VARIATION IN PREFERRED TECHNIQUE FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN THE SKELETALLY IMMATURE: WHERE DO WE STAND?

Abstract

Purpose: Despite several well-described operative techniques, the optimal management of anterior cruciate ligament (ACL) injuries in pediatric patients remains unclear. The goal of this study was to identify preferred techniques in skeletally immature patients of various ages and analyze differences in operative strategy based on surgeon and practice demographics. Methods: An electronic survey was administered to members of the Pediatric Research in Sports Medicine society, a cohort of experienced surgeons who perform a high volume of pediatric ACL reconstructions. The survey presented a scenario of a patient who had a physical exam and imaging consistent with an acute, isolated ACL tear. The respondent was asked to select their preferred reconstruction technique for females and males at consecutive skeletal ages from 8 to 15 years. Surgeon and practice demographic information was recorded. Univariate analysis was followed by stepwise multinominal logistic regression to control for confounders. Results: Eighty-eight of 103 surgeons (85%) responded to the survey, the majority of whom (68%) performed more than 25 pediatric ACL reconstructions annually. The greatest variation in technique was from ages 11 to 13 in females and 11 to 14 in males. The modified MacIntosh was the most frequently utilized from ages 8 to 10. An all-epiphyseal technique was preferred over a broader age range in males than females, with peak utilization at age 11 in both. A partial trans-physeal (hybrid) technique was preferred in slightly older patients, with peak utilization at age 12 in females and 13 in males. The trans-physeal technique was most widely used at age 13 and up in females and 14 and up in males. The impact of fellowship training on technique preference was statistically significant for males ages 11-13 and females 11 and 12 (p<0.05 for all). Surgeons with pediatric orthopaedic training tended to prefer an all-epiphyseal reconstruction, while those with both pediatric and sports training preferred the modified MacIntosh. Conclusions: The preferred ACL reconstruction technique for skeletally immature patients varied considerably, especially in the 11-13 year-old age range, highlighting a lack of consensus among orthopedic surgeons for the optimal ACL reconstruction strategy in skeletally immature patients. Surgeon’s fellowship training was significantly associated with their preferred surgical technique.