Anterior Cruciate Ligament Tears In Children Research Articles

Association Between Posterior Tibial Slope and ACL Injury in Pediatric Patients: A Systematic Review and Meta-analysis

Background: The posterior tibial slope (PTS) has been proposed to be a radiographic risk factor for anterior cruciate ligament (ACL) injury in adults. However, this has not been well established in pediatric patients. Purpose: This systematic review and meta-analysis was performed to investigate any association between PTS and ACL tears in the pediatric population. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: A systematic review was performed to identify studies that examined the relationship between PTS, medial tibial slope (MTS), and lateral tibial slope (LTS) and ACL tears in children and adolescents aged ≤18 years. Full-text observational studies comparing PTS, MTS, and/or LTS values between pediatric (≤18 years of age) patients with and without ACL injury were included in this analysis. Review articles and case series were excluded. The authors calculated the mean difference (MD) via a restricted maximum-likelihood estimator for tau square and a Hartung-Knapp adjustment for random-effects model. Results: A total of 348 articles were identified in the initial database search, yielding 10 for final inclusion and analysis. There was no statistically significant association between PTS (MD, 1.13°; 95% CI, –0.55° to 2.80°; P = .10), MTS (MD, 0.36°; 95% CI, –0.37° to 1.10°; P = .27), or LTS (MD, 1.41°; 95% CI, –0.20° to 3.02°; P = .075) and risk for ACL injury in this population. Conclusion: The current study found that unlike what has been shown in adult populations, increased PTS may not be a significant risk factor for ACL tears in pediatric and adolescent patents. LTS was the only measured parameter that neared statistical significance, perhaps suggesting a potential role for this measurement in determining ACL risk if further research is done in this population.

IS PERCUTANEOUS MEDIAL COLLATERAL LIGAMENT (MCL) RELAXATION DURING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION A SAFE OPTION FOR GAINING ACCESS TO THE MEDIAL KNEE COMPARTMENT IN CHILDREN?

Introduction:With participation in youth sports anterior cruciate ligament (ACL) injuries are a common occurrence. Nearly 70% of ACL tears in children and adolescents have an associated meniscus tear. Percutaneous medial collateral ligament (MCL) relaxation has been described as utilitarian in accessing the medial meniscus for diagnostic assessment and treatment in the adult population to increase medial compartment working space in arthroscopic surgery. The technique has not been evaluated in the pediatric population. The purpose of this study was to compare the outcomes of children and adolescents that underwent anterior cruciate ligament reconstruction (ACLR) with and without percutaneous relaxation of the medial collateral ligament (MCL) for meniscal tear management.Methods:A retrospective review was performed of patients aged 8 to 19 years old that had undergone knee arthroscopy for an (ACLR) with meniscus pathology. Those that underwent MCL relaxation were grouped together and compared to a matched cohort that did not have MCL relaxation performed. Preoperative, operative and postoperative data was analyzed. The primary measurement was obtained using a validated patient reported outcome score (Pedi-IKDC), secondary outcome measures were defined as superficial or deep infection, saphenous nerve dysesthesias, ACL graft failure and return to the operating room. Statistical analysis of the two cohorts was performed.Results:Fifty-four patients were included in the study (27 in each group) with average age 15 years (range 10-19). Average follow-up for the MCL relaxation group was 22.4 months versus 58 months for the non-MCL relaxation group. The average Pedi-IKDC score was 93.3 for the MCL relaxation group and 91.4 for the non-MCL relaxation group (p=0.34). There was no difference in patient demographics, return to the operating room (p=0.49), saphenous nerve dysesthesia (p=0.49), superficial or deep infection (p=0.32).Conclusion:ACL reconstruction in children and adolescents with MCL relaxation for the management of medial meniscal tears appears to be a safe option. Equivocal patient reported outcome scores as compared to the control group were found with no increase in post-operative complications. In children with ACL tears, appropriate diagnosis and management of medial meniscal pathology is important to maintain secondary restraint to anterior tibial translation and prevent premature graft failure. Pediatric knees can have tight medial compartments, making access difficult, potentially leading to poor visualization and iatrogenic chondral damage. Percutaneous medial collateral ligament (MCL) relaxation has been described in the adult population to increase medial compartment working space without long term sequela. We report similar findings in an all pediatric cohort.

MAGNETIC RESONANCE IMAGING OF LATERAL MENISCAL POSTERIOR ROOT TEARS IN THE ADOLESCENT KNEE: IS THE DIAGNOSIS MISSED, MENTIONED, OR MADE?

Background:The meniscal roots play a vital role in maintaining proper knee kinematics. Neglected meniscal root tears place excess stress on the articular cartilage and increase the risk of premature osteoarthritis. As opposed to medial meniscal root tears, lateral meniscal posterior root tears (LMPRTs) are more likely to be associated with anterior cruciate ligament (ACL) pathology. Failure to identify and address meniscal root tears may place undue loads on ACL grafts and lead to inferior post-surgical outcomes.Purpose:To examine preoperative knee magnetic resonance imaging (MRI) radiologist interpretations for the identification of lateral meniscal root pathology in children and adolescents.Methods:We performed a retrospective review of children and adolescents that underwnent knee arthroscopy between 3/1/2010 and 4/1/2020 and had an arthroscopically confirmed LMPRT. Arthroscopic findings were compared to the reading radiologist’s preoperative MRI interpretations. LMPRTs were graded using the LaPrade classification. ANOVA was performed to assess if body mass index (BMI), open physes, time from injury to MRI, time from MRI to surgery, MRI magnet field strength, musculoskeletal radiologist designation, insurance type and tear grade were associated with the preoperative MRI identification of a LMPRT.Results:During the study period, 1285 knee arthroscopies were performed. 607 of which were ACL reconstructions. 54 children were found to have a LMPRT arthroscopically and all were associated with an ACL tear 54/607 (9%). One patient had 2 preoperative MRIs for a total of 55 MRIs in 54 pateints. Average age was 16 years (range 14-21). Preoperative MRI diagnosis of a LMPRT was made in only 14/55 (25%) and missed in 22/55 (40%). In 19/55 (35%), pathology of the lateral meniscus nonspecific to the root was mentioned. Lateral joint line tenderness was present in 23/54 (46%). There was no statistical significance found in regards to patient BMI, skeletal maturity, time from injury to MRI, time from MRI to surgery, MRI magnet strength, if the radiologist was musculoskeletal fellowship-trained, or insurance type, with a reliable diagnosis. (Table)Conclusion:The final interpretation of preoperative MRIs did not provide a clear definitive diagnosis of a LMPRT in 75 % in patients. As the intraoperative management of LMPRTs can be involved and diverge from standard meniscal work, preoperative diagnosis would be advantageous. All LMPRTs in this study were associated with a concomitant ACL tear. Surgeons caring for ACL tears in children and adolescents should be prepared to treat a LMPRT regardless of a inconclusive MRI interpretation for meniscal root pathology.

Intercondylar notch dysplasia in open-physis anterior cruciate ligament injuries: A case-control study

BackgroundThe incidence of anterior cruciate ligament (ACL) tears in children is rising steadily due to a variety of factors including growing participation in sports. A narrow intercondylar notch is an intrinsic risk factor that is well documented in adults but rarely investigated in children. The objective of this study was to evaluate the potential association between a narrow intercondylar notch and ACL tears in children. HypothesisA narrow intercondylar notch is associated with ACL tears. Material and methodsIn a paediatric case-control study, we compared intercondylar notch morphology as assessed by magnetic resonance imaging (MRI) in 49 patients with ACL tears (33 males and 16 females with a mean age of 13.6 years) and 50 controls with normal knees (18 boys and 32 girls with a mean age of 13.8 years). In each participant, posterior tibial slope was measured, as well as the notch width index (NWI) (width of the intercondylar notch over bicondylar width at the same level). In addition, to evaluate anterior impingement, the angle formed by Blumensaat's line and the axis of the tibia (α angle) was measured with the knee extended. ResultsThe NWI was significantly lower in the cases than in the controls (0.244±0.02 and 0.263±0.02, respectively; P<0.05). The α angle was also significantly smaller in the cases (138.74°±4.6° vs. 141.30°±7.9° in the controls; P<0.05). DiscussionACL tears are associated with a small NWI in children. A narrow intercondylar notch is an established risk factor for ACL tears and should be sought routinely to determine whether notch-plasty should be performed during the ACL reconstruction procedure in order to decrease the risk of recurrent ACL tears. Level of evidenceIII, case-control study.

Rehabilitation Following Anterior Cruciate Ligament Tears in Children: A Systematic Review.

Anterior cruciate ligament (ACL) tears are increasingly prevalent in the pediatric population. ACL rehabilitation is an essential component of recovery following injury and reconstruction, yet there are few explicit descriptions of pediatric-specific ACL rehabilitation protocols in the literature, especially in the context of varying treatment interventions. Our aim was to systematically review the literature on rehabilitation following ACL tears in children in order to describe common principles among different treatment options and areas of future research. Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we performed a systematic review of the PubMed, EMBASE, and Cochrane databases (for the past five years) to identify detailed rehabilitation protocols described in the pediatric population following ACL rupture. When available, the following aspects of rehabilitation were extracted: "prehabilitation" (exercises prior to surgery), bracing, weight-bearing status, range of motion, strength, modalities (ice, heat, electrical stimulation, etc.), plyometrics/proprioceptive exercises, return-to-sport criteria, and suggested ACL injury-prevention programs. Two hundred and two unique articles were identified. Twenty-seven articles meeting inclusion criteria with extractible rehabilitation data were included. A table, categorized by differing orthopaedic intervention, was designed to detail the components and duration of the different aspects of rehabilitation. While there are substantial differences across protocols, several trends emerged, particularly regarding weight-bearing, bracing, range of motion, and strength training. Interestingly, we found that many current protocols are based on time frame alone rather than on functional milestones; of the fourteen unique articles that addressed return-to-sport criteria by specific orthopaedic intervention, seven were based on temporal progression whereas seven also involved achievement of physical milestones. In addition, only three of the eight articles that mentioned a future ACL injury-prevention plan described a formal prevention program. We systematically identified, and subsequently outlined and compared, the current trends of the various components of pediatric-specific ACL rehabilitation protocols, categorized by orthopaedic intervention. Several protocols are based on time frames rather than milestones achieved, with newer protocols involving milestone-based progression. Newer protocols are also incorporating formal prevention programs. Just as skeletally immature patients require unique methods of operative fixation, so too do they require catered rehabilitation protocols. To effectively prevent re-rupture or contralateral injury, future research should focus on prospectively evaluating each component of the rehabilitation protocols described and return-to-sport criteria for young patients.

A Study of Epiphyses in the Young Prepubescent Knee Using Magnetic Resonance Imaging: Evaluation of Parameters for Anterior Cruciate Ligament Reconstruction.

Background:Questions have been raised concerning the safety of intra-articular anterior cruciate ligament (ACL) reconstruction in prepubescent children aged <7 years. However, normal values for the width of the lateral femoral condylar epiphysis and height of the tibial epiphysis have yet to be established through the use of magnetic resonance imaging (MRI).Purpose:To determine normal values for the width of the lateral femoral condylar epiphysis and height of the tibial epiphysis at the knee in prepubescent children aged <7 years by use of MRI and to compare this age group with an older cohort of prepubescent children aged <10 years.Study Design:Cross-sectional study; Level of evidence, 3.Methods:An electronic search was conducted for pediatric knee MRI examinations at the authors’ institution from March 2003 to March 2013. The total and ossified lateral femoral condylar widths were determined on coronal proton density–weighted images. The total and ossified tibial epiphyseal heights were recorded on the sagittal T1-weighted image best containing the ACL footplate. The intraclass correlation coefficient (ICC) was calculated to determine interobserver agreement. Knees were stratified by age into 2 groups: children between the ages of 3 and 6 years (group 1) and children between the ages of 7 and 9 years (group 2). Each cohort was further stratified by sex.Results:Group 1 consisted of 10 children (mean age, 4.3 years) and group 2 consisted of 10 children (mean age, 8.5 years). There were a total of 20 knees. There was a statistically significant difference between groups 1 and 2 for the ossified lateral femoral condylar width where femoral tunnel location would be expected (20.00 ± 4.20 vs 26.27 ± 4.12 mm, respectively; P = .0035) and for total lateral femoral condylar width (25.57 ± 3.47 vs 29.43 ± 4.04 mm, respectively; P = .0339). No difference was found for total tibial epiphyseal height between the 2 groups. However, there was a difference between groups 1 and 2 for ossified tibial epiphyseal height (13.20 ± 1.63 vs 15.27 ± 0.94 mm, respectively; P = .0028). No difference was found for average ossified tibial epiphyseal height or ossified lateral femoral condylar width between boys and girls in the younger or older cohorts. The ICC was strong (>0.7) at femoral and tibial locations where tunnel placement would be expected.Conclusion:Prepubescent children <7 years old have smaller knee epiphyses than older prepubescent children, and on average, present with an osseous bone stock of 20 mm for lateral femoral condylar width and 13 mm for tibial epiphyseal height. Study results suggest that children aged <7 years possess enough osseous bone stock at the lateral femoral condyle to support transepiphyseal ACL reconstruction. However, future studies will be necessary to determine the safety and effectiveness of this procedure in children aged <7 years.Clinical Relevance:ACL tears in children are more frequently being recognized by the orthopaedic community. The trend toward increasing participation in competitive and recreational sports has contributed to this phenomenon. Young patients with complete ACL tears and open growth plates often provide a management dilemma for surgeons who wish to perform reconstructive surgery.

20 Years of Pediatric Anterior Cruciate Ligament Reconstruction in New York State

Background: There have been no population-based studies to evaluate the rate of pediatric anterior cruciate ligament (ACL) reconstruction. Purpose: The primary aim of the current study was to determine the yearly rate of ACL reconstruction over the past 20 years in New York State. Secondary aims were to determine the age distribution for ACL reconstruction and determine whether patient demographic and socioeconomic factors were associated with ACL reconstruction. Study Design: Descriptive epidemiology study. Methods: The Statewide Planning and Research Cooperative System (SPARCS) database contains a census of all hospital admissions and ambulatory surgery in New York State. This database was used to identify pediatric ACL reconstructions between 1990 and 2009; ICD-9-CM (International Classification of Diseases, 9 Revision, Clinical Modification) and CPT-4 (Current Procedural Terminology, 4th Revision) codes were used to identify reconstructions. Patient sex, age, race, family income, education, and insurance status were assessed. Results: The rate of ACL reconstruction per 100,000 population aged 3 to 20 years has been increasing steadily over the past 20 years, from 17.6 (95% confidence interval [CI], 16.4-18.9) in 1990 to 50.9 (95% CI, 48.8-53.0) in 2009. The peak age for ACL reconstruction in 2009 was 17 years, at a rate of 176.7 (95% CI, 160.9-192.5). In 2009, the youngest age at which ACL reconstruction was performed was 9 years. The rate of ACL reconstruction in male patients was about 15% higher than in females, and ACL reconstruction was 6-fold more common in patients with private health insurance compared with those enrolled in Medicaid. Conclusion: This study is the first to quantify the increasing rate of ACL reconstructions in the skeletally immature. Only ACL reconstructions were assessed, and it is possible that some ACL tears in children are not diagnosed or are treated nonoperatively. The rate of ACL tears in New York State is likely higher than the rate of reconstructions reported in this study. Significance: This study quantifies the increasing rate of ACL reconstruction in the skeletally immature and suggests that there may be some disparities in care based on insurance status.

Anterior Cruciate Ligament Injuries in the Pediatric Population

There are many injuries that are clinically challenging musculoskeletal disorders in emergency department patients. One of those is an anterior cruciate ligament (ACL) injury. Injuries to the ACL are among the most common injuries incurred to the knee in sports. ACL tears in children and adolescents are becoming more common as participation in formalized sports increases. This injury typically occurs with trauma to the knee. The purpose of this article is to discuss the assessment and management of patients with ACL injuries using an actual case presentation. It is imperative for the healthcare provider to appropriately assess and manage the patient with an ACL injury promptly to ensure that outcome is improved. Failure to recognize the severity of the problem may lead to increased morbidity with poor functional outcomes.

Hamstring Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient

Summary: Intrasubstance anterior cruciate ligament (ACL) tears in children and adolescents are being reported with increasing frequency. For behavioral, or other reasons, the natural history of ACL tears in children and adolescents is poor. The consequences of nonoperative treatment are often recurrent instability, meniscal damage, and sports-related disability. The risks of surgery include iatrogenic leg length discrepancy or angular deformity. There is a deficiency in the orthopaedic literature regarding basic science on the effects of physeal injury and clinical studies documenting safety and efficacy of transphyseal drill holes for ACL replacement in children and adolescents. Consequently, the methods of surgical treatment are controversial. Even so, it is widely accepted that the surgical technique is influenced by the patient’s skeletal maturity. Therefore, the treating physician must know the patient’s skeletal age, risk factors for iatrogenic growth disturbance, and treatment options. Anatomic intraarticular ACL replacements are biomechanically superior to extraarticular and modified physeal-sparing procedures. High-risk prepubescent patients may be treated with efficacy and relative safety using a transepiphyseal ACL replacement. Low-risk pubescent Tanner stage IV patients, nearing skeletal maturity, may be treated with transphyseal reconstruction with small, centrally placed, perpendicular drill holes and quadruple hamstring grafts. Postpubescent Tanner stage V patients may be treated as adults.