All-Epiphyseal Anterior Cruciate Ligament Repair Using Suture Ring Device in the Skeletally Immature Patient

Modified MacIntosh (Over-the-Top Iliotibial Band Autograft) Technique for Pediatric Anterior Cruciate Ligament Reconstruction Using Knotless All-Suture Anchor Fixation

Anterior cruciate ligament (ACL) injury is a significant cause of injury among pediatric patients with an increasing incidence. ACL insufficiency can lead to lifelong disability as further joint deterioration occurs in the form of meniscal and subsequently chondral pathology. Techniques for pediatric ACL reconstruction can broadly be classified as physeal-sparing and non-physeal-sparing. Bone age is frequently used when deciding which technique to employ. Patients are candidates for physeal-sparing, over-the-top iliotibial band reconstruction (i.e., modified MacIntosh II) when they have >4 years remaining before skeletal maturity. The modified Macintosh procedure provides both intra- and extra-articular rotational and translational constraint. This Technical Note describes the senior author's modified MacIntosh technique using knotless all-suture anchor fixation in a suture staple technique to mitigate risk of physeal damage.

Anterior cruciate ligament reconstruction in skeletally immature patients is effective: A systematic review

PURPOSE

The present study evaluated the outcomes of anterior cruciate ligament (ACL) reconstruction in children with open physes. The outcomes of interest were to compare the increase in joint laxity and PROMs from baseline to the last follow-up, the rate and features of the return to sport and the rate of complications.

METHODS

This study was conducted according to the 2020 PRISMA guidelines. In October 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles which clearly stated that surgeries were conducted in children with open physis were eligible.

RESULTS

Data from 53 studies (1691 procedures) were collected. 35% (597 out of 1691 patients) were women. The mean length of the follow-up was 44.7 ± 31.3 months. The mean age of the patients was 12.7 ± 1.1 years old. All PROMs significantly improved from the baseline values to those at the last follow-up. The mean time to return to sport was 8.3 ± 1.9 months. 89% (690 out of 771 patients) returned to sports, 15% (109 out of 721 patients) reduced their level of sports activity or league, and 84% (651 out of 771 patients) returned to their previous level of sport. 9% (112 out of 1213) of patients experienced re-tear of the reconstructed ACL, and 11% (75 out of 660) of patients underwent a further ACL reoperation. No patients (0 out of 83) demonstrated increased laxity at the last follow-up, and persistent sensation of instability was reported by 5% (11 out of 235) of patients.

CONCLUSION

ACL reconstruction in skeletally immature patients is effective and safe, and is associated with fast recovery and a high rate of return to sport.

LEVEL OF EVIDENCE

Level IV.