Anterior Cruciate Ligament Reconstruction In Adolescents Research Articles

Graft Choice for Adolescent Athletes Returning to High-Risk Sports: A Matched Cohort Analysis of Patellar Tendon and Hamstring Autografts

Objectives:Graft selection for skeletally mature adolescents undergoing anterior cruciate ligament (ACL) reconstruction is guided by surgeon and patient preference. In young patients returning to high-risk cutting and pivoting sports, graft rupture is the most feared complication of ACL reconstruction. Some studies have demonstrated slightly lower rates of graft failure and decreased laxity in the short term associated with patellar tendon (BTB) autografts as compared to hamstring (HS) autografts, but these studies are limited by their heterogeneity of ages and activity level. The purpose of this study is to compare the rates of graft failure between BTB and HS ACL reconstruction cohorts matched by age, sex, and sport.Methods:A single-institution retrospective review was performed of consecutive patients less than 19 years of age treated with ACL reconstructions using either patellar tendon (BTB) or hamstring (HS) autograft performed by a single surgeon. Skeletally mature or nearly mature patients in “high-risk” ACL injury sports (basketball, football, soccer, lacrosse, and gymnastics) were initially treated with hamstring autografts but the graft preference transitioned to BTB autografts as the preferred graft choice during the study period. This transition in graft preference for adolescents participating in “high risk” sports allows for a comparison of outcomes based on graft types. Inclusion criteria were ages 13 – 18 years, participation in a “high risk” sport, and minimum 24-month follow-up. The two cohorts of patients were matched by age, gender, and sport. The primary outcome measure was graft rupture.Results:One hundred twenty-six patients with an average age of 15.8 years (range 13 – 18 years) met inclusion criteria. There were 60 BTB reconstructions and 66 HS reconstructions. There were 55 females and 71 males. There was no difference in age, sex, BMI, or laterality between groups. There were more patients who played soccer in the BTB cohort (44%) vs HS cohort (22%) and fewer who played basketball in the BTB cohort (24%) vs HS cohort (38%), p = 0.005. There were no differences between the BTB and HS cohorts in terms of meniscus tears (60% v 68%, p = 0.34), meniscus repair (20% v 30%, p = 0.19), or partial meniscectomy (33% v 39%, p = 0.48). Mean duration of follow-up was 41 months (range 24-78 months). There was a difference in follow-up between cohorts (BTB 36 months and HS 50 months, p < 0.05). There were 16 graft ruptures (12.6%). There was no difference in the rate of graft rupture between cohorts (BTB 10.0% vs HS 15.2%, p = 0.45). Mean time to graft rupture was 21 months (range 8 – 35 months) and Kaplan-Meier survival curves demonstrated no difference between cohorts. The mean age of graft failures within the BTB cohort was 15.5 years as compared to 16.1 years for those that did not have a graft failure (p=0.268). The mean age of graft failures within the HS cohort was 14.9 years as compared to 15.9 years for those that did not have a graft failure (p<0.05).Conclusion:ACL reconstruction in adolescents returning to high-risk sports can be performed utilizing BTB or HS autografts with similar rates of graft rupture. Patients under the age of 15 years have a greater risk of failure associated with HS autograft as compared to patients 16 years of age and older with the same graft. In contrast, BTB grafts have similar failure rates regardless of age. There is a trend toward lower rates of graft rupture associated with BTB autografts, but additional patients will be necessary to determine if this trend will become a statistically significant difference.

Anterior Cruciate Ligament Re-tear and Revision Reconstruction in the Skeletally Immature Athlete.

With an increase in high-demand sporting activity, the rate of pediatric and adolescent anterior cruciate ligament (ACL) reconstruction is increasing. Yet, the failure rates after reconstruction are much higher than the adult population. The purpose of this paper is to understand failure rates, reasons for graft failure, and strategies for successful revision surgery. A complete understanding of the failure etiology is essential for the clinician treating this population prior to revision. This begins with an assessment of post-operative patient compliance and sporting activity. Surgical technique must then be scrutinized for non-anatomic tunnel placement and poor graft size/type. Concurrent bony deformity must also be addressed including lower extremity valgus alignment and tibial slope abnormalities. Meniscus and chondral injury must be aggressively treated. Furthermore, imaging must be examined to look for missed posterolateral corner injury. Lateral extra-articular tenodesis (in the setting of ligamentous laxity or rotational instability) may be also indicated as well. The surgeon can then choose a graft type and surgical technique that optimizes outcome and respects skeletal growth. Prior to surgical intervention, the clinician must also counsel patients in regard to the guarded prognosis and outcomes in this setting. Prolonged rehabilitation protocols/return-to-play timing as well as sporting activity modification in the post-operative period after revision are critical. There is limited literature on revision ACL reconstruction in the skeletally immature athlete. An understanding of all the risk factors for failure is essential in order to achieve treatment success.

Prospective Study of Acute Opioid Use After Adolescent Anterior Cruciate Ligament Reconstruction Shows No Effect From Patient- or Surgical-Related Factors.

Patient-reported pain scores and opioid use have not been quantified after outpatient adolescent anterior cruciate ligament reconstruction (ACLR). Patients aged 12 to 18 years undergoing primary isolated ACLR, with or without meniscal treatment, were prospectively recruited. Patients actively taking opioids or with previous extended use of opioids were excluded. Two orthopaedic surgeons performed ACLR and determined the use of a hamstring or bone-patellar tendon-bone autograft. For postoperative pain management, patients were prescribed 40 tablets of hydrocodone/acetaminophen 5/325 mg. Patients were instructed to document daily pill consumption and side effects through a daily log for 6 weeks. Patients completed the American Pain Society Patient Outcome Questionnaire at the end of weeks 1 and 6. One hundred three patients were enrolled, with age: 12.5 to 18.9 years (mean 16.2 y ± 1.3), weight: 41.3 to 113.6 kg (mean 72.4 kg ± 17.2), and body mass index: 17.8 to 40.1 (mean 25.9 ± 4.9). Sixty-nine patients received a hamstring autograft, and 34 received a bone-patellar tendon-bone autograft. Fifty-six received additional meniscal procedures. The median number of postoperative opioids taken by patients was 17 (range 0 to 40). No notable differences were found in total pill consumption with regard to age, weight, body mass index, sex, block type, autograft type, or meniscal treatment at 1 week post-op or 6 weeks post-op. No correlation was found between the self-reported "worst pain in the past 24 hours" at the end of the first postoperative week or after 6 weeks (r = 0.112, P = 0.26, and r = 0.093, P = 0.36). No correlation was found between the level of satisfaction with pain treatment and total number of pills taken during the first postoperative week or at the end of 6 weeks (r = -0.090, P = 0.37, and r = -0.172, P = 0.08). Patients take most pain medication during the first postoperative week after adolescent ACLR, although patient and surgical variables had no notable influence on pill consumption. Level IV, case series.

Complications of Bioabsorbable Tibial Interference Screws After Anterior Cruciate Ligament Reconstruction in Pediatric and Adolescent Athletes.

Background:Interference screw fixation using bioabsorbable implants has become the most common form of tibial-sided graft fixation in anterior cruciate ligament reconstruction (ACLR). Complications related to implant use in the pediatric and adolescent population have not been well studied.Purpose/Hypothesis:The purpose of this study was to retrospectively analyze the complications associated with tibial bioabsorbable interference screw use in adolescents after ACLR. We hypothesized that complication rates would be low (<5%) and that different screw types would have similar complication rates and clinical outcomes.Study Design:Case series; Level of evidence, 4.Methods:Included in this study were patients aged ≤18 years who underwent ACLR with a bioabsorbable tibial interference screw between 2000 and 2011 at a single institution. The subpopulation with screw-related symptoms or complications were identified through chart review. The following 2 outcomes were considered: screw-related symptoms and secondary surgery related to the screw. Multivariable logistic regression was used for adjusted analysis of any screw-related problem.Results:There were 925 ACLR procedures in 858 patients (mean age, 15.7 years; range, 10-18 years) who met inclusion criteria. The median follow-up period was 32.0 months. Of the 925 knees, 89 (9.6%) developed a screw-related problem. In 44 (4.8%) cases, no surgery was required; in 45 (4.9%) cases, surgery for a screw-related problem occurred at a median of 24 months postoperatively. The most common surgical indication was pain at the tibial screw site (42/45, 93%), followed by intra-articular screw issues (3/45, 7%). In adjusted analysis, ACLR procedure performed by a “low-volume” ACL surgeon was the only significant predictor identified. After screw removal surgery, 25 of 27 (93%) patients with at least 12 months of follow-up had complete resolution of screw site symptoms, 18 of 23 (78%) evaluable patients returned to sports, while 8 of 27 (30%) patients underwent additional surgeries, 7 of which were unrelated to the screw procedure.Conclusion:The rate of clinical sequelae from bioabsorbable tibial interference screws was surprisingly high, with symptoms arising after approximately 1 of 10 ACLRs in adolescents. Reoperation for these symptoms was performed in approximately 5% of the knees in the study, at a median 2 years postoperatively. Most patients were able to return to sports after screw removal surgery.

Combined Transphyseal and Lateral Extra-articular Pediatric Anterior Cruciate Ligament Reconstruction: A Novel Technique to Reduce ACL Reinjury While Allowing for Growth

Background: Treatment of anterior cruciate ligament (ACL) injuries in the adolescent population continues to be complicated by an unacceptably high rate of secondary ACL injury. Purpose: To describe the failure rate and outcomes after a hybrid pediatric ACL reconstruction (ACLR) employing transphyseal hamstring (TPH) autograft combined with an extra-articular technique using an iliotibial band (ITB) autograft. Study Design: Case series; Level of evidence, 4. Methods: Consecutive patients undergoing combined TPH-ITB ACLR between January 2012 and April 2017 with a minimum 2-year follow-up were reviewed. With the goal of decreasing ACL graft injury in this high-risk group, this technique employed anteromedial portal drilling for TPH with an extraosseous femoral ITB technique and intra-articular TPH-ITB grafts fixed within the tibial bone tunnel. Demographics, bone age, standing alignment radiograph for growth and mechanical axis grade, return to sport, graft failure, and patient-reported outcome measures were analyzed. Results: A total of 61 knees in 60 adolescents underwent the combined TPH-ITB ACLR, with 57 knees (93.4%) meeting inclusion criteria with a mean follow-up of 38.5 months (range, 24-78 months). Only 3 of 57 knees (5.3%) sustained ACL reinjury. The mean age was 13.0 years (range, 11-16 years) with 36 male patients (mean bone age, 14.2 years) and 21 female patients (mean bone age, 13.3 years), and 91% of patients (52 of 57) returned to sport. Participants demonstrated a high functional level at final follow-up, with a mean score of 91.2 (range, 46.7-100) on the Pediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form and mean score of 22.4 (range, 4-30) on the Pediatric Functional Activity Brief Scale (Pedi-FABS). To critically assess growth, a cohort with ≥18 months of growth remaining at surgery was evaluated at maturity. No difference was seen in mean operative and nonoperative leg growth (49.7 mm and 49.8 mm). Although no family reported cosmetic or functional alignment or length concerns, 1 of 18 (5.5%) had a final limb length discrepancy >10 mm (12 mm) and a perioperative alignment difference (0-Grade II valgus). Conclusion: Combined TPH-ITB ACLR in adolescents resulted in high activity levels (Pedi-FABS, 22.4; median, 25) and a low (5.3%) graft failure rate at a mean 38.5 months.

Effect of Graft Type on Thigh Circumference, Knee Range of Motion, and Lower-Extremity Strength in Pediatric and Adolescent Males Following Anterior Cruciate Ligament Reconstruction.

To treat anterior cruciate ligament (ACL) injury, ACL reconstruction (ACLR) surgery is currently a standard of the care. However, effect of graft type including bone-patellar tendon-bone (BTB), hamstring tendon, or iliotibial band (ITB) on thigh size, knee range of motion (ROM), and muscle strength are understudied. To compare postoperative thigh circumference, knee ROM, and hip and thigh muscle strength in adolescent males who underwent ACLR, based on the 3 different autograft types: BTB, hamstring (HS), and ITB. Biomechanical laboratory. Male ACLR patients who are younger than 22 years of age (total N = 164). At 6- to 9-month postoperative visits, thigh circumference, knee ROM, and hip and thigh muscle strength were measured. Deficits of each variable between the uninvolved and ACLR limb were compared for pediatric and adolescent ACLR males in the BTB, HS, and ITB cohorts. Baseline characteristics, including physical demographics and meniscus tear status, were compared, and differences identified were treated as covariates and incorporated in analysis of covariance. Data were from 164 adolescent male ACLR patients [mean age 15.7 (1.2) years]. There were no statistical differences in thigh circumference, knee ROM, hip abductor, and hip-extensor strength among the 3 autografts. However, patients with BTB demonstrated 12.2% deficits in quadriceps strength compared with 0.5% surplus in HS patients (P = .002) and 1.2% deficits in ITB patients (P = .03). Patients with HS showed 31.7% deficits in hamstring strength compared with 5.4% deficits in BTB (P = .001) and 7.7% deficits in ITB (P = .001) groups at 6- to 9-month postoperative visits. Adolescent male ACLR patients with BTB and HS autografts demonstrated significant deficits in quadriceps and hamstring strength, respectively, at 6 to 9 months postoperatively. Minimal lower-extremity strength deficits were demonstrated in pediatric male ACLR patients undergoing ITB harvest.

Research progress of double-bundle anterior cruciate ligament reconstruction in adolescents

To review the advances in double-bundle anterior cruciate ligament (ACL) reconstruction in adolescents at home and abroad. Recent literature about double-bundle ACL reconstruction in adolescents at home and abroad was extensively consulted, and the relationship between bone canal and epiphyseal plate, clinical verification of surgical safety, and clinical effectiveness of double-bundle ACL reconstruction in adolescents were summarized and analyzed. Double-bundle ACL reconstruction has certain advantages in clinical stability and re-rupture rate when compared with single-bundle ACL reconstruction in adolescents, and there is no significant difference in safety between them. Double-bundle ACL reconstruction in adolescents can achieve lower re-rupture rate and better stability when compared with single-bundle reconstruction. However, the sample size of clinical research is too small, and the follow-up time is too short, so the effectiveness needs to be continuously observed.

Comparison of Drop Jump Landing Biomechanics and Asymmetry among Adolescents with Recent Hamstring, Patellar Tendon, and Quadriceps Tendon Anterior Cruciate Ligament Reconstruction

INTRODUCTION Anterior cruciate ligament reconstruction (ACLR) in adolescents commonly utilizes hamstring (HT), patellar (PT) or quadriceps tendon (QT) autografts. Recent studies demonstrated improved outcomes with PT and QT grafts over HT, but consensus is lacking regarding optimal graft choice. This study compared landing biomechanics and symmetry during the rehabilitation period among adolescent ACLR patients reconstructed with HT, PT and QT grafts as well as uninjured controls. METHODS 61 adolescent patients with recent unilateral ACLR (27 HT, 20 PT, 14 QT; 4-12 months post-surgery, mean 6.4; age 15.4±1.4 years) and …

RE-TEAR AND RE-OPERATION RATES FOR PEDIATRIC AND ADOLESCENT ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

BACKGROUND Anterior cruciate ligament (ACL) injuries have become increasingly common in pediatric and adolescent patients over the last several decades, as this population has become more involved in athletic competition. ACL injuries in skeletally immature patients had historically been treated conservatively with bracing and activity modification; however, poor outcomes including extensive chondral and meniscal damage, increased recurrent instability, and increased sports drop out rates have been observed. Recognition of these poor outcomes has led to a shift towards early operative treatment, resulting in a significant rise in the number of pediatric ACL reconstructions being performed. Yet, a higher failure rate has been noted in this younger population within larger adult cohort studies. The purpose of this study was to evaluate the re-tear and re-operation rates in pediatric and adolescent ACL reconstruction. METHODS The was a retrospective review of pediatric and adolescent patients treated at a single tertiary children’s hospital for ACL reconstruction from 2011 to 2017 by the same pediatric orthopedic surgeon. Review of the electronic medical record was performed to obtain patient demographics, preoperative clinical and radiographic findings, operative notes, and postoperative outcomes. Re-tear and re-operation rates were calculated. RESULTS A total of 308 patients were identified during the study period of which sixty-six percent were female. The mean age of patients was 15.8 years with a mean follow-up of 1.8 +/- 0.8 years. Two-hundred fifty-three hamstring autografts (mean age 15.7+/- 4.1 years) and 55 bone tendon bone autograft (mean age 16.9 +/- 1.45 years) were performed. Two hundred forty-three patents had adult-style reconstructions performed, 40 had transphyseal reconstructions, 24 had partial transphyseal reconstruction, and 1 patient had an all-epiphyseal reconstruction. Average hamstring graft size was 8.3 mm +/- 0.5 mm and all BTB graft were 9 mm. The overall graft re-tear rate was 8.2%. The overall re-operation rate was 13.2% (17 revisions, 5 medial meniscus repairs, 3 I+D’s, 2 cyclops debridements, 1 removal of hardware, and 1 manipulation under anesthesia). The highest re-tear (12.5%) and re-operation (22.5%) rates were found in patients who underwent a transphyseal reconstruction. No growth disturbances which required surgical intervention were noted. CONCLUSIONS / SIGNIFICANCE Pediatric and adolescent ACL reconstruction can be performed safely without a risk of growth disturbance. Patients had a high re-tear and re-operation rate; particularly in patients who underwent transphyseal reconstruction. Strategies must be developed to decrease the re-tear and re-operation rate in this population.

OUTCOMES FOLLOWING ACL RECONSTRUCTION USING PATELLAR TENDON VERSUS HAMSTRING TENDON AUTOGRAFT IN ADOLESCENT ATHLETES: AN AGE-MATCH, SEX-MATCHED, AND BODY MASS INDEX-MATCHED COHORT STUDY

Background: Anterior cruciate ligament reconstruction (ACLR) remains one of the most commonly performed orthopaedic surgeries in adolescents and young adults. However, selection of the optimal graft for the individual patient remains controversial, considering multiple graft options, subtle technique differences, and wide-ranging bodies of evidence for each graft option in largely adult populations. However, multiple epidemiologic studies clearly demonstrate adolescents as the most greatly affected age-based sub-population, with the highest rates of re-tear and global morbidity, due to psychological and physical effects of long absences from athletic activity. Nevertheless, methodologically rigorous comparative studies specific to the adolescent athlete are largely absent from the literature. The purpose of the current study is to therefore investigate the outcomes of ACLR in adolescents receiving either patellar tendon/bone-tendon-bone (BTB) autograft (ACLR-BTB) or hamstring tendon autograft (ACLR-HS), using retrospective propensity score matching techniques to generate comparable cohorts. Methods: The study was designed as a retrospective chart review, with collection of cross-sectional data from a single pediatric tertiary care center over a thirteen year period (2003-2015). An initial cohort of patients, aged 13-19 years at time of primary ACLR-BTB or primary ACLR-HS by one of 5 surgeons, was identified through a comprehensive electronic medical record database query. Propensity score matching of ACLR-BTB and ACLR-HS subjects through a logistic regression model, with caliper restriction of 0.1 standard deviations, was then applied, based upon specific baseline characteristics that are frequently used by some surgeons to guide graft selection: age, sex, and body mass index (BMI). The resultant cohort of patients obtained a 1:2 (ACLR-BTB: ACLR-HS, 83 patients:186 patients) match. A chart review was performed to identify patient demographics, surgical data, and post-operative outcomes including graft rupture/re-tear and length of clinical follow-up. Patients were additionally contacted to obtain longer term sport participation and re-injury data that may have been investigated or addressed at outside institutions, as well as to obtain functional outcomes using region-specific questionnaires (Pedi-IKDC and HSS-Pedi FABS), which are validated for both this younger population and adult populations. Due to previous literature-based reports on greater anterior knee pain following ACLR-BTB, compared to ACL-HS, scores from the questions specific to knee pain or kneeling pain were extracted from the Pedi-IKDC results and analyzed to assess the potential influence of anterior knee pain on overall scores within this adolescent population. Results: At time of ACLR, the mean age and BMI of the matched ACLR-BTB patients were 17.1 years (sd: +/-1.14 years) and 25.8 (sd: +/-5.04), compared to 16.9 years (sd: +/- 1.38, p: 0.18) and 24.9 (sd: +/- 5.01, p: 0.18) for matched ACLR-HS patients, with similar male preponderance (ACLR-BTB: 77%, ACLR-HS: 72%, p: 0.47) and mean length of follow-up (ACLR-BTB: 42.9 months; ACLR-HS: 43.3 months). While mean Pedi-IKDC scores were slightly higher in the ACLR-BTB group (88.8; sd: +/-10.2, range: 56.5-100) than the ACLR-HS group (85.2; sd: +/- 16.1, range: 23.9-100), this difference was not statistically different (p: 0.50). When scores on questions regarding knee pain and kneeling difficulty were analyzed, no differences were seen between graft cohorts (ACLR-BTB: median knee pain score: 4, ACLR-HS: 4 p: 0.73; ACLR-BTB median kneeling difficulty score: 4, ACLR-HS: 4, p: 0.21). Activity level, based on the HSS-Pedi FABS score, was also similar (ACLR-BTB: 16, range: 3-29 vs. ACLR-HS: 17, range: 0-30; p: 0.96). Rates of ACL graft re-tear were not significantly different between groups, both when calculated based all possible follow-up methods (ACLR-BTB: 11%, ACLR-HS: 11%, p: 0.91), or when those patients responding to long-term follow up questionnaires were isolated (ACLR-BTB: 15%, ACLR-HS: 16%, p: 0.85). Conclusion/Significance: Despite previous studies, including large, multi-country registry-based analyses, demonstrating lower re-tear rates following ACLR-BTB than ACLR-HS, the current study, focused exclusively on adolescent cohorts matched for age, sex, and BMI, showed no difference in graft re-tear rates between the two cohorts at medium-term follow-up. Moreover, activity scores and functional knee outcome scores appear to be equivalent between these younger graft-based populations. In contrast to previous studies associating BTB autograft with greater long term anterior knee pain, adolescents appear to have equal degrees of knee pain or kneeling pain, regardless of graft choice, which may stem from greater healing and biologic remodeling capacity at graft harvest sites than adults or more modern techniques of patellar bone grafting and paratenon closure. Given the consistently high adolescent ACL re-tear rates in this and other studies, continued focus on ACL prevention programs and optimizing the timing and safety of return to play remains critical.

AGE APPROPRIATENESS OF COMMON NEUROMUSCULAR TRAINING EXERCISES

Background Anterior cruciate ligament (ACL) injury is a significant public health concern in the US with at least 250,000 injuries occurring annually. The rate of ACL reconstruction in adolescents has risen 33% in the past 20 years. Much effort has been dedicated to developing neuromuscular training (NMT) programs to reduce the risk of ACL injury. While preventive programs have been successful in decreasing the rate of ACL injury in young populations, the appropriateness of NMT exercises across different age groups has not yet been demonstrated. The purpose of this study is to determine if children ages 8-11 and 12-15 can perform common NMT exercises with equal ability. Methods In 2016, Hospital for Special Surgery (HSS) developed a series of NMT programs for young athletes. Seven exercises were selected for evaluation from both the Beginner (8-11) and Intermediate (12-15) programs. Male and female subjects aged 8-15 were recruited from schools and youth sports organizations in and around New York City. Informed consent/assent was obtained from each subject. Participants completed a demographic survey and were assigned a subject ID before testing. Participants completed two trials of each exercise. Performance was assessed after receiving visual/verbal exercise instruction and again after receiving visual/verbal cues that reinforced correct exercise technique. Three sports medicine practitioners evaluated each exercise using three performance criteria. Exercise technique was deemed correct when at least two evaluators agreed that neutral alignment of the cervical spine, lumbopelvic complex and lower extremities was maintained during each exercise. Comparisons of performance within each sex were made for 8-9 &amp; 10-11 and 12-13 &amp; 14-15 groups using Chi-square test or Fisher’s exact test using SAS version 9.4 (SAS Inc., Cary, NC). Results 301 total participants were evaluated (8-11 years: n = 165, 54.2% female; 12-15 years: n = 136, 39.9% female). The percentage of participants who performed exercises correctly are shown in Table 1 and 2 (attached). There was no significant difference between male and female participants who completed exercises correctly in either cohort. There was also no significant difference noted in exercise performance between participants aged 8-9 &amp; 10-11 years or between participants aged 12-13 &amp; 14-15 years. The use of technique cues significantly increased the percentage of participants who correctly completed the exercise across all ages and sexes (p &lt; 0.001). 21% of the cohort aged 8-11 completed exercises correctly when provided with exercise instruction and 45% completed exercises correctly when provided with technique cues. 29% of the cohort aged 12-15 completed exercises correctly when provided with exercise instruction and 59% completed exercises correctly when provided with technique cues. The kappa statistic was used to measure inter-rater reliability and among all criteria for all evaluators k = 0.31 (8-11 cohort) and k = 0.42 (12-15 cohort). Conclusion Our results indicate that male and female children aged 8-9 &amp; 10-11 years and 12-13 &amp; 14-15 years can perform common NMT exercises with equal ability. This is an important consideration when designing preventive programs for young athletes based on chronological age. Additionally, only one-fourth all study participants were able to perform common NMT exercises with correct technique when provided with visual/verbal exercise instruction, while over one-half of the participants were able to perform these same exercises correctly when provided with visual/verbal technique cues. This improvement highlights the importance of providing cues that effectively improve exercise technique for young athletes. Based on motor learning theory, repeated cuing would likely increase the percentage of children who perform NMT exercises correctly. These results call attention to the urgent need for coaches and physical educators to provide appropriate technique cues when implementing NMT programs. [Table: see text][Table: see text]

GRAFT CHOICE FOR ADOLESCENT ATHLETES RETURNING TO HIGH-RISK SPORTS: A MATCHED COHORT ANALYSIS OF PATELLAR TENDON AND HAMSTRING AUTOGRAFTS

Background: Graft selection for skeletally mature adolescents undergoing anterior cruciate ligament (ACL) reconstruction is guided by surgeon and patient preference. In young patients returning to high-risk cutting and pivoting sports, graft rupture is the most feared complication of ACL reconstruction. Some studies have demonstrated slightly lower rates of graft failure and decreased laxity in the short term associated with patellar tendon (BTB) autografts as compared to hamstring (HS) autografts, but these studies are limited by their heterogeneity of ages and activity level1-3. The purpose of this study is to compare the rates of graft failure between BTB and HS ACL reconstruction cohorts matched by age, sex, and sport. Methods: A single-institution retrospective review was performed of consecutive patients less than 19 years of age treated with ACL reconstructions using either patellar tendon (BTB) or hamstring (HS) autograft performed by a single surgeon. Skeletally mature or nearly mature patients in “high-risk” ACL injury sports (basketball, football, soccer, lacrosse, and gymnastics) were initially treated with hamstring autografts but the graft preference transitioned to BTB autografts as the preferred graft choice during the study period. This transition in graft preference for adolescents participating in “high risk” sports allows for a comparison of outcomes based on graft types. Inclusion criteria were ages 13 – 18 years, participation in a “high risk” sport, and minimum 6-month follow-up. The two cohorts of patients were matched by age, gender, and sport. The primary outcome measure was graft rupture. Results: One hundred fifty-two patients with an average age of 16 years (range 13 – 18 years) underwent ACL reconstruction during the study period. There were 71 BTB reconstructions and 81 HS reconstructions. There were 64 females and 88 males. There was no difference in age, sex, BMI, or laterality between groups. There were more patients who played soccer in the BTB cohort (44%) vs HS cohort (20%) and fewer who played basketball in the BTB cohort (24%) vs HS cohort (41%), p = 0.005. There were no differences between the BTB and HS cohorts in terms of meniscus tears (61% v 72%, p = 0.15), meniscus repair (21% v 32%, p = 0.13), or partial meniscectomy (32% v 33%, p = 0.90). Mean duration of follow-up was 28 months (range 7-57 months). There was no difference in follow-up between cohorts (BTB 28 months and HS 29 months, p = 0.19). There were a total of 16 graft ruptures (10.5%). There was no difference in the rate of graft rupture between cohorts (BTB 8.5% vs HS 12.3%, p = 0.60). Mean time to graft rupture was 21 months (range 8 – 35 months) and Kaplan-Meier survival curves demonstrated no difference between cohorts. Conclusions: ACL reconstruction in adolescents returning to high-risk sports can be performed utilizing BTB or HS autografts with similar rates of graft rupture. There is a trend toward lower rates of graft rupture associated with BTB autografts, but additional patients will be necessary to determine if this trend will become a statistically significant difference. Beynnon BD, Johnson RJ, Fleming BC, et al. Anterior cruciate ligament replacement: comparison of bone-patellar tendon bone grafts with two-strand hamstring grafts. A prospective, randomized study. J Bone Joint Surg Am 2002;84(9):1503-1513. Ho B, Edmonds EW, Chambers HG et al. Risk factors for early ACL reconstruction failure in pediatric and adolescent patients: a review of 561 cases. J Pediatr Orthop 2016. Samuelsen BT, Webster KE, Johnson NR, et al. Hamstring autograft versus patellar tendon autograft for ACL reconstruction: is there a difference in graft failure rate? A meta-analysis of 47,613 patients. Clin Orthop Relat Res 2017;475(10):2459-2468.

SEX-BASED DIFFERENCES IN THE OUTCOMES OF ACL RECONSTRUCTION WITH QUADRICEPS TENDON – PATELLAR AUTOGRAFT IN ADOLESCENT PATIENTS

Background: Female athletes suffer anterior cruciate ligament (ACL) injuries at a 2- to 10-fold greater rate than male athletes participating in the same sports. Previous research demonstrates worse patient reported outcomes and increased postoperative laxity in females with an HA autograft or BTB autograft compared to their male counterparts. Quadriceps tendon-patellar autograft has been established as a reliable graft choice for adolescent ACL reconstruction. The purpose of this study is to investigate sex-based differences in graft survival, patient reported outcomes, and joint laxity after ACL reconstruction with QPA among adolescent patients. Methods: All patients who underwent ACL reconstruction with QPA between November 2013 and November 2015 who were a minimum of 1-year post-operative were identified. Demographic data, surgical information, and graft failure was collected retrospectively. Subjects were then contacted by phone to administer International Knee Documentation Committee (IKDC) and Lysholm questionnaires. KT1000 arthrometer measurements were available for a subset of patients who attended a clinic follow-up appointment greater than 1 year postoperative. Results: The final cohort included 18 females and 20 males ages 10 to 18 years old. After adjusting for age and medial meniscus procedures, the hazard of graft failure among male athletes was 2.11 times [95% CI: 0.17 to 26.10, p = 0.5577] the hazard of failure among female athletes. No significant sex-based differences were found in time to return to sport, contralateral ACL injuries, or patient reported outcomes. KT 1000 joint laxity measurements were similar in male [median: 1 mm, IQR: 1 to 2 mm] and in female athletes [median: 1 mm, IQR: 1 to 2 mm]. After adjusting for BMI and medial meniscus procedures performed, KT1000 measurements were 8.74% higher [95% CI: 16.4% lower to 41.40% higher, p = 0.51999] in male athletes compared to female athletes. Conclusion/Significance: There were no differences between males and females in patient reported outcomes, post-operative laxity, or graft failure among subjects who underwent ACL reconstruction with QPA at a minimum of 1 year postoperative. The quadriceps tendon-patellar autograft is a reliable graft choice for both adolescent males and females. We will be completing further data collection in the next month and aim to consider subjects who are a minimum of 2 years postoperative.

Comparison of drop jump landing biomechanics and asymmetry among adolescents with hamstring, patellar and quadriceps tendon autografts for anterior cruciate ligament reconstruction

BackgroundAdolescent anterior cruciate ligament reconstruction (ACLR) commonly utilizes hamstring (HT), patellar (PT) or quadriceps (QT) tendon autografts, but consensus is lacking regarding optimal graft choice. This study compared landing biomechanics and asymmetries among ACLR patients with HT, PT and QT grafts and uninjured controls. MethodsThis retrospective study included 61 adolescents with unilateral ACLR (27 HT, 20 PT, 14 QT; four to 12 months post-surgery, mean 6.4; age 15.4, SD 1.4 years) and 27 controls (14.6, SD 0.9 years) who were evaluated during drop jump landings. Lower extremity 3D biomechanics and asymmetries were compared. ResultsCompared to controls, all operative limbs exhibited 1) greater hip flexion and lower dorsiflexion angles; 2) higher hip and lower knee and ankle flexion moments; 3) higher energy absorption at the hip (HT and QT only) and lower at the knee and ankle; and 4) higher knee abduction moments. Asymmetries observed in all ACLR groups included 1) lower knee and ankle flexion angles; 2) lower knee and ankle flexion moments; 3) lower energy absorption at the knee and ankle; and 4) higher hip and knee abduction moments on the operative side. The PT and QT groups demonstrated greater asymmetry in hip and knee flexion moments compared to HT. ConclusionsWhile adolescent ACLR limbs offloaded the knee and ankle, patients with PT or QT grafts demonstrated greater deficiencies during rehabilitation than those reconstructed with HT. Graft choice in ACLR should remain patient-specific and aim to optimize biomechanics with the ultimate goal of minimizing graft re-tear and donor site morbidity.

Socioeconomic Status Impacts Outcomes Following Anterior Cruciate Ligament Reconstruction Status

Objectives:Delays in pediatric and adolescent anterior cruciate ligament reconstruction (ACLR) are associated with increased prevalence of concomitant knee injuries and worse post-operative outcomes. However, few studies have described the factors that may contribute to these delays and adverse events. This study seeks to determine the impact socioeconomic status has on outcomes following ACLR.Methods:Patients who underwent primary ACLR at a pediatric hospital between 2009 and 2015 were retrospectively reviewed. Variables included clinical outcomes and post-operative complications, as well as chronologic, demographic, and socioeconomic factors. Post-operative complication variables included graft failure, return to operating room, stiffness, and infection. Socioeconomic status was measured using health insurance type (commercial vs. government) and city block group level median household income levels derived from 2009-2015 U.S. Census Bureau data. Patients were excluded if they had multiligamentous knee injuries, prior ACLR, presented more than 365 days after injury, or had missing medical record data.Results:Overall, 127 patients (69 male, 58 female) were included in data analysis. The mean age at time of surgery was 15.0 ± 2.3 years (range = 9 to 21 years). There were 68 patients in the commercial insurance group and 59 patients in the government insurance group. Patients in the commercial insurance group had an average household median income of $87,767 (SD = $38,325) compared to $51,366 (SD = $25,330) in the government insurance group, p = < 0.0001. Patients in the government insurance group demonstrated greater delays in time from injury to first appointment (p = 0.0003), injury to MRI (p = 0.021), injury to surgery (p = < 0.0001), first appointment to surgery (p = 0.0036), and injury to return to play, p = 0.044 (Table 1). At time of surgery, 81% (48/59) of patients in the government insurance group presented with concomitant meniscal injuries compared 65% (44/68) of patients in the commercial insurance group, p = 0.034 (Odds Ratio = 2.38). Post-operatively, 22% (13/58) of patients in the government insurance group experienced decreased knee range of motion (“stiffness”) compared to 9% (6/68) in the commercial insurance group, p = 0.033 (Odds Ratio = 2.99). No significant differences were found between insurance types for rates of concomitant chondral injuries, graft failure, re-operation, or post-operative infection.Conclusion:Pediatric patients with government health insurance may experience delays in receiving definitive knee injury management and be at risk for complications and diminished outcomes. These delays are likely multifactorial, and may be attributed to decreased access to care, familial resources, and social support. Of note, our findings suggest a significant discrepancy in time to treatment as well as rates of concomitant knee injuries and post-operative complications between government and commercial insurance types.Table 1.Comparsion of insurance types by chronologic variables Commercial Government P Injury to First Appointment (days) 48.9 ± 57.196.5 ± 85.40.0003 Injury to MRI (days) 44.2 ± 83.385.9 ± 80.80.021 Injury to Surgery (days) 90.4 ± 83.7174.6 ± 122.2<0.0001 First Appointment to Surgery (days) 41.9 ± 65.278.1 ± 71.80.0036 Injury to Return to Play (days) 336.2 ± 130.4394.7 ± 153.60.044 Surgery to Return to Play (days) 255.7 ± 116.8238.9 ± 98.50.445

Use of Posterior Hamstring Harvest During Anterior Cruciate Ligament Reconstruction in the Pediatric and Adolescent Population.

Background:Posterior hamstring harvest has been described in the adult population in a limited fashion, but no study is available describing the use of posterior hamstring harvest in an active pediatric and adolescent cohort. At times, surgeons may be faced with a challenging anterior harvest due to patient anatomic characteristics, particularly the anatomic features and size of the pes tendons. Clinicians need to have multiple harvest approaches at their disposal. Complications with hamstring harvest such as premature graft transection are more problematic in this population due to higher failure rates with allograft tissue. The posterior harvest via its more proximal location may allow for easier tendon identification, visualization of the accessory attachments, and longer preserved tendon length if transection error occurs when the anterior approach is avoided based on surgical technique, patient anatomic characteristics, and surgeon and patient preference.Purpose:To describe the technique of a posterior hamstring harvest in pediatric and adolescent patients and to analyze complications.Study Design:Case series; Level of evidence, 4.Methods:This study was a retrospective review of a consecutive series of pediatric and adolescent patients who underwent posterior hamstring harvest. During surgery, the patient’s leg was abducted and externally rotated to expose the posteromedial aspect of the knee. A 2-cm incision was made overlying the palpable medial hamstring at the popliteal crease. The posterior hamstring tendons were first harvested proximally with an open tendon stripper and distally with a closed stripper. Preoperative, intraoperative, and postoperative findings and complications were analyzed.Results:A total of 214 patients (mean ± SD age, 15.7 ± 4.1 years; range, 8.0-19.8 years) underwent posterior harvest, with a mean ± SD follow-up of 1.83 ± 1.05 years. No complications occurred in our series related to graft harvest—no graft transections, neurovascular injuries, secondary procedures for wound healing or closure, cosmetic concerns, or limitations in return to activity due to the posterior incision.Conclusion:The posterior hamstring harvest is a safe and reliable technique to harvest autograft tendon in pediatric and adolescent anterior cruciate ligament reconstructions. The posterior technique entailed no complications related to harvest. No patients expressed any cosmetic concerns about their incision or had limitations in return to sport due to the posterior harvest.

Outcomes and Return to Sport After Revision Anterior Cruciate Ligament Reconstruction in Adolescent Athletes

Background:The number of adolescent anterior cruciate ligament (ACL) injuries is rising with increased participation in higher level athletics at earlier ages. With an increasing number of primary ACL reconstructions (ACLRs) comes a rise in the incidence of revision ACLRs.Purpose:To evaluate the clinical results of revision ACLR across a group of high-level adolescent athletes with at least 2-year follow-up.Study Design:Case series; Level of evidence, 4.Methods:A retrospective review of 21 adolescent athletes (age range, 10-19 years) who underwent revision ACLR with at least 2-year follow-up was conducted. Patient-reported outcome measures (PROMs) included the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm knee scoring scale, Tegner activity level scale, and modified Cincinnati Knee Rating System. Return to sport (RTS) and overall patient satisfaction were also assessed.Results:The mean age at the time of surgery was 16.5 years (range, 14-19 years), and the mean follow-up was 46.4 months (range, 24-97 months); 42.9% of patients were female, and 52.4% of patients participated in collision sports. The mean time to failure after primary ACLR was 13.1 ± 8.0 months, and the most common mechanism of failure was noncontact in at least 66.7% of cases. The revision graft type included bone–patellar tendon–bone (BPTB) in 71.4% of cases; 26.7% of BPTB grafts were from the contralateral extremity. Concomitant procedures were performed for intra-articular lesions in 71.4% of patients. The mean patient satisfaction rate was 95.3%. There were 3 cases of a graft reinjury at a mean of 25 months postoperatively. The mean PROM scores were as follows: IKDC, 87.5 ± 12.7; Tegner, 7.2 ± 2.0; Lysholm, 93.7 ± 9.8; and Cincinnati, 93.4 ± 10.0. Of those attempting to RTS, 68.4% of patients successfully returned at the same level of competition. Patients with a lateral compartment chondral injury were less likely to RTS (P < .05). Independent variables shown to have no significant relationship to PROMs or RTS included age, follow-up, sport classification, associated meniscal tears, revision graft size/type, and concomitant procedures.Conclusion:Revision ACLR can be an effective surgical option in adolescents participating in collision and contact sports, with good to excellent subjective outcome scores. At a minimum 2-year follow-up, a graft rupture after revision ACLR occurred in 14% of cases. Of the athletes attempting to RTS, 68.4% returned to their preinjury level of competition.

Effect of Graft Type on Balance and Hop Tests in Adolescent Males Following Anterior Cruciate Ligament Reconstruction.

Context: Recent epidemiology studies indicated a steady increase of anterior cruciate ligament (ACL) injury in young athletes. ACL reconstruction (ACLR) is currently a standard of care, but the effect of ACLR graft including bone patellar tendon bone (BTB), hamstring tendon (HT), or iliotibial band (ITB) on balance and hop performance is understudied. Objective: To compare balance and hop deficits between uninvolved and reconstructed limbs in each autograft type (aim 1) and among the 3 autograft groups (aim 2). Setting: Biomechanical laboratory. Participants: Male ACLR patients who are younger than 22 years (total N = 160; BTB: N = 19, HT: N = 108, ITB: N = 33). Intervention: Approximately 6 to 9 months following ACLR, Y-balance and 4 types of hop tests were measured bilaterally. Main Outcome Measures: Limb symmetry index of balance and hop tests within each graft type and between the 3 graft types. Results: In the BTB group, significant anterior reach, single hop, triple hops, and cross-over hops deficits were observed on the ACLR limb compared with the uninvolved limb. The HT group showed significant deficits in single hop, triple hops, and cross-over hops on the ACLR limb relative to the uninvolved limb. Compared with the uninvolved limb, significantly decreased triple hops and 6-m timed hop deficits in the ACLR limb were recorded in the ITB group. When controlling for confounders and comparing among the 3 autograft types, the only significant difference was anterior reach, in which the BTB group showed significant deficits. Conclusion: Compared with the uninvolved limb, significant hop deficits in ACLR limb were prevalent among adolescent ACLR at ∼6 to 9 months postoperatively. After controlling covariates, significantly reduced anterior reach balance was found in the BTB group compared with the HT and ITB groups.

Allograft augmentation of hamstring autografts was not a cost-effective treatment option for middle aged patients undergoing primary anterior cruciate ligament reconstruction

Background: By lessening the rate of graft failure, augmentation of hamstring autografts with semitendinosus allograft tissue has been demonstrated to provide a cost-effective treatment option for adolescent anterior cruciate ligament reconstruction (ACLR) patients. However, with the overall rate of graft failure being much lower in older patients, it remains unclear if these so-called hybrid hamstring grafts are a cost-effective option in the middle-aged patient population. We hypothesized that hybrid hamstring grafts would not result in a clinically meaningful reduction in the prevalence of graft failure and, as such, would not be a cost-effective treatment option for middle-aged patients. Methods: We retrospectively identified patients ≥25 years of age that had undergone ACLR by a single surgeon between 2010 and 2015. Patient demographics, graft type, and the need for secondary surgical procedures were compared between hamstring autografts (HAM) and hamstring autografts augmented with semitendinosus allograft tissue (HYBRID). The clinical results were then used to assess the potential cost effectiveness of HYBRID grafts in this group of middle-aged ACL patients. Results: There were a total of 288 patients (HAM = 138, HYBRID = 150). The rate of graft failure did not differ between groups (HAM = 3/138, 2.2% vs. HYBRID = 4/150, 2.7%, P>0.99). The cost-effectiveness analysis demonstrated that the HAM graft provided incremental cost savings of $1,322.39 compared to the HYBRID graft, and the HAM graft was the preferred strategy in 85% of cases. Conclusions: In younger patients, the initial cost of allograft augmentation is offset by a significant reduction in graft failure; however, similar findings were not realized in series of middle-aged patients. This information can assist surgeons as the both the techniques and patient selection criteria for hybrid grafts continues to evolve.

A 10-year Retrospective Review of Functional Outcomes of Adolescent Anterior Cruciate Ligament Reconstruction.

Rupture of the anterior cruciate ligament (ACL) is an increasingly prevalent sporting injury in adolescents. Surgical reconstruction of the ACL in adolescents has been controversial and there has been little reported on functional outcomes after surgery.The aim of this study was to undertake a retrospective notes review and questionnaire survey of a group of adolescents who had their ACL surgically reconstructed over the previous 10 years, assessing delay to surgery, levels of meniscal damage, reoperation rates, and functional outcomes. A retrospective chart review was performed on 100 adolescent patients who underwent arthroscopic ACL reconstruction using a transphyseal technique. These patients were also contacted and completed the Knee Osteoarthritis Outcome Score (KOOS). One hundred patients had their records reviewed. The average age at follow-up was 20.5 (SD, 2.4) years. There were 49 females and 51 males. Meniscal tears were present in 76% of patients at the time of surgery. The rate of medial meniscal tears increased with delay to surgical intervention beyond 3 months. Reoperation rate for these patients was 24%.Eighty patients completed the KOOS questionnaire. Patients were a mean of 4 (SD, 2.2) years postsurgery. The main findings indicate that in the 5 key KOOS domains patients scored a mean of 60 (SD, 13) for symptoms, 65 (SD, 10) for pain, 70 (SD, 6.4) for activities of daily living, 54 (SD, 17.6) for sport and recreation, and 47.2 (SD, 20.1) for quality of life. This study demonstrates that young people with ACL injuries have a very high associated incidence of meniscal pathology at the time of surgery. There is a high reoperation rate for meniscal surgery and graft failure. Four years post-ACL reconstruction many have not yet returned to a fully functional state.Further research to understand why functional outcomes are modest is required. Level IV-retrospective case series.