20 Years of Pediatric Anterior Cruciate Ligament Reconstruction in New York State
BACKGROUND:There have been no population-based studies to evaluate the rate of pediatric anterior cruciate ligament (ACL) reconstruction. PURPOSE:The primary aim of the current study was to determine the yearly rate of ACL reconstruction over the past 20 years in New York State. Secondary aims were to determine the age distribution for ACL reconstruction and determine whether patient demographic and socioeconomic factors were associated with ACL reconstruction. STUDY DESIGN:Descriptive epidemiology study. METHODS:The Statewide Planning and Research Cooperative System (SPARCS) database contains a census of all hospital admissions and ambulatory surgery in New York State. This database was used to identify pediatric ACL reconstructions between 1990 and 2009; ICD-9-CM (International Classification of Diseases, 9 Revision, Clinical Modification) and CPT-4 (Current Procedural Terminology, 4th Revision) codes were used to identify reconstructions. Patient sex, age, race, family income, education, and insurance status were assessed. RESULTS:The rate of ACL reconstruction per 100,000 population aged 3 to 20 years has been increasing steadily over the past 20 years, from 17.6 (95% confidence interval [CI], 16.4-18.9) in 1990 to 50.9 (95% CI, 48.8-53.0) in 2009. The peak age for ACL reconstruction in 2009 was 17 years, at a rate of 176.7 (95% CI, 160.9-192.5). In 2009, the youngest age at which ACL reconstruction was performed was 9 years. The rate of ACL reconstruction in male patients was about 15% higher than in females, and ACL reconstruction was 6-fold more common in patients with private health insurance compared with those enrolled in Medicaid. CONCLUSION:This study is the first to quantify the increasing rate of ACL reconstructions in the skeletally immature. Only ACL reconstructions were assessed, and it is possible that some ACL tears in children are not diagnosed or are treated nonoperatively. The rate of ACL tears in New York State is likely higher than the rate of reconstructions reported in this study.Significance:This study quantifies the increasing rate of ACL reconstruction in the skeletally immature and suggests that there may be some disparities in care based on insurance status.
Available from: Bryan G Vopat
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ABSTRACT: Anterior cruciate ligament (ACL) surgery is being increasingly performed in the adolescent population. Computer navigation offers a reliable way to quantitatively measure knee stability during ACL reconstruction. A retrospective review of all adolescent patients (<18 years old) who underwent computer-assisted primary single bundle ACL reconstruction by a single surgeon from 2007 to 2012 was performed. The average age was 15.8 years (SD 3.3). Female adolescents were found to have higher internal rotation than male adolescents both pre- (25.6° vs 21.7°, P=0.026) and post-reconstruction (20.1° vs 15.1°, P=0.005). Compared to adults, adolescents demonstrated significantly higher internal rotation both pre- (23.3° vs 21.5°, P=0.047) and post-reconstruction (17.1° vs 14.4°, P=0.003). They also had higher total rotation both pre- (40.9° vs 38.4°, P=0.02) and post-reconstruction when compared to adults (31.56° vs 28.67°, P=0.005). In adolescent patients, anterior translation was corrected more than rotation. Females had higher pre- and residual post-reconstruction internal rotation compared to males. When compared to adults, adolescents had increased internal rotation and total rotation both pre-and post-reconstruction.
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ABSTRACT: Femoral nerve block (FNB) has become a popular method of postoperative analgesia for anterior cruciate ligament (ACL) reconstruction in pediatric and adolescent patients. Successful rehabilitation after surgery involves return of quadriceps and hamstring strength.
To compare knee strength and function 6 months after ACL reconstruction in pediatric and adolescent patients who received FNB versus patients with no nerve block.
Cohort study; Level of evidence, 3.
Patients 18 years or younger who underwent primary ACL reconstruction between 2000 and 2010 at a single institution were identified. If the patient was skeletally immature, a transphyseal ACL reconstruction was performed. Of these patients, 68% underwent reconstruction with a patellar tendon autograft, and in 32% of patients a hamstring autograft was utilized. There were 124 patients who met the study inclusion criteria, including 62 in the FNB group (31 males, 31 females) and 62 patients in the control group (25 males, 37 females). All study patients participated in a comprehensive rehabilitation program that included isokinetic strength and functional testing at 6 months postoperatively.
Univariate analysis showed a significantly higher deficit at 6 months in the FNB group with respect to fast isokinetic extension strength (17.6% vs 11.2%; P = .01) as well as fast (9.9% vs 5.7%; P = .04) and slow (13.0% vs 8.5%; P = .03) isokinetic flexion strength. There was no difference in slow isokinetic extension strength deficit between the 2 groups (FNB, 22.3% vs control, 18.7%; P = .20). With respect to function, there were no differences in deficit for vertical jump (FNB, 9.4% vs control, 11.3%; P = .30), single hop (7.6% vs 7.5%; P = .96), or triple hop (8.0% vs 6.6%; P = .34) between the 2 groups. A significantly higher percentage of patients in the control group met functional and isokinetic criteria for return to sports at 6 months (90.2% vs 67.7%; odds ratio, 4.37; P = .002).
Pediatric and adolescent patients treated with FNB for postoperative analgesia after ACL reconstruction had significant isokinetic deficits in knee extension and flexion strength at 6 months when compared with patients who did not receive a nerve block. Patients without a block were 4 times more likely to meet criteria for clearance to return to sports at 6 months.
© 2014 The Author(s).
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