Pediatric Anterior Cruciate Ligament Research Articles

Pediatric ACL Reconstruction in Children—An Evaluation of the Transphyseal Technique’s Efficacy and Safety

Introduction: 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. Purpose/Hypothesis: Our study aims to verify if ACL reconstruction (ACLR) using transphyseal technique in skeletally immature patients will provide angular deviations or growth restrictions. Study Design: Retrospective cohort study; Level of evidence 4. Methods: 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. Results: 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. Conclusions: 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.

Anterior Proximal Tibial Screw Hemiepiphysiodesis Decreases Posterior Tibial Slope in Knee Flexion Contracture: A Case Report.

A 13-year-old adolescent boy with hemiplegic cerebral palsy suffering from fixed knee flexion deformity of 10° despite extensive conservative treatment. Owing to a posterior tibial slope (PTS) of 16°, anterior hemiepiphysiodesis was applied to the proximal tibia. The 2 screws were removed after 9 months. Final follow-up at 16 months showed complete knee extension and a PTS of 4°. The presented technique is a good alternative in knee flexion deformity with an increased PTS and has surprisingly not been described in the literature. This might be worth considering for other pathologies such as pediatric anterior cruciate ligament injury with an increased PTS.

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.

Functional Rehabilitation of Anterior Cruciate Ligament Tear in the Pediatric Population: A Comprehensive Review.

Pediatric sports injuries are a growing concern due to increased youth participation in sports. Effective rehabilitation strategies are essential for ensuring optimal recovery, restoring knee function, and preventing long-term consequences. This research aims to explore and evaluate various functional rehabilitation approaches tailored to pediatric anterior cruciate ligament (ACL) tear injuries. Functional rehabilitation of ACL tears in pediatric sports injuries is an important area of research due to the unique considerations and challenges that arise when treating ACL injuries in young athletes. Over the last 20 years, there has been a well-documented uptick in ACL injuries among pediatric populations. This rise can be attributed to the growing involvement of the younger population in competitive sports, as well as heightened awareness regarding sports-linked injuries. This study highlights the importance of early surgical reconstruction in children to enable a quick return to sports and prevent long-term cartilage and meniscal damage resulting from instability. The use of physeal-sparing ACL reconstruction techniques, particularly hamstring autografts, is recommended for favorable clinical outcomes while minimizing growth disturbances. This study offers valuable insights for healthcare professionals and researchers, serving as a reference to guide optimal approaches in managing pediatric ACL injuries and achieving successful results in this field.

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.

Similar outcomes after anterior cruciate ligament reconstruction in paediatric and adult populations: a 1-year follow-up of 506 paediatric operations in Denmark.

To present 1-year results after all paediatric anterior cruciate ligament (ACL) reconstructions in Denmark (5.9M inhabitants) for the 10½year period, 1 July 2011 to 31 December 2021. All children who had an ACL reconstruction were enrolled. They were asked to complete Pedi-IKDC preoperatively and at 1-year follow-up. Independent observers performed pivot shift test and instrumented laxity assessment preoperatively and at 1-year follow-up. The median age of the 506 children (47.2% girls) was 14.3years (9.3-15.9). The Pedi-IKDC score increased from preoperatively 61.6 ± 15.8 (mean ± SD) to 85.9 ± 13.0 at 1-year follow-up (p < 0.0001). There were concomitant injuries (to meniscus and/or cartilage) in 49.9%, but these children had preoperative and follow-up Pedi-IKDC scores similar to the scores for children with isolated injury to ACL (n. s.). Instrumented anterior laxity was 4.3 ± 1.4 (mean ± SD) mm preoperatively and 1.4 ± 1.4mm at follow-up (p < 0.0001). Preoperatively, 3% had no pivot shift whilst this was the case for 68% postoperatively (p < 0.0001). Twenty-five children (5.6%) had 4mm instrumented laxity or more relative to the unoperated knee at follow-up. Two patients (0.4%) had an operatively treated deep infection, three (0.5%) were operated on for reduced range of motion and two (0.4%) had a revision ACL reconstruction. ACL reconstruction resulted in a clinically meaningful increase in Pedi-IKDC, an improved instrumented stability, a reduction in the grade of pivot shift and the complication rate was low at 1-year follow-up. The risk of graft insufficiency at 1-year follow-up was the same as in an adult population. II.

Evaluating the Readability and Quality of Online Patient Education Materials for Pediatric ACL Tears.

As the rate of anterior cruciate ligament (ACL) tears increases in children, the internet has become a major source of information and education. In the United States, the average adult reads at about an eighth grade level. The National Institutes of Health recommends that patient education materials do not exceed a sixth-grade reading level. Therefore, the most accessed resources on the internet should be created with this in mind. The purpose of this study is to assess the readability and quality of online patient resources for pediatric ACL tears. Google was queried using the term "Pediatric ACL Tear" on May 26, 2022. The most popular sites were identified through page one of a Google search. All content was evaluated to assure information was directed toward patients. To determine reading difficulty, the most widely accepted readability tests: Flesch Reading Ease Index, Flesch-Kincaid Grade Level, and Gunning Fog Index were calculated through plain text in Microsoft Word and URL in online readability checker Readable.io. The average grade level for all resources was above the recommended reading level based on both Microsoft Word and Readable.io calculations. Each source exceeded the NIH recommendation by 2.6 grade levels on average (Mean grade level readability was 8.6 ± 1.9). Four of the 6 sites were above the average US reading level, exceeding the eighth grade by an average of 1.5 grade levels. All 6 sites analyzed had a mean DISCERN score of 61.9, meeting the 'good quality' criteria. The most readily available online materials for Pediatric ACL tears were of 'good quality' but above both the NIH-recommended readability level and the average US adult reading level. With the increasing need for treatment of ACL tears in pediatric and adolescent patients and greater internet accessibility in these populations, it is important to consider the readability of these resources in support of increased health literacy and improved outcomes. It is important for physicians treating young patients with ACL tears to be aware of all sources of information and support, including content shared online as these platforms are increasingly utilized, especially by patients and families of lower socioeconomic status.

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.

Poster 151: Femoral Cartilage T2* Relaxation Times Correlate With Inflammatory Biomarker MCP-1 Levels In Serum, But Not Synovial Fluid, After ACL Injury In A Skeletally Immature Porcine Model

Poster 151: Femoral Cartilage T2* Relaxation Times Correlate With Inflammatory Biomarker MCP-1 Levels In Serum, But Not Synovial Fluid, After ACL Injury In A Skeletally Immature Porcine Model

Leg-Length and Alignment Changes in Children and Adolescents After Transphyseal Anterior Cruciate Ligament Reconstruction With Soft Tissue Graft: Results at 1-Year Follow-up.

Growth disturbance to leg length or coronal plane alignment are important considerations in pediatric anterior cruciate ligament (ACL) reconstruction (ACLR). The purpose of this study was to investigate the lower limb alignment and leg length of pediatric patients preoperatively and at approximately 1 year after transphyseal ACLR. Our hypothesis was that there would be no significant change in leg-length discrepancy (LLD) or operated-side alignment at follow-up. Case series; Level of evidence, 4. Data were extracted from the prospective Queensland Children's Hospital Pediatric ACL Injury Registry. Long-leg alignment radiographs were captured preoperatively and at an approximately 12-month postoperative follow-up. Radiographic measures included leg length, LLD (injured minus uninjured leg length), mechanical axis deviation (MAD), mechanical and anatomical lateral distal femoral angle (mLDFA and aLDFA, respectively), and medial proximal tibial angle. We evaluated the effect of time (annual vs baseline) on imaging measurements with analysis of covariance, using the covariates of age, sex, and body mass index. Data were available for 104 patients, of whom 34 (33%) had >12 months of skeletal growth remaining based on skeletal age. At an average follow-up time of 14.5 months after ACLR, there were no significant differences in mean lower limb alignment or longitudinal growth compared with baseline. However, seven patients demonstrated clinically significant changes to their mechanical axis or LLD (>10 mm change). A subgroup analysis of patients with >12 months of growth remaining (n = 34) demonstrated no statistically significant changes in mean alignment or LLD. Before surgery, LLD was -1.39 mm and the injured limb was in significantly more valgus compared with the uninjured lower limb (mean difference: MAD, 4.79 mm [95% CI, 2.64 to 6.94 mm]; mLDFA, -0.93° [95% CI, -1.29° to -0.57°], and aLDFA, -0.91° [95% CI, -1.31° to -0.50°]). After ACLR, there were no statistically significant changes in mean alignment or longitudinal growth; however, 7 out of 104 patients (6.7%) demonstrated clinically significant changes in alignment or LLD. Preoperatively, the injured limb was statistically significantly in more valgus compared with the uninjured limb with lateralized MAD.

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.

Preliminary experience of an international orthopaedic registry: The ESSKA Paediatric Anterior Cruciate Ligament Initiative (PAMI) registry

To evaluate the effect of preconditioning according to intraoperative workflow on initial tension and elongation behavior for femoral adjustable loop devices (ALDs) and closed loop devices (CLDs) in suspensory anterior cruciate ligament reconstruction (ACLR) with tibial screw fixation in a biomechanical in vitro study.Three ACLR groups with tibial screw fixation were biomechanically tested in a full-construct setup using porcine tibias. Groups (n = 8 per group) varied by femoral fixation method and consisted of a CLD (group 3) and ALD fixation with (group 2) and without simulated intraoperative preconditioning (group 1). The change in tension after screw insertion and the displacement to restore the initial loading situation were measured. Grafts underwent dynamic cycling (1,000 cycles at 0.75 Hz) using both a position and a force control mode.Data are presented as mean [standard deviation]. Placement of an interference screw induced a graft tension loss of 62% (49.4 [0.4] N vs 19.0 [10.0] N, P < .001) by introducing a laxity of 0.53 [0.26] mm. Intraoperative preconditioning led to a higher initial load level (228.3 [19.8] N) compared with unconditioned ALD (156.1 [25.5] N, P < .001) and CLD groups (156.6 [12.8] N, P < .001) with less force decrease over position-controlled cyclic loading. Furthermore, initial (−0.22 [0.16] mm) and dynamic elongation (0.88 [0.23] mm) were reduced compared with the unconditioned ALD (0.65 [0.35] mm, P < .001; and 1.56 [0.19] mm, P < .001) and CLD groups (0.16 [0.26] mm, P < .001; and 1.64 [0.24] mm, P < .001).ACLR with femoral ALD fixation and intraoperative preconditioning allows for restoration of time-zero screw-imparted slack and leads to significantly reduced cyclic elongation in accordance with native ACL function. Both ALD and CLD control groups behaved similarly, with total elongation less than 3 mm including time-zero slack.Although the clinical relevance of time-zero graft tension loss is uncertain, the use of an ALD in concert with tibial screw fixation may be favorable to allow for tension optimization.

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.

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.

Pediatric anterior cruciate ligament tears and associated lesions: Epidemiology, diagnostic process, and imaging.

The incidence of anterior cruciate ligament injuries in skeletally immature patients has increased in recent years. The gold standard treatment of this type of trauma in children is not yet established. Conservative management may underestimate the risk of new meniscal and chondral tears; on the other hand, a more interventional approach may expose the patient to iatrogenic damage to the growth plate. A correct approach to the skeletally immature patient with knee trauma is therefore essential to guide the decision-making process. This review article aims to present an update on the epidemiology and diagnostic process of pediatric patients with anterior cruciate ligament tears and possible associated injuries. Level of Evidence: V.