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The incidence of anterior cruciate ligament injuries in skeletally immature patients has increased in recent years. The gold standard treatment of this type of trauma in children is not yet established. Conservative management may underestimate the risk of new meniscal and chondral tears; on the other hand, a more interventional approach may expose...
Context in source publication
Context 1
... baseline knee radiograph is also useful to initially evaluate the skeletal maturity of the patient: open, closing, and closed physis are the three main class. 56 Magnetic resonance imaging is the method of choice to evaluate an injured knee with a clinical suspect of ACL tear (Figure 4). Primary findings are an abnormal signal intensity of the ACL, discontinuity of the ligament, and Blumensaat's angle of >9.5° ( Figure 5). ...
Citations
... To ensure appropriate and timely diagnosis, a thorough history and physical examination should be obtained, including a musculoskeletal examination and performance of specific orthopedic examination techniques such as the Lachman test, pivot shift test, and anterior drawer test (Barnes & Vanderpool, 2020). For comparison, the uninjured knee should also be evaluated to determine baseline healthy joint characteristics (Duart et al., 2023). The patient will typically present with an apparent injury to the knee joint secondary to a fall, sudden turn in direction, or sports-related trauma. ...
... Upon physical examination, effusion, swelling, deformity, pain, inability to bear weight, and limited range of motion are noted in the affected knee (Duart et al., 2023). In 10%-65% of pediatric clients with ACL injuries, hemarthrosis (bleeding into the space around the joint) is present because of acute trauma and is manifested by a black and blue discoloration around the knee (Duart et al., 2023). ...
... Upon physical examination, effusion, swelling, deformity, pain, inability to bear weight, and limited range of motion are noted in the affected knee (Duart et al., 2023). In 10%-65% of pediatric clients with ACL injuries, hemarthrosis (bleeding into the space around the joint) is present because of acute trauma and is manifested by a black and blue discoloration around the knee (Duart et al., 2023). In addition, assessment data collection should include the timing of the injury, the type of movement that occurred when the injury happened, whether a "pop" was heard or felt, the timing of swelling and pain to appear, whether the knee "gave out" or felt unsteady, any associated injuries, and an eyewitness account of the injury if available. ...
The incidence of anterior cruciate ligament (ACL) tears is increasing in youth, with rates higher in female athletes. The injury is usually noncontact; rather, a quick change of direction induces a “popping” sensation. The injury will be swollen, bruised, and painful, and there will be a limited range of motion and an inability to bear weight. The Lachman test, pivot test (used when patients are anesthetized), and anterior drawer test help diagnose ACL injuries. ACL injuries are categorized by severity as Grade I, II, or III sprains. Prompt first aid care can help reduce pain and swelling using the RICE method, an acronym for rest, ice, compression, and elevation. Medical treatment with stabilization braces might be enough to promote a return-to-normal function, but surgical options are usually required for Grade II and III injuries. Reconstructive surgeries can use an autograft or allograft, but consideration of the growth plates in children might delay the surgery. Postoperative therapy helps reduce edema and immobility. It is essential that injury prevention programs are implemented. Prevention programs and increased awareness of parents and coaches are called for with the population of youth athletes.
... Return to the patients' previous sports activity Chambers [7] 100% 11.3 ± 3.3 (9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23) Return to unrestricted athletics Cohen [8] 89% . ...
... Return to the same level of sports activity as before the injury Cordasco [10] 96% 13.5 (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22) Return to unrestricted competitive sports after successful completion of the QMA and RTS performance analysis Graziano [29] 93% 12 ± 2.0 Athletes were cleared for return to sports based on quantitative measures using the limb symmetry index and qualitative measures (QMA) as well as the ability to meet the demands of their sport. Guzzanti [31] 100% . ...
Background
Different types of grafts can be used for anterior cruciate ligament reconstruction (ACLR). There is little published data regarding skeletally immature patients. The purpose of this systematic review was to assess the clinical outcomes and complications for different autograft types used in all-epiphyseal, transphyseal and partial epiphyseal/hybrid ACLR in skeletally immature children and adolescents.
Methods
PubMed, Embase and Cochrane databases were systematically searched for literature regarding ACLR using hamstrings, quadriceps or bone-patellar-tendon-bone (BPTB) autografts in skeletally immature patients. Studies were included if they examined at least one of the following outcomes: graft failure, return to sport(s), growth disturbance, arthrofibrosis or patient reported outcomes and had a minimum follow-up of 1 year. Case reports, conference abstracts and studies examining allografts and extra-articular or over-the-top ACL reconstruction techniques were excluded. Graft failure rates were pooled for each graft type using the quality effects model of MetaXL. A qualitative synthesis of secondary outcomes was performed.
Results
The database search identified 242 studies. In total 31 studies were included in this review, comprising of 1358 patients. Most patients (81%) were treated using hamstring autograft. The most common used surgical technique was transphyseal. The weighted, pooled failure rate for each graft type was 12% for hamstring tendon autografts, 8% for quadriceps tendon autografts and 6% for BPTB autografts. Confidence intervals were overlapping. The variability in time to graft failure was high. The qualitative analysis of the secondary outcomes showed similar results with good clinical outcomes and low complication rates across all graft types.
Conclusions
Based on this review it is not possible to determine a superior graft type for ACLR in skeletally immature. Of the included studies, the most common graft type used was the hamstring tendon. Overall, graft failure rates are low, and most studies show good clinical outcomes with high return to sports rates.
... Liu et al. [3] studied the injury status of badminton players aged 7-12 years and reported the following site-dependent injury incidence rates (per 1000 h): 0.23 for the ankle and 0.24 for the knee. These results are comparable to those of adult athletes, suggesting that sports injury rates are high among school-age children [4,5]. In badminton, players repeatedly thrust and jump quickly in multiple directions; high loads are generated in the musculoskeletal system, which is highly likely to lead to injuries, especially in school-age children competitions. ...
Purpose
Lower extremity sports injuries are associated with impaired dynamic balance function, and the modified Star Excursion Balance Test (mSEBT) is proposed as a screening tool for lower extremity injuries. This study aimed to clarify the relationship between dynamic balance function and lower limb injury experience among school-age female badminton players.
Methods
Forty-two subjects were included. The mSEBT was used for dynamic balance function evaluation. Furthermore, lower limb joint range of motion, lower limb muscle strength, and foot arch height ratio were measured. Lower limb injury experience within the past year was assessed using a questionnaire. The subjects were divided into the injury and non-injury groups according to lower limb injury experience, and mSEBT and physical function results were compared. Multiple regression analysis was conducted with the mSEBT value as the dependent variable and previous lower limb injury experience as the independent variable, with the knee extension muscle strength, arch height ratio, and age as covariates.
Results
Intergroup comparison showed that the injury group had significantly higher mSEBT and dorsiflexion angle values and lower arch height ratios. No significant differences were found for the other parameters. In the multiple regression analysis, mSEBT had a significant relationship with previous lower limb injury experience.
Conclusions
A high mSEBT score was significantly related to previous lower limb injury experience. Further research is needed to examine this difference, including external factors such as training intensity and frequency, as well as physical function factors.
Background
Arthrofibrosis is a fibrotic joint disorder resulting in restricted joint motion and pain. Risk factors associated with the development of postoperative arthrofibrosis include female sex, type of graft, and quicker time to reconstruction. These patients have typically benefitted from manipulation under anesthesia or arthroscopic lysis of adhesions. The purpose of this study was to retrospectively review the rate of arthrofibrosis in children and adolescents who previously underwent anterior cruciate ligament (ACL) reconstruction.
Materials and Methods
This was a retrospective chart review examining patients 18 years or younger who underwent ACL reconstruction between 2013 and 2023. Data collected included age, body mass index, reconstruction technique, concomitant meniscal or ligamentous pathology, and need for revision surgery for arthroscopic lysis of adhesions vs manipulation under anesthesia.
Results
A total of 461 patients 18 years or younger who underwent ACL reconstruction were included in this study. Eighteen (3.90%) patients required reoperation for the development of arthrofibrosis. Skeletally immature patients were found to have a statistically significant lower rate of arthrofibrosis compared with skeletally mature patients (0% vs 4.80%; P =.0184). Patients with a higher weight and body mass index had an increased rate of arthrofibrosis ( P =.0485 and P =.0410, respectively). Graft type did not have a significant impact on arthrofibrosis rates. There were no significant findings in terms of concomitant injuries and rate of arthrofibrosis.
Conclusion
Arthrofibrosis developed in 3.90% of patients after ACL reconstruction. Skeletal immaturity may be protective against the development of arthrofibrosis. No association was found between graft type or concomitant knee pathology and arthrofibrosis. [ Orthopedics . 202x;4x(x):xx–xx.]
Introduction
Although 200 000 adolescents undergo anterior cruciate ligament reconstruction (ACLR) surgery annually, no benchmarks for pediatric post-ACLR pain management exist. We created a multicenter, prospective, observational registry to describe pain practices, pain, and functional recovery after pediatric ACLR.
Methods
Participants (n=519; 12–17.5 years) were enrolled from 15 sites over 2 years. Data on perioperative management and surgical factors were collected. Pain/opioid use and Lysholm scores were assessed preoperatively, on postoperative day 1 (POD1), POD3, week 6, and month 6. Descriptive statistics and trends for opioid use, pain, and function are presented.
Results
Regional analgesia was performed in 447/519 (86%) subjects; of these, adductor canal single shot was most frequent (54%), nerve catheters placed in 24%, and perineural adjuvants used in 43%. On POD1, POD3, week 6, and month 6, survey response rates were 73%, 71%, 61%, and 45%, respectively. Over these respective time points, pain score >3/10 was reported by 64% (95% CI: 59% to 69%), 46% (95% CI: 41% to 52%), 5% (95% CI: 3% to 8%), and 3% (95% CI: 1% to 6%); the number of daily oxycodone doses used was 2.8 (SD 0.19), 1.8 (SD 0.13), 0, and 0. There was considerable variability in timing and tests for postdischarge functional assessments. Numbness and weakness were reported by 11% and 4% at week 6 (n=315) and 16% and 2% at month 6 (n=233), respectively.
Conclusion
We found substantial variability in the use of blocks to manage post-ACLR pain in children, with a small percentage experiencing long-term pain and neurological symptoms. Studies are needed to determine best practices for regional anesthesia and functional assessments in this patient population.
iNtrOdUctiON: acL reconstruction in pediatric patients presents unique challenges due to the presence of growth plates and the potential for growth disturbances. Various surgical techniques have been developed to address these concerns , including physeal-sparing techniques such as the modified MacIntosh procedure and the all-epiphyseal technique, as well as the minimally invasive all inside technique. however, the occurrence of growth abnormalities and long-term outcomes in this population require further investigation. eVideNce acQUisitiON: this review examines existing literature on growth plate injuries and complications following acL reconstruction in pediatric patients. a comprehensive search of relevant articles was conducted, including meta-analyses and case series, to gather evidence on the incidence and types of growth disturbances, surgical techniques employed, and functional outcomes. eVideNce sYNthesis: the analysis reveals that growth disturbances after acL reconstruction can manifest as limb overgrowth, limb shortening, and angular malformation. Limb overgrowth appears to be independent of the surgical technique used, while limb shortening may result from misplacement of bone blocks or hardware across the growth plates. Valgus malalignment is the most common deformity observed. physeal-sparing and transphyseal techniques show similar rates of growth abnormalities, highlighting the need for caution in surgical decision-making. cONcLUsiONs: acL reconstruction in pediatric patients requires careful consideration of growth plate preservation and choice of surgical technique. While favorable functional outcomes and high patient satisfaction have been reported, further investigation through randomized controlled trials is needed to address methodological limitations and refine the management of acL injuries in this population. proper rehabilitation and guidance are crucial for a successful return to sports and minimizing the risk of re-injury. Future research should focus on understanding the risk factors, technical features, and underlying mechanisms associated with growth disturbances to develop strategies that minimize these complications and optimize outcomes for young athletes. (Cite this article as: placella G, Biavardi NG, alessio-Mazzola M, conca M, cerulli G, salini V. pediatric acL injuries: navigating the challenges and advancements in surgical reconstruction and rehabilitation strategies. Minerva Orthop 2024;75:43-57.
Background
As there has been an increasing incidence of anterior cruciate ligament (ACL) tears in children and adolescents in the past few decades, nonoperative management is seen to result in less favorable clinical outcomes, resulting in meniscal and cartilage damage, and arthritic changes. Despite the risk of iatrogenic physeal injuries with operative approach, several reconstruction options, such as physeal-sparing techniques for skeletally immature patients, are described to restore joint stability.
Indications
We bring a combined extra-articular and intra-articular ACL reconstruction technique using autogenous iliotibial band (ITB), which is indicated for prepubescent patients (Tanner stages 1 or 2) with open physes, significant growth potential (≤11 years for girls and ≤12 years for boys) and smaller knees, where an all-epiphyseal ACL reconstruction would lack epiphyseal space
Technique Description
The technique consists of a modified MacIntosh intra-articular and extra-articular ITB reconstruction, described by Micheli and further characterized by Kocher. The central portion of the ITB is harvested proximally (at least 15 cm) and left attached to Gerdy's tubercle distally. The harvested graft is brought from over-the-top posteriorly and passed under the intermeniscal ligament anteriorly through an epiphyseal groove on the tibia.
Results
The outcomes shown for the Kocher ITB ACL reconstruction technique are favorable at a mean follow-up of 5.3 years: from 44 patients, 41 returned to sports involving cutting or pivoting, and the revision rate was low at 4.5%.
Discussion/Conclusion
The awareness of physeal injury related to the operative treatment of ACL tears in the pediatric population has resulted in several physeal-sparing and physeal-respecting techniques of reconstruction. Some of these have shown to reduce the risk of physeal damage, maintaining stability and providing excellent functional outcomes, with low revision rates in long-term follow-up and minimal risk of growth disturbance.
Patient Consent Disclosure Statement
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
