Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients With Transphyseal Tunnels

Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, U.S.A.
Arthroscopy The Journal of Arthroscopic and Related Surgery (Impact Factor: 3.1). 08/2012; 28(11). DOI: 10.1016/j.arthro.2012.04.145
Source: PubMed

ABSTRACT PURPOSE: Our purpose was to evaluate the results of transphyseal anterior cruciate ligament (ACL) reconstruction with hamstring autograft in skeletally immature patients. METHODS: Eighteen knees in 18 skeletally immature pubescent patients with a mean chronologic age of 14.2 years underwent transphyseal ACL reconstruction with hamstring autograft between 2002 and 2007. Concurrent meniscal surgery was performed in 9 knees. The final patient evaluation occurred at a mean of 43.4 months (range, 24.0 to 86.6 months) and included physical examination, KT-1000 arthrometry testing (MEDmetric, San Diego, CA), and functional outcome instruments, including the International Knee Documentation Committee subjective knee form, the Lysholm knee score, and the Tegner knee activity scale. RESULTS: At the latest follow-up, the mean International Knee Documentation Committee subjective knee score was 92.4 ± 10, the mean Lysholm knee score was 94.3 ± 8.8, and the mean Tegner activity scale score was 8.5 ± 1.4. Lachman and pivot-shift testing were negative in all knees. No restriction in knee range of motion of 5° or greater when compared with the contralateral knee was observed in any patient. The mean manual maximum side-to-side difference with KT-1000 testing was 0.29 ± 1.07 mm, and no patients had a difference greater than 3 mm. No angular deformities were noted, and all leg-length measurements were symmetric bilaterally on clinical examination. No patients had traumatic graft disruption or underwent revision ACL reconstruction, whereas 3 patients sustained an ACL injury in the contralateral leg while participating in sports. CONCLUSIONS: Transphyseal ACL reconstruction with autogenous quadrupled hamstring graft with metaphyseal fixation in skeletally immature pubescent patients yielded excellent functional outcomes in a high percentage of patients without perceived clinical growth disturbance. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

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    ABSTRACT: Background ACL injuries in preteens and teens are common occurrences. Reconstruction is believed to be optimum treatment for those wishing to return to running, cutting, and jumping sports. Rates of reoperation, satis-faction, and long-term return to and maintenance of preinjury activity after ACL reconstruction in young ath-letes are important information for physicians, patients, and parents. Questions/purposes The purposes of this study were to address the following questions in this skeletally immature patient population undergoing ACL reconstruction: (1) What is the reinjury rate and the need for subsequent surgeries? (2) How do patient satisfaction and function as assessed by patient and physician correlate with return to sport? (3) What factors contribute to failure to return to preinjury activity levels? Methods This is a retrospective review of 29 patients who underwent transphyseal ACL reconstruction using soft tissue grafts passed through open physes and followed to skeletal maturity, and at least 2 years from their index surgery, who were invited and returned for a study inter-view and examination. Pre-and postinjury activity levels were assessed via the Tegner activity score, satisfaction was determined using a 10-point Likert scale, function was assessed via the Lysholm score and IKDC grade, and an open-ended questionnaire was used for explanations of changes in activity levels. Reoperations were classified as major or minor, determined from a review of the medical records conducted after interview and examination. Results At a minimum followup of 2 years (mean, 4 years; range, 2–8 years), four revision reconstructions and seven minor operations were performed for a reoperation rate of 11 of 29 (38%). Eight of 29 patients (28%) sustained contralateral ACL ruptures. The mean satisfaction score was 9 (range, 4–10) and mean Lysholm score was 91 (range, 61–100). Only 12 of 29 (41%) patients returned to and maintained their preinjury level of sport. High satis-faction correlated with return to prior level of sports, although there was no relationship between function and activity level. Reoperation on the index knee or contralat-eral ACL tear did not correlate with a change in activity level; rather, most patients who were less active indicated a change in interest with advancing age. Funding for this study was received from the L.T. Staheli Endowment (Seattle, WA, USA). All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use. Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained. Conclusions Despite high satisfaction and function, less than 50% of patients maintained their preinjury level of play 4 years after ACL reconstruction. Satisfaction corre-lated significantly with knee function; highly satisfied patients were more likely to return to and maintain their prior level of participation in sports. Contributing factors to decreased activity include changes in lifestyle with increasing age. Reoperation did not correlate with lower activity scores or failure to return to sports. Level of Evidence Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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    ABSTRACT: To review the most recent literature on the epidemiology, diagnosis, treatment, and outcomes of pediatric anterior cruciate ligament injury. There is an increasing prevalence of anterior cruciate ligament injuries in pediatric and adolescent athletes, and nonoperative management of these injuries results in worse outcomes than surgical reconstruction. Prevention exercise protocols are cost-effective in preventing this injury in adolescent athletes. A number of techniques are currently in practice that address anterior cruciate ligament injuries in the skeletally immature, but there is no consensus on the optimal technique. The reported clinical outcomes from anterior cruciate ligament reconstruction in young patients are favorable.
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