Pediatric Anterior Cruciate Ligament Reconstruction Research Articles

Pediatric ACL Reconstruction in Children-An Evaluation of the Transphyseal Technique's Efficacy and Safety.

Injuries of the anterior cruciate ligament (ACL) are commonly found in the general population, both among adult and pediatric patients, and their incidence has been increasing in recent years. Most of the late literature agrees that surgical reconstruction of the ACL is effective in improving long-term outcomes in pediatric patients, while others in the past have pleaded for non-surgical management. Our study aims to verify if ACL reconstruction (ACLR) using transphyseal technique in skeletally immature patients will provide angular deviations or growth restrictions. Retrospective cohort study; Level of evidence 4. We perfomed a retrospective study to verify if transphyseal ACLR in children with less than or equal to 2 years of remaining growth leads to either limb length discrepancies or axis deviations. Most patients who were treated using transphyseal technique showed significant improvements in their functional scores. There were statistically significant differences in lateral distal femoral angles (LDFA) and medial proximal tibial angles (MPTA), with no clinical impact. There was no significant limb length discrepancy (LLD) during the 2-year follow-up. Transphyseal ACLR is safe among children who have less than or equal to 2 years of remaining growth and brings no risk of axis deviations or limb length discrepancy.

Multisite prospective study of perioperative pain management practices for anterior cruciate ligament reconstruction in adolescents: Society for Pediatric Anesthesia Improvement Network (SPAIN) Project Report

IntroductionAlthough 200 000 adolescents undergo anterior cruciate ligament reconstruction (ACLR) surgery annually, no benchmarks for pediatric post-ACLR pain management exist. We created a multicenter, prospective, observational registry to describe pain...

Sensitivity analysis of paediatric knee kinematics to the graft surgical parameters during anterior cruciate ligament reconstruction: A sequentially linked neuromusculoskeletal-finite element analysis

Background and objectiveIncidence of paediatric anterior cruciate ligament (ACL) rupture has increased substantially over recent decades. Following ACL rupture, ACL reconstruction (ACLR) surgery is typically performed to restore passive knee stability. This surgery involves replacing the failed ACL with a graft, however, surgeons must select from range of surgical parameters (e.g., type, size, insertion, and pre-tension) with no robust evidence guiding these decisions. This study presents a systemmatic computational approach to study effects of surgical parameter variation on kinematics of paediatric knees. MethodsThis study used sequentially-linked neuromusculoskeletal (NMSK) finite element (FE) models of three paediatric knees to estimate the: (i) sensitivity of post-operative knee kinematics to four surgical parameters (type, size, insertion, and pre-tension) through multi-input multi-output sensitivity analysis; (ii) influence of motion and loading conditions throughout stance phase of walking gait on sensitivity indices; and (iii) influence of subject-specific anatomy (i.e., knee size) on sensitivivty indices. A previously validated FE model of the intact knee for each subject served as a reference against which ACLR knee kinematics were compared. ResultsSensitivity analyses revealed significant influences of surgical parameters on ACLR knee kinematics, albeit without discernible trend favouring any one parameter. Graft size and pre-tension were primary drivers of variation in knee translations and rotations, however, their effects fluctuated across stance indicating motion and loading conditions affect system sensitivity to surgical parameters. Importantly, the sensitivity of knee kinematics to surgical parameter varied across subjects, indicating geometry (i.e., knee size) influenced system sensitivity. Notably, alterations in graft parameters yielded substantial effects on kinematics (normalized root-mean-square-error > 10 %) compared to intact knee models, indicating surgical parameters vary post-operative knee kinematics. ConclusionsOverall, this initial study highlights the importance of surgical parameter selection on post-operative kinematics in the paediatric ACLR knee, and provides evidence of the need for personalized surgical planning to ultimately enhance patient outcomes.

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.

Trends in Pediatric Anterior Cruciate Ligament Reconstruction in Australia: An Analysis of Australian Medicare Benefits Schedule Database From 2001 to 2020.

Anterior cruciate ligament (ACL) injuries are common and increasingly prevalent in the pediatric population. However, there remain sparse epidemiological data on the surgical treatment of these injuries. The objective of this study is to assess the trends in the rate of pediatric ACL reconstruction in Australia over the past 2 decades. The incidence of ACL reconstruction from 2001 to 2020 in patients 5 to 14 years of age was analyzed using the Australian Medicare Benefits Schedule (MBS) database. Data were stratified by sex and year. An offset term was introduced using population data from the Australian Bureau of Statistics to account for population changes over the study period. A total of 3719 reconstructions for the management of pediatric ACL injuries were performed in Australia under the MBS in the 20-year period from 2001 to 2020. There was a statistically significant annual increase in the total volume and per capita volume of pediatric ACL reconstructions performed across the study period ( P <0.0001). There was a significant increase in the rate of both male and female reconstructions ( P <0.0001), with a greater proportion of reconstructions performed on males (n=2073, 56%) than females (n=1646, 44%). In 2020, the rate of pediatric ACL reconstructions decreased to a level last seen in 2015, likely due to the effects of COVID-19. The incidence of ACL reconstruction in skeletally immature patients has increased in Australia over the 20-year study period. This increase is in keeping with evidence suggesting poor outcomes with nonoperative or delayed operative management.

Return to Sport After Pediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review of the Criteria

Background: Postoperative rehabilitation is an important component of recovery after anterior cruciate ligament (ACL) reconstruction (ACLR), facilitating successful return to sport (RTS) by reducing risk factors for repeat injury. Purpose: This systematic review aimed to determine the best protocol for RTS after ACLR in children. Study Design: Systematic review; Level of evidence, 4. Methods: PubMed, Embase, PEDro, SPORTDiscus, and Web of Science databases were searched from October 3, 2014, to November 3, 2022. The inclusion criteria were the pediatric population (<18 years old) after ACLR with clear RTS criteria and/or mean/median time to RTS. Multiligament knee injuries were excluded from this study. The methodologic quality of the included articles was assessed using the methodological index for non-randomized studies (MINORS). The highest possible score was 24 points for comparative studies (ie, a study comparing 2 protocols or more). Noncomparative studies or studies with a single protocol could score a maximum of 16 points as assessed by the MINORS score. Results: The search yielded 1816 titles, and 24 were retained based on the inclusion and exclusion criteria. Every study was published between 2015 and 2022. Among the 24 studies included, 13 were retrospective and 11 were prospective. The mean MINORS score for the noncomparative studies was 13 of 16 (n = 23) and 23 of 24 for the comparative study (n = 1). The studies were categorized into unspecified clearance (n = 10), milestone based (n = 13), and combined time and milestone (n = 1). A total of 1978 patients (57% female) were included in the review. The mean age at ACLR was 14.7 years. The most common endpoint used was graft rupture (0% to 35%). In the unspecified group, the quickest RTS was 5.8 months and the longest was 9.6 months. Statistically significant risk factors for ACL reinjury included younger age and earlier RTS. The latter was a significant contributor to graft failure for combined time-based and milestone-based RTS. In the milestone-based group, the most common criteria were ≥90% limb symmetry measured using hamstring strength, quadriceps strength, and/or hop tests. The mean RTS time was 6.8 to 13.5 months. Conclusion: RTS should be delayed, when possible, especially in the younger population. A combination of quantitative tests and qualitative tests is also recommended. However, optimal RTS criteria have yet to be determined. Future prospective studies should focus on comparing the different times and milestones currently available.

Modification of Outside-In Technique In Preparing Femoral Tunnel During Anterior Cruciate Ligament Reconstruction—“PL-Portal Outside-In Technique”

We propose modifying the outside-in technique by adopting a posterolateral (PL) portal as the working portal to introduce the anterior cruciate ligament reconstruction (ACLR) aiming guide while keeping the anteromedial portal as the viewing portal, the “PL-portal outside-in technique.” This modification facilitates the preparation of an anatomical femoral tunnel, even when preserving a “big” ACL remnant or in small joint scenarios, such as pediatric ACLR. There is a minimal learning curve in adopting this technique because a standard 30° arthroscope is used, and the viewing portal is anterior.

The Risk of Growth Disturbance Is Low After Pediatric Anterior Cruciate Ligament Reconstruction With a Femoral Growth Plate Sparing Technique

To evaluate radiological tibial and femoral length and axis growth disturbances, as well as clinical outcome in skeletal immature anterior cruciate ligament reconstruction (ACLR) patients treated with a femoral growth plate-sparing ACLR technique. Skeletally immature patients who underwent operation between 2013 to 2019 with ALCR using the femoral growth plate-sparing technique were investigated with follow-up after growth plate closure. The inclusion criteria were isolated ACL rupture in patients with open physis in the distal femur and proximal tibia seen at plain radiography. The minimum follow-up time was 29 months. Patients were evaluated with full extremity radiographs measuring limb length discrepancy and coronal knee alignment compared to contralateral leg, as well as clinical evaluation with Rolimeter measurements and the Knee Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee subjective knee form (IKDC), and Tegner Activity Scale scores. Sixty-five patients were examined with radiography, and 52 patients were assessed with clinical examination. The mean follow-up time was 68 (range, 29-148) months. No limb-length discrepancy (-0.65 mm [confidence interval {CI},-2.21 to 0.92]) or angular deformity at tibia (-0.25° [CI,-0.78° to 0.28°]) was found. There was a small but statistically significant different angular deformity at the distal femur compared to the contralateral leg (-1.51° [CI,-2.31 to-0.72]) at follow-up. The side-to-side difference in knee laxity at follow-up was 2.4 mm. At follow-up the KOOS Sport, KOOS Quality of Life (QoL), IKDC, and Tegner scores were 80, 75, 86, and 5, respectively. Sixty-seven percent of the patients met the Patient Acceptable Symptom State, and 52% reported results exceeding the KOOS Sport MCID Level and 69% the KOOS QoL level. Femoral physis-sparing ALCR is associated with a low risk of alignment and length disturbances. The technique provides otherwise good subjective clinical outcome and knee stability. Level IV, therapeutic case series.

Use of cryotherapy in the postoperative management of paediatric anterior cruciate ligament reconstruction: a prospective randomised controlled trial.

To investigate the efficacy of cryotherapy in relieving postoperative pain and restoring knee range-of-motion (ROM) after paediatric anterior cruciate ligament reconstruction (ACLR). Patients undergoing primary ACLR were randomised into cryotherapy or non-cryotherapy groups. Those receiving cryotherapy were subjected to a standardised icing protocol. Icing schedules were used to assess compliance. Standard postoperative rehabilitation protocol was followed for both groups. Outcome measurements were visual analogue scale at rest and movement and knee ROM. Patients were assessed on postoperative day 1 (POD1), 1, 4 and 6 weeks. Twenty-one out of 42 patients received cryotherapy. Both groups were similar in demographics, surgical technique and use of intraoperative anaesthesia. Patients in the cryotherapy group reported lower overall mean pain scores throughout the study duration at rest (0.61 ± 1.70, 95% CI = 0.23-0.99 vs. 1.06 ± 2.03, 95% CI = 0.60-1.53) and on movement (2.19 ± 2.68, 95% CI = 1.59-2.79 vs. 3.13 ± 2.75, 95% CI = 2.51-3.75; P = 0.032). Knee flexion in the cryotherapy group showed better recovery of knee flexion from week 4 onwards. Improvement of knee flexion from POD1 is statistically significant at week 6 (98.7 ± 19.1°, 95% CI = 89.5-107.9 vs. 65.4 ± 49.9°, 95% CI = 42.7-88.1; P = 0.010) and overall mean (71.2 ± 35.9°, 95% CI = 61.2-81.1 vs. 45.3 ± 55.5°, 95% CI = 30.4-60.2; P = 0.005). The cryotherapy group reported statistically significant better degree of overall mean knee extension (1.2 ± 3.3°, 95% CI = 0.5-2.0 vs. 2.6 ± 4.6°, 95% CI = 1.6-3.7; P = 0.032). The use of cryotherapy in postoperative ACLR recovery in paediatrics is a simple yet effective measure resulting in short-term pain relief and improvement in knee flexion.

Management of Pediatric Anterior Cruciate Ligament Injuries: A Critical Analysis.

» Overall evidence for the treatment of an anterior cruciate ligament (ACL) injury in a pediatric or skeletally immature patient remains lows.» An ACL reconstruction is recommended with concomitant repairable chondral and meniscus injury or with symptoms of persistent instability despite high-quality rehabilitation.» Treatment decision for pediatric ACL reconstruction should use a shared decision-making model weighing the risks and benefits of both a nonoperative vs. surgical treatment.

Analysis of Growth After Transphyseal Anterior Cruciate Ligament Reconstruction in Children.

Pediatric transphyseal anterior cruciate ligament reconstruction (ACLR) bears several advantages and is widely used. The main concern is the risk of growth disturbance. Our purpose was to investigate the incidence and risk factors of growth disturbance in skeletally immature patients who underwent transphyseal ACLR. We hypothesized that this procedure would generate neither clinically relevant limb length discrepancy (LLD) nor axis deviation. This prospective, consecutive, single-center series included skeletally immature patients who underwent primary transphyseal ACLR using semitendinosus tendon autograft, with a 2-year follow-up bone length standing radiograph of both lower limbs from pelvis to ankle in anterior posterior view. Lower limb length, mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA) were measured. The definition of postoperative growth disturbance was defined as ≥10mm for LLD or ≥3 degrees for axis deviation in comparison to the contralateral lower limb. Predictive variables included age at surgery, gender, side, and diameter of bone tunnels. Student or Mann-Whitney test was used for numerical variables, and Chi-square test or Fisher exact test was used for categorical variables. P values <0.05 were considered statistically significant. Fifty consecutively treated patients were included. Forty-seven patients (31 boys, 16 girls) with a mean age of 13.2 years (range, 9 to 16) at the time of surgery were available for analysis. Six patients had an LLD of at least 10mm. Twenty-five patients had a difference in MPTA of a least 3 degrees (range, 5 to 8). Sixteen patients had a difference in LDFA of a least 3 degrees (range, 4 to 9). No patients presented with a clinical deformity or related symptoms. Regarding coronal alignment, there was no statistical difference in mechanical axis deviation, LDFA, or MPTA. Gender, side, age, and bone tunnel diameter did not influence growth disturbance. Transphyseal pediatric ACLR generated a high rate of growth disturbances (leg length discrepancy and axis deviation) although none clinically relevant. Mild proximal tibial axis deviation in patients operated on near skeletal maturity should be further investigated. Level III. Case-control study.

Growth Disturbances Following Paediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Growth disturbances after transphyseal paediatric anterior cruciate ligament (ACL) reconstruction have led to the development of physeal-sparing techniques. The aim of this study is to investigate growth disturbances following paediatric ACL reconstruction and identify associated risk factors. A systematic search on PubMed, Scopus and Web of Science databases was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify case series reporting paediatric ACL reconstructions. Of 518 articles, 78 met the inclusion criteria, and data related to growth disturbances and graft failures were extracted. A total of 2,693 paediatric ACL reconstructions resulted in 70 growth disturbances (2.6%): 17 were varus, 26 were valgus, 13 were shortening, 14 were lengthening and five patients had reduced tibial slope. Some patients showed deformities in more than one plane. Coronal plane deformities were seen more frequently with eccentric physeal arrest and lengthening with intraepiphyseal tunnelling. Shortening and reduced tibial slope were related to large central physeal arrest and anterior tibial physeal arrest, respectively. Sixty-two studies documented 166 graft failures in 2,120 reconstructions (7.8%). The extraphyseal technique was least likely to result in growth disturbances and graft failure. Paediatric ACL reconstruction is a safe and effective treatment of rupture. Growth disturbances are least likely following extraphyseal tunnelling, and those resulting from transphyseal techniques can be minimised by reducing drill size, drilling steep and avoiding the physeal periphery. The insertion of hardware, synthetic material, or a bone plug through the drilled physis should be avoided. There is a greater need for robust long-term data collection, such as national ligament registries, to standardise practice and evaluate the risk of growth disturbance and re-ruptures in this treatment.

Knee valgus and patellofemoral instability after pediatric anterior cruciate ligament reconstruction: a case report and review of the literature

BackgroundPediatric athletes who undergo anterior cruciate ligament reconstruction are at risk for a growth deformity if the surgery violates the physes.CaseA 12-year-old African American boy underwent anterior cruciate ligament reconstruction using a hamstring autograft. The procedure violated the distal femoral growth plate and the perichondrial ring of LaCroix, resulting in a distal femoral lateral physeal growth arrest. Three years later, he had developed a 15° valgus deformity, an increased quadriceps angle and patellofemoral instability. He was able to return to sports after undergoing a distal femoral osteotomy to correct the valgus and medial patellofemoral ligament reconstruction to stabilize the patella.ConclusionAnterior cruciate ligament reconstruction in athletes with open physes has the potential to cause distal femoral valgus deformity, an increased quadriceps angle, and subsequent patellofemoral instability.

Single-Shot Versus Continuous Nerve Blocks for Pediatric Anterior Cruciate Ligament Reconstruction: Analgesic Efficacy and Postoperative Outcomes

Background: Regional anesthesia is often used to minimize postoperative pain, enable early mobilization, and improve patient/family satisfaction after ACL reconstruction. Little is known about the effects of nerve blocks on patient-reported outcomes and functional outcomes in pediatric ACL reconstruction. This study was performed to compare analgesic efficacy, isokinetic strength testing, and Patient-Reported Outcomes Measurement Information System (PROMIS) scores between single-shot femoral nerve block (SSNB) and femoral nerve catheter (FNC).Methods: Pediatric patients (<18 years old) who underwent primary ACL reconstruction at a tertiary care children's hospital between January 2018 and August 2019 were included. Patients were grouped based on their anesthesia technique (SSNB or FNC) and compared to identify differences in the occurrence of uncontrolled postoperative pain and opioid refills. PROMIS domain scores, active range of motion (AROM), and isokinetic strength testing at multiple timepoints up to 6 months postoperatively were also collected. Linear regression multiple imputation analysis was performed to account for variable outcome measure availability.Results: A total of 78 patients were included (SSNB:42; FNC:36). The groups had similar pain medication needs and pain scores at 1 week postoperatively. The FNC group had significantly longer in-room to incision times (P<0.001), were less likely to return to school by 1 week after surgery (P=0.03), and had lower mobility scores at the 1-week postoperative visit. Patients in the SSNB group had significantly weaker quadriceps function at 3 months (P=0.02), although this difference resolved by the 6-month visit. There were no cases of infection or neuropathy in either group.Conclusion: Our findings indicate that both FNC and SSNB are viable options with similar efficacy for postoperative pain management in pediatric ACL reconstruction. However, we did not find any evidence of superior analgesia with FNC. Additionally, FNC was associated with lower PROMIS mobility scores at 1 week, delayed return to school, and 30 minutes of additional time spent in the operating room. There were no significant differences between groups in terms of function and PROMIS scores at 6 months postoperatively.Level of Evidence: Level III, retrospective cohort studyKey Concepts•Femoral nerve catheter and single-shot femoral blocks are both viable management options for post-ACL reconstruction pain in children and adolescents.•We found that patients who received a femoral nerve block were less likely to return to school and had lower mobility scores at 1 week postoperatively and spent an additional 30 minutes in the operating room.•Both regional anesthesia techniques had similar PROMIS scores and functional outcomes at 6 months postoperatively.

Femoral Physeal-Sparing ACL Reconstruction With Iliotibial Band Autograft Over-the-Top With Associated Lateral Extra-Articular Tenodesis

Background: Injuries to the anterior cruciate ligament (ACL) in the pediatric population have been exponentially increasing over the years. However, surgical techniques typically employed for ACL reconstruction (ACL-R) in adults may injure the physes of skeletally immature patients, resulting in growth disturbances. Indications: Currently, ACL-R is recommended for most patients, aiming to return the patient to their previous activities as well as reduce the risk of further instability, meniscal and chondral injuries, and early osteoarthritis. Pediatric ACL-R techniques may vary widely. In this video, the technique chosen was over-the-top on the femur with a vertical tibial tunnel, in addition to a lateral extra-articular tenodesis, using the iliotibial (IT) band as the graft. Technique Description: The patient is positioned in standard supine arthroscopic position. An incision is made over the lateral epicondyle and the IT band is exposed. A 2-cm-wide graft is harvested. The proximal aspect of the graft is truncated as high as possible, and the distal aspect is left attached to Gerdy tubercle. Arthroscopic portals are established, and the remanent ACL is debrided, exposing the posterior aspect of the lateral femoral condyle. The capsule is penetrated using a Schnidt tonsil to establish the over-the-top position, which is subsequently exchanged for a cardiac clamp. The graft sutures are grasped using the clamp and pulled into the joint. The tibial tunnel is drilled at the anatomic footprint of the ACL. The graft is threaded over-the-top of the lateral femoral condyle and through the tibial tunnel. Finally, femoral graft fixation is performed on the lateral femoral condyle using interrupted sutures through the IT band and periosteum, and tibial graft fixation is performed with standard interference fixation. Results: Previous literature shows low re-rupture rates, excellent postoperative patient-reported outcomes, and high return to sport rates. Conclusion: In the pediatric population, there is still no ACL-R technique defined as the gold standard. The described technique is a valuable option for ACL-R in skeletally immature patients, with low revision rates and excellent postoperative outcomes. In addition, this technique minimizes the risk of growth disturbances and effectively stabilizes the knee, allowing patients to return to previous activities. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Femoral-Physeal-Sparing ACL Reconstruction With Lateral Extra-articular Tenodesis and Inside-Out Repair of Lateral Meniscus in a Skeletally Immature Patient

Background: Anterior cruciate ligament (ACL) reconstructions in skeletally immature patients have an increased risk of graft failure and a decreased rate of successful return to sports. Anterior cruciate ligament reconstructions (ACLRs) combined with lateral extra-articular tenodesis (LET) procedures are reported to limit anterolateral rotary instability of the knee, decreasing tension on the ACL graft. However, the open physes found in pediatric patients present unique challenges for ACLR. This video demonstrates a technique to avoid the femoral physis and necessary precautions for performing an ACLR with LET in a skeletally immature patient. Indications: The indications for combined ACLR and LET, as opposed to ACLR alone, mainly center on the risk factors for graft failure. These include the following: posterior tibial slope &gt;12°, revision ACLR, high-grade pivot shift on physical examination, meniscal deficiency, generalized ligamentous hyperlaxity, and—especially pertinent to this procedure—skeletally immature patients. Technique Description: Standard plain radiographs and long-leg alignment films, along with a magnetic resonance imaging (MRI) study, are necessary to assess for malalignment, bone age, and concomitant meniscal and chondral pathology. This technique describes the senior author’s preferred technique for pediatric ACLR with LET. The senior author’s preferred order of operations includes performing the autologous hamstring graft harvest and LET before performing the diagnostic arthroscopy. This is followed by the intra-articular work including the ACLR. It is also the senior author’s preference to perform physeal-sparing femoral tunnels, using fluoroscopy for tunnel placement. Results: Getgood et al reported that an ACLR with an LET in young patients with a high risk of graft failure had a significant reduction in graft rupture compared to an ACLR alone. Furthermore, Noyes et al reported a significantly lower rate of graft failure and a higher rate of return to sports in those who received LET in addition to ACLR compared with those who received ACLR alone. Discussion: An ACLR combined with an LET has been reported to reduce graft failure rates and improve clinical outcomes in high-risk patients. An ACLR with LET may also be considered in skeletally immature patients with appropriate indications and extra precautions to avoid growth arrest or deformity. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Presentation of an intraosseous suspensory fixation technique for pediatric and adult ACL reconstruction

The aim is to present a technique for pediatric and adult ACL reconstruction using an intraosseous suspensory fixation. This technique uses a 4-strands hamstring graft fixed in the femoral tunnel, with a loop locked in a polyetheretherketone (PEEK) cage. The ACLip® device offers an inside-out drilling system and a closer fixation to the joint than an extracortical button fixation. The technique can be easily used both in adults and in skeletally immature patients. The first practical experience shows promising results regarding the safety and the effectiveness of the technique. Level of evidence: IV.

Comparison of clinical outcomes between anterior cruciate ligament reconstruction with over-the-top route procedure and anatomic single-bundle reconstruction in pediatric patients

The purpose of this study is to evaluate the clinical results of over-the-top route (OTTR) reconstruction for pediatric anterior cruciate ligament (ACL) injuries and compare them with results of anatomic single-bundle reconstruction (SBR), which used the bone tunnel technique and was performed early after epiphyseal closure (age ≤15 years). This study included pediatric patients aged 11-15 years who underwent ACL reconstruction. The mean age at surgery was 13.4 years (11-15 years), including 14 men and 29 women. Operative procedures were determined according to growth plate closure. In all cases, the tibial side was reconstructed using a bone tunnel procedure. On the femoral side, we selected the OTTR procedure (group O) with open physis. Where the physis was closed, we selected the anatomical SBR (group B). The clinical results were evaluated with manual examination, the side-to-side difference (SSD) in tibial anterior translation using the Kneelax 3, and knee function score. There were no significant differences in the Lachman and pivot-shift tests, SSD in tibial anterior translation with Kneelax 3, or knee function score between the two groups before or after the surgery. Growth disturbance was not observed on either the femoral or tibial side in group O. The OTTR method provided comparable results with the bone tunnel anatomical method in manual examination, Kneelax 3, and knee clinical function scores, suggesting that the OTTR method is very useful for pediatric ACL reconstructions. Level of evidence: III; retrospective study.

Complications After Pediatric ACL Reconstruction: A Meta-analysis.

*Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX †Department of Orthopaedic Surgery Rady Children’s Hospital, San Diego, CA D.J.C.: performed analysis and manuscript preparation. H.G.C.: performed manuscript editing No funding sources. H.G.C. reports a non-financial conflict of interest having previously designed Orthopediatrics physeal sparing kit. D.J.C. declares no conflicts of interest.

Surgical techniques in the management of pediatric anterior cruciate ligament tears: Current concepts.

Anterior cruciate ligament injury in the child and adolescent patient remains a controversial topic when considering management, especially regarding surgical choices. Treatment variations are seen not just when comparing different countries but also within nations. This arises partly as contemporary treatment is mostly inferred from the adult population who physiologically and in terms of outcomes differ significantly from children. There is an increasing body of evidence for this cohort of patients who have specific challenges and difficulties when determining the optimum treatment. Within this article, we will summarize the current evidence for surgical management of anterior cruciate ligament injury for the pediatric patient. There remain many controversies and gaps inthe treatment of Paediatric Anterior cruciate ligament reconstruction and this high risk cohort continues to cause difficulty in identifying the best mode of surgical management. level IV.