Adolescent Anterior Cruciate Ligament Research Articles

Effects of various load magnitudes on ACL: an in vitro study using adolescent porcine stifle joints

IntroductionThe escalating incidence of anterior cruciate ligament (ACL) injuries, particularly among adolescents, is a pressing concern. The study of ACL biomechanics in this demographic presents challenges due to the scarcity of cadaveric specimens. This research endeavors to validate the adolescent porcine stifle joint as a fitting model for ACL studies.MethodsWe conducted experiments on 30 fresh porcine stifle knee joints. (Breed: Yorkshire, Weight: avg 90 lbs, Age Range: 2–4 months). They were stored at − 22 °C and a subsequent 24-h thaw at room temperature before being prepared for the experiment. These joints were randomly assigned to three groups. The first group served as a control and underwent only the load-to-failure test. The remaining two groups were subjected to 100 cycles, with forces of 300N and 520N, respectively. The load values of 300N and 520N correspond to three and five times the body weight (BW) of our juvenile porcine, respectively.ResultThe 520N force demonstrated a higher strain than the 300N, indicating a direct correlation between ACL strain and augmented loads. A significant difference in load-to-failure (p = 0.014) was observed between non-cyclically loaded ACLs and those subjected to 100 cycles at 520N. Three of the ten samples in the 520N group failed before completing 100 cycles. The ruptured ACLs from these tests closely resembled adolescent ACL injuries in detachment patterns. ACL stiffness was also measured post-cyclical loading by applying force and pulling the ACL at a rate of 1 mm per sec. Moreover, ACL stiffness measurements decreased from 152.46 N/mm in the control group to 129.42 N/mm after 100 cycles at 300N and a more significant drop to 86.90 N/mm after 100 cycles at 520N. A one-way analysis of variance (ANOVA) and t-test were chosen for statistical analysis.ConclusionsThe porcine stifle joint is an appropriate model for understanding ACL biomechanics in the skeletally immature demographic. The results emphasize the ligament’s susceptibility to injury under high-impact loads pertinent to sports activities. The study advocates for further research into different loading scenarios and the protective role of muscle co-activation in ACL injury prevention.

Prevalence and Predictors of Concomitant Meniscal Surgery During Pediatric and Adolescent ACL Reconstruction: Analysis of 4729 Patients Over 20 Years at a Tertiary-Care Regional Children's Hospital.

The rate of concomitant meniscal procedures performed in conjunction with anterior cruciate ligament (ACL) reconstruction is increasing. Few studies have examined these procedures in high-risk pediatric cohorts. That (1) the rates of meniscal repair compared with meniscectomy would increase throughout the study period and (2) patient-related factors would be able to predict the type of meniscal operation, which would differ according to age. Cohort study (prevalence); Level of evidence, 2. Natural language processing was used to extract clinical variables from notes of patients who underwent ACL reconstruction between 2000 and 2020 at a single institution. Patients were stratified to pediatric (5-13 years) and adolescent (14-19 years) cohorts. Linear regression was used to evaluate changes in the prevalence of concomitant meniscal surgery during the study period. Logistic regression was used to determine predictors of the need for and type of meniscal procedure. Of 4729 patients (mean age, 16 ± 2 years; 54.7% female) identified, 2458 patients (52%) underwent concomitant meniscal procedures (55% repair rate). The prevalence of lateral meniscal (LM) procedures increased in both pediatric and adolescent cohorts, whereas the prevalence of medial meniscal (MM) repair increased in the adolescent cohort (P = .02). In the adolescent cohort, older age was predictive of concomitant medial meniscectomy (P = .031). In the pediatric cohort, female sex was predictive of concomitant MM surgery and of undergoing lateral meniscectomy versus repair (P≤ .029). Female sex was associated with decreased odds of concomitant LM surgery in both cohorts (P≤ .018). Revision ACLR was predictive of concomitant MM surgery and of meniscectomy (medial and lateral) in the adolescent cohort (P < .001). Higher body mass index was associated with increased odds of undergoing medial meniscectomy versus repair in the pediatric cohort (P = .03). More than half of the young patients who underwent ACLR had meniscal pathology warranting surgical intervention. The prevalence of MM repair compared with meniscectomy in adolescents increased throughout the study period. Patients who underwent revision ACLR were more likely to undergo concomitant meniscal surgeries, which were more often meniscectomy. Female sex had mixed effects in both the pediatric and adolescent cohorts.

Impact of Lateral Extra-Articular Procedure Augmentation on Rerupture Risk and Tegner Activity Scale Outcomes in Adolescent Anterior Cruciate Ligament: A Matched Comparative Study With a Minimum 2-Year Follow-up

Background: Despite the well-established role of lateral extra-articular procedures (LEAPs) in reducing failure rates after anterior cruciate ligament (ACL) reconstruction (ACLR) in the adult population, similar in-depth research for the adolescent and pediatric population remains lacking. Purpose: To examine the effect of the LEAP augmentation on the rerupture rate after ACLR in patients aged <18 years. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective analysis of prospectively collected data from October 2012 to June 2020, involving adolescents <18 years old undergoing primary ACLR with a minimum follow-up of 2 years. Two groups, matched for age, sex, Tegner activity scale, and presence of meniscal injury, were established: ACLR alone and ACLR+LEAP augmentation. The primary outcome measure was the rate of rerupture after ACLR. The secondary outcome measures were the rate of non–graft rupture related reoperation after ACLR; rate of return to sport (RTS) rate, timing, and level compared with preinjury status; and functional scores including the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) (Pain, Symptoms, Activities of Daily Living, Sport and Recreation, and Quality of Life), Tegner activity scale score, ACL Return to Sport after Injury (ACL-RSI) score, and Lysholm score. Results: After accounting for follow-up losses, we analyzed 132 patients who underwent ACLR alone and 121 patients who underwent ACLR+LEAP from the initial 147 per group. The mean age of the patients in both groups was 16.1 years (SD, 1.1 and 1.0 years, respectively), with similar patient and injury characteristics across both groups (P > .05). Both groups also showed comparable preoperative functional scores. A significantly lower preoperative ACL-RSI score was observed in the ACLR-alone group compared with the ACLR+LEAP group (P = .0044). Graft rupture was significantly less common in the ACLR+LEAP group (2.5%) than in the ACLR-alone group (13.6%) (P = .002). The attributable risk reduction for ACLR+LEAP was 11.1%, and the calculated number needed to treat was 9. Kaplan-Meier analysis showed significantly better rerupture-free survival at 5 years for the ACLR+LEAP group (P = .001). Cox regression confirmed a 6-fold increased rerupture risk in the ACLR-alone group (P = .004). At the final follow-up, despite similar IKDC, KOOS, Lysholm, and ACL-RSI values across both groups, the ACLR+LEAP group had a significantly higher Tegner score (7.2 vs 6.3; P = .0042). No significant differences were observed in RTS rates or sport level compared with preinjury states between the groups. Conclusion: ACLR+LEAP augmentation significantly reduced rerupture risk and facilitated higher postoperative activity levels in adolescents. Registration: NCT02511158 (ClinicalTrials.gov identifier).

Evaluation of changes in the length and cross-sectional dimension of autogenous grafts from semitendinosus and gracilis tendons used for anterior cruciate ligament (ACL) reconstruction in patients with active growth plates: MRI analysis

Introduction. In recent years, there has been an increase in anterior cruciate ligament (ACL) injuries during childhood and adolescence. Aim. The aim of this study is to observe the diameter and length of the graft change in the postoperative period. Materials and methods. The study group consisted of 21 adolescents (11 boys and 10 girls) who underwent ACL reconstruction using hamstring and gracilis tendon grafts. MRI evaluations were performed at 3-6 and 24-26 months postoperatively to assess the width and length of the graft. The graft cross-sectional dimension was measured at the mid-substance of the tendons on sagittal scans in T1 and T2-weighted sequences. Length measurement was performed on axial ACL scans at its central portion (assessing mid-substance length). The collected measurements from both postoperative periods were compared and statistically analysed. Results. MRI analysis conducted postoperatively showed a statistically significant decrease in graft cross-sectional dimension, from an average 7.21-5.82 mm. The intra-articular graft length measured in MRI at 3-6 months post-surgery averaged 21.52 mm, while the length measured at 24-26 months post-surgery averaged 22.42 mm. Conclusions. Postoperative MRI analysis of reconstructed ACLs in adolescents with active growth plates demonstrated a reduction in graft cross-sectional dimension and a slight increase in graft length.

Investigation of Morphometric Factors Associated With Adolescent ACL Rupture.

There are no definitive anatomic morphometric risk factors for adolescent anterior cruciate ligament (ACL) injury. To compare the parameters used to define the tibial and femoral morphometric structure of the knee between adolescent patients with and without ACL rupture. Cross-sectional study; Level of evidence, 3. Included were magnetic resonance imaging (MRI) scans and radiographs of 115 patients aged 10 to 17 years who were evaluated for ACL rupture at a single institution between February 1, 2019, and January 31, 2022. Images from 115 patients with intact MRI scans were included as controls. We investigated the following imaging parameters: tibial slope (on lateral radiograph), lateral condylar height, tibial sulcus height, medial condylar height, condylar width, intercondylar notch with, intercondylar notch angle, notch index, eminence width, tibial plateau width, eminence width/tibial plateau width, medial/lateral/overall eminence height, medial plateau depth, and 2 different eminence angles. Parameters were compared between groups using the chi-square, Fisher exact, Student t, or Mann-Whitney U test, as appropriate. Receiver operating characteristic analysis was conducted for cutoff values of significant parameters. There were no significant differences in age, sex, or side affected between groups. Only the medial plateau depth was found to be statistically significant between the ACL rupture and ACL intact groups (2.6 vs 2.2 mm; P = .015). A statistically significant cutoff value could not be obtained for the medial plateau depth. Medial plateau depth was found to be significantly greater in adolescent patients with ACL rupture compared with ACL-intact controls.

Major Increase in Incidence of Pediatric ACL Reconstructions From 2005 to 2021: A Study From the Norwegian Knee Ligament Register

Background: The incidence of pediatric and adolescent anterior cruciate ligament reconstruction (ACLR) is increasing in several countries. It is uncertain whether this trend applies to countries that traditionally prefer an initial nonoperative treatment approach whenever possible, like Norway. Nationwide, long-term patient-reported outcomes and revision rates after ACLR in the pediatric population are also lacking. Purpose: To determine the incidence of pediatric ACLR in Norway since 2005, as well as to detect trends in surgical details and describe patient-reported outcomes up to 10 years after ACLR. Study Design: Descriptive cohort study. Methods: This study is based on prospectively collected data on girls ≤14 years and boys ≤16 years, registered in the Norwegian Knee Ligament Register at the time of their primary ACLR, between 2005 and 2021. The main outcome was the incidence of ACLR, adjusted to the corresponding population numbers for each year. The time trend was analyzed by comparing the mean of the first and last 3-year period (2005-2007 and 2019-2021). Patient-reported outcomes were assessed using the Knee injury and Osteoarthritis Outcome Score preoperatively and at 2, 5, and 10 years postoperatively. Results: A total of 1476 patients (1484 cases) were included, with a mean follow-up of 8.1 years (range, 1-17). The incidence of pediatric ACLRs per 100,000 population increased from 18 to 26, which corresponds to an increase of 40% for boys and 55% for girls. Concurrent meniscal procedures increased significantly from 45% to 62%, and the proportion of meniscal repairs increased from 19% to 43% when comparing the first and last time period. The mean Knee injury and Osteoarthritis Outcome Score values for the Sport and Recreation and Quality of Life subscales were between 72 and 75 at the 2-, 5- and 10-year follow-up. The 5-year revision rate was 9.9%. Conclusion: There was a major increase in incidence of pediatric ACLR in Norway during the study period. There was a shift in the approach to concomitant meniscal procedures from resection to repair, with more than a doubling of the proportion of meniscal repairs. Patient-reported outcomes revealed long-lasting reduced knee function.

Anterior Cruciate Ligament Rehabilitation for the 10- to 18-Year-Old Adolescent Athlete: Practice Guidelines Based on International Delphi Consensus.

There are 2 treatment options for adolescent athletes with anterior cruciate ligament (ACL) injuries-rehabilitation alone (nonsurgical treatment) or ACL reconstruction plus rehabilitation. However, there is no clear consensus on how to include strength and neuromuscular training during each phase of rehabilitation. To develop a practical consensus for adolescent ACL rehabilitation to help provide care to this age group using an international Delphi panel. Consensus statement. A 3-round online international Delphi consensus study was conducted. A mix of open and closed literature-based statements were formulated and sent out to an international panel of 20 ACL rehabilitation experts. Statements were divided into 3 domains as follows: (1) nonsurgical rehabilitation; (2) prehabilitation; and (3) postoperative rehabilitation. Consensus was defined as 70% agreement between panel members. Panel members agreed that rehabilitation should consist of 3 criterion-based phases, with continued injury prevention serving as a fourth phase. They also reached a consensus on rehabilitation being different for 10- to 16-year-olds compared with 17- and 18-year-olds, with a need to distinguish between prepubertal (Tanner stage 1) and mid- to postpubertal (Tanner stages 2-5) athletes. The panel members reached a consensus on the following topics: educational topics during rehabilitation; psychological interventions during rehabilitation; additional consultation of the orthopaedic surgeon; duration of postoperative rehabilitation; exercises during phase 1 of nonsurgical and postoperative rehabilitation; criteria for progression from phase 1 to phase 2; resistance training during phase 2; jumping exercises during phase 2; criteria for progression from phase 2 to phase 3; and criteria for return to sports (RTS). The most notable differences in recommendations for prepubertal compared with mid- to postpubertal athletes were described for resistance training and RTS criteria. Together with available evidence, this international Delphi statement provides a framework based on expert consensus and describes a practice guideline for adolescent ACL rehabilitation, which can be used in day-to-day practice. This is an important step toward reducing practice inconsistencies, improving the quality of rehabilitation after adolescent ACL injuries, and closing the evidence-practice gap while waiting for further studies to provide clarity.

Techniques in Pediatric Anterior Cruciate Ligament Reconstruction

In recent years, the frequency of anterior cruciate ligament (ACL) tears and ACL reconstruction (ACLR) in skeletally immature patients has increased. Because distal femoral and proximal tibial physes account for the majority of lower-extremity growth, surgical technique and graft selection are crucial to minimize iatrogenic physeal injury. Combined extra- and intra-articular, all-epiphyseal, and transphyseal with soft-tissue grafts are the most common ACLR techniques used in children. Combined extra- and intra-articular ACLR typically is offered to prepubescent patients with ≥2 years of growth remaining. This technique uses iliotibial band (ITB) autograft passed over the lateral femoral condyle and fixed to the anterior tibial periosteum. All-epiphyseal ACLR is similarly used in patients with ≥2 years of growth remaining, provided sufficient epiphyseal maturity to accommodate an all-epiphyseal socket because both the femoral and tibial tunnels are contained within the epiphyses. In postpubertal patients with <2 years of growth remaining, transphyseal ACLR using a soft-tissue autograft (typically hamstring or quadriceps tendon) and metaphyseal femoral fixation can be performed. This minimizes risk of physeal injury. In borderline patients with approximately 2 years of growth remaining, an additional option includes partial transphyseal ACLR, which uses a soft-tissue graft and a transphyseal tibial tunnel, but an all-epiphyseal or over-the-top femoral graft trajectory. Recently, transphyseal ITB ACLR and hybrid transphyseal hamstring with combined over-the-top ITB ACLR also have been described. Existing clinical studies focused on pediatric and adolescent ACL reconstructions have reported a wide range of graft rupture rates for these techniques (4.3%-25%), with contralateral ACL injury rates of 2.9% to 15.6%. Ongoing multicenter research is underway to directly compare surgical techniques for this demographic and quantify graft rupture rates and other clinical outcomes.

Influence of Sex, Race/Ethnicity, and Socioeconomic Factors on Meniscal Treatment With Pediatric and Adolescent ACL Reconstruction

Background: The rate of anterior cruciate ligament (ACL) reconstruction is increasing over time in pediatric/adolescent populations, but there is less evidence to support how concomitant meniscal procedures are changing over time. There are also less data to suggest which characteristics are associated with meniscectomy versus meniscal repair treatment. Hypothesis: Age, sex, race/ethnicity, income, and insurance type may independently affect the rate of concomitant meniscal procedures and treatment modalities in pediatric patients with ACL reconstruction. Study Design: Descriptive epidemiology study. Methods: The Pediatric Health Information System database was queried for all patients aged ≤18 years who underwent ACL reconstruction with or without concomitant meniscal procedures from 2015 to 2019. Basic demographic data including age, sex, self-identified race/ethnicity, rural-urban commuting area code, predicted median income, and insurance status were collected. Linear regression was used to model trends and multiple logistic regression modeling was used to test for associations. Results: A total of 14,398 patients aged ≤18 years underwent ACL reconstruction during the study period, with 8337 patients (58%) having concomitant meniscal procedures with a 1.24-fold increase over 5 years. Of the concomitant meniscal treatment cohort, 41% had a meniscectomy and 59% had meniscal repair. There was a 0.82-fold change in meniscectomy and a 1.67-fold increase in meniscal repair during the study period. Male patients, older patients, Black race, living in an urban area, and those with nonprivate insurance had increased odds of undergoing a concomitant meniscal procedure (all P < .05). Patients of non-White race and those with nonprivate insurance had increased odds of having a meniscectomy versus meniscal repair (all P < .05). There were no associations detected between income bracket and the outcomes in this study. Conclusion: This study shows that in pediatric and adolescent patients undergoing ACL reconstruction, there was a rise in concomitant meniscal procedures from 2015 to 2019. In addition, patients of non-White race and those with nonprivate insurance have increased odds of undergoing meniscectomy versus meniscal repair.

Poster 223: Evidence-Based Opioid Prescribing Guidelines Following Anterior Cruciate Ligament Reconstruction (ACLR)

Objectives:Opioid prescriptions following anterior cruciate ligament reconstruction (ACLR) vary substantially.1-3 Expert panel guidelines recommend up to 50 pills for ACLR with many surgeons refilling 40 or more tablets.1,3 The CDC warns that a five-day supply is sufficient to develop opiate dependence.4 Current recommendations are based on consensus rather than evidence and place a vulnerable population at risk for opiate misuse.2,3 Orthopaedic surgeons do not possess evidence driven regimens for opioid prescriptions following ACLR.5,6 The purpose of this study was to develop evidence-based prescription guidelines for ACLR. We hypothesized that patients would require fewer opioids than traditional guidelines suggest with a high rate of patient satisfaction.1. Beck, J.J., et al., Prospective Study of Acute Opioid Use After Adolescent Anterior Cruciate Ligament Reconstruction Shows No Effect From Patient- or Surgical-Related Factors. J Am Acad Orthop Surg, 2020. 28(7): p. 293-300.2. Wyles, C.C., et al., Implementation of Procedure-Specific Opioid Guidelines: A Readily Employable Strategy to Improve Consistency and Decrease Excessive Prescribing Following Orthopaedic Surgery. JB JS Open Access, 2020. 5(1): p. e0050.3. Stepan, J.G., et al., Development of an Institutional Opioid Prescriber Education Program and Opioid-Prescribing Guidelines: Impact on Prescribing Practices. J Bone Joint Surg Am, 2019. 101(1): p. 5-13.4. Shah A HC, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017:265-269.5. Reider, B. Opioid Epidemic. Am J Sports Med, 2019. 44(5): p. 1039-1042.6. Morris BJ, Mir HR. The opioid epidemic: Impact on orthopaedic surgery. J Am Acad Orthop Surg 2015;23: 267-271.Methods:This multicenter prospective study enrolled 46 patients undergoing ACLR. Subject demographics and opioid prescriptions were recorded at the time of enrollment. All patients were given instructions and education on opiate use. All patients followed the same perioperative, multimodal analgesic regimen (Table 1). Following surgery, patients were given postoperative “Pain Journals” to document visual analog scale (VAS) pain scores and to track their daily opioid consumption for the first 7 postoperative days (PODs) and on postoperative visit (POV) at 14 days. No changes were made to existing prescribing habits, postoperative physical rehabilitation, or surgical methodology.Results:35 patients were included in this analysis. Mean subject age was 39 years old. 46% of patients were male; 54% of patients were female. Patients were prescribed a median of 15 oxycodone 5 mg pills and consumed a median of 2 pills postoperatively. Mean postoperative opioid consumption was 5 pills (range 0 to 31 pills). 42% of patients consumed 0 opioid pills; 77% of patients consumed ≤ 5 opioid pills; 73% of patients discontinued opioid use after POD 2 (Figure 1). Patients reported a mean daily VAS value of 2.5 of 10; mean satisfaction with pain management was high at 4.16/5 on a Likert satisfaction score. Overall, patients consumed a mean 28% of their opioid prescriptions, leaving 230 opioid pills not consumed.Conclusions:This study suggests that current expert panels may be recommending an unrequired volume of opioids. As the third largest prescriber of opiate medication, orthopedic surgeons are charged with reducing the risk of opiate dependence, particularly in the ACLR vulnerable population.6 Based on our findings, patients only require 15 Oxycodone 5mg tablets following ACLR. Despite this lower volume prescription, mean pain scores remained below 3/10, patient satisfaction with pain control remained high, and 72% of opiate medication prescribed was not used.

Paper 23: The Impact of Graft Choice on Return to Sport Testing After Adolescent ACL Reconstruction

Objectives:The number of anterior cruciate ligament (ACL) injuries and reconstructions observed in the adolescent population continues to rise. While the use of quadriceps tendon autograft has increased in popularity in this population, there remains no consensus on the ideal graft for pediatric ACL reconstruction. The objective of this study was to compare three commonly used ACL graft types with respect to i) performance on return to sport assessments and ii) timing to clearance for return to sports in an adolescent population.Methods:All patients, less than or equal to 19 years of age, who underwent reconstruction for ACL tears between 2016 and 2020 at a large, urban, academic institution were identified. Graft choice was made in a shared decision-making model with patient, parents, and surgeon. Patient demographics, laterality, graft type, time from surgery to clearance, number of physical therapy (PT) visits, and presence of concomitant meniscus injuries were collected from the electronic medical record. At a minimum of 6 months postoperatively, patients completed a formal return to sport test (RTS) including isometric strength assessments, Y- balance testing, and hop testing. Treatment cohorts based on graft type were compared with respect to RTS performance and timing to clearance. Associations between patient demographics and return to sport timing and performance were also assessed. Clearance for return to sport was determined by the treating surgeon with limb symmetry index of 90% on RTS as the goal for clearance.Results:A total of 110 adolescents, 44 female (40%), with a mean age of 16.3 years (SD, 1.7; range, 10-19) met our inclusion criteria (Table 1). Average time to first RTS assessment was 280 days (9.3 months) and average time to clearance was 371 days (12.2 months) after surgery. ACL grafts included 58 (52.7%) hamstring autografts, 26 (23.6%) bone-patellar tendon-bone (BPTB) autografts, 21 (19.1%) bone quadriceps (BQT) autografts, and 5 (4.6%) iliotibial band (ITB) autografts. ITB patients were younger on average (12.5 years old) than those receiving hamstring, BPTB or BQT grafts. There were no significant differences between groups with respect to laterality, number of physical therapy visits, or rate of concurrent meniscus surgery.Patients receiving BQT grafts were more likely to be cleared within 1 year of surgery compared to hamstring graft patients (82.4% vs. 39.6%, p=0.002) and had similar rates of clearance within 1 year compared to BPTB patients (82.4% vs. 65.2%, p=0.230). Patients with BQT and BPTB grafts both demonstrated significantly better hamstring strength symmetry compared to hamstring graft patients (5.8% strength deficit compared to healthy side vs. 1.3% vs. 29.3%, p<0.001) (Table 2). There were no differences in quadriceps strength or hop test asymmetry between graft types. Multivariate regression with age, gender, and number of PT sessions included as covariates demonstrated that hamstring graft choice was associated with decreased odds of clearance at 1 year.Conclusions:In this study of 110 adolescent ACL reconstruction patients who underwent return to sport evaluations, we found no significant difference between BPTB and BQT autografts with respect to RTS performance and time to clearance. Hamstring autograft was associated with significantly worse hamstring strength asymmetry and significantly lower rates of clearance within 1 year. Concurrent meniscus surgery, age, gender, and number of PT sessions completed prior to RTS evaluation were not significantly associated with timing of clearance or performance on the RTS assessment.Table 1.Patient Demographics and Surgical CharacteristicsTable 2.Patient Demographics and Performance by 3 Common Graft Types

Opiate prescribing patterns in the adolescent population following anterior cruciate ligament reconstruction.

We sought to determine prescribing patterns for opioid analgesia following anterior cruciate ligament (ACL) reconstruction among age- and gender-stratified adolescents in a nationally representative database. A retrospective study. PearlDiver Patient Records. Outpatient opioid claims within 30 days of surgery were extracted. The patients were defined into age groups 10-14 ("younger") and 15-19 ("older"). A total of 1,139 patients were included in this study (536 female and 603 males) with 108 patients in the 10-14 age category and 1,034 patients in the 15-19 category. The primary study outcome measures the average number of opioid pills administered, average total morphine milligram equivalents (MMEs) prescribed, and the average prescription strength (MMEs/pill). No difference was found in the average number of pills (p = 0.26) or normalized total MMEs (p = 0.312) prescribed by age group. Normalized total morphine equivalents per prescription was significantly lower in females than males (p = 0.005). Multivariate linear regression analysis demonstrated that increasing patient age was predictive of fewer total pills (p = 0.017), after accounting for gender. There are age- and gender-based disparities in prescription patterns for adolescent ACL reconstruction. Our findings indicate that patients in the older age group on average received fewer pills than the younger age group, which consequently trended toward receiving higher total MMEs prescribed. This suggests that surgeons may be inadvertently overprescribing in the younger cohort. Additional studies that account for concurrent factors should be conducted to observe potentially similar trends.

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

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. 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. The average age at the time of surgery was 15years. 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 2.8years (range 2-5years). At final follow-up, there were no angular deformities or leg length discrepancies. The average quadriceps atrophy of the operative leg was 4mm. 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. Use of quadriceps tendon autograft for ACL reconstruction in adolescent patients allows reliable return to sport with minimal complications. 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.

Early Operative Versus Delayed Operative Versus Nonoperative Treatment of Pediatric and Adolescent Anterior Cruciate Ligament Injuries: A Systematic Review and Meta-analysis

Background: Treatment options for pediatric and adolescent anterior cruciate ligament (ACL) injuries include early operative, delayed operative, and nonoperative management. Currently, there is a lack of consensus regarding the optimal treatment for these injuries. Purpose/Hypothesis: The purpose was to determine the optimal treatment strategy for ACL injuries in pediatric and adolescent patients. We hypothesized that (1) early ACL reconstruction results in fewer meniscal tears than delayed reconstruction but yields no difference in knee stability and (2) when compared with nonoperative management, any operative management results in fewer meniscal tears and cartilage injuries, greater knee stability, and higher return-to-sport rates. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: A systematic search of databases was performed including PubMed, Embase, and Cochrane Library using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were a pediatric and adolescent patient population (≤19 years old at surgery), the reporting of clinical outcomes after treatment of primary ACL injury, and original scientific research article. Exclusion criteria were revision ACL reconstruction, tibial spine avulsion fracture, case report or small case series (<5 patients), non–English language manuscripts, multiligamentous injuries, and nonclinical studies. Results: A total of 30 studies containing 50 cohorts and representing 1176 patients met our criteria. With respect to nonoperative treatment, knee instability was observed in 20% to 100%, and return to preinjury level of sports ranged from 6% to 50% at final follow-up. Regarding operative treatment, meta-analysis results favored early ACL reconstruction over delayed reconstruction (>12 weeks) for the presence of any meniscal tear (odds ratio, 0.23; P = .006) and irreparable meniscal tear (odds ratio, 0.31; P = .001). Comparison of any side-to-side differences in KT-1000 arthrometer testing did not favor early or delayed ACL reconstruction in either continuous mean differences (P = .413) or proportion with difference ≥3 mm (P = .181). Return to preinjury level of competition rates for early and delayed ACL reconstruction ranged from 57% to 100%. Conclusion: Delaying ACL reconstruction in pediatric or adolescent patients for >12 weeks significantly increased the risk of meniscal injuries and irreparable meniscal tears; however, early and delayed operative treatment achieved satisfactory knee stability. Nonoperative management resulted in high rates of residual knee instability, increased risk of meniscal tears, and comparatively low rates of return to sports.

Predictive Value of the Magnetic Resonance Imaging–Based Coronal Lateral Collateral Ligament Sign on Adolescent Anterior Cruciate Ligament Reconstruction Graft Failure

Background: The coronal lateral collateral ligament (LCL) sign is the presence of the full length of the LCL visualized on a single coronal magnetic resonance imaging (MRI) slice at the posterolateral corner of the knee. The coronal LCL sign has been shown to be associated with elevated measures of anterior tibial translation and internal rotation in the setting of anterior cruciate ligament (ACL) tear. Hypothesis: The coronal LCL sign (with greater anterior translation, internal rotation, and posterior slope of the tibia) will indicate a greater risk for graft failure after ACL reconstructive surgery. Study Design: Cohort study; Level of evidence, 3. Methods: Retrospective review was performed of adolescent patients with ACL reconstruction: a cohort without graft failure and a cohort with graft failure. MRI was utilized to measure tibial translation and femorotibial rotation and to identify the coronal LCL sign. The posterior tibial slope was measured on lateral radiographs. Patient-reported outcomes were collected. Results: We identified 114 patients with no graft failure and 39 patients with graft failure who met all criteria, with a mean follow-up time of 3.5 years (range, 2-9.4 years). Anterior tibial translation was associated with anterolateral complex injury (P < .001) but not graft failure (P = .06). Internal tibial rotation was associated with anterolateral complex injury (P < .001) and graft failure (P = .042). Posterior tibial slope was associated with graft failure (P = .044). The coronal LCL sign was associated with anterolateral complex injury (P < .001) and graft failure (P = .013), with an odds ratio of 4.3 for graft failure (95% CI, 1.6-11.6; P = .003). Subjective patient-reported outcomes and return to previous level of sport were not associated with failure. Comparison of MRI before and after ACL reconstruction in the graft failure cohort demonstrated a reduced value in internal rotation (P = .003) but no change in coronal LCL sign (P = .922). Conclusion: Our study demonstrates that tibial internal rotation and posterior slope are independent predictors of ACL graft failure in adolescents. Although the value of internal rotation could be improved with ACL reconstruction, the presence of the coronal LCL sign persisted over time and was predictive of graft rupture (without the need to make measurements or memorize values of significant risk). Together, these factors indicate that greater initial knee deformity after initial ACL tear predicts greater risk for future graft failure.

Comparative analysis of arthroscopic techniques of anterior cruciate ligament reconstruction in adolescents

Background. According to the considerably contradictory information across the international literature, both the anatomical and transtibial reconstruction of the anterior cruciate ligament (ACL), under similar conditions, yield good functional results from treatment. Therefore, it is important to evaluate the comparative effectiveness and the prospects of certain methods of ACL reconstruction. The purpose of this study was to analyze the possibilities and advantages of anatomical technologies for the reconstruction intervention.&#x0D; Aim. To compare the outcomes of ACL reconstructions among adolescent children using different methods.&#x0D; Materials and methods. The outcomes of 94 arthroscopic reconstructions of the ACL in adolescents were analyzed. The patients were categorized into 3 groups: Group 1 included 32 patients (34%) who underwent isometric plastic surgery of the ACL, wherein the femoral canal was formed using the transtibial technique. Group 2 included 30 patients (32%) who underwent anatomical plastic surgery of the ACL, with the formation of the femoral canal through additional anteromedial arthroscopic access. Group 3 included 32 patients (34%) who underwent the all-inside anatomical reconstruction of the ACL.&#x0D; Results. A comparative analysis of the outcomes of reconstruction of the ACL among adolescents revealed that the anterior-posterior and rotational stability of the knee joint was better in group 3 patients than in groups 1 and 2 patients. In fact, the group 3 patients showed a significantly less positive pivot-shift (0 degree to 87.5%; I+ the extent of 12.5%) than the group 1 patients (0 degree 46.8%; I+ degree 25%; II+ degree and 21.9%; III+ degree and 6.3%), followed by the group 2 patients (0 degree to 86.6%; I+ degree 6.7%; II+ degree of 6.7%).&#x0D; Conclusion. Considering the safety aspects of intra-articular structures and for the better anatomical orientation of the femoral canal, the all-inside method of ACL reconstruction yielded better outcomes of postoperative anterior-posterior and rotational stability of the knee joint.

A Practical Pre-Operative Predictive Model for Determining Hamstring Autograft Size for Anterior Cruciate Ligament Reconstruction in Children and Adolescents

Objectives:The most commonly used graft for pediatric and adolescent anterior cruciate ligament (ACL) reconstruction is the hamstring autograft. Recent evidence has suggested that graft sizes less than 8 mm and age less than 20 years old are the most significant factors influencing graft failure. Additionally, studies examining the role of augmenting smaller grafts with allograft have demonstrated mixed results and potentially increased failure rates. Efforts to predict hamstring size preoperatively using MRI and ultrasound in the adult population have shown promise. However, there have been no studies in an entirely pediatric population. The purpose of this study was to evaluate the predictive value of MRI in determining hamstring autograft size preoperatively for pediatric ACL reconstructions.Methods:Children and adolescents from 10-20 years old that had undergone ACL reconstruction using hamstring autograft were identified from 2017-2018. Semitendinosus and gracilis cross-sectional area and diameter were measured on preoperative knee MRIs using the field of interest (FOI) and distance measurement tools. The slice used for measurement was identified as the largest section by the measuring surgeon. Two surgeons independently measured all MRIs. Preoperative demographic data (height, weight, body mass index (BMI), gender) and operative data (graft size) was collected. Data was analyzed by an independent statistician. Ordinal regression analysis was performed to determine the relationship between demographic data and graft size. A Classification and Regression Tree (CART) was constructed to identify predictors for the pre-determined graft sizes of 8 mm. Receiver operating characteristics (ROC) analysis were then created to assess the performance of the predictive model and determine sensitivity and specificity. All analyses were performed using SPSS v. 24 with alpha set at p<0.05 to declare significance.Results:One hundred and ten children (54 boys, 56 girls) were included in this study with an average age of 15.93 years (range 11.81-20.22) and average BMI of 25.98 (range 16.02-40.08). CART analysis determined that if the sum of the cross-sectional areas of the semitendinosus and gracilis tendons were greater than 31.17 mm then 87.5% of children had graft sizes of 8 mm or greater. The ROC analysis determined the model to have an 80% sensitivity and 74% specificity for predicting a graft size of 8 mm or larger.Conclusion:A preoperative summation of the cross-sectional areas of the semitendinosus and gracilis tendons greater than 31.17 mm predicts an intraoperative graft size of 8 mm or larger in 87.5% of children.Figure 1.Table 1:Magnetic resonance imaging (MRI) measurements comparing children with graft sizes less than 8 mm with those 8 mm or greater. 95% Confidence Interval Mean Lower Upper P-value Height (cm)<8162.28159.66164.908+169.02166.56171.47<0.001Weight (kg)<867.3562.2772.438+76.8871.1682.600.014BMI<825.3823.7726.998+26.5725.1228.020.274Age (years)<815.8915.3916.388+15.9715.5716.370.793Semitendinosus<815.8314.8616.81 Cross-sectional Area8+19.1518.1420.16<0.001Semitendinosus Diameter<84.824.664.99 (Anteroposterior)8+5.174.975.370.009Semitendinosus Diameter<84.023.844.21 (Medial/lateral)8+4.494.334.65<0.001Gracillis<89.849.2210.46 Cross-sectional Area8+11.3310.6811.980.001Gracillis Diameter<84.224.094.36 (Anteroposterior)8+4.584.364.800.01Gracillis Diameter<82.872.752.99 (Medial/lateral)8+3.102.973.220.013Semitendinosus + Gracillis<825.6724.3227.02 Cross-sectional Area8+30.4829.0331.93<0.001Diameter Sum<815.9415.5516.338+17.3316.9017.77<0.001

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.