The outcome of operatively treated anterior cruciate ligament disruptions in the skeletally immature child

The Double-Edged Sword: Anterior Cruciate Ligament Reconstructions on Adolescent Patients-Growth Plate Surgical Challenges and Future Considerations

The management of anterior cruciate ligament (ACL) injuries in pediatric patients presents unique challenges due to the presence of open growth plates in the proximal tibia and distal femur. Delaying ACL reconstruction until skeletal maturity may protect the physes but increases the risk of secondary injuries, such as meniscal tears and chondral damage, due to prolonged joint instability. Conversely, early surgical intervention restores knee stability but raises concerns about potential growth disturbances, including leg-length discrepancies and angular deformities. This narrative review examines current approaches to pediatric ACL management, highlighting the risks and benefits of both conservative and surgical treatments. Additionally, it explores the role of finite element modeling (FEM) as an innovative tool for pre-surgical planning. FEM offers a non-invasive method to optimize surgical techniques, minimize iatrogenic damage to growth plates, and improve patient outcomes. Despite its potential, FEM remains underutilized in clinical practice. This review underscores the need to integrate FEM into pediatric ACL care to enhance surgical precision, reduce complications, and improve long-term quality of life for young patients. By synthesizing available evidence, this review aims to provide clinicians with a comprehensive framework for decision-making and identify future directions for research in pediatric ACL reconstruction.

Quadriceps tendon autograft is promising with lower graft rupture rates and better functional Lysholm scores than hamstring tendon autograft in pediatric ACL reconstruction. A systematic review and meta-analysis

Purpose

Graft rupture is the most prevalent complication following pediatric anterior cruciate ligament reconstruction (ACLR). The hamstring tendon (HT) autograft is frequently employed, while the quadriceps tendon (QT) autograft has garnered increased attention recently. This study aims to perform a systematic review to assess the complication rates and functional outcomes associated with these two widely used autografts in skeletally immature patients - comparing HT versus QT autografts.

Research question

Is QT autograft better than HT autograft for ACLR in skeletally immature cohorts?

Methodology

Three electronic databases (PubMed/Medline, Scopus, and Ovid) were comprehensively searched to identify pertinent articles reporting the outcomes of HT and QT autografts in pediatric ACLR with a minimum 2-year follow-up. Data on the outcome parameters, such as graft rupture rates, contralateral ACL injury rates, functional outcomes, and growth disturbances rates, were extracted. Meta-analysis was performed using OpenMeta Analyst software.

Results

Twelve studies were included for meta-analysis (pooled analysis) with 659 patients (QT: 205; HT: 454). The analysis showed that QT autografts had a significantly lesser graft rupture rate than HT autografts (3.5 % [95 % CI 0.2, 6.8] and 12.4 % [95 % CI 6.1, 18.7] respectively, p < 0.001). The graft rupture rates between QT with bone and without bone block showed no statistically significant difference (4.6 % [95 % CI 0.8, 1.0] and 3.5 % [95 % CI 2.0, 8.9] respectively, p = 0.181). The overall contralateral ACL injury rate was 10.2 %, and the subgroup analysis revealed no statistically significant difference between the QT and HT groups (p = 0.7). Regarding functional outcome scores at the final follow-up, the mean Lysholm score demonstrated a significant increase in the QT group compared to the HT group (p < 0.001). There were no significant differences between the two groups concerning growth disturbances at the final follow-up. Return to sports (RTS) varied between 6 and 13.5 months after surgery.

Conclusion

QT autografts demonstrate encouraging outcomes, showcasing lower graft rupture rates, better functional outcomes, and comparable contralateral ACL injury rates and growth disturbances relative to the commonly used HT autograft in skeletally immature patients undergoing ACLR.

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.

Graft choices for paediatric anterior cruciate ligament reconstruction: State of the art

The paediatric population is at particularly high risk for anterior cruciate ligament (ACL) injuries due to high rates of sports participation. Other risk factors for ACL injuries in children include but are not limited to being female, generalised ligamentous laxity, a high body mass index (BMI), and poor neuromuscular control. ACL reconstruction (ACLR) is commonly done to treat ACL injuries and allow for return to sports and daily activities. ACL repair is another option with ongoing techniques being developed. The high rates of graft failure in children reported in recent publications on ACL repair are very concerning. Special consideration must be taken in ACLR in the skeletally immature patient due to the risk of growth-related complications, such as limb deformity or growth arrest, that can arise from drilling across or disrupting the physis. Graft choices for paediatric ACLR include iliotibial band (ITB) over the top and over the front, hamstring autograft, bone patellar tendon bone (BTB) autograft, quadriceps tendon autograft, and allograft. Factors for each graft choice to consider include graft size, graft failure rates, donor site morbidity, requirement for bony tunnels, the post-op rehabilitation process, and return to sport outcomes. Each graft has its benefits and disadvantages for the individual patient, depending on age, skeletal maturity, and goals for recovery. Lateral extra-articular tenodesis (LET) is another option to consider with paediatric ACLR because LET has been shown to decrease the re-rupture rate in adult ACLR. After surgery, patient follow-up until at least the growth plates are closed is important. This article aims to provide an overview and comparison of the various graft types to aid in the graft choice decision making process for paediatric ACLR.

Growth Disturbances Following Paediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review

Growth disturbances after transphyseal paediatric anterior cruciate ligament (ACL) reconstruction have led to the development of physeal-sparing techniques. The aim of this study is to investigate growth disturbances following paediatric ACL reconstruction and identify associated risk factors. A systematic search on PubMed, Scopus and Web of Science databases was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify case series reporting paediatric ACL reconstructions. Of 518 articles, 78 met the inclusion criteria, and data related to growth disturbances and graft failures were extracted. A total of 2,693 paediatric ACL reconstructions resulted in 70 growth disturbances (2.6%): 17 were varus, 26 were valgus, 13 were shortening, 14 were lengthening and five patients had reduced tibial slope. Some patients showed deformities in more than one plane. Coronal plane deformities were seen more frequently with eccentric physeal arrest and lengthening with intraepiphyseal tunnelling. Shortening and reduced tibial slope were related to large central physeal arrest and anterior tibial physeal arrest, respectively. Sixty-two studies documented 166 graft failures in 2,120 reconstructions (7.8%). The extraphyseal technique was least likely to result in growth disturbances and graft failure. Paediatric ACL reconstruction is a safe and effective treatment of rupture. Growth disturbances are least likely following extraphyseal tunnelling, and those resulting from transphyseal techniques can be minimised by reducing drill size, drilling steep and avoiding the physeal periphery. The insertion of hardware, synthetic material, or a bone plug through the drilled physis should be avoided. There is a greater need for robust long-term data collection, such as national ligament registries, to standardise practice and evaluate the risk of growth disturbance and re-ruptures in this treatment.

Comparison of clinical outcomes between anterior cruciate ligament reconstruction with over-the-top route procedure and anatomic single-bundle reconstruction in pediatric patients

The purpose of this study is to evaluate the clinical results of over-the-top route (OTTR) reconstruction for pediatric anterior cruciate ligament (ACL) injuries and compare them with results of anatomic single-bundle reconstruction (SBR), which used the bone tunnel technique and was performed early after epiphyseal closure (age ≤15 years). This study included pediatric patients aged 11-15 years who underwent ACL reconstruction. The mean age at surgery was 13.4 years (11-15 years), including 14 men and 29 women. Operative procedures were determined according to growth plate closure. In all cases, the tibial side was reconstructed using a bone tunnel procedure. On the femoral side, we selected the OTTR procedure (group O) with open physis. Where the physis was closed, we selected the anatomical SBR (group B). The clinical results were evaluated with manual examination, the side-to-side difference (SSD) in tibial anterior translation using the Kneelax 3, and knee function score. There were no significant differences in the Lachman and pivot-shift tests, SSD in tibial anterior translation with Kneelax 3, or knee function score between the two groups before or after the surgery. Growth disturbance was not observed on either the femoral or tibial side in group O. The OTTR method provided comparable results with the bone tunnel anatomical method in manual examination, Kneelax 3, and knee clinical function scores, suggesting that the OTTR method is very useful for pediatric ACL reconstructions. Level of evidence: III; retrospective study.

Surgical techniques in the management of pediatric anterior cruciate ligament tears: Current concepts

Background

Anterior cruciate ligament injury in the child and adolescent patient remains a controversial topic when considering management, especially regarding surgical choices. Treatment variations are seen not just when comparing different countries but also within nations. This arises partly as contemporary treatment is mostly inferred from the adult population who physiologically and in terms of outcomes differ significantly from children. There is an increasing body of evidence for this cohort of patients who have specific challenges and difficulties when determining the optimum treatment.

Methods

Within this article, we will summarize the current evidence for surgical management of anterior cruciate ligament injury for the pediatric patient.

Results and Conclusions

There remain many controversies and gaps inthe treatment of Paediatric Anterior cruciate ligament reconstruction and this high risk cohort continues to cause difficulty in identifying the best mode of surgical management.

Level of evidence

level IV.

Quadriceps Tendon Anterior Cruciate Ligament Reconstruction: A Systematic Review of Postoperative Rehabilitation and Complication Profiles

PURPOSE

The purposes of this study are to explore current elements for postoperative rehabilitation protocol after quadriceps tendon-anterior cruciate ligament reconstruction (QT-ACLR), outline general timelines for progression of those elements, and explore their associated complication rates and profiles.

METHODS

In accordance with PRISMA guidelines, 5 online databases (EMBASE, MEDLINE, CINAHL, Cochrane, and PubMed) were searched and screened in duplicate using predetermined criteria for studies on the aforementioned patient population. Descriptive statistics are presented.

RESULTS

A total of 56 studies were included, with 31 studies using quadriceps tendon with bone block (B-QT) and 26 studies using all-soft tissue quadriceps tendon (S-QT). The majority of studies permitted full weightbearing and range of motion (ROM) within the first 12 postoperative weeks, and motion-controlled braces within 6 weeks. Isometric exercises were initiated within 1 week after surgery, closed-chain exercises within 12 weeks, and open-chain and sports-specific exercises within 36 weeks. Complication profiles were similar between graft types and included graft failure (1.2%-1.6%), cyclops syndrome (0.4%-0.7%), and persistent stiffness (0.9%).

CONCLUSIONS

Current postoperative rehabilitation strategies in ACLR with QT offer a complication profile comparable to those reported with other graft types. Based on the included rehabilitation regimen, these protocols should focus on early ROM, specifically on achieving full extension, alongside isometric quadriceps strengthening. Progression to closed- and open-chain exercises should follow in a progressive manner, similar to existing protocols in ACLR. Adjuncts such as motion-controlled bracing and continuous passive motion machines may be used if graft protection is prioritized. This review highlights the need for comparison of defined protocols against one another in the setting of QT-ACLR.

LEVEL OF EVIDENCE

IV, systematic review of Level I-IV studies.

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.

Transepicondylar Distance Can Predict Graft and Tunnel Length for Different Pediatric Anterior Cruciate Ligament Reconstruction Techniques: A Magnetic Resonance Imaging Study

PURPOSE

To find a correlation and mathematical formulas between a linear 2-dimensional (2D) magnetic resonance imaging (MRI) measurement around the knee and the length of the grafts and tunnels required for both all-inside-all-epiphyseal and Kocher-Micheli pediatric anterior cruciate ligament (ACL) reconstruction techniques.

METHODS

At time 0 and 30 days after, 2 observers measured: (1) on standard 2D knee MRI, 7 linear distances, representing morphologic measurements, such as transepicondylar distance (TD), and (2) on 3-dimensional (3D) MRI, 5 curved distances, corresponding to Kocher-Micheli and all-epiphyseal ACL reconstruction techniques. Intra- and interobserver reliability was tested for all measurements. The correlation between 2D and 3D measurements was tested. The 2D measurement with highest repeatability and reproducibility and with strongest correlation with 3D measurements was used to extract formulas to calculate the tunnel and graft length for the 2 techniques.

RESULTS

Seventy-six MRIs were used. The intra- and interobserver reliability of 2D measurement was high, with TD showing the highest reproducibility and repeatability. 3D measurements also showed good intra and inter-observer reliability. A linear correlation was found between 2D and 3D measurements, with TD showing the strongest correlation. TD was used to extract formulas to calculate graft or tunnel length for Kocher-Micheli and all-epiphyseal ACL reconstruction. All formulas were proven to be accurate. A reference chart was also created to be used in the surgical setting.

CONCLUSIONS

With specific formulas, TD can be used to calculate the length of the tunnels, intra-articular portion and graft length for an all-inside all-epiphyseal pediatric ACL reconstruction and the length of the iliotibial band required for the Kocher-Micheli technique.

CLINICAL RELEVANCE

The surgeon can use these formulas in pediatric ACL reconstruction preoperative planning, graft harvesting and tunnel drilling.

Assessment of Skeletal Maturity and Postoperative Growth Disturbance After Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: A Systematic Review

BACKGROUND

Growth disturbance is an uncommon but potentially serious complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients.

PURPOSE

To describe how the pediatric ACL literature has assessed preoperative skeletal maturity and the amount of growth remaining and to comprehensively review the incidence, reporting, and monitoring of postoperative growth disturbance.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

This review included studies reporting original research of clinical outcomes of skeletally immature patients after ACL reconstruction. Patient characteristics, surgical techniques, preoperative assessments of skeletal maturity or growth remaining, and postoperative assessments of growth disturbances were extracted.

RESULTS

A total of 100 studies met inclusion criteria. All studies reported chronological age, and 28 studies (28%) assessed skeletal age. A total of 44 studies (44%) used Tanner staging, and 12 studies (12%) obtained standing hip-to-ankle radiographs preoperatively. In total, 42 patients (2.1%) demonstrated a leg length discrepancy (LLD) >10 mm postoperatively, including 9 patients (0.5%) with LLD >20 mm; furthermore, 11 patients (0.6%) with LLD underwent growth modulation. Shortening was the most common deformity overall, but overgrowth was reported more frequently in patients who had undergone all-epiphyseal techniques. Most LLDs involved the femur (83%). A total of 26 patients (1.3%) demonstrated a postoperative angular deformity ≥5°, and 9 of these patients underwent growth modulation. The most common deformities were femoral valgus (41%), tibial recurvatum (33%), and tibial varus (22%). Although standing hip-to-ankle radiographs were the most common radiographic assessment of growth disturbance, most studies inadequately reported the clinical and radiographic methods of assessment for growth disturbance. Additionally, only 35% of studies explicitly followed patients to skeletal maturity.

CONCLUSION

This systematic review described significant variability in the reporting and monitoring of growth-related complications after ACL reconstruction in skeletally immature patients. The incidence of LLD and angular deformity appeared to be low, but the quality of research was not comprehensive enough for accurate assessment.

REGISTRATION

CRD42019136059 (PROSPERO).

Pediatric Revision Anterior Cruciate Ligament Reconstruction: Current Concepts Review

OBJECTIVE

We present a review of revision anterior cruciate ligament (ACL) reconstruction in pediatric patients, discussing risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes.

DATA SOURCES

PubMed, Cochrane, and Embase databases were queried for relevant articles about revision ACL topics. All types of manuscripts, including clinical studies, basic science studies, case series, current concepts reviews, and systematic reviews were analyzed for relevant information. Current concepts on risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes were synthesized.

MAIN RESULTS

Surgical treatment should be individualized, and the graft type, fixation devices, tunnel placement, and complementary procedures (eg, extra-articular tenodesis) should be tailored to the patient's needs and previous surgeries. Rehabilitation programs should also be centered around eccentric strengthening, isometric quadriceps strengthening, active flexion range of motion of the knee, and an emphasis on closed chain exercises. Despite adherence to strict surgical and postoperative rehabilitation principles, graft refailure rate is high, and return to sports rate is low.

CONCLUSION

Rerupture of the ACL in the pediatric population is a challenging complication that requires special attention. Diagnostic evaluation of repeat ACL ruptures is similar to primary injuries. Although outcomes after revision ACL reconstruction are expectedly worse than after primary reconstruction, athletes do return to sport after proper rehabilitation. Further research is needed to continue to improve outcomes in this high-risk population, aimed at continued knee stability, graft survivorship, and improved quality of life.

The outcomes of quadriceps tendon autograft for anterior cruciate ligament reconstruction in adolescent athletes: a retrospective case series

BACKGROUND

Multiple graft options exist for anterior cruciate ligament (ACL) reconstruction in an adolescent athlete. Patellar tendon harvest can lead to anterior knee pain, while hamstring tendon harvest can affect knee flexion strength and alter mechanics. Allograft is less desirable in pediatric patients due to the higher failure rate and slight risk of disease transmission. Quadriceps tendon autograft has rarely been reported for adolescent ACL reconstruction in the USA, but is an excellent option due to its large size, low donor site morbidity, and versatility. The purpose of this study is to report the outcomes of adolescents who have undergone ACL reconstruction using quadriceps tendon autograft.

METHODS

Twenty-two ACL reconstructions using the quadriceps autograft were performed on 21 pediatric patients by the senior author between 2010 and 2017. The patient's demographics, injury characteristics, imaging, physical examination findings, operative findings, outcomes and sports were recorded.

RESULTS

The average age at the time of surgery was 15 years. Two patients had open physes; the remainder had closing physes. 64% of patients had additional meniscal tears and 76% had bony contusions. The average duration of follow-up was 2.8 years (range 2-5 years). At final follow-up, there were no angular deformities or leg length discrepancies. The average quadriceps atrophy of the operative leg was 4 mm. The average Lysholm score was 98. 86% of patients returned to sports. No patients had re-rupture of their operative ACL. No incidences of infections, numbness, or anterior knee pain were reported. Two patients had a second arthroscopy for re-injury, revealing new meniscal tears but intact ACL grafts.

CONCLUSIONS

Use of quadriceps tendon autograft for ACL reconstruction in adolescent patients allows reliable return to sport with minimal complications.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Influential Articles on Pediatric and Adolescent Anterior Cruciate Ligament Injuries: A Bibliometric Analysis

BACKGROUND

The understanding of pediatric anterior cruciate ligament (ACL) injuries and optimal treatment has evolved significantly. Influential articles have been previously evaluated using article citations to determine impact.

PURPOSE

To identify and characterize the 50 most cited and recent influential articles relating to pediatric and adolescent ACL injuries, to examine trends in publication characteristics, and to evaluate correlations of study citations with quality of evidence.

STUDY DESIGN

Cross-sectional study.

METHODS

The top 50 most cited articles on pediatric and adolescent ACL injuries were gathered using the Web of Science and Scopus online databases by averaging the number of citations from each database. Articles from recent years were also aggregated and sorted by citation density (citations/year). Publication and study characteristics were recorded. Level of evidence and methodologic quality were assessed where applicable using the modified Coleman Methodology Score (mCMS), modified Jadad scale, and Methodological Index for Non-Randomized Studies (MINORS). Spearman correlation was used to evaluate the association between citation data and level of evidence or methodologic quality scorings.

RESULTS

The top 50 cited papers had a mean of 117.5 ± 58.8 citations (range, 58.5-288.5 citations), with a mean citation density of 9.4 ± 5.4 citations per year (range, 2.9-25.8 citations/year); 80% were published in 2000 or later, and 6% were considered basic science. Articles were mainly level 4 evidence (27/42; 64.3%), and none was level 1. There were moderate, significant associations between publication year and level of evidence (r S = -0.45; P = .0030) and citation density and publication year (r S = 0.59; P < .001). Mean methodologic quality scores were as follows: mCMS, 53 ± 7.2 (range, 39-68); modified Jadad scale, 3.2 ± 1.1 (range, 2-6); and MINORS, 11.2 ± 3.2 (range, 6-20). There was a significant, strong correlation between rank of mean citations and modified Jadad scale (r S = 0.76; P < .0001), suggesting poorer score associated with more mean citations.

CONCLUSION

Influential articles on pediatric and adolescent ACL injuries were relatively recent, with a low proportion of basic science-type articles. Most of the studies had a lower evidence level and poor methodologic quality scores. Higher methodologic quality did not correlate positively with citation data.

Quadriceps Strength Is Influenced by Skeletal Maturity in Adolescents Recovering From Anterior Cruciate Ligament Reconstruction

BACKGROUND

Anterior cruciate ligament injuries and anterior cruciate ligament reconstructions (ACLRs) are common, especially in adolescent patients. Recovery of strength, jumping performance, and perceived/subjective function are often used to make a return to sports decisions after injury. It is unknown how skeletal maturity may influence strength recovery after ACLR. The purpose of this study was to compare the strength and patient-reported outcomes in adolescent ACLR patients with and without open distal femur and proximal tibia physes.

METHODS

One hundred seventeen consecutive patients under the age of 18 were referred for routine strength and subjective outcomes evaluation following ACLR, 100 were included in the final analyses after excluding those with prior injuries, those tested outside for 4 to 12 month postoperative window, and those with incomplete clinical data. All study patients completed patient-reported outcomes, and underwent isometric and isokinetic testing of knee extensor and flexor strength to calculate normalized peak torque and limb symmetry. Statistical analyses were performed on all outcomes data using a 2×2 (physeal status: open, closed; and sex: male, female) with analysis of covariance where age and preoperative activity level were used as covariates.

RESULTS

A significant interaction between sex and physeal status for isokinetic knee extension peak torque and isometric knee extension peak torque, and limb symmetry index was found. This indicated that males with open physes were stronger and more symmetric than males with closed physes and females with open physes at ~6 months post-ACLR. There were no differences between sexes for patients with closed physes. No interactions were observed for flexion strength. Male patients and patients with open physes had higher perceived knee function compared with their corresponding counterparts.

CONCLUSIONS

After ACLR, adolescent patients with open physes had higher quadriceps strength compared with patients with closed physes. Overall, those skeletally less mature patients actually fared better on the functional strength tests, suggesting that functional recovery is not hindered by the presence of an incompletely closed physis.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Assessing the effect of physeal biopsy on angular deformity in a rabbit model

Obtaining a biopsy of the physis in a pediatric/juvenile could provide the ability to diagnose and manage children with physeal abnormalities. However, it has not yet been determined whether a physeal biopsy procedure affects angular deformity. We employed a rabbit model to collect biopsies of the distal femoral and proximal tibial physes on anesthetized, 8-week old New Zealand rabbits. The contralateral limb served as a control. At 8 (n = 5) and 16 (n = 5) weeks postbiopsy, animals were euthanized. Micro-computed tomography (CT) was employed to estimate percentage of the physis biopsied and assess structural abnormalities resulting from biopsy. Bone samples were embedded in polymethylmethacrylate and analyzed. The percentage of physis sampled was ≤1.5% of the total femoral physis while all but one of the tibiae had ≤2.3% removed. There were no iatrogenic clinical or radiographic deformities (frontal or sagittal). Micro-CT and histological analysis suggested that physeal defects had signs of healing that did not lead to subsequent angular deviation. A defect caused by physeal biopsy may not lead to angular deformity. Long-term data could help determine the safety and efficacy of collecting biopsies for histological analyses. Advanced imaging may demonstrate a detailed picture of anatomic or structural alteration of a given physis, but provides no functional information. The diagnostic and therapeutic information that could be gleaned from one or more serial biopsy samples could be invaluable in decision making and clinical management (e.g. skeletal dysplasias and metabolic conditions), so long as subsequent deformity is not a future possibility.

ACL injuries before 15 years of age: could the young become an athlete?

PURPOSE

The purpose of this study was to systematically assess the possibility for a patient younger than 15 to return to a competitive level of sport following an ACL injury.

METHODS

Four databases were analyzed (PubMed, MedLine, Cinahl, Cochrane Library and LISTA). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to guide the screening of the literature. Studies about functional and surgical treatments were included with a minimum of 5 years of mean follow-up. Methodological quality of individual studies was assessed with the Methodological Index for Non-Randomized Studies scale.

RESULTS

Ten studies were included, corresponding to a total of 217 patients. All studies were retrospective with level 4 evidence. Seven studies reported results of a transphyseal technique reconstruction, two studies a physeal-sparing reconstruction, and one studied the results of a repair (« healing response »). Only one study compared functional treatment and surgery. The mean age of patients at the time of surgery was 12.29 years (range 2-16) with a mean follow-up of 7.9 years (range 5.5-18.3). Return to sport was possible for 80 to 100% of patients (average of 91.7%) at the final follow-up but the level for return to sport was reported in only four studies and found between 61 and 89% for return to the same level and at 42% for return to a competitive level. Evolution of the Tegner score was analyzed in five studies and was reported to decrease at the follow-up in three studies. ACL re-ruptures can be considered as failure of the graft (nine studies with surgical technique) and occurred with an average of 16%.

CONCLUSION

This review demonstrate that ACL reconstruction is superior to conservative treatment and 'healing response' in terms of revision rates and knee laxity. Return to sport is possible for more than 4/5 of patients but only two thirds of them were able to return to the same level or to competitive level, and failure rates of the graft were not superior to global population. However, qualities of included studies and variability of treatment limited the clinical application of results. Despite this, patients and parents should be informed that ACL injuries are lesions that may influence the level of sport at a 5-year follow-up.

LEVEL OF EVIDENCE

Level IV, systematic review.

Over-the-top ACL reconstruction restores anterior and rotatory knee laxity in skeletally immature individuals and revision settings

PURPOSE

To investigate the objective outcomes following anterior cruciate ligament reconstruction (ACLR) with the over-the-top (OTT) technique.

METHODS

Thirty-five ACL-deficient patients with mean follow-up of 2.2 years were retrospectively reviewed. This included 14 skeletally immature individuals (age: 14 ± 1 years) who underwent primary OTT ACLR (adolescent group) and 21 skeletally mature individuals (age: 25 ± 8 years) who underwent OTT revision ACLR (revision group). The tibial tunnel was created at the anatomic position for all cases. No lateral extra-articular tenodesis was performed. Before and after surgery, the side-to-side difference (SSD) in anterior laxity was measured using KT-1000 arthrometer. Lachman and pivot-shift tests were assessed according to IKDC grade. The graft failure rate was assessed.

RESULTS

The post-operative SSD in anterior laxity was significantly reduced in the adolescent (pre-op, 3.9 ± 1.8 mm; post-op, 1.2 ± 0.8 mm; p = 0.040) and revision groups (pre-op, 4.2 ± 1.7 mm; post-op, 1.2 ± 1.4 mm; p < 0.001). Postoperative knee laxity measured by Lachman and pivot-shift tests were also significantly improved in both groups. Graft rupture occurred in two patients in the adolescent group (14.3%), and one patient in the revision group (4.8%).

CONCLUSION

ACLR with the OTT technique restored anterior and rotatory knee laxity in skeletally immature individuals and in revision settings. This one-step procedure may be a good option for skeletally immature individuals and revision settings.

LEVEL OF EVIDENCE

IV.

Pediatric Anterior Cruciate Ligament Reconstruction

The increasing incidence of anterior cruciate ligament injuries in skeletally immature children demands careful attention by orthopedic surgeons. Assessing skeletal age is essential to selecting the appropriate reconstruction technique. Males with a bone age of 15 years or older and females of 13 years and older are ideal candidates for a transphyseal anterior cruciate ligament reconstruction because there is minimal risk of growth disturbance. Children with substantial growth remaining (skeletal age males ≤12 years and females ≤10 years) seem to be at risk for more significant growth disturbance, so we generally recommend physeal-sparing techniques for these younger patients.

Transphyseal Anterior Cruciate Ligament Reconstruction in the Skeletally Immature: Quadriceps Tendon Autograft Versus Hamstring Tendon Autograft

Background:

It is unclear what the optimal graft choice is for performing anterior cruciate ligament (ACL) reconstruction in a skeletally immature patient.

Purpose:

To evaluate outcomes and complications of skeletally immature patients undergoing transphyseal ACL reconstruction with a hamstring tendon autograft versus a quadriceps tendon autograft.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Between 2012 and 2016, 90 skeletally immature patients from a single institution underwent primary transphyseal ACL reconstruction with either a quadriceps tendon autograft or a hamstring tendon autograft based on surgeon preference (n = 3). Patient demographic, injury, radiographic, and surgical variables were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation (SANE), Tegner activity score, pain, satisfaction, and complications such as graft tears and physeal abnormalities.

Results:

A total of 83 patients (56 hamstring tendon, 27 quadriceps tendon) were available for a minimum follow-up of 2 years or sustained graft failure. The mean age of the patients was 14.8 ± 1.4 years at the time of ACL reconstruction. No differences in chronological age, bone age, sex, patient size, or mechanism of injury were noted between groups. There were no differences in surgical variables, except that the quadriceps tendon grafts were larger than the hamstring tendon grafts (9.6 ± 0.6 mm vs 7.8 ± 0.7 mm, respectively; P < .001). Patient outcomes at a mean follow-up of 2.8 ± 0.9 years revealed no differences based on graft type, with mean Lysholm, SANE, pain, satisfaction, and Tegner scores of 96, 93, 0.6, 9.6, and 6.6, respectively, for the quadriceps tendon group and 94, 89, 0.9, 9.2, and 7.1, respectively, for the hamstring tendon group. While there were no physeal complications in either group, patients undergoing ACL reconstruction with a hamstring tendon autograft were more likely to tear their graft (21% vs 4%, respectively; P = .037).

Conclusion:

Skeletally immature patients undergoing ACL reconstruction can be successfully managed with either a quadriceps tendon autograft or a hamstring tendon autograft with good short-term outcomes, high rates of return to sport, and low rates of physeal abnormalities. The primary differences between grafts were that the quadriceps tendon grafts were larger and were associated with a lower retear rate. ACL reconstruction performed with a quadriceps tendon autograft may reduce early graft failure in skeletally immature patients.

Surgical treatment of posterior cruciate ligament lesions does not cause growth disturbances in pediatric patients

PURPOSE

The aim of the present study was to describe epidemiology, management and outcome of pediatric and adolescent patients with posterior cruciate ligament (PCL) injuries.

METHODS

Sixteen patients of less than 18 years of age with 7 PCL avulsion fractures and 9 PCL tears were included over a 10-year period. Trauma mechanism, additional injuries and treatment methods were analyzed. Follow-up examination included range of motion and ability to perform squats. Pedi-IKDC and Lysholm score were obtained and posterior shift was measured in kneeling view radiographs and compared to the contralateral side. Patients were grouped into pediatric patients with open physes at the time surgery and adolescent patients with closing or closed physes. In case of open physes, growth disturbances were assessed.

RESULTS

Six of the treated patients (median age 12.5 years, range 10-13) had open physes at time of surgery. Five of those sustained avulsion fractures and treatment consisted of open reduction and screw fixation in four cases and graft reconstruction in one case. One patient sustained a PCL tear and underwent graft reconstruction. Follow-up at a median of 71.5 months (range 62-100) did not reveal any growth disturbances. Median Pedi-IKDC was 71.9 (range 51.7-92.1), median Lysholm score was 81.5 (range 66-88) and median posterior shift difference was 2.5 mm (range 0-11). The remaining 10 patients (median age 16 years, range 14-17) had closing/closed physis at the time of operation. Two patients presented with avulsion fractures treated with open reduction and screw fixation and 8 patients sustained PCL tears treated with graft reconstruction. At a median follow-up of 69.5 months (range 11-112), median Pedi-IKDC was 86.8 (range 36.8-97.7), median Lysholm score was 84.0 (range 45-95) and median posterior shift difference was 4 mm (range 0-15).

CONCLUSIONS

In our small number of pediatric patients with PCL injuries, open reduction and epiphyseal screw fixation of displaced avulsed fractures and steep tunnel drilling in case of PCL reconstruction did not cause growth disturbances. Nevertheless, long-term functional impairment should be expected and close follow-up has to be recommended.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

MRI assessment of growth disturbances after ACL reconstruction in children with open growth plates-Prospective multicenter study of 100 patients

INTRODUCTION

We were interested in the consequences of anterior cruciate ligament (ACL) reconstruction on the growth plates and the impact on growth in children with open growth plates. The primary objective was related to growth disturbances with the null hypothesis being that ACL reconstruction in open growth plates does not cause any. The secondary objective related to the presence of physis lesions on MRI, with the null hypothesis being that ACL reconstruction in open growth plates does not induce any.

MATERIAL AND METHODS

In the context of a 2017 SFA symposium on ACL reconstruction with open growth plates, we conducted a prospective multicenter study with 2 years' follow-up. The study enrolled 100 patients; 71 were available for analysis. Four reconstruction techniques were used: semitendinosus-gracilis (STG), short graft (SG), quadriceps tendon (QT) and fascia lata (FL). MRI was used to look for growth disturbances as evidenced by deviation of the Harris lines or modification of the physis and diaphysis angles. Physis lesions were determined on MRI based on the presence of physeal bone bridges (PBB).

RESULTS

No growth disturbances were found. However, PBBs were found in 14 patients (20%). At the femur, the relative risk (RR) was higher when a STG graft was used (RR=2.1) and the tunnel diameter was≥9mm (RR=1.7). Epiphyseal fixation had a higher risk than transphyseal fixation (RR=1.6 vs. 1.2). At the tibia, the RR was higher when a QT graft was used (RR=3.6), when screw fixation was performed (RR=3.7) or when the graft did not fill the tunnel sufficiently (RR=1.5).

DISCUSSION

The absence of growth disturbances after 2 years' follow-up validates the possibility of ACL reconstruction with open growth plates, including with transphyseal techniques. The presence of small growth plate lesions such as bone bridges means that precautions should be taken with respect to tunnel trajectory, tunnel diameter, graft and tunnel diameter matching and graft fixation.

LEVEL OF EVIDENCE

III, prospective cohort study.

Treatment of ACL Tears in the Skeletally Immature Patient

The understanding and treatment of anterior cruciate ligament tears in skeletally immature patients continues to evolve. While conservative management was a mainstay of treatment, poor outcomes have led to several surgical techniques aimed at stabilizing the knee, optimizing outcome, and minimizing the chance of growth disturbance. Current techniques have, in large part, accomplished these goals but challenges remain. Looking to the future, different graft options, primary repair techniques, and rigorous prospective studies will help improve outcomes for this challenging patient population.

Outcomes of Physeal-Sparing ACL Reconstruction with Iliotibial Band Autograft in Skeletally Immature Prepubescent Children

BACKGROUND

Anterior cruciate ligament (ACL) tears are occurring in youth athletes with increasing frequency. Many ACL reconstruction procedures designed to allow for continued growth in patients with open physes have been described, but large series with mid- to long-term outcomes data are lacking. The purpose of the current study was to assess the clinical outcomes of a large cohort of prepubescent children who underwent a physeal-sparing, combined intra- and extra-articular ACL reconstruction with iliotibial (IT) band autograft over a 23-year period.

METHODS

Included in our analysis were 237 patients (240 knees) who underwent ACL reconstruction using IT band autograft at Tanner stage 1 or 2 (mean age of 11.2 ± 1.7 years). Physical examination data were analyzed for 225 of the 240 knees (mean follow-up, 25.8 months), and 137 (57%) of the knees had corresponding patient-reported clinical outcomes (patient-reported graft rupture and Pediatric International Knee Documentation Committee [Pedi-IKDC], Tegner activity scale, and Lysholm scores; mean follow-up, 6.2 years). Rates of growth arrest, IT band graft-harvest morbidity, and return to sports were analyzed.

RESULTS

Physical examination revealed that 96.8% of the knees were grade A on the Lachman test and 98.8% were grade A on the pivot-shift test. Graft rupture occurred in 9 (6.6%) of 137 knees, at an average of 33.5 months (range, 8.2 months to 8.0 years) postoperatively. For patients who did not sustain a graft rupture, the mean Pedi-IKDC score was 93.3 ± 11.0, the mean Lysholm score was 93.4 ± 9.9, and the mean score on the Tegner activity scale was 7.8 (mode, 7). While lateral thigh asymmetry at the IT band harvest site was noted by 48% of the subjects, only 1.6% reported associated pain. No cases of limb-length discrepancy or angular deformity were observed.

CONCLUSIONS

This procedure was associated with excellent functional outcomes, minimal risk of growth disturbance, and a low graft-rupture rate in skeletally immature prepubescent children. These results appear durable at mid- to long-term follow-up, at an average of >6 years postoperatively.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A systematic review of long-term patient reported outcomes for the treatment of anterior cruciate ligament injuries in the skeletally immature

PURPOSE

To systematically review the available literature regarding outcomes for the treatment of anterior cruciate ligament (ACL) injuries in the skeletally immature at skeletal maturity or more than five years after surgery.

METHODS

A systematic search was performed of seven online databases for literature reporting patient reported outcomes for the treatment of ACL injuries in the skeletally immature. A systematic review of this literature was performed examining the outcomes and their association with skeletal immaturity and treatment techniques.

RESULTS

A total of 18 articles reported the outcomes of 425 subjects. The mean age at surgery ranged from 10.3 to 15 years. Mean follow-up ranged from 36 to 163 months. Ten studies followed up subjects until skeletal maturity. Mean outcome scores were similar for extraphyseal (Lysholm 96.2 (95.7 to 97.4), Tegner 6.75, IKDC 95.4 (94 to 100)) and transphyseal surgery (Lysholm 94.3 (84.6-100), Tegner 7.6 (6 to 8.7), International Knee Documentation Committee (IKDC) 93.6 (84 to 99)). However, the lower range boundary for Lysholm and IKDC was worse for the transphyseal group. The results for non-surgical treatments were worse (Lysholm 63.2, Tegner 4.8, IKDC 87). No significant differences were found in the incidence of limb-length discrepancy (p = 0.32), coronal plane growth disturbance (p = 0.48), graft rupture (p = 0.88) and persistent symptomatic instability (p = 0.11) with transphyseal and extraphyseal surgical techniques.

CONCLUSION

Both transphyseal and extraphyseal reconstructive techniques produced good patient reported outcomes, with no significant differences in the incidence of limb-length discrepancy, coronal plane growth disturbance, graft rupture and persistent symptomatic instability. They compare favourably with the repair techniques reviewed and the natural history of the condition. Further high-quality studies comparing the transphyseal and extraphyseal techniques are required.

LEVEL OF EVIDENCE

Level IV.

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.

Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Early Results Using a Hybrid Physeal-Sparing Technique

Background:

Reconstruction of the anterior cruciate ligament (ACL) in the skeletally immature patient is frequently performed in hopes of preventing new or additional chondral damage and meniscal injuries. Patients within a few years of skeletal maturity are more at risk for ACL injuries than prepubescent patients, about whom several physeal-sparing techniques have been described. Reconstruction techniques in the former higher risk group need to be better understood.

Purpose:

To review a series of adolescent patients with ACL injuries surgically treated with the hybrid physeal-sparing technique.

Study Design:

Case series; Level of evidence, 4.

Methods:

Surgical logs of ACL reconstructions (ACLRs) performed at a single pediatric/adolescent sports medicine center over a 6-year period were reviewed. Patients with open physes who had undergone ACLR with a femoral physeal-sparing tunnel and transphyseal tibial tunnel were identified. Their demographics, operative reports, rehabilitative course, time to return to play, outcome scores, and postoperative radiographs were collected and analyzed.

Results:

Twenty-three patients with a mean chronological age and bone age of 13.0 and 13.6 years, respectively, were identified. Examination and subjective outcome scores were obtained at a mean of 19 months and overall demonstrated positive results, with a mean Pediatric International Knee Documentation Committee (Pedi-IKDC) score of 96.0 and a mean Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) score of 89.1. Full-length mechanical axis films obtained at a mean 21 months postoperatively demonstrated no leg-length discrepancies or angular deformities in 21 of 23 patients. Two patients had an identified growth disturbance in the form of femoral and tibial growth acceleration on the ACL-reconstructed limb.

Conclusion:

The femoral physeal-sparing with transphyseal tibial drilling “hybrid” technique in skeletally maturing patients appears to have a high rate of success with low morbidity. However, the possibility of physeal abnormalities does exist, which demonstrates the importance of a close postoperative follow-up and evaluation until skeletal maturity is achieved. ACLR in skeletally immature patients is performed on an increasingly regular basis. Establishing the best and safest technique to do so is therefore important.

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.

Anterior cruciate ligament reconstruction in skeletally immature patients : a systematic review

AIMS

Different methods of anterior cruciate ligament (ACL) reconstruction have been described for skeletally immature patients before closure of the growth plates. However, the outcome and complications following this treatment remain unclear. The aim of this systematic review was to analyse the outcome and complications of different techniques which may be used for reconstruction of the ACL in these patients.

MATERIALS AND METHODS

We performed a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This involved a comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using the following combinations of keywords, "knee", "anterior cruciate ligament", "reconstruction", "injury", "children", "adolescent", "skeletally immature", "open physis" and "surgery".

RESULTS

A total of 53 studies met the inclusion criteria and were included for analysis. The overall rate of disturbance of growth after ACL reconstruction was 2.6%, with no statistical difference between transphyseal and physeal-sparing techniques. Physeal-sparing techniques had a lower rate of post-operative complications compared with transphyseal techniques (p = 0.0045). Outcomes assessed were Lysholm score, International Knee Documentation Committee (IKDC) score, the IKDC grade, the Tegner score and the KT-1000. Both techniques had similar clinical outcomes.

CONCLUSIONS

This review reveals low rates of disturbance of growth after ACL reconstruction in skeletally immature patients. Although limited, the available evidence did not support any particular surgical technique when considering disturbance of growth or clinical outcome. Further randomised controlled trials are needed to investigate the efficacy of differing surgical techniques on outcomes in skeletally immature patients. Cite this article: Bone Joint J 2017;99-B:1053-60.

All-Epiphyseal ACL Reconstruction in Children: Review of Safety and Early Complications

BACKGROUND

All-epiphyseal anterior cruciate ligament (ACL) reconstruction is a well-described technique for skeletally immature patients. The purpose of this study was to elucidate the early complication rate and identify associated risk factors for rerupture after this procedure in children.

METHODS

We retrospectively reviewed patients who underwent all-epiphyseal ACL reconstructions performed at a large, tertiary care children's hospital between January 2007 and April 2013. Relevant postoperative data including the development of leg-length discrepancy, angular deformity, rerupture, infection, knee range of motion, arthrofibrosis, and other complications were recorded. Independent variables analyzed for association with rerupture included age, body mass index, graft type, graft size, and associated injuries addressed at surgery.

RESULTS

A total of 103 patients (average 12.1 y old; range, 6.3 to 15.7) were analyzed. The mean follow-up was 21 months. The overall complication rate was 16.5% (17/103), including 11 reruptures (10.7%), 1 case (<1.0%) of clinical leg-length discrepancy of <1 cm, and 2 cases (1.9%) of arthrofibrosis requiring manipulation under anesthesia. Two patients (1.9%) sustained contralateral ACL ruptures and 3 (2.9%) sustained subsequent ipsilateral meniscus tears during the study period. There were no associations found between age, sex, graft type, graft thickness, body mass index, or associated injuries addressed during surgery and rerupture rate. Knee flexion continued to improve by 20 degrees on an average between the 6 weeks and 6 months postoperative visits (P<0.001; paired samples Student's t test).

CONCLUSIONS

When taken in the context of known risk of future injury in an ACL-deficient knee, all-epiphyseal ACL reconstruction in children is safe. The rate of growth disturbance in this study is similar to previous reports in this patient demographic. The rerupture rate in this cohort is slightly higher compared with ACL reconstruction in older patients.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

Lateral Radiographic Landmarks for ACL and LCL Footprint Origins During All-Epiphyseal Femoral Drilling in Skeletally Immature Knees

BACKGROUND

This study was conducted to evaluate the spatial relationship of the anterior cruciate ligament (ACL) and lateral collateral ligament (LCL) femoral footprint origins in knee specimens from skeletally immature donors as viewed on lateral radiographs.

METHODS

Fourteen cadaver specimens of skeletally immature knees from children between 7 and 11 years old at the time of death were examined through gross dissection. Metallic pins were placed at the center of the ACL and LCL femoral footprints, and computed tomography (CT) scans were performed. Sagittal plane CT images were merged to create a view analogous to an intraoperative C-arm image with overlaid ACL and LCL ligament footprints. Ligament origins were then measured as a percent of the epiphyseal depth (% P-A [posterior-anterior]) and height (% P-D [proximal-distal]).

RESULTS

The ACL origin was centered at a point located 14% (14% P-A) of the total lateral femoral condyle (LFC) depth from the most posterior aspect of the LFC and 38% (38% P-D) of the LFC height from the most proximal aspect of the posterior physis. The LCL origin was centered at a point 27% P-A and 37% P-D. When viewed on a sagittal CT reconstruction analogous to a perfect lateral intraoperative fluoroscopic view, the ACL footprint origin is posterior and slightly inferior to the LCL origin. Both origins are distal to the distal femoral physis and are posterior to the origin of the popliteus.

CONCLUSIONS

This study demonstrates a consistent relationship between the origin of the ACL and LCL, which may be useful in guiding safe tunnel placement during all-epiphyseal ACL reconstruction in skeletally immature knees.

CLINICAL RELEVANCE

This anatomic reference can be used intraoperatively to guide and radiographically evaluate ACL tunnel placement while avoiding the LCL origin in skeletally immature patients.

Arthroscopic anterior cruciate ligament repair for proximal anterior cruciate ligament tears in skeletally immature patients: Surgical technique and preliminary results

BACKGROUND

Anterior cruciate ligament (ACL) tears in children are increasingly common and present difficult treatment decisions due to the risk of growth disturbance. Although open primary ACL repair was abandoned in the historical literature, recent studies have suggested that there is a role for arthroscopic primary repair in patients with proximal tears.

METHODS

This is a retrospective review of five consecutive patients aged 9.2years (range 8 to 10) who underwent suture anchor ACL reinsertion. Patients were included if they were Tanner stages 1-2 and proximal ACL tears with adequate tissue quality confirmed arthroscopically. The time frame was 81days. Arthroscopic ACL reinsertion was performed with bioabsorbable suture anchor. Clinical evaluation, KT-1000™, and MRI were re-evaluated. Clinical outcomes were measured using International Knee Documentation Committee (IKDC), Lysholm and Tegner activity score.

RESULTS

At a mean follow-up of 43.4months (range 25 to 56), no re-injury and leg length discrepancies were observed. Four patients had negative Lachman tests. The remainder had a grade 1 Lachman test. The mean side-to-side difference was 3 (2-4mm). In MRI obtained at the last follow-up, no articular lesions or growth arrest were observed and the reinserted ACL was recognized in every exam. All patients returned to previous level of activity and presented normal and nearly normal IKDC score. The mean Lysholm score was 93.6.

CONCLUSION

Arthroscopic ACL repair can achieve good short-term results with joint stability and recovery of sport activity in skeletally immature patients, with proximal ACL avulsion tear.

Sports injuries in children

Sports injuries in children affect both growing bone and soft tissues, and can result in damage of growth mechanisms with subsequent lifelong growth disturbance. During growth, there are significant changes in the biomechanical properties of bone. In young athletes, as bone stiffness increases and resistance to impact diminishes, sudden overload may cause bones to bow or buckle. Epiphyseal injuries are usually due to shearing and avulsion forces, although compression also plays a significant role. Given the remarkable healing potential of bone in childhood, fractures that initially united with some deformity can completely remodel, and the bone may appear totally normal in later life. Most injuries in children’s sports are minor and self-limiting, suggesting that children and youth sports are safe. However, as the risk of injuries sustained by young athletes can be significant, training programmes should take into account their physical and psychological immaturity, so that growing athletes can adjust to their own body’s changes.

Growth Abnormalities Following Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient: A Systematic Review

PURPOSE

To identify all reported cases of growth disturbances after anterior cruciate ligament (ACL) reconstruction in patients with open growth plates and analyze trends with respect to different surgical techniques, graft choices, and methods of fixation.

METHODS

A systematic literature review was conducted using the MEDLINE, EMBASE, and SCOPUS databases with the following term: "((anterior cruciate ligament OR ACL) AND ((((immature) OR growth plates) OR physes) OR pediatric))." Only studies that evaluated ACL reconstruction in patients with open growth plates and reported angular malformations or limb length discrepancy were included. Data were extracted, including patient characteristics, surgical technique, and postoperative growth disturbance.

RESULTS

Twenty-one studies containing 39 patients with growth abnormalities were included in the review. Mean chronological age was 13 years, and 89% of patients were male. Overall, there were 16 cases of angular malformations and 29 cases of limb length discrepancy. The most common angular malformation was genu valgum (81%, n = 13; mean of 6.5°). The most common surgical technique on the tibia and femur was transphyseal (54%, and 77% respectively), and the most common graft used was hamstring autograft (58%). Among patients with limb length discrepancy, overgrowth was most common (62%, n = 18; mean of 13 mm). Interestingly, we observed that 50% of patients with overgrowth underwent a physeal-sparing technique, whereas 64% of patients with shortening underwent a transphyseal technique.

CONCLUSIONS

At present, there are 21 studies reporting 39 patients with growth abnormalities in the current literature, of which 29 cases were of limb length discrepancy and 16 of angular malformation. Of the 29 cases of limb length discrepancy, limb overgrowth accounted for 62% of cases. Perhaps most interestingly, physeal-sparing techniques were performed in 25% of the cases of angular malformation and 47% cases of limb length discrepancy, despite the commonly held belief that this technique mitigates the risks of ACL reconstruction by not violating the growth plate. According to this study, it is clear that growth abnormalities after ACL reconstruction in the skeletally immature patient are underreported, and our current understanding of the etiology of these abnormalities is limited.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II to IV studies.

Growth Arrest Following ACL Reconstruction With Hamstring Autograft in Skeletally Immature Patients: A Review of 4 Cases

BACKGROUND

Anterior cruciate ligament (ACL) tears are becoming more common in the skeletally immature population as participation in high-risk sports continues to grow. This presents a challenge for the treating surgeon as ACL reconstruction in this patient set has the added aim of preservation of the growth plate anatomy. The purpose of this investigation is to report on 4 patients who developed growth arrest following ACL reconstruction and offer a review of the available literature.

METHODS

Four skeletally immature patients (2 male and 2 female) were identified who underwent ACL reconstruction at mean age of 14.2 years (range, 13.5 to 14.8 y) and developed growth arrests. Bone ages at the time of reconstruction were 14 and 16 years for the boys and 13 years 6 months and 14 years for the girls. All patients had a transphyseal reconstruction with a hamstring autograft. Standard postoperative care was provided including clinical and radiographic follow-up at regular intervals. Clinically significant postoperative physeal arrest was confirmed on MRI or CT scan. Detailed chart review examined demographics, operative variables, and postoperative subjective and objective clinical measures.

RESULTS

Two patients developed tibial recurvatum; 2 patients developed genu valgum. Three patients required further surgery. One patient underwent distal femoral-guided growth procedure, 2 underwent proximal tibial epiphysiodesis, and 1 patient was skeletally mature at presentation and did not require deformity correction.

CONCLUSIONS

This report of 4 patients demonstrates that growth arrest following ACL reconstruction in skeletally immature patients is a real concern and highlights the importance of careful preoperative evaluation and discussion with patients and family members. We routinely obtain long-leg AP and lateral hip-to-ankle films on skeletally immature patients before performing an ACL reconstruction and then at 6 and 12 months postoperatively or every 6 months until the growth plates are closed to assess leg lengths and lower extremity alignment.

LEVEL OF EVIDENCE

Level IV-therapeutic study, case series.

Anterior Cruciate Ligament Reconstruction Using the Transphyseal Technique in Prepubescent Athletes: Midterm, Prospective Evaluation of Results

PURPOSE

To evaluate the efficacy, results, and complications of transphyseal technique of anterior cruciate ligament (ACL) reconstruction in prepubertal patients and to assess a possible influence of children's growth on the outcome.

METHODS

Between 2005 and 2009, 22 (16 boys and 6 girls) prepubescent patients, Tanner stage 1 and 2, underwent ACL reconstruction and the follow-up 6, 12, and 24 months after surgery and after growth plate closure. The average age of the girls was 11.2 years, and of the boys, 12.3 years. The average follow-up period was 77.2 months. Clinical outcome was evaluated by Lysholm, Tegner, and International Knee Documentation Committee (IKDC) objective and subjective knee scores. Standard radiograms were performed for potential axial growing disturbance.

RESULTS

The average follow-up period was 77.2 months (range, 54 to 102 months), and IKDC subjective scores changed from 58 (range, 44 to 69) before surgery to 87 (range, 86 to 87; P = .00) at 6 months, 93 (range, 88 to 97; P = .00) at 12 months, and 95 (range, 92 to -98; P = .5) at final examination. Lysholm score increased from 58 (range, 53 to 64) before surgery to 89 (range, 85 to 92; P = .00) at 6 months and 96 (range, 94 to 100; P = .00) at 12 months, 24 months (P = .9), and final examination (P = .8). Before injury, all patients were graded 7 on the Tegner scale. Nineteen athletes reached at least grade 7 and returned to the level of activity a mean of 9 months after the surgery. No patient had deformity or growth disturbances observed clinically.

CONCLUSIONS

Arthroscopic-assisted transphyseal ACL reconstruction in prepubescent patient is a promising technique, provided that all technical details are respected. It gives excellent subjective and objective knee scores and provides a very good function of the knee joint in the midterm period with no or only minor effect on the leg length. The rate of growth after surgery did not influence the results.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Allograft and Autograft Transphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Outcomes and Complications

PURPOSE

The purpose of the study was to evaluate outcomes, graft failure rates, and complications after transphyseal soft-tissue allograft and autograft anterior cruciate ligament (ACL) reconstruction (ACLR) in patients with open growth plates.

METHODS

Twenty-nine skeletally immature athletes (30 knees) with a mean age of 13.9 years (range, 9 to 16 years) underwent transphyseal ACLR (22 with quadrupled hamstring autograft and 8 with tibialis anterior allograft). Of the patients, 5 were Tanner stage I, 17 were Tanner stage II, and 7 were Tanner stage III. Outcomes included KT-1000 (MEDmetric, San Diego, CA) measurements and International Knee Documentation Committee (IKDC), Cincinnati, and Lysholm scoring. Radiographs were evaluated for asymmetrical physeal closure, growth arrest lines, and knee alignment.

RESULTS

The mean outcomes scores, excluding the 5 graft failures, were 91.8 points for the IKDC score, 93.0 points for the Cincinnati score, and 91.5 points for the Lysholm score at a mean of 4 years' follow-up (range, 24 to 84 months). The 95% confidence intervals for the differences were -27.7 to -18.0 for the IKDC score, -26.4 to -12.1 for the Cincinnati score, and -20.1 to -6.4 for the Lysholm score. One hundred percent of patients ultimately returned to their prior level of sports, but only 76% maintained that level at most recent follow-up. The mean KT-1000 side-to-side difference at most recent follow-up was 0.4 mm (SD, 1.3 mm; range, -2 to 3 mm) (n = 25). Evaluation at a minimum of 2 years postoperatively showed 4 patients with Harris growth arrest lines and 1 genu valgum deformity that spontaneously corrected at latest follow-up. For the remaining 29 knees, there was a mean side-to-side difference of 1.3° (range, 0° to 4°) in the radiographic tibiofemoral angle and 0.2 cm (range, 0 to 1 cm) for clinical leg-length measurements. Sports-related graft failure occurred at a mean of 24 months after ACLR in 16.7% of patients (37.5% with allografts [3 of 8] v 9% with autografts [2 of 22], P = .10). In 5 patients (16.7%), a contralateral ACL injury was sustained.

CONCLUSIONS

Transphyseal ACLR in patients with open growth plates resulted in a high rate of return to sports with a low rate of growth arrest and deformity at a mean of 4 years' follow-up. Harris growth arrest lines and a case of genu valgum deformity that spontaneously corrected, however, were observed. Graft failure rates and contralateral ACL tears were not insignificant in this young patient population.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Anterior cruciate ligament and intercondylar notch growth plateaus prior to cessation of longitudinal growth: an MRI observational study

PURPOSE

Increasing numbers of children and adolescents are being treated for ACL tears. In order for surgeons to safely optimize treatment during ACL surgery, we must better understand ACL growth and intercondylar notch patterns in the skeletally immature knee. The aim of this study is to measure ACL and intercondylar notch volume in paediatric patients and observe how these volumes change as a function of age and gender.

METHODS

Data were extracted from the picture archiving and communication systems (PACS) computer records. Sample consisted of 137 MRI knee examinations performed between January 2006 and July 2010 in patients aged 3-13. Subjects were grouped into 1-year age intervals. Patients with imaging reports including ACL tears, previous surgeries, congenital structural anomalies, or syndromes were excluded.

RESULTS

Measures of ACL volume significantly increased with age (P < 0.001). A linear increase in ACL volume was observed until the age 10, with a mean increase in volume of 148 mm(3) per age group. ACL volume plateaued at 10 years, after which minimal increase in ACL volume was observed. Sex was not found to be a significant predictor of ACL volume in the multiple linear regression (P = 0.57). Similar to ACL volume, there was a significant increase in intercondylar notch volume with age with a mean increase of 835 mm(3) per age group (P < 0.0001). Intercondylar notch volume reached a plateau at age 10, after which a minimal increase in notch volume was observed in older groups. Female patients had notch volumes that were on average 892 + 259 mm(3) smaller than male patients who were in the same age group (P = 0.0006).

CONCLUSION

The plateau in the growth of ACL and notch volume occurs at age 10, prior to the halt in longitudinal growth of boys and girls. Female patients have significantly smaller intercondylar notch volumes than their age-matched male counterparts, while no gender difference was seen in ACL volume. These results suggest that notch volume is an intrinsically sex-specific difference, which may contribute to the higher rate of ACL tears among females. These growth patterns are clinically relevant as it allows surgeons to better understand the anatomy, pathology, and risk factors related to ACL tears and its reconstruction.

LEVEL OF EVIDENCE

Observational Study, Level IV.

A comparison of revision and rerupture rates of ACL reconstruction between autografts and allografts in the skeletally immature

PURPOSE

Anterior cruciate ligament reconstructions (ACLRs) in skeletally immature patients are increasing. The purpose of this study is to describe the demographics, graft usage, revision, and re-operation rates in skeletally immature ACLRs in the Kaiser Permanente healthcare system.

METHODS

Skeletally immature patients (<17.0 years old with open physes) were identified using the Kaiser Permanente ACLR registry. Multi-ligament reconstructions and physeal-sparing ACLRs were excluded. Aseptic revision and same-knee re-operation were the outcomes of interest. Exposure of interest was graft type; bone-patellar-tendon-bone (BPTB) autograft, hamstring autograft, and any type of allograft. Age, gender, body mass index (BMI), and race were evaluated as confounders. Cox proportional hazard models stratified by surgeon were used to analyse the risk of revision and re-operation.

RESULTS

A total of 534 primary ACLR cases were evaluated with a mean follow-up of 2.9 years. The majority were hamstring autografts (n = 388, 72.7%), male (n = 339, 63.9%), and White (n = 232, 43.4%). Median age was 14.9 years, and median BMI was 21.9 kg/m(2). There were 44 (8.2%) aseptic revisions and 48 (9.0%) same-knee re-operations. The incidence rate for revision was BPTB autograft 5.5%, hamstring autograft 7.5%, and allograft 13.2%. After adjusting for confounders and surgeon clustering effect, the risk of aseptic revision and revision between allograft and hamstring autograft did not reach statistical significance.

CONCLUSION

Graft selection differs in skeletally immature patients with a preponderance of surgeries being performed with hamstring tendon autografts. High revision rates were identified for all graft types used, though differences in revision rates across different graft types did not reach statistical significance. Surgeons should be aware of high rates of revision in this skeletally immature young population, although type of graft used did not appear to make a difference.

LEVEL OF EVIDENCE

III.

Limb Deformity Caused by Distal Femoral and Proximal Tibial Growth Arrest After ACL Reconstruction in a Child: A Case Report

CASE

We report the case of a twelve-year-old boy with limb deformity caused by physeal closure after transphyseal intra-articular reconstruction of the anterior cruciate ligament of the left knee at the age of seven years. We treated premature closure of the physis with a Langenskiöld procedure. Lengthening and correction of the deformity were accomplished with use of the Ilizarov method. Although gross instability remained, reasonable limb alignment was attained with prolonged treatment.

CONCLUSION

We document growth arrest and severe limb deformity after transepiphyseal anterior cruciate ligament reconstruction with an artificial polyester ligament and successful surgical correction.

Surgical-experimental principles of anterior cruciate ligament (ACL) reconstruction with open growth plates

Objective

To review surgical and animal experimental studies performed with open growth plates in relation with pediatric anterior cruciate ligament (ACL) reconstruction.

Backround

When it comes to the treatment of ACL injured children, there is a lack of current international guidelines, leaving the treating physicians with a therapeutic dilemma. A variety of surgical and animal experimental studies have been undertaken over the last decades in relation with open growth plates and ACL-reconstruction.

Method

Based on our own previous animal experimental data, we highlighted 15 specific points concerning pediatric ACL-reconstruction and reviewed additional literature concerning these individual items.

Results

Pediatric ACL-reconstruction could be proven to be safe in animal models. Growth abnormalities, risk factors and factors, which were specifically related to biological healing processes in children, were identified. From them surgical principles for safe pediatric ACL replacements can be deducted. Applying these principles through a correct technical execution of surgery may prevent clinically significant growth changes.

Conclusion

Over the last 2 decades it has been shown that a technically correct pediatric ACL reconstruction has little risk in creating clinically significant growth abnormalities. Animal experiments support this hypothesis despite the fact that the gained knowledge cannot be fully generalized to humans. More long time follow-up is needed to fully understand the complete risk factors related to ACL surgery with open growth plates.

Electronic supplementary material

The online version of this article (doi:10.1186/s40634-015-0027-z) contains supplementary material, which is available to authorized users.

Height, weight, and age predict quadriceps tendon length and thickness in skeletally immature patients

BACKGROUND

Quadriceps tendon autografts have been used with success in adults and are becoming a popular graft option in pediatric patients because of size, decreased donor site morbidity, ease of harvest, and favorable biomechanical characteristics. However, little is known about the length and thickness of the quadriceps tendon in pediatric patients.

PURPOSE

This study aimed to determine whether quadriceps tendon length and thickness follow a predictable pattern of development based on height, weight, age, and body mass index in skeletally immature patients.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

The height, weight, age, and sex of 151 children between 4 and 16 years old were recorded. Ultrasound measurements of the length and thickness of bilateral quadriceps tendons were performed by a single technician and recorded for statistical analysis.

RESULTS

The average quadriceps tendon length and thickness were 6.87 ± 1.49 cm and 0.37 ± 0.12 cm, respectively. Tendon length averaged 3.89 cm at age 4 years and 7.98 cm at 16 years, whereas thickness averaged 0.24 cm at 4 years and 0.40 cm at 16 years of age. There was no significant difference in tendon length or thickness between males and females (P = .97). Tendon length and thickness increased significantly with age, weight, and height (P < .01 for all).

CONCLUSION

The quadriceps tendon is of sufficient length and thickness to be used as an autograft for pediatric patients. The size of the graft is predictable using the age, height, and weight of the patient. Graft length and thickness can be easily confirmed using ultrasound.

A comparison of distal femoral physeal defect and fixation position between two different drilling techniques for transphyseal anterior cruciate ligament reconstruction

The defect of the femoral tunnel at the level of the physeal scar during transtibial and anteromedial portal (AMP) drilling for transphyseal anterior cruciate ligament reconstruction was compared. Five matched pairs of knees (n=10) were drilled, and computed tomography was used to evaluate tunnel position and size at the level of the physeal scar. Significant radiographic changes were observed, including tunnel defect area at the physeal scar: 0.44 cm (1.2%) in the transtibial group versus 0.99 cm (2.7%) in the AMP group (P=0.008). AMP drilling creates a larger and more lateral tunnel defect at the level of the physeal scar.

Revision single-bundle anterior cruciate ligament reconstruction with over-the-top route procedure

PURPOSE

In revision anterior cruciate ligament reconstruction (ACLR), the single-stage technique and the over-the-top route (OTTR) procedure were usually selected for cases where the bone tunnel cannot be created at an anatomical position due to tunnel enlargement and overlap with the mal-positioned tunnel of primary reconstruction. The purpose of this study was to evaluate the clinical results of revision single-bundle ACL reconstruction using OTTR procedure and to compare the clinical results of OTTR procedure with those of anatomical single-bundle revision reconstruction (SBR).

HYPOTHESIS

The results of OTTR procedure are equivalent to that of SBR.

METHODS

Seventy-six revision ACL reconstruction knees from April 2002 to December 2012 were involved in our study. We focused on 21 knees which underwent surgery with SBR and 22 knees with OTTR using hamstring tendon. The clinical results were evaluated by means of the Lysholm score and the knee stability was assessed by the Lachman test, pivot-shift test and side-to-side difference by KT-2000 pre-operatively and after 1 year post-operatively. AP translation and rotational laxity using a navigation system were evaluated before and after revision ACL reconstruction under anesthesia in 8 cases of OTTR and in 6 cases of SBR.

RESULTS

There was no statistically significant difference between the OTTR and SBR regarding Lysholm score, Lachman test, pivot-shift test, ATT by KT-2000, and AP translation and rotational laxity with a navigation system.

CONCLUSIONS

The clinical results of OTTR are almost equivalent to those of SBR. For the cases in which it is impossible to create the femoral tunnel in an anatomical position, OTTR is a valuable revision ACL reconstruction method.

LEVEL OF EVIDENCE

Case-control study. Level III.

High satisfaction yet decreased activity 4 years after transphyseal ACL reconstruction

BACKGROUND

ACL injuries in preteens and teens are common occurrences. Reconstruction is believed to be optimum treatment for those wishing to return to running, cutting, and jumping sports. Rates of reoperation, satisfaction, and long-term return to and maintenance of preinjury activity after ACL reconstruction in young athletes are important information for physicians, patients, and parents.

QUESTIONS/PURPOSES

The purposes of this study were to address the following questions in this skeletally immature patient population undergoing ACL reconstruction: (1) What is the reinjury rate and the need for subsequent surgeries? (2) How do patient satisfaction and function as assessed by patient and physician correlate with return to sport? (3) What factors contribute to failure to return to preinjury activity levels?

METHODS

This is a retrospective review of 29 patients who underwent transphyseal ACL reconstruction using soft tissue grafts passed through open physes and followed to skeletal maturity, and at least 2 years from their index surgery, who were invited and returned for a study interview and examination. Pre- and postinjury activity levels were assessed via the Tegner activity score, satisfaction was determined using a 10-point Likert scale, function was assessed via the Lysholm score and IKDC grade, and an open-ended questionnaire was used for explanations of changes in activity levels. Reoperations were classified as major or minor, determined from a review of the medical records conducted after interview and examination.

RESULTS

At a minimum followup of 2 years (mean, 4 years; range, 2-8 years), four revision reconstructions and seven minor operations were performed for a reoperation rate of 11 of 29 (38%). Eight of 29 patients (28%) sustained contralateral ACL ruptures. The mean satisfaction score was 9 (range, 4-10) and mean Lysholm score was 91 (range, 61-100). Only 12 of 29 (41%) patients returned to and maintained their preinjury level of sport. High satisfaction correlated with return to prior level of sports, although there was no relationship between function and activity level. Reoperation on the index knee or contralateral ACL tear did not correlate with a change in activity level; rather, most patients who were less active indicated a change in interest with advancing age.

CONCLUSIONS

Despite high satisfaction and function, less than 50% of patients maintained their preinjury level of play 4 years after ACL reconstruction. Satisfaction correlated significantly with knee function; highly satisfied patients were more likely to return to and maintain their prior level of participation in sports. Contributing factors to decreased activity include changes in lifestyle with increasing age. Reoperation did not correlate with lower activity scores or failure to return to sports.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.