Management of ACL Injuries in Skeletally Immature Athletes

Anterior cruciate ligament (ACL) injuries in skeletally immature athletes are encountered with increasing frequency. The management of such injuries is controversial. Nonsurgical management often results in functional instability and a higher risk of meniscal and chondral injury to the knee. Conventional methods of ACL reconstruction carry the risk of growth disturbance because of iatrogenic damage to the physes around the knee. Multiple cases of growth disturbance have been reported. This article discusses the relevant anatomy, natural history, risk factors, treatment, and prevention of ACL injuries in skeletally immature patients. Surgical treatment is based on physiologic age. For prepubescent patients, we recommend physeal-sparing combined intra-articular/extra-articular reconstruction with autogenous iliotibial band. In adolescent patients with significant growth remaining, we recommend transphyseal ACL reconstruction with hamstrings autograft and fixation away from the physes. In older adolescent patients, we recommend conventional adult ACL reconstruction with autogenous hamstrings or patellar tendon.

Arthroscopic repair of isolated meniscal tears in patients 18 years and younger

BACKGROUND

Isolated meniscal tears in the skeletally immature patient are infrequent but well-recognized injuries. Although few studies have evaluated the pediatric and adolescent population, arthroscopic surgical repair remains the standard of care for patients in this age group with unstable meniscal tears.

PURPOSE

To review our results of arthroscopic repair of isolated meniscal tears in pediatric and adolescent patients to further define future management of these injuries.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The records of all patients 18 years old or younger who underwent isolated meniscal repair between 1990 and 2005 were retrospectively reviewed. Forty-four patients (6 girls, 38 boys) with an average age of 15.8 years (range, 9.9-18.7 years) were included in this study, for a total of 45 isolated meniscal tears. Clinical examinations were performed, International Knee Documentation Committee forms were administered, and Tegner scores were determined at an average of 5.8 years (range, 2.5 months-13.8 years) postoperative follow-up. Three patients were lost to follow-up.

RESULTS

The clinical success rate of arthroscopic meniscal repair was 80% for simple tears, 68% for displaced bucket-handle tears, and 13% for complex tears. Seventeen menisci (38% overall) failed initial repair at a mean of 17 months (range, 3-61 months) postoperatively and underwent repeat arthroscopic surgery (15 partial meniscectomies, 2 rerepair). The average Tegner and International Knee Documentation Committee scores were 8 (range, 5-9) and 89.4 (range, 79-99), respectively, at the time of final follow-up. Risk factors for failure included complex tears and rim width greater than 3 mm.

CONCLUSION

Clinically successful repair of an isolated meniscal tear in patients 18 years or younger was variable depending on tear type, with complex tears and rim width 3 mm or greater being negative prognostic factors.

Intra-articular traumatic disorders of the knee in children and adolescents

Intra-articular knee injuries in children traditionally have been considered rarer than injuries in adults. Few studies establish the prevalence of knee injuries before skeletal maturity, but arthroscopic studies suggest an increased frequency of anterior cruciate ligament ruptures, meniscal tears, and osteochondral fractures. We report our experience with 15 anterior cruciate ligament injuries and 38 meniscus injuries treated between 1996 and 2001. The treatment of anterior cruciate ligament injuries is determined by Tanner's maturity criteria. In the three cases of Stage II injuries, surgery was delayed for up to 24 months in the 12 older patients, an immediate reconstruction was done using hamstring tendons in the three youngest patients, and patellar tendon treatment was done in the remaining cases. We had only one complication caused by the fracturing of the bone plug. The most frequent meniscus injuries were the traumatic tears (23 cases), 80% of which were peripheral and longitudinal. Whenever possible, the entire meniscus (suture in 4 cases) or the greater part of it (economic resection in 19 cases) should be conserved. Despite the satisfactory results, the average followup of the meniscal series (26.1 months) is too short a period to evaluate thoroughly the deterioration of the joint after a meniscectomy.

Magnetic resonance imaging of the knee in children and adolescents. Its role in clinical decision-making

BACKGROUND

Recent studies have questioned the utility of magnetic resonance imaging in the diagnosis of pediatric knee disorders because of the morphologic changes during growth and the low accuracy of the formal interpretation of the magnetic resonance imaging scan by a radiologist. The purpose of this study was twofold: (1) to report the accuracy of formal interpretations of magnetic resonance imaging scans of the knee in children and adolescent patients by a radiologist, and (2) to determine the benefit, if any, of a personal review of the magnetic resonance imaging scan of the knee by the orthopaedic surgeon, as a routine part of the diagnostic evaluation.

METHODS

A three-year prospective study of all patients who underwent knee arthroscopy performed by a single surgeon, at two children's hospitals, was completed. The analysis focused on the six most common diagnoses: anterior cruciate ligament tear, lateral meniscal tear, medial meniscal tear, osteochondritis dissecans, discoid lateral meniscus, and osteochondral fracture. The preoperative diagnosis of the surgeon was determined by integrating the history and the findings on the clinical examination, plain radiographs, and magnetic resonance imaging scans (including the radiologist's interpretation).

RESULTS

Ninety-six patients with ninety-six abnormal knees were included. The mean age was 14.6 years at the time of surgery. Relative to operative findings, kappa values for the formal interpretations of the magnetic resonance imaging scans by a radiologist were 0.78 for an anterior cruciate ligament tear, 0.76 for a medial meniscal tear, 0.71 for a lateral meniscal tear, 0.70 for osteochondritis dissecans, 0.46 for discoid lateral meniscus, and 0.65 for osteochondral fracture. Relative to operative findings, kappa values for the preoperative diagnoses by the surgeon were 1.00 for an anterior cruciate ligament tear, 0.90 for a medial meniscal tear, 0.92 for a lateral meniscal tear, 0.93 for osteochondritis dissecans, 1.00 for discoid lateral meniscus, and 0.90 for osteochondral fracture. The preoperative diagnosis by the surgeon was better (p < 0.05) than the formal interpretation of the magnetic resonance imaging scans by the radiologist with respect to an anterior cruciate ligament tear, lateral meniscal tear, osteochondritis dissecans, and discoid lateral meniscus.

CONCLUSIONS

Integration of patient information with an orthopaedic surgeon's review of the magnetic resonance imaging scan of the knee in children and adolescent patients improves the identification of pathological disorders in four of the six categories evaluated. This study questions the necessity for and appropriateness of a routine interpretation of a magnetic resonance imaging scan of the knee in children and adolescents by a radiologist.

Fate of the anterior cruciate ligament-injured knee

Most patients with anterior cruciate ligament (ACL) injuries do well with activities of daily living even after follow-up in the range of 5 to 15 years. Most can participate in some sports activity if they are inclined to do so, but most will have some limitations in vigorous sports, and only a few will be entirely asymptomatic. The challenge to the clinician is to understand and predict how ACL deficiency in a given patient will affect that patients's life and activities. In counseling patients about treatment after an ACL injury, the clinician can use knee ligament arthrometry measurements and pre-injury sports activity to estimate the risk of injury over the next 5 to 10 years. Meniscus, chondral, and sub-chondral injuries are not uncommon, but rarely require surgical intervention in the early phase of ACL deficiency. The prevalence of clinically significant meniscal damage increases with time, and is associated with increasing disability, surgery, and arthrosis in high-risk patients. Ligament reconstruction has not been shown to prevent arthrosis, but in prospective studies it appears to reduce the risk of subsequent meniscal injury, improve passive anteroposterior knee motion limits, and facilitate return to high-level sporting activities.

Diagnostic performance of clinical examination and selective magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents

To determine the diagnostic performances of clinical examination and selective magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents we compared them with arthroscopic findings in a consecutive series of pediatric patients (< or = 16 years old). Stratification effects by patient age and magnetic resonance imaging center were examined. There were 139 lesions diagnosed clinically, 128 diagnosed by magnetic resonance imaging, and 135 diagnosed arthroscopically. There was no significant difference between clinical examination and magnetic resonance imaging with respect to agreement with arthroscopic findings (clinical examination, 70.3%; magnetic resonance imaging, 73.7%), overall sensitivity (clinical examination, 71.2%; magnetic resonance imaging, 72.0%), and overall specificity (clinical examination, 91.5%; magnetic resonance imaging, 93.5%). Stratified analysis by diagnosis revealed significant differences only for sensitivity of lateral discoid meniscus (clinical examination, 88.9%; magnetic resonance imaging, 38.9%) and specificity of medial meniscal tears (clinical examination, 80.7%; magnetic resonance imaging, 92.0%). For magnetic resonance imaging, children younger than 12 years old had significantly lower overall sensitivity (61.7% versus 78.2%) and lower specificity (90.2% versus 95.5%) compared with children 12 to 16 years old. There was no significant effect of magnetic resonance imaging center. In conclusion, selective magnetic resonance imaging does not provide enhanced diagnostic utility over clinical examination, particularly in children, and should be used judiciously in cases where the clinical diagnosis is uncertain and magnetic resonance imaging input will alter the treatment plan.

Arthroscopic findings in the knees of preadolescent children: report of 23 cases

PURPOSE

The aim of this review was to correlate the preoperative clinical diagnoses and the diagnostic arthroscopic findings in preadolescents with knee problems. We also studied the incidence of different types of knee pathology in this age group.

TYPE OF STUDY

Consecutive case series.

MATERIALS AND METHODS

Twenty-three preadolescents, 13 girls and 10 boys under the age of 13 years, presenting with mechanical knee problems underwent knee arthroscopy after clinical assessment.

RESULTS

Symptomatic plica synovialis was found to be the most frequent pathology (n = 8). This pathology was far more common in girls compared with boys. Anterior cruciate ligament injuries (n = 4) followed symptomatic plica synovialis in frequency. This was an isolated injury in all cases. The arthroscopic findings were negative in 4 patients.

CONCLUSION

In 61% of preadolescent patients, the clinical diagnoses and arthroscopic findings were compatible and correct. The main error tended to be misdiagnosis of meniscal pathology (4 patients) and overdiagnosis (5 cases of negative arthroscopy).

Meniscal repair in the young athlete

Twenty-nine meniscal repairs in 26 patients 17 years of age or younger were performed using arthroscopic techniques. Clinical follow-up examinations were performed and the SF-36 Health Status Survey and International Knee Documentation Committee evaluation form were administered. A Lysholm score was determined for each patient. All 26 patients were seen for follow-up at an average of 5.0 years (range, 2.0 to 13.5). All patients had a full range of motion with no effusion, joint line tenderness, or McMurray sign present at the time of examination. No patient experienced symptoms of locking. No patient underwent repeat surgery for a nonhealed meniscal repair. The clinical healing rate in this group was 100%. The SF-36 data demonstrated an average physical functioning score of 91 and an average role physical score of 91. The average Lysholm score was 90. Twenty-two patients (85%) were performing level I activities based on the International Knee Documentation Committee rating. Excellent rates of healing, even higher than those obtained in the adult population, can be obtained with meniscal repairs performed in this young age group.

Knee arthroscopy in Chinese children and adolescents: an eight-year prospective study

In the period January 1985 to December 1992, 69 Chinese boys and 20 Chinese girls (average 14.6 years, age range 6 to 16 years) with a total of 92 involved knees underwent examination under anaesthesia and knee arthroscopy. Two thirds of the patients were engaged in sports activities. A haemarthrosis was present in 51 patients. In one patient, Staphylococcus aureus was shown, and in two children a serous-purulent aspirate grew Mycobacterium tuberculosis. The lateral meniscus was torn in four knees and the medial meniscus in six. An intact discoid lateral meniscus was found in five girls. Three partial anterior cruciate ligament (ACL) tears, three complete ACL tears and two posterior cruciate ligament tears were diagnosed. One child had an osteochondral defect of the lateral femoral condyle accompanying an ACL and a lateral meniscal tear. Nonspecific synovitis of unknown etiology was diagnosed in six patients who had presented subacutely with at least a 2-month history of a symptomatic monoarticular knee effusion with low grade local inflammation and no history of major trauma. The synovitis gradually resolved over a 6- to 10-month period after arthroscopy. Knee arthroscopy in children and adolescent patients is safe, gives a high diagnostic accuracy, and allows treatment of a variety of intraarticular conditions. This study also demonstrates that the range of intraarticular knee problems found in Chinese children and adolescents differs from that described in their Western counterparts.

Arthroscopy of the acute traumatic knee in children. Prospective study of 138 cases

We performed diagnostic arthroscopy for acute knee trauma in 138 children and adolescents aged 13 (1-15) years. The compatibility between the clinical examination and the arthroscopic findings was 59 percent. Ligament injuries were found in 32 cases, 14 of which had rupture of the anterior cruciate ligament. The compatibility in the case of ligament injuries was 31 percent. 48 patients had dislocation of the patella, and a displaced osteochondral fragment was seen in 19, 14 of which were radiographically silent. In 37 cases of distortion of the knee a correct diagnosis would have been missed unless arthroscopy had been performed. Arthroscopy is therefore indicated in children with severe distortion of the knee, hemarthrosis and with dislocation of the patella.

The importance of arthroscopy in sports injuries in children and adolescents

Within a 3-year period (1985-1988), 60 children and adolescents with knee injuries sustained mainly while skiing or playing football (soccer) underwent clinical examination, X-radiography and arthroscopy. Nearly all the patients still had open epiphyseal plates in the knee region. Arthroscopy revealed more severe intra-articular trauma than had been suspected on the basis of clinical findings. The skiing injuries most commonly involved anterior cruciate ligament tears, whereas injuries of the patellar retinaculum and medial meniscus lesions predominated in soccer injuries. On comparison with arthroscopic diagnosis, clinical diagnosis was erroneous in about 45%. The most common mistaken clinical diagnosis was "medial meniscus tear". Of the 60 knee joints subjected to arthroscopy, 40 were severely enough injured to warrant surgery. Only one had normal intra-articular findings. The study demonstrates that children and adolescents can suffer knee trauma requiring surgery, despite open growth plates. Downhill skiing and soccer are particularly risky sports in this respect. Therefore, sports injuries involving haemarthrosis are clearly an indication for arthroscopy, even in childhood and adolescence. Arthroscopy enables early identification of the type and extent of intra-articular trauma and subsequent early initiation of appropriate therapy.

Arthroscopy in children

Arthroscopy was performed on the knees of 67 children aged 2-16 years with an overall clinical diagnostic accuracy of 45%. The most common clinical diagnoses were meniscal tear and patello-femoral pain and the accuracy of these diagnoses was 33% and 59% respectively. Diagnostic accuracy seemed unrelated to age. Arthroscopy led to definitive treatment which relieved symptoms in 21 (31%) of cases, revealed a diagnosis only in 43 (64%), and was non-contributory in 3 (4.5%). The procedure did not significantly help patients with patello-femoral pain.

Late results after meniscectomy in children

Seventy-five children undergoing 77 meniscectomies have been reviewed from 1 to 30 years (mean 15) after operation in order to determine the late results of meniscectomy. Arthroscopy of the patients with a poor result was performed at the follow-up. In 30 per cent osteoarthrosis was diagnosed, all with follow-up times from 19 to 25 years. Delay in operation resulted in worse results. The younger the patient the worse the result. The benefit of operation was less in girls than in boys. Bucket-handle lesions and peripheral tears produced the best results after meniscectomy. Fifty-eight per cent of men and 26 per cent of women had symptom-free knees at follow-up. Removing a meniscus is not a benign procedure. Only 44 per cent of patients in whom a damaged meniscus and 17 per cent in whom a normal meniscus had been removed were without symptoms. These results stress the need for making an accurate diagnosis by careful examination and arthroscopy before embarking on meniscectomy in children. Efforts to preserve the meniscus in children must be made whenever possible.