Anterior Cruciate Ligament Injuries in the Skeletally Immature Athlete: Diagnosis and Management
Intrasubstance anterior cruciate ligament (ACL) injuries in children and adolescents were once considered rare occurrences, with tibial eminence avulsion fractures generally regarded as the pediatric ACL injury equivalent. However, with increased single-sport focus, less free play, and year-round training at younger ages, intrasubstance ACL injuries in children and adolescents are being diagnosed with increased frequency. As in the adult, a knee devoid of ligamentous stability predisposes the pediatric patient to meniscal and chondral injuries and early degenerative changes. Management of ACL injuries in skeletally immature patients includes physeal-sparing, partial transphyseal, and complete transphyseal ACL reconstruction. Complications include iatrogenic growth disturbance resulting from physeal violation.
Available from: Nicola Maffulli
- "If mismanaged, epiphyseal injuries can also lead to long-term complications which could negatively affect ability to participate in sports
. Management of ACL injuries is an area of controversy and if not managed appropriately, can affect long-term growth and recovery as well as the ability to participate in sports
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ABSTRACT: The increased participation of children and adolescents in organized sports worldwide is a welcome trend given evidence of lower physical fitness and increased prevalence of overweight in this population. However, the increased sports activity of children from an early age and continued through the years of growth, against a background of their unique vulnerability to injury, gives rise to concern about the risk and severity of injury. Three types of injury-anterior cruciate ligament (ACL) injury, concussion, and physeal injury - are considered potentially serious given their frequency, potential for adverse long-term health outcomes, and escalating healthcare costs. Concussion is probably the hottest topic in sports injury currently with voracious media coverage and exploding research interest. Given the negative cognitive effects of concussion, it has the potential to have a great impact on children and adolescents during their formative years and potentially impair school achievement and, if concussion management is not managed appropriately, there can be long term negative impact on cognitive development and ability to resume sports participation. Sudden and gradual onset physeal injury is a unique injury to the pediatric population which can adversely affect growth if not managed correctly. Although data are lacking, the frequency of stress-related physeal injury appears to be increasing. If mismanaged, physeal injuries can also lead to long-term complications which could negatively affect ability to participate in sports. Management of ACL injuries is an area of controversy and if not managed appropriately, can affect long-term growth and recovery as well as the ability to participate in sports. This article considers the young athlete's vulnerability to injury, with special reference to ACL injury, concussion, and physeal injury, and reviews current research on epidemiology, diagnosis, treatment, and prevention of these injury types. This article is intended as an overview of these injury types for medical students, healthcare professionals and researchers.
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ABSTRACT: Tears of the anterior cruciate ligament in skeletally immature patients were operated with four different methods and their outcome compared to each other. Sixty-eight patients (33 males, 35 females), mean 12.5 years, were treated in four different centers from 1984 to 2001. Twenty-eight patients underwent the ACL-reconstruction with hamstring grafts, 16 patients with bone-patella-bone autografts, 12 patients with quadriceps grafts and 12 patients with facia lata. The mean follow-up was 32 months. Postoperative evaluation included radiographs, KT-1000/2000 stability measurements, Lysholm score, The Tegner activity scale and IKDC score. Neither leg length discrepancy nor angular deformities were noted. Mean KT-1000 difference was 2.1 mm, mean postoperative Lysholm knee score 93.3, IKDC 87% normal or nearly normal. The Tegner index decreased from 6.6 to 5.7. In total, six patients developed instability due to an adequate trauma 1 year after the index operation. Two patients showed mild arthrotic changes. All but two patients were able to return to the same level of preoperative sports participation. None of the four methods studied showed major differences in outcome compared to the other. No growth disturbance could be noted.
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ABSTRACT: The long-term results after using the iliotibial band autograft (ITB) in anterior cruciate ligament (ACL) reconstruction are not fully known. If equal in quality to conventional methods, the ITB graft could be a useful alternative as a primary graft, in revision surgery or multi-ligament reconstruction. The purpose is to assess whether the ITB autograft is a long-term reliable alternative to the bone-patella-tendon-bone (BPTB) autograft, using a prospective randomized controlled trial design.
From 1995 to 1996, sixty patients scheduled for primary ACL reconstruction were included in a prospective randomized controlled trial. Three senior knee surgeons, experienced in both types of ACL surgery, performed all the operations. A standardized and supervised rehabilitation programme was used for both groups for 6 months. Thirty patients received the ITB reconstruction, and 30 received the BPTB reconstruction. Forty-nine participated at follow-up in 2010 (82 %). Primary outcome was the failure rate after ACL reconstruction. Secondary outcomes were knee injury osteoarthritis outcome score (KOOS) [pain, symptoms, Sport/Rec, quality of life (QOL), daily living function], Tegner activity scale, anterior knee pain-score, Lysholm score, Rolimeter laxity, extension deficit, single hop and crossover hop for distance.
At 15-year follow-up, no significant difference existed between the groups. Graft failure occurred in 4 ITB subjects (16 %) and 3 BPTB subjects (13 %). KOOS (Sport/Rec) for the ITB group was 75 and 73 for the BPTB group. The KOOS (QOL) was 72 and 68 for the ITB group and BPTB group, respectively.
Similar graft failure rates and KOOS were found when comparing ITB- and BPTB-operated individuals, at 15-year follow-up. The ITB graft had equal long-term clinical results compared to the BPTB graft and is recommended as a reliable alternative autograft for ACL reconstruction.
Therapeutic studies, Level I.
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