Pediatric International Knee Documentation Committee Research Articles

Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: 3-Year Clinical and Patient-Reported Outcomes.

The rate of anterior cruciate ligament (ACL) rupture in active, skeletally immature patients is increasing. Although hamstring tendon autograft (HTA) was previously deemed the gold standard, recent studies have shown HTA to have a high failure rate in this high-risk population of young competitive athletes, and quadriceps tendon autograft (QTA) has yielded excellent preliminary outcomes in some studies examining this population. To evaluate 3-year clinical and patient-reported functional outcomes of primary ACL reconstruction (ACLR) with soft tissue QTA in skeletally immature patients. Case series; Level of evidence, 4. Skeletally immature patients who underwent ACLR with a full-thickness soft tissue QTA were included. Preoperative patient and surgical data were collected. The ACLR technique was selected predicated upon skeletal age and included all-epiphyseal and complete transphyseal techniques. Patients were followed for a minimum of 2 years with successive clinical visits or were contacted via telephone. Patients who did not have minimum 2-year follow-up after 3 contact attempts via telephone were excluded. Information regarding return to sports (RTS) and concomitant or subsequent surgical procedures was collected. Pediatric International Knee Documentation Committee (Pedi-IKDC), Hospital for Special Surgery Functional Activity Brief Scale (HSS Pedi-FABS), and Single Assessment Numeric Evaluation (SANE) scores were collected. Of 85 adolescent patients aged 11.1 to 17.6 years (mean age, 14.1 ± 1.2 years), 2 patients were determined to be lost to follow-up after 3 failed contact attempts. Of the patients included in this study (N = 83), 26 patients (31%) underwent all-epiphyseal and 57 patients (69%) underwent complete transphyseal ACLR. Additionally, 48 patients (58%) underwent concomitant lateral extra-articular tenodesis using the iliotibial band with a modified Lemaire technique. The mean follow-up time was 3.7 ± 1.2 years (range, 2-7 years). Twenty (24%) patients had subsequent surgical procedures, of which 3 (4%) were due to graft failures. At a mean 3-year follow-up, the mean Pedi-IKDC, HSS Pedi-FABS, and SANE scores were 90, 23, and 94 respectively; the RTS rate was 100%; and the rate of RTS at the previous level of performance was 93%. Use of a soft tissue QTA for ALCR in a high-risk skeletally immature population of athletes resulted in excellent postoperative outcomes with low rates of graft failure and high return to sport rates.

A Modified 4-in-1 Stanisavljevic Procedure for Treating Obligatory or Congenital Patellar Dislocations in Children: A Surgical Technique.

Patellar instability and dislocation pose complex clinical and surgical challenges, especially in children. Congenital (fixed) and obligatory (habitual) dislocations present significant anatomical and etiological complexity, frequently leading to deformities and functional impairments, which can range from walking difficulties to sports limitations. Conservative treatment is often inadequate. We describe a surgical technique for treating congenital or obligatory patellar dislocations in patients with various underlying diagnoses-including Down syndrome, nail-patella syndrome, and skeletal dysplasia-that involves extensive subperiosteal quadriceps realignment, distal realignment (Roux-Goldthwait or tibial tuberosity transfer), and optional medial plication. This modified 4-in-1 technique follows the principles described in 1976 by Stanisavljevic, which involves subperiosteal quadriceps mobilization, thus minimizing muscle damage, bleeding, and postoperative muscular adherences. In 24 patients treated at our institution between 2002 and 2021 (35 knees; age range = 5.5-16.8 years; 13 girls, 11 boys), with a mean follow-up of 8.2 years (2.4-20 years), we achieved satisfactory improvements in patellar stability, range of motion, and quality of life with a modified 4-in-1 Stanisavljevic technique. A total of 9 patients (7 with obligatory dislocations and 2 with congenital dislocations) could engage in recreational or competitive sports. The average postoperative pediatric International Knee Documentation Committee (pedi-IKDC) score was 78.45 ± 22.3 (range = 0-100); a patient with DiGeorge syndrome and 1 with multiple epiphyseal dysplasia had scores of 35 and 48, respectively. We found at our institution that a modified 4-in-1 Stanisavljevic technique produced favorable outcomes in patellar stability, range of motion, and quality of life in pediatric patients with congenital or obligatory patellar dislocation. More study is warranted to determine the procedure's overall benefits for children with obligatory or congenital dislocations of complex etiology.

Outcomes of treatment of patella fractures in children and adolescents.

The purpose of this study is to assess clinical and functional outcomes in separate cohorts of operatively and nonoperatively managed pediatric patella fractures. A retrospective review was completed for patients aged 5-19 years treated for a unilateral patella fracture at a single pediatric level-1 trauma center. Patients were excluded for osteochondral fracture associated with patellar dislocation, polytrauma presentation with additional fractures, or <3 months of clinical follow-up. Functional outcomes were assessed via the Pediatric International Knee Documentation Committee form and the Marx Knee Activity Scale. A total of 53 patients met inclusion criteria; 30 patients were treated operatively and 23 patients were treated nonoperatively. Patients with patellar sleeve/pole fractures were significantly younger by 5.2 years (p < 0.01) and presented with greater variability in mechanism of injury (p < 0.01). The nonoperative cohort achieved bony healing and returned to sports at a median (interquartile range) of 1.7 (1.2-2.3) months and 2.8 (2.3-3.3) months, respectively, post-injury. The operative group achieved bony healing and returned to sports at 2.8 (2.1-3.5) months and 5.9 (4.0-7.1) months, respectively, following surgery. Median (interquartile range) Pediatric International Knee Documentation Committee and Marx scores were 98 (89-100) and 14 (10-16), respectively, for the nonoperative group, and 92 (84-99) and 13 (12-16), respectively, for the operative group. No significant differences in patient-reported outcomes were observed between fracture patterns or treatment cohorts. Pediatric and adolescent patients sustaining patella fractures reported long-term functional outcomes comparable to normative values, across multiple fracture patterns and with appropriate operative and nonoperative treatment. Fractures requiring surgery were expectedly associated with slower healing and return to sport timelines. Therapeutic Level III.

Early- and Late-Stage Benefits of Blood Flow Restriction Training on Knee Strength in Adolescents After Anterior Cruciate Ligament Reconstruction.

Blood flow restriction training (BFRT) after anterior cruciate ligament reconstruction (ACLR) is rising in popularity because of its benefits in reducing muscle atrophy and mitigating knee strength deficits. To investigate the impact BFRT has on adolescent knee strength after ACLR at 2 postoperative time points: at 3 months and the time of return to sport (RTS). Cohort study; Level of evidence, 3. A prospective intervention (BFRT) group was compared to an age-, sex-, and body mass index-matched retrospective control group. Patients aged 12 to 18 years who underwent primary ACLR with a quadriceps tendon autograft were included. Along with a traditional rehabilitation protocol, the BFRT group completed a standardized BFRT protocol (3 BFRT exercises performed twice weekly for the initial 12 weeks postoperatively). Peak torque values for isometric knee extension and flexion strength (at 3 months and RTS) and isokinetic strength at 180 deg/s (at RTS) as well as Pediatric International Knee Documentation Committee (Pedi-IKDC) scores were collected. Differences between the BFRT and control groups were compared with 2-way mixed analysis of variance and 1-way analysis of variance. The BFRT group consisted of 16 patients (10 female; mean age, 14.84 ± 1.6 years) who were matched to 16 patients in the control group (10 female; mean age, 15.35 ± 1.3 years). Regardless of the time point, the BFRT group demonstrated significantly higher isometric knee extension torque compared to the control group (2.15 ± 0.12 N·m/kg [95% CI, 1.90-2.39] vs 1.74 ± 0.12 N·m/kg [95% CI, 1.49-1.98], respectively; mean difference, 0.403 N·m/kg; P = .024). The BFRT group also reported significantly better Pedi-IKDC scores compared to the control group at both 3 months (68.91 ± 9.68 vs 66.39 ± 12.18, respectively) and RTS (89.42 ± 7.94 vs 72.79 ± 22.81, respectively) (P = .047). In adolescents, the addition of a standardized BFRT protocol to a traditional rehabilitation protocol after ACLR significantly improved knee strength and patient-reported function compared to a traditional rehabilitation program alone.

Validation of the ACL-RSI Scale in Pediatric and Adolescent Patients

Background: The Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) scale is a 12-item questionnaire assessing psychological readiness to return to sport after anterior cruciate ligament reconstruction. It has been validated for use in adults in multiple languages and in an abbreviated 6-question short form. Additionally, literature has been published using this scale in pediatric and adolescent populations, however it has not yet been validated for use with them. Purpose: To validate the ACL-RSI scale for use with pediatric and adolescent patients. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Scores of 6- and 12-item ACL-RSI scales for patients undergoing return-to-sport readiness testing 6 to 8 months after anterior cruciate ligament reconstruction were analyzed. Convergent validity testing was performed against the International Knee Documentation Committee (IKDC)/Pediatric IKDC score, Single Assessment Numeric Evaluation (SANE) score, and peak torque asymmetry of knee flexion and extension using Spearman correlations. Discriminant validity testing was performed against age (Spearman correlation), body mass index (Spearman correlation), and sex (Mann-Whitney U test). Reliability testing was performed by calculating Cronbach’s alpha. Floor and ceiling effects were assessed by calculating the number of minimum and maximum scores in the cohort. Results: A total of 51 patients were included in the final analysis. The mean age at surgery was 15.2 ± 2.2 years, and 51.0% were female. The 6- and 12-item ACL-RSI scales demonstrated a strong significant positive correlation with IKDC/Pediatric IKDC scores (R = 0.723 and 0.717, respectively; P < .001) and moderate significant positive correlation with Single Assessment Numeric Evaluation scores (R = 0.516 and 0.502, respectively; P < .001) Age at surgery, body mass index, and sex were not correlated with either ACL-RSI scale. Cronbach’s alpha values of the 12- and 6-item ACL-RSI scales in this population were 0.959 and 0.897, respectively. For both the 12- and the 6-item ACL-RSI scales, no floor or ceiling effects were found as the minimum score (0) was not observed in either version, and the maximum score (100) was only observed twice (3.9%) in both versions. Conclusion: The ACL-RSI scale is valid to use with pediatric and adolescent patients. The 6-item scale may be a better choice because it has fewer redundancies and minimizes the risk of questionnaire fatigue.

Association of Grit With Postoperative Knee Outcomes and Physical Function After ACL Reconstruction in Adolescent Athletes.

Grit is the disposition to strive for long-term goals despite setbacks and challenges. Given the lengthy, arduous process of rehabilitation after anterior cruciate ligament reconstruction (ACLR), an athlete's grit may predict postoperative outcomes across time. The primary aim of the study was to evaluate the relationships between baseline (preoperative) grit and postoperative knee outcomes across the year after ACLR among adolescents. We hypothesized that athletes with more grit would achieve better postoperative outcomes over time than less gritty athletes. Cohort study; Level of evidence, 2. All participants completed the Short Grit Scale, the Pediatric International Knee Documentation Committee (Pedi-IKDC) Scale, the Lysholm Knee Scoring Scale, the Patient-Reported Outcomes Measurement Information System (PROMIS) pediatric scale for pain interference and mobility, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS), and the Quality of Life in Neurological Disorders (NeuroQoL) Lower Extremity Function Short Form at a preoperative appointment and then again at approximately 3, 6, and 12 months after ACLR. We constructed linear mixed models to assess the relationships between baseline grit, time, age, sex, and postoperative outcome measures (statistical significance of α = .05). We included 137 participants (mean age 15.8 ± 2.74 years, 70% female) from a prospective registry of athletes undergoing ACLR by 1 surgeon at a single institution. There were no statistically significant changes in grit over time or differences in grit between age and sex. Higher baseline grit was significantly associated with greater postoperative HSS Pedi-FABS scores (β = 3.72 ± 1.46; P = .01; 95% CI, 0.85-6.59) and NeuroQoL scores across time (β = 3.37 ± 0.93; P < .001; 95% CI, 1.55-5.20). There were no significant associations between baseline grit and Pedi-IKDC, Lysholm, and PROMIS pain interference or mobility scores. Athletes with higher baseline grit reported superior postoperative physical function and activity level over the course of 1 year after ACLR compared with less gritty athletes. Grit may be a useful measure in predicting success in regaining physical function across time after ACLR in adolescent athletes.

Poster 338: Analysis of Patient Reported Outcomes and Subsequent Surgery Rate following Quadriceps Tendon Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis in Skeletally Immature Patients: Two Year Follow-Up

Objectives: The incidence of anterior cruciate ligament reconstruction (ACLR) in pediatric and adolescent patients is increasing significantly and many patients possess risk factors that predispose to ACL re-tear. Lateral extra-articular tenodesis (LET) may be performed in conjunction with ACLR to reduce the risk of ACL re-tear. The purpose of this study is to evaluate the 2-year clinical outcomes of ACLR with soft tissue quadriceps tendon (QUAD) autograft and a lateral extra-articular tenodesis (LET) using a modified Lemaire technique in skeletally immature patients. Methods: A consecutive series of patients who underwent QUAD tendon autograft ACLR and LET with a minimum of 2-year follow-up data was analyzed retrospectively. ACLR techniques included all- epiphyseal (AE) and complete transphyseal (CT) and were indicated based on skeletal age. Outcome measures included participants’ return to sports (RTS), concomitant or subsequent surgical procedures and multiple patient-reported outcome measures, including Single Assessment Numeric Evaluation (SANE), Pediatric International Knee Documentation Committee (Pedi-IKDC) and HSS Functional Activity Brief Scale (HSS Pedi-FABS) scores. Results: The final cohort included 50 consecutive adolescent patients aged 11 to 16 years (mean 14.2 ± 1 years) with a minimum follow-up of 2 years. Two patients were lost to follow-up. Of the patients included in the study (n=48), 98% participated in high-risk competitive sports (Table 1). Two patients (4%) were revision ACLR. Ten (21%) patients underwent AE and 38 (79%) underwent CT ACLR. Sixteen patients (33%) had subsequent surgical procedures, including 5 contralateral ACLR, 4 meniscus surgeries, 4 QUAD autograft scar revision, 4 irrigation and debridement (2 patients, 2 each) and 3 hardware removal procedures (2 for hemi-epiphysiodesis and 1 tibial socket button removal). The rate of graft failure was 0%. At two-year follow-up, mean SANE score was 93, mean Pedi-IKDC score was 90, and mean HSS-Pedi-FABS score was 23. RTS rate was 100%. Conclusions: A LET when performing an ACLR is safe and should be considered as a concomitant procedure for adolescent patients that are at high risk of re-tear. [Table: see text]

Pedi-IKDC exhibits questionable measurement properties in a cohort of pediatric patients with ACL rupture.

Pedi-IKDC is commonly used to evaluate anterior cruciate ligament (ACL) deficiency in children. However, its construct validity has not been thoroughly assessed. The aim was to examine the measurement properties of the Pediatric International Knee Documentation Committee (Pedi-IKDC) by modern test theory (MTT) models, confirmatory factor analysis (CFA), and item response theory (IRT). The cohort consisted of all children and adolescents in Denmark (n = 535, age 9-16) treated with physeal-sparing ACL reconstruction 2011-2020. Patient-reported outcome measure (PROM) data were collected before surgery and at 1 year follow-up. Structural validity of Pedi-IKDC was assessed with MTT models. Reliability was reported as McDonalds coefficient omega. Responsiveness was evaluated with standardized response means. Sufficient PROM data were available for 372 patients. The original unidimensional construct did not fit CFA model expectations neither before surgery (χ2 = 462.0, df = 163, p < 0.0001; RMSEA: 0.109, CFI: 0.910, TFI: 0.895) nor at follow-up. Neither did a two-factor CFA model with "Symptoms" and "Sports activities" as individual subscales (χ2 = 455.6, df = 162, p < 0.0001) nor a bifactor model (χ2 = 338.9, df = 143, p < 0.0001), although fit indices improved with the latter (RMSEA: 0.094, CFI: 0.941, TFI: 0.922). The IRT models confirmed this pattern. The scale was responsive (SRM 1.66 (95% CI: 1.46-1.88)). Coefficient omega values were 0.866 before surgery and 0.919 at follow-up. The Pedi-IKDC exhibited inadequate structural validity. Neither the original construct, a two-factor model, nor bifactor models fitted data well. We advise that data obtained by Pedi-IKDC are interpreted with caution.

Transarticular Versus Retroarticular Drilling of Stable Osteochondritis Dissecans of the Knee: A Prospective Multicenter Randomized Controlled Trial by the ROCK Group

Background: When stable osteochondritis dissecans (OCD) lesions of the femoral condyle in a skeletally immature patient fail to heal with nonoperative methods, the standard of care treatment is condylar OCD drilling. Two primary OCD drilling techniques have been described, but no prospective studies have compared their relative effectiveness. Purpose/Hypothesis: The purpose of this study was to compare the healing and function after transarticular drilling (TAD) with that after retroarticular drilling (RAD). It was hypothesized that there would be no difference in rate or time to healing, rate or time to return to sports, patient-reported outcomes (PROs), or secondary OCD-related surgery. Study Design: Randomized controlled clinical trial; Level of evidence, 1. Methods: Skeletally immature patients with magnetic resonance imaging–confirmed stable OCD lesions of the medial femoral condyle who did not demonstrate substantial healing after a minimum of 3 months of nonoperative treatment were prospectively enrolled by 1 of 17 surgeon-investigators at 1 of 14 centers. Patients were randomized to the TAD or RAD group. Tourniquet time, fluoroscopy time, and complications were compared between the treatment groups. Postoperatively, serial radiographs were obtained every 6 weeks to assess healing, and PROs were obtained at 6 months, 12 months, and 24 months. Results: A total of 91 patients were included, consisting of 51 patients in the TAD and 40 patients in the RAD group, who were similar in age, sex distribution, and 2-year PRO response rate. Tourniquet time and fluoroscopy time were significantly shorter with TAD (mean, 38.1 minutes and 0.85 minutes, respectively) than RAD (mean, 48.2 minutes and 1.34 minutes respectively) (P = .02; P = .004). In the RAD group, chondral injury from K-wire passage into the intra-articular space was reported in 9 of 40 (22%) patients, but no associated postoperative clinical sequelae were identified in these patients. No significant differences between groups were detected in follow-up Pediatric–International Knee Documentation Committee, Lysholm, Marx Activity Scale, or Knee injury and Osteoarthritis Outcome Score Quality of Life scores. Healing parameters were superior at 6 months and 12 months in the TAD group, compared with the RAD group, and secondary OCD surgery occurred in 4% of patients who underwent TAD and 10% of patients who underwent RAD (P = .40). Patients in the TAD group returned to sports earlier than those in the RAD group (P = .049). Conclusion: TAD showed shorter operative time and fluoroscopy time and superior healing parameters at 6 and 12 months, but no differences were seen in 24-month healing parameters or PROs at all follow-up time points, when compared with RAD. Registration: NCT01754298 (ClinicalTrials.gov identifier).

A Modified Lemaire Lateral Extra-articular Tenodesis in High-Risk Adolescents Undergoing Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft: 2-Year Clinical Outcomes

Background: The incidence of anterior cruciate ligament (ACL) reconstruction (ACLR) in children and adolescents has increased significantly, and many such patients are at increased risk for ACL retear. Lateral extra-articular tenodesis (LET) may be performed in conjunction with ACLR to reduce the risk of ACL retear. Purpose: To evaluate the 2-year clinical outcomes of ACLR with soft tissue quadriceps tendon (QUAD) autograft performed with a concomitant LET using a modified Lemaire technique in skeletally immature patients. Study Design: Case series; Level of evidence, 4. Methods: A consecutive series of adolescent patients who underwent QUAD autograft ACLR and LET with a minimum of 2 years of follow-up data were analyzed retrospectively. ACLR techniques, including all-epiphyseal and complete transphyseal, were indicated based on skeletal age. Outcome measures included return to sports, concomitant or subsequent surgical procedures, and multiple patient-reported outcome measures, including Single Assessment Numeric Evaluation (SANE), Pediatric International Knee Documentation Committee (Pedi-IKDC), and Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) scores. Results: The final cohort included 49 consecutive adolescent patients aged 11 to 16 years (mean, 14.2 ± 1 years) with a minimum follow-up of 2 years. One patient was lost to follow-up. Of the patients included in the study (N = 48; 27 male, 21 female), 98% participated in high-risk competitive sports. Two (4%) patients were undergoing revision ACLR. Thirty-eight (79%) patients underwent complete transphyseal, and 10 (21%) patients underwent all-epiphyseal ACLR. Sixteen (33%) patients had subsequent surgical procedures, including 5 contralateral ACLR, 4 meniscal surgery, 4 QUAD autograft scar revision, 4 irrigation and debridement (2 patients, 2 each), and 3 hardware removal (2 for hemi-epiphysiodesis and 1 tibial socket button removal) procedures. The rate of graft rupture was 0%. At a mean follow-up of 3.4 ± 1.2 years (range, 2-7 range), the mean SANE score was 93, the mean Pedi-IKDC score was 89, and the mean HSS Pedi-FABS score was 23. The return-to-sports rate was 100%. Conclusion: An LET performed concomitantly with an ACLR is safe and should be considered as a concomitant procedure for adolescent patients with nonmodifiable risk factors who are at high risk of retear.

Age-, Sex-, and Graft-Specific Reference Values From 783 Adolescent Patients at 5 to 7 Months After ACL Reconstruction: IKDC, Pedi-IKDC, KOOS, ACL-RSI, Single-Leg Hop, and Thigh Strength.

OBJECTIVE: To describe age-, sex-, and graft source-specific reference values for patient-reported, physical function, and strength outcome measures in adolescents at 5 to 7 months after anterior cruciate ligament reconstruction. DESIGN: Cross-sectional study. METHODS: Data were collected at 3 universities and 2 children's hospitals. The participants completed at least one of the International Knee Documentation Committee (IKDC) Subjective Evaluation Form, Pediatric IKDC (Pedi-IKDC), Knee Injury and Osteoarthritis Outcomes Score (KOOS), and Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale. Participants also completed single-leg hop tests and/or isokinetic quadriceps and hamstrings strength assessments (at 60°/s). Reference values were summarized using descriptive statistics and stratified for age, sex, and graft source. RESULTS: Reference values were reported for common patient-reported outcomes and measures of physical function and strength from 783 participants (56% females, age = 16. 4 ± 2.0 years) who were in early adolescence (12-14 years, N = 183, 52% females), middle adolescence (15-17 years, N = 456, 58% females), or late adolescence (18-20 years, N = 144, 55% females). Three hundred seventy-nine participants (48.4%) received a bone-patellar tendon-bone autograft, 292 participants (37.3%) received hamstring tendon autograft, and 112 participants (14.3%) received autograft or allograft from an alternative source. CONCLUSION: Reference values for common patient-reported outcomes and measures of physical function and strength differed depending on a patient's age, sex, and graft source. Using patient-specific reference values, in addition to previously described age-appropriate cutoff values, may help clinicians monitor and progress patients through rehabilitation and return to physical activity after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 2023;53(4):1-8. Epub: 23 January 2023. doi:10.2519/jospt.2023.11389.

Combined Anterior Cruciate Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis Better Restores Knee Stability and Reduces Failure Rates Than Isolated Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

Background: The increase in anterior cruciate ligament (ACL) injuries in pediatric patients and the high failure rate reported in the literature in this population are driving surgeons to search for specific techniques to better restore knee stability. Recent literature has reported that the combination of lateral extra-articular tenodesis (LET) and ACL reconstruction improves outcomes in high-risk patients. However, such advantages in pediatric patients have been infrequently evaluated. Purpose: To assess whether adding LET to ACL reconstruction can significantly improve knee stability, clinical outcomes, and failure rates in pediatric patients. Study Design: Cohort study; Level of evidence, 3. Methods: A multicentric study involving 3 orthopaedic teaching centers was conducted to evaluate pediatric patients aged between 12 and 16 years who had undergone primary ACL reconstruction using a physeal-sparing femoral tunnel drilling technique. A minimum 2-year follow-up evaluation was required. Based on the surgical technique performed, the patients were divided into 2 group. The patients in group 1 underwent an isolated arthroscopic ACL reconstruction, while the patients in group 2 had an arthroscopic ACL reconstruction in combination with a modified Lemaire LET procedure. Group 1 was a historical control cohort of patients, whereas group 2 was prospectively enrolled. All the patients included in the present study were clinically evaluated using the Pediatric International Knee Documentation Committee (Pedi-IKDC) subjective score and the Pediatric Functional Activity Brief Scale (Pedi-FABS) score. Anteroposterior knee stability was measured using the KT-1000 knee ligament arthrometer, and the objective pivot-shift evaluation was documented using a triaxial accelerometer (Kinematic Rapid Assessment [KiRA]). The included patients also underwent a standardized radiological protocol to evaluate leg-length discrepancies, axial deviation, and degenerative signs preoperatively and at last follow-up. Results: This study included 66 pediatric patients with an anatomic hybrid ACL reconstruction using an autologous 4-strand hamstring graft. In group 1, there were 34 patients (mean age, 13.5 ± 1.2 years), while 32 patients (mean age, 13.8 ± 1.4 years) were included in group 2. The clinical outcome scores showed no difference between the 2 groups (Pedi-IKDC, P = .072; Pedi-FABS, P = .180). Nevertheless, the patients in group 2 had better anteroposterior stability measured using a KT-1000 arthrometer (1.9 ± 1.1 mm in group 1 vs 0.8 ± 0.8 mm in group 2; P = .031), as well as better rotational stability measured using the KiRA (–0.59 ± 1.05 m/s2 in group 2 vs 0.98 ± 1.12 m/s2 in group 1; P = .012). The patients in group 1 returned to sports at the same competitive level at a rate of 82.4%, while patients included in group 2 returned at the same competitive level in 90.6% of the cases without a significant difference between the 2 groups (P = .059). No leg-length discrepancies were found between the 2 groups at last follow-up (P = .881). Two patients displayed an increased valgus deformity of 3° on the operated limb at last follow-up (1 patient in group 1 and 1 patient in group 2). Group 1 had a significatively higher cumulative failure rate (14.7% vs 6.3%; P = .021). No intra- or postoperative complications was observed between the 2 groups. Conclusion: Performing a modified Lemaire LET along with an ACL reconstruction with hamstring graft in pediatric patients reduced the cumulative failure rate and improved objective stability with no increase in intra- or postoperative complications. No significant difference was found between the 2 groups in terms of patient-reported outcomes or in the return-to-sports activity.

Portuguese Cross-Cultural Adaptations of the Pediatric International Knee Documentation Committee Score

The aim of this study was to translate the Pediatric International Knee Documentation Committee Score (Pedi-IKDC) into European Portuguese language. The Pedi-IKDC was originally developed in the English language and its main construct is functional assessment of knee disorders in children and adolescents. The original English version of the questionnaire was translated to European Portuguese using the forwardbackwards method. Patients aged eight to 17 with knee disorders were considered eligible for the study. An online platform was implemented to collect patient responses, including general patient information, the questionnaires Pedi-IKDC, EuroQol-5 Dimension Youth and Childhood Health Assessment Questionnaire. Three surveys were sent: at the moment of first evaluation (T0), after two (T1) and ten (T2) weeks. These surveys followed the Consensus-based Standards for the Selection of Health Measurement Instruments - COSMIN Checklist recommendations. The internal consistency, reliability, error of measurement, structural and construct validity (by means of correlation with previously validated scales), responsiveness and interpretability (floor/ceiling effects, MIC and ROC curve) were evaluated. Forty-seven patients completed T0, 42 patients completed T1 and 40 patients completed T2. The factorial analysis confirmed that the scale has one dimension. Cronbach alpha (α) was 0.94; interclass correlation coefficient was 0.92; smallest detectable change was 19.04 for individuals and 3.31 for groups; standard error of measurement was 6.87; minimum important change was 18.48; floor and ceiling effects were absent. More than 75% of the hypotheses tested for construct validity were confirmed, showing its adequacy. The variation of scores between T0 and T2 correlated with the clinical evolution of the participants (r = 0.421, p < 0.05). The Portuguese version of Pedi-IKDC demonstrated good psychometric properties, being a valuable tool for clinical assessment of pediatric patients with knee disorder.

Clinical Outcomes of Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis Procedures in Skeletally Immature Patients: A Systematic Review From the SANTI Study Group.

The treatment of anterior cruciate ligament (ACL) tears in the pediatric population has changed significantly in the past few decades. Pediatric patients who underwent ACL reconstruction (ACLR) have a high risk of rerupture of up to 32%. The addition of lateral extra-articular procedures [lateral extra-articular tenodesis (LET)], already shown to be effective in reducing the risk of rerupture in adults, may also be effective in pediatric patients. The purpose of this study was to systematically review the clinical outcomes of ACLR+LET tenodesis in pediatric patients. Data were collected from Pubmed, MEDLINE, Cochrane, and Scopus Databases according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Studies reporting the clinical outcomes of ACLR+LET in the pediatric population using autograft, return to play, growth disturbances, failure rate, and surgical complications were included. A total of 5 studies comprising 381 pediatric patients were included. Three main surgical techniques with common features were used. The mean age of all pediatric patients in the included studies was 11.73 years (range, 5.6 to 16) with a mean follow-up of 50.1 months. The overall graft failure rate of the included studies was 4.65%. The return to play was 95.11%. The mean Lysholm score was 94.51 and the mean Pediatric International Knee Documentation Committee (Pedi-IKDC) was 93.39. In all, 1.9% of the patients had a coronal plane deformity and 0.8% had a limb length discrepancy. 4.6% of the patients had a contralateral ACL tear. A combined ACLR+LET in pediatric patients showed a graft failure ranging from 0% to 13.6% at a mean follow-up of 50.1 months. This low graft failure rate is consistent with ACLR+LET in adults. Further investigations are needed to validate these findings and the potential role of LET in reducing graft rupture rates in this population. Level IV-systematic review of level IV studies.

Poster 230: A Modified Lemaire Lateral Extra-Articular Tenodesis in High-Risk Adolescents Undergoing Anterior Cruciate Ligament Reconstruction: Two-Year Clinical Outcomes

Objectives:This study aimed to evaluate the safety and efficacy of performing a lateral extra-articular tenodesis (LET) with a modified Lemaire technique (MLT) in conjunction with anterior cruciate ligament reconstruction (ACLR) in children and adolescents at increased risk for failed ACLR.Methods:A consecutive series of patients ≤19 years who underwent simultaneous ACLR and LET with minimum two-year follow-up data were reviewed. Patients were indicated for LET when one or more of the following risk factors were present: participant in high-risk competitive sport such as football, lacrosse, soccer or basketball, grade 3 pivot shift, hyperlaxity (Beighton score > 6), recurvatum, revision ACLR, contralateral ACLR, or chronic ACL insufficiency. ACLR was performed using either full-thickness quadriceps tendon (QUAD) for skeletally immature patients or bone-patellar tendon-bone (BTB) autograft for skeletally mature patients. All-epiphyseal (AE) or complete transphyseal (CT) techniques were used depending on patients’ skeletal maturity. At a minimum two-year follow-up, patient-reported outcome measures included Single Assessment Numeric Evaluation (SANE), Pediatric International Knee Documentation Committee (Pedi-IKDC), and the HSS Functional Activity Brief Scale (HSS Pedi-FABS) scores. Return-to-sport (RTS) data and second surgeries were also obtained.Results:Sixty-one consecutive patients (mean age 15.17 ±1.73 years, range 11-19 years, 62% female) were analyzed (Table 1). 59 patients (97%) participated in organized sports including soccer, basketball, football and lacrosse, with soccer being the most popular one. The average grade at the time of surgery was 9th grade. Ten patients (16%) were revision ACLR procedures. Seven (11%) patients underwent AE and 54 (89%) underwent CT ACLR. Forty-two (69%) cases employed a QUAD autograft, while 19 (31%) utilized a BTB autograft. All patients underwent a LET with a MLT and 2 patients underwent simultaneous implant mediated guided growth with a plate for structural genu valgum. At two-year follow-up, mean SANE score was 95, median Pedi-IKDC score was 91, and median HSS-Pedi Fabs score was 27. RTS rate was 91.8%. Ten patients had subsequent surgical procedures, including two hardware removal procedures for hemiepiphysiodesis, three contralateral ACLR, three meniscus surgeries, one lysis of adhesions, and one revision ACLR for BTB graft re-rupture. Two patients were lost to follow-up and excluded from the study.Conclusions:The findings suggest that concomitant LET and ACLR in adolescent patients with risk factors for failed ACLR is associated with favorable patient-reported outcomes, high return to sports participation, and low ACL re-rupture rate at two years follow-up.Table 1.Patient Demographics and Surgical Characteristics.

Grit After Acl Reconstruction: Sex Differences and Association with Knee Outcomes Among Adolescent Athletes

Background: Grit reflects perseverance for pursuing long-term goals. Recovery from ACL reconstruction requires a long and challenging rehabilitation process. While grit has previously been used to predict success in education and military settings, little is known about the association between grit and the rehabilitation process among adolescent athletes after ACL reconstruction. Purpose: The primary aim of the study was to determine differences in GRIT-S scores between male and female athletes pre-operatively to 6 months post-ACL reconstruction. The second aim of the study was to assess the relationship between pre-operative GRIT-S scores and knee outcome measures 6 months post-operatively. Methods: All participants completed the GRIT-S questionnaire, the Pediatric International Knee Documentation Committee (Pedi-IKDC) subjective knee form, and the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) at a pre-operative appointment and then again approximately 6 months after ACL reconstruction. We conducted a linear mixed model analysis to assess the effects of sex and time on GRIT-S scores. We then conducted a linear regression analysis to determine if pre-operative GRIT-S scores predicted IKDC and HSS Pedi-FABS scores at 6 months post-operatively. We defined statistical significance as p &lt; 0.05. Results: We included 83 participants (mean age 16.0 +/- 2.3 years, 70% female) from a prospective registry of pediatric athletes undergoing ACL reconstruction by one surgeon at a single institution. For the entire study population, there was no statistically significant change in GRIT-S scores from the pre-operative assessment to 6 months post-operatively. However, there was a statistically significant effect of sex (p=0.03) on GRIT-S scores from pre-operative assessment to 6 months post-operatively, with female athletes demonstrating more grit than male athletes across both assessments (Figure 1). Additionally, there was no significant association between pre-operative GRIT-S scores and Pedi-IKDC and HSS Pedi-FABS scores 6 months post-operatively for the entire group (Figure 2). Conclusion: In our study population, female athletes reported higher GRIT-S scores than male athletes across the first 6 months of rehabilitation after ACL reconstruction. Pre-operative GRIT-S scores do not appear to be significantly associated with knee outcome measures 6 months post-operatively, which could suggest that grit may not necessarily predict success in the rehabilitation process after ACL reconstruction. However, future studies will examine how grit is associated with return-to-sport outcomes to determine if grit is a useful marker in predicting successful return-to-sport after ACL reconstruction in adolescent athletes. [Figure: see text][Figure: see text]

A Modified Lemaire Lateral Extra-Articular Tenodesis in High Risk Adolescents Undergoing Anterior Cruciate Ligament Reconstruction: Two-Year Clinical Outcomes

Background:The incidence of anterior cruciate ligament reconstruction (ACLR) in patients aged 19 years or younger is increasing significantly and many patients possess risk factors that predispose to ACL re-tear. Lateral extra-articular tenodesis (LET) may be performed in conjunction with ACLR to reduce the risk of ACL re-tear.Purpose:To evaluate the safety and efficacy of performing a lateral extra-articular tenodesis (LET) with a modified Lemaire technique (MLT) in conjunction with anterior cruciate ligament reconstruction (ACLR) in children and adolescents at increased risk for failed ACLR.Methods:A consecutive series of patients who underwent ACLR and LET with a minimum of 2-year follow-up data was analyzed retrospectively. ACLR techniques included all-epiphyseal (AE) and complete transphyseal (CT) and were indicated based on skeletal age. Skeletally immature patients underwent a QUAD ACLR. Patients with closed or closing growth plates underwent a BTB ALCR. Outcome measures included participants’ return to sports, concomitant or subsequent surgical procedures and multiple patient-reported outcome measures, including Single Assessment Numeric Evaluation (SANE), Pediatric International Knee Documentation Committee (Pedi-IKDC) and HSS Functional Activity Brief Scale (HSS Pedi-FABS) scores.Results:Sixty-seven consecutive patients (mean age 15.16 ±1.74 years, range 11-19 years, 64% female) were analyzed (Table 1). Sixty-five patients (97%) participated in organized sports including soccer, basketball, football and lacrosse, with soccer being the most popular one. The median grade at the time of surgery was 9th grade. Eleven patients (16%) were revision ACLR procedures. Eight (12%) patients underwent AE and 59 (88%) underwent CT ACLR. Forty-six (69%) cases employed a QUAD autograft, while 21 (31%) utilized a BTB autograft. All patients underwent a LET with a MLT and 2 patients underwent simultaneous implant mediated guided growth with a plate for structural genu valgum. At two-year follow-up, median SANE score was 97, median Pedi-IKDC score was 91, and median HSS-Pedi Fabs score was 25. RTS rate was 93%. Fifteen patients had subsequent surgical procedures, including 3 hardware removal procedures for hemiepiphysiodesis, 4 contralateral ACLR, 5 meniscus surgeries, 1 lysis of adhesions, 1 hammertoe correction and 1 revision ACLR for BTB graft re-rupture. Two patients were lost to follow-up and excluded from the study.Conclusion:The findings suggest that concomitant LET and ACLR in adolescent patients with risk factors for failed ACLR is associated with favorable patient-reported outcomes, high return to sports participation, and low ACL re-rupture rate at two years follow-up.Table 1Patient Demographics and Surgical Characteristics

Outcomes of Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients:2-Year Follow-Up

Background:The quadriceps tendon (QUAD) autograft has recently become an alternative to the hamstring tendon autograft that demonstrates superior preliminary outcomes in pediatric anterior cruciate ligament reconstruction (ACLR).Purpose:To evaluate 2-year clinical and patient-reported functional outcomes of primary ACLR with soft tissue QUAD autograft in skeletally immature patients.Methods:Consecutive skeletally immature patients who underwent ACLR with QUAD autograft were included. All cases utilized full thickness soft tissue QUAD autograft without a bone plug and were performed on patients with open growth plates. Preoperative demographic and surgical data were collected (Table 1). The ACLR technique was selected predicated upon skeletal age and included all-epiphyseal (AE) and complete transphyseal (CT). Patients were followed for a minimum of 24 months with successive clinical visits or contacted via telephone. Information regarding the return to sports and concomitant or subsequent surgical procedures was collected. KT-1000 was performed post-operatively, and Pediatric International Knee Documentation Committee (Pedi-IKDC) and HSS Functional Activity Brief Scale (HSS Pedi-FABS) scores were collected for each subject at their 2-year follow-up appointment.Results:The final cohort included of 60 consecutive adolescent patients aged 11.1 to 17.1 (13.9 ±1.2) with a minimum follow-up of 2 years. One patient was lost to follow-up. Prior to surgery, 86% of patients reported playing team sports including soccer, basketball, football and lacrosse, with soccer being the most popular one. 21 (35%) patients underwent AE and 39 (65%) underwent CT ACLR. Additionally, 35 (58%) underwent an a lateral extra-articular tenodesis procedure using the iliotibial band (ITB) with a modified Lemaire technique, and 5 (8%) patients underwent simultaneous implant mediated guided growth with a plate for structural genu valgum, both procedures were performed for non-modifiable risk factors as previously published for hamstring autograft ACLR. The rate of graft failure was 0%, and 10 patients had additional surgical procedures, of which 4 were concomitant removal of hardware for hemi-epiphysiodesis, 3 were contralateral ACLR, 3 were meniscal injuries that required surgical intervention and 2 were lysis of adhesions. The mean KT-1000 at 2-year follow-up was -0.36 ±0.75. The median Pedi-IKDC score was 87, and the median HSS-Pedi FABS score was 25. At 2 years after surgery, 90% patients reported returning to sports.Conclusion:This study reveals that QUAD autograft ACLR had a low failure rate when compared to previously reported studies of ACLR with hamstring autograft. Based on these results, we recommend this technique for skeletally immature patients undergoing ACLR.Table 1.Demographic and Surgical data of included knees.

Paper 02: A Modified Lemaire Lateral Extra-Articular Tenodesis in High Risk Adolescents Undergoing Anterior Cruciate Ligament Reconstruction: Two-Year Clinical Outcomes

Objectives:This study aimed to evaluate the safety and efficacy of performing a lateral extra-articular tenodesis (LET) with a modified Lemaire technique (MLT) in conjunction with anterior cruciate ligament reconstruction (ACLR) in children and adolescents at increased risk for failed ACLR.Methods:A consecutive series of patients ≤19 years who underwent simultaneous ACLR and LET with minimum two-year follow-up data were reviewed. Patients were indicated for LET when one or more of the following risk factors were present: participant in high-risk competitive sport such as football, lacrosse, soccer or basketball, grade 3 pivot shift, hyperlaxity (Beighton score > 6), recurvatum, revision ACLR, contralateral ACLR, or chronic ACL insufficiency. ACLR was performed using either full-thickness quadriceps tendon (QUAD) for skeletally immature patients or bone-patellar tendon-bone (BTB) autograft for skeletally mature patients. All-epiphyseal (AE) or complete transphyseal (CT)techniques were used depending on patients’ skeletal maturity. At a minimum two-year follow-up, patient-reported outcome measures included Single Assessment Numeric Evaluation (SANE), Pediatric International Knee Documentation Committee (Pedi-IKDC), and the HSS Functional Activity Brief Scale (HSS Pedi-FABS) scores. Return-to-sport (RTS)data and second surgeries were also obtained.Results:Sixty-one consecutive patients (mean age 15.17 ±1.73 years, range 11-19 years, 62% female) were analyzed (Table 1). 59 patients (97%) participated in organized sports including soccer, basketball, football and lacrosse, with soccer being the most popular one. The average grade at the time of surgery was 9th grade. Ten patients (16%) were revision ACLR procedures. Seven (11%) patients underwent AE and 54 (89%) underwent CT ACLR. Forty-two (69%) cases employed a QUAD autograft, while 19 (31%) utilized a BTB autograft. All patients underwent a LET with a MLT and 2 patients underwent simultaneous implant mediated guided growth with a plate for structural genu valgum. At two-year follow-up, mean SANE score was 95, median Pedi-IKDC score was 91, and median HSS-Pedi Fabs score was 27. RTS rate was 91.8%. Ten patients had subsequent surgical procedures, including two hardware removal procedures for hemiepiphysiodesis, three contralateral ACLR, three meniscus surgeries, one lysis of adhesions, and one revision ACLR for BTB graft re-rupture. Two patients were lost to follow-up and excluded from the study.Conclusions:The findings suggest that concomitant LET and ACLR in adolescent patients with risk factors for failed ACLR is associated with favorable patient-reported outcomes, high return to sports participation, and low ACL re-rupture rate at two years follow-up.

High recall bias in retrospective assessment of the pediatric International Knee Documentation Committee Questionnaire (Pedi-IKDC) in children with knee pathologies.

The increasing incidence of knee injuries among children is well known by sports physicians. Papers dealing with this topic have often collected patient-reported outcomes measures (PROMs) in a retrospective manner; this limitation could lead to a misinterpretation of the results, because pediatric patients might not remember their preoperative conditions adequately. This study aims to evaluate the reliability and the reproducibility of the IKDC pediatric score when administered retrospectively at a 12-month follow-up. From September 2018 and June 2019, all patients aged 7-18 scheduled for surgery due to different knee pathologies in a single center were considered eligible. Parents were contacted by phone for consent. An open-source platform was implemented to collect the responses: two surveys were created (Q1, Q2). They included general information and the Pedi-IKDC score. Q1 was completed prospectively, while Q2 was completed 12months after surgery. The two questionnaires were identical, and patients were carefully advised to complete Q2 recalling their health status before surgery. ICC and the concordance correlation coefficient (ρc) were used to assess the reproducibility between the prospective and recalled scores. Sixty-six patients responded to Q1 and Q2, and the mean age was 12.9 ± 2.2years at Q1 and 14.1 ± 2.2years at Q2. The mean time between Q1 and Q2 was 14.1 ± 2.1months. Between prospective-IKDC and recall-IKDC, the ICC coefficient was "poor" at 0.32 (CI 0.09 to 0.5) and the ρc was "poor" at 0.4 (CI 0.29 to 0.51). Mean prospective-IKDC was 76.8 ± 23.52 mean recalled-IKDC was 60.4 ± 11.5 (P < 0.0001), while mean difference was -16.3 ± 2.09. Simple linear regression models showed that Δ-IKDC is independently associated with age at Q1 (R2 = 0.2676; P0.0001) and prospective-IKDC (R2 = 0.653; P < 0.0001). Retrospective collection of the Pedi-IKDC score is not reliable and has high recall bias. This should be avoided in children with knee conditions. III.