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Anterior cruciate ligament injury in pediatric and adolescents patients: a review of basic science and clinical research
... 9 Further, soccer-related ACL injury risk increases dramatically in females around ages 12-14 and peaks in the mid-to late teens. 4 The higher risk of injury in postpubescent females has been attributed to alterations that occur during the puberty process, including anatomic changes and hormonal variations. 10 Another possible reason for females' increased ACL injury risk-one that is potentially modifiable-is sex-specific changes in neuromuscular function during the adolescent growth spurt. ...
... 3,23 Furthermore, the incidence of sports-related ACL injury increases during adolescence and peaks during the mid-to late teens in female athletes. 4 Previous investigators have suggested that the increased incidence of lower extremity injury in adolescent females could potentially be due in part to sex-specific changes in relative strength, power, and coordination during puberty; and that interventions that coincide with the timing of these changes might mitigate the negative effects seen in maturing female athletes, thereby reducing their risk of lower extremity injury. 14 Unfortunately, despite the impact that implementing IPPs before and during puberty might have on preventing lower extremity injury, only 23% of U9-U14 teams had a coach that reported using an IPP. ...
The use of a lower extremity injury prevention program by female soccer players before the completion of puberty may mitigate movement changes that develop during puberty and contribute to post-pubescent females’ greater anterior cruciate ligament-injury risk. It is unknown whether club soccer coaches are using injury prevention programs with younger athletes and if player age is associated with soccer coaches’ knowledge, attitudes, and behaviors surrounding injury prevention programs. Fifty-four coaches of female soccer teams from Oregon and Washington states (USA) completed a web-based survey. Associations between team age (U9–U14 teams = 57 and U15–U19 teams = 19 teams) and coaches’ (a) attitudes and perceptions; and (b) injury prevention program awareness, adoption, and implementation fidelity were assessed. Coaches of U15–U19 teams perceived injuries to be more of a problem and soccer to present a high risk of injury. Coaches of older teams more strongly agreed that preventive exercises should be performed by their players during training. Injury prevention program awareness among coaches of U15–U19 and U9–U14 age groups was 79% and 60%, respectively. Injury prevention program-aware coaches of U15–U19 teams were more likely to use an injury prevention program than injury prevention program-aware coaches of U9–U14 teams (67% vs. 38%), but they were not more likely to do so with high fidelity (60% vs. 54%). Team age is associated with coaches’ short-term perceptions of injury risk, but not perceptions about the long-term ramifications of injury. Educating coaches about the potential benefits of injury prevention programs for mitigating injury-related maturational changes and the long-term ramifications of lower extremity injuries may facilitate greater use of injury prevention programs by coaches of younger female soccer players.
... Algesic contracture and fear of examination hamper examination and testing. Th e treatment of a complete tear of the ACL in a child poses great diffi culties[1,[5][6][7][8][9][10][11]because of the nearby growth plates. In addition, in many such patients, the knee joint is not unstable; therefore doctors tend to question whether urgent surgical treatment is needed[12][13][14][15]. ...
... Reconstruction of the ACL is performed by modern techniques with laying canals for a graft via the bone growth plates, thus forming a joint. However, this can lead to complications, such as angular deformity of the limb and its shortening[7,11,[16][17][18]. Taking this diffi culty into account, Stanitski[19]has recommended that reconstruction of the ACL be delayed until adolescence or till the time when skeletal maturity has been reached and the growth plates are closed. ...
Introduction. Anterior cruciate ligament (ACL) tears are observed in 10%–32% of all traumatic lesions of the knee joint in children. Open growth plates are a serious problem in the treatment of ACL tears. Most modern methods of ACL reconstruction use transepiphyseal channels, which go through the growth plates. This may lead to angle deformity of the knee development, limb shortening and early arthritis.
Material and methods. We observed 12 patients (11–17 years old; mean age, 13.2 years) with ACL tears with opened growth plates, who were operated on between 2006 and 2010. ACL reconstruction was performed arthroscopically using the BTB-technique and synthetic grafts DONA-M.
Results. In all cases, we achieved poor results, especially when the operation was done by BTB. We avoided shortening of the leg, but arthritis was common and progressed quickly. When we tried stabilize the joint, we achieved the reverse effect – pain in the knee, with a decreased quality of life.
Conclusion. Our results demonstrate that ACL reconstruction in children with opened growth pates is not effective; we suggest performing the procedure after the growth has finished.
... Numerous studies have shown poor results with conservative management of ACL injuries, particularly in active children, who demonstrate an increased risk of progressive instability, meniscal tears, and early osteoarthritis [1,10,28]. Initial concerns regarding physeal injury and growth disturbance following ACL reconstruction in skeletally immature patients [11,31,39] have been attenuated by the use of physeal-sparing surgical techniques [39]. McCarthy et al. [26] developed a technique that uses a four-strand hamstring autograft and suspensory fixation in patients with 3-6 years of growth remaining, reflecting an increasing trend to reconstruct the ACL in selected paediatric patients [31,39]. ...
... Initial concerns regarding physeal injury and growth disturbance following ACL reconstruction in skeletally immature patients [11,31,39] have been attenuated by the use of physeal-sparing surgical techniques [39]. McCarthy et al. [26] developed a technique that uses a four-strand hamstring autograft and suspensory fixation in patients with 3-6 years of growth remaining, reflecting an increasing trend to reconstruct the ACL in selected paediatric patients [31,39]. ...
Purpose
Increasing numbers of children and adolescents are being treated for ACL tears. In order for surgeons to safely optimize treatment during ACL surgery, we must better understand ACL growth and intercondylar notch patterns in the skeletally immature knee. The aim of this study is to measure ACL and intercondylar notch volume in paediatric patients and observe how these volumes change as a function of age and gender.
Methods
Data were extracted from the picture archiving and communication systems (PACS) computer records. Sample consisted of 137 MRI knee examinations performed between January 2006 and July 2010 in patients aged 3–13. Subjects were grouped into 1-year age intervals. Patients with imaging reports including ACL tears, previous surgeries, congenital structural anomalies, or syndromes were excluded.
Results
Measures of ACL volume significantly increased with age (P < 0.001). A linear increase in ACL volume was observed until the age 10, with a mean increase in volume of 148 mm3 per age group. ACL volume plateaued at 10 years, after which minimal increase in ACL volume was observed. Sex was not found to be a significant predictor of ACL volume in the multiple linear regression (P = 0.57). Similar to ACL volume, there was a significant increase in intercondylar notch volume with age with a mean increase of 835 mm3 per age group (P < 0.0001). Intercondylar notch volume reached a plateau at age 10, after which a minimal increase in notch volume was observed in older groups. Female patients had notch volumes that were on average 892 + 259 mm3 smaller than male patients who were in the same age group (P = 0.0006).
Conclusion
The plateau in the growth of ACL and notch volume occurs at age 10, prior to the halt in longitudinal growth of boys and girls. Female patients have significantly smaller intercondylar notch volumes than their age-matched male counterparts, while no gender difference was seen in ACL volume. These results suggest that notch volume is an intrinsically sex-specific difference, which may contribute to the higher rate of ACL tears among females. These growth patterns are clinically relevant as it allows surgeons to better understand the anatomy, pathology, and risk factors related to ACL tears and its reconstruction.
Level of evidence
Observational Study, Level IV.
... Četnost poranění předního zkříženého vazu (PZV) u pacientů v adolescentním věku má ve společnosti rostoucí trend (15,25,29). Riziko poranění PZV je u pacientů s otevřenými růstovými ploténkami nízké, nicméně sportovní aktivity toto riziko výrazně zvyšují (27). ...
... Poranění PZV má negativní vliv na stabilitu kolenního kloubu, v řadě případů je třeba přistoupit k operačnímu řešení a rekonstrukci poškozeného vazu pro klinicky výraznou a subjektivně vnímanou nestabilitu kolena, obdobně jako u dospělých pacientů. Terapie ruptury PZV u dětských pacientů je dlouhodobě diskutovanou problematikou, především ve vztahu k existenci růstových plotének (2,6,15,20,29). V současné době stále panuje kontradikce v názorech na vhodnost použití různých fixačních materiálů, resp. techniky náhrady PZV (6). ...
Purpose of the study:
Treatment for tears of the anterior cruciate ligament (ACL) in paediatric patients has been a long-discussed issue because of complications associated with ligament reconstruction in the presence of growth plates. Various fixation materials and their efficiency as well as ACL techniques are still under investigation. The aim of our study was to find an optimal strategy of treating acute intra-articular ACL injury in childhood.
Material and methods:
The paediatric patients treated for primary traumatic ACL injury between 2003 and 2013 were retrospectively evaluated. Only patients with a healthy contralateral knee (with no signs of instability or previous injury) and no record of previous ACL repair were included. A total of 78 patients were assessed; there were 39 girls and 39 boys with an average age of 15.4 years (11 - 16). The physical development of the patients was assessed on the Tanner scale, their satisfaction was recorded on the basis of the IKDC subjective knee evaluation form and the Tegner-Lysholm scoring system. The instrumented Lachman test using a rollimeter was performed to assess knee stability at 12 and 24 months of follow-up. In addition, the range of knee motion in comparison with the other side, complications and the re-rupture rate of reconstructed ACLs were recorded. Four patients with open growth plates were operated on using the transepiphyseal technique, the remaining 74 underwent reconstruction by the standard transphyseal method.
Results:
The average Tegner-Lysholm scores were 54 (41-62) pre-operatively and 86.1 (74-96) at 24 months post-operatively. The average IKDC score increased from 48 (42-56) points to 91 (73-97) points. The Lachman test was positive in all patients before ACL reconstruction and negative in 96% of them at 12 and 24 months after surgery. The full range of joint motion was restored after ACL surgery, with minimal motion restriction in flexion and extension, in 70 (89.7%) patients. Motion restriction by 15° or less in flexion and 5° or less in extension was recorded in seven (9%) patients and a significant restriction in extension exceeding 10° was found in one (1.3%) patient. No differences in results were found between the two scoring systems. Five patients (6.4 %) sustained a re-tear in the reconstructed ACL due to a trauma. Non-traumatic subjective instability after the primary repair was not recorded. Revision ACL surgery was carried out due to fixation materials protruding from the bone surface in two patients and because of a Cyclops lesion with extension deficit in one patient. No development of deformity or instability was observed at 24 months in the patients in whom the transepiphyseal technique was used. DISCUSSION In the current literature ACL reconstruction by the transphyseal technique has been described in patients older than 15 years of age but no optimal age has been suggested. Animal experiments have shown that tunnels taking up more that 7-9% of the growth plate surface can result in growth restriction or angular deformity. ACL reconstruction in patients with distinct bone immaturity carries a high risk. The effect of growth on the biomechanical properties of a graft and a long-term consequence of surgical intervention in the growth plate is not yet understood.
Conslusions:
Although indications for surgical ACL repair and its timing are bound to be different in each patient, we consider the age of over 15 years to be ideal for ACL reconstruction. In patients younger than 15 years, the necessity of surgical treatment is questionable and conservative therapy can give good outcomes. No adverse effect of an applied graft on the post-operative results was demonstrated. The features of an immature skeleton are specific and complicated therefore, in our view, the relevant health care for paediatric patients should be concentrated into specialised institutions.
... There are multiple animal studies trying to quantify how much damage to the physis will result in growth deformities. Although there are no exact numbers, studies in rabbits show that a drill hole measuring up to 7-9 % of the crosssectional plane of the tibial plateau can induce a growth disturbance [24]. In children and adolescents, however, where the transplant averages around 5-6 mm, it is possible to stay well under that threshold. ...
... Excessive tensioning of the soft-tissue graft is thought to have an adverse effect on growth. In an animal model, valgus deformities due to overly tensioned grafts have been observed [24]. ...
As more children and adolescents are involved in sporting activities, the number of injuries to immature knees rises. We will focus on three entities: ruptures of the anterior cruciate ligament, patellar dislocation, and meniscal injuries. There is a trend in recent literature toward early reconstruction of the anterior cruciate ligament in children and adolescents. In this article, we will try to highlight the anatomic specialities and the diagnostic steps toward the correct diagnosis, review technical considerations and risks of the different surgical techniques, and present outcomes and offer a treatment recommendation. The treatment of patellar dislocation has changed considerably since we gained a better understanding of the unique anatomy of the patellofemoral joint. We will show diagnostic steps and risk factors for recurrent patellar dislocation, discuss conservative and different operative therapy options, and present a modified technique to achieve a dynamic reconstruction of the medial patellofemoral ligament without damage to the growth plates. Meniscal tears and discoid menisci are rare in comparison to the other injuries. We will herein explain what specialities in the anatomy should be considered in children and adolescents concerning the menisci, and present the diagnostic steps and treatment options available.
... numbers of ACL reconstruction (ACLR) and posterior cruciate ligament (PCL) reconstruction (PCLR) are described for the pediatric population. 16 The morphology and anatomy of the cruciate ligaments is well known in adults. 6,11 Unfortunately, there is still a lack of scientific studies regarding the size and morphology of these ligaments in children and adolescents. ...
Background
The incidence of anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) tears in children and adolescents has increased over the past decade, with increasing numbers of ACL and PCL reconstructions in this patient population.
Purpose
To evaluate the size and morphology of both the ACL and the PCL by magnetic resonance imaging (MRI) in different pediatric age groups.
Study Design
Cross-sectional study; Level of evidence, 3.
Methods
MRI examinations of 127 knees (67 female, 60 male; aged 0-18 years) were analyzed retrospectively. The cohort was split into 6 age subgroups, 1 subgroup for every 3 years (minimum 8 patients per subgroup). The following parameters were measured by 2 independent raters at 2 different time points: ACL length, anteroposterior and mediolateral ACL width, sagittal and coronal ACL inclination, inclination of the intercondylar notch, bicondylar width, notch width, coronal ACL and PCL width, PCL length, and sagittal width of the lateral femoral condyle. The following indices, areas, and volumes were calculated: sagittal width of the lateral femoral condyle/PCL length, ACL area and volume, notch width index, ACL width/notch width, PCL width/notch width, ACL width/bicondylar width, and PCL width/bicondylar width. A correlation analysis was performed for patient age, height, weight, and body mass index (BMI).
Results
ACL length was between 18 and 37 mm, and ACL width was between 4 and 6 mm. PCL length ranged between 27 and 43 mm, while PCL width was between 7 and 9 mm. Growth of the cruciate ligaments was the most pronounced between the ages of 4 and 12 years. Correlations with size and weight were strong, while BMI correlated slightly with the measurements. Measurements in female patients were slightly larger than in their male counterparts between the ages of 0 and 6 years, while male patients tended to have larger values starting from ages 7 to 9 years. These values were significantly larger in male patients from the ages of 16 to 18 years ( P < .05).
Conclusion
This study provides normative data on the morphology of pediatric anatomic features in the knee as a basis for age-appropriate and individualized surgical care of ACL and PCL injuries in children and adolescents.
... Mapując 8-milimetrowe tunele kostne na poziomie chrząstki nasadowej obliczono naruszenie ok 2,4% dystalnej chrząstki wzrostowej kości udowej i ok 2,5% bliższej chrząstki wzrostowej kości piszczelowej [22]. Na bazie podobnej analizy trójwymiarowej skanów MR obliczono, iż zwiększenie kąta wiercenia na przymiarze piszczelowym z 45 do 70 stopni zmniejsza naruszenie chrząstki nasadowej piszczeli z 4,1 do 3,1 %, nie oceniono jednak możliwych następstw biomechanicznych takiej nieanatomicznej rekonstrukcji [23]. ...
The incidence of anterior cruciate ligament (ACL) injuries in children and adolescents has been growing recently. This problem is a challenge for the treating orthopedic surgeon, especially when the patient is in the prepubertal period with a high growth potential. Since reconstructive procedures require interventions close to active growth plates, they are associated with the risk of postoperative limb length discrepancies and limb deformities. Postponing ACL reconstruction until the end of growth is not a solution, as persistent knee instability increases the risk of secondary intra-articular damage. The key to success is not only knowledge of the anatomy and biomechanics of the pediatric knee but also the ability to predict the remaining growth potential and familiarity with a wide range of reconstructive surgical procedures available for patients at different ages.
... Although true nationwide incidence rates remain unknown, various studies have reported high rates of ACL injuries in selected skeletally immature populations [6][7][8]. ...
Purpose
Anterior cruciate ligament (ACL) injury is a common knee injury in paediatric and adolescent patients. The population-based incidence of paediatric ACL injury is, however, unknown. Recent studies suggest increased ACL injury rates among adolescents, especially in active, sports-participating population. The purpose of this study was to investigate the population-based incidence rates of ACL injuries and trends in paediatric ACL reconstruction surgery.
Method
All ACL injuries were identified (ICD-10 diagnosis code S83.5) leading to hospitalisation or surgery using validated Finnish National Hospital Discharge Register (NHDR) data from 1997 to 2014. The sample comprised 19,961,205 Finnish residents aged less than 18 years at the time of injury. Hospital admissions with the diagnosis code S83.5 were analysed more thoroughly including, sex, age and the need for surgical interventions.
Results
During the 18-year study period, 4725 subjects of the study population had sustained an ACL injury. The total ACL injury incidence in study population was 23.3 per 100,000 person-years. The median age of the patients at the time of injury was 16 years (range 4–17). The incidence of ACL injury increased with age, and the highest incidence was observed among 17-year old (113.5 per 100,000 person-years). Incidence rate did not differ between genders. From the total ACL injury population of 4725 hospitalisations, 3168 (67.0%) underwent ACL reconstruction, of which 2988 (94.3%) were treated with arthroscopic reconstruction and 180 (5.6%) with open surgery. In addition, 1557 (33.0%) were treated non-operatively without ACL reconstruction. The annual incidence of ACL injuries in the Finnish paediatric population has increased during the past 15 years. The lowest incidence rate was seen in 1999 (incidence of 17.7 per 100,000 person-years, 195 ACL injuries) and the highest in 2011 (incidence of 31.5 per 100,000 person-years, 346 ACL injuries). The highest increase in ACL injuries was seen in girls aged 13–15 years, with an increase of 143%.
Conclusion
ACL injury is not a negligible knee injury in the paediatric population. The incidence of paediatric ACL injury has increased during the past 15 years. Moreover, a twofold increase in incidence of paediatric ACL injury was noted during the last 10 years of the study period. Incidence rates among male and female paediatric patients were comparable.
Level of evidence
III.
... Tunnel diameter should always be kept under 9 mm [59]. On the tibial side, care must be taken to position the tunnel entrance more medially than in adults, in order to protect the apophysis of the tibial tuberosity and to avoid subsequent development of a varus and/or a recurvatum knee [60]. On the femoral side, an injury to the perichondral structures should be avoided to prevent a posterolaterally located growth plate fusion and the iatrogenic development of a valgus knee [61]. ...
... Tunnel diameter should always be kept under 9 mm [59]. On the tibial side, care must be taken to position the tunnel entrance more medially than in adults, in order to protect the apophysis of the tibial tuberosity and to avoid subsequent development of a varus and/or a recurvatum knee [60]. On the femoral side, an injury to the perichondral structures should be avoided to prevent a posterolaterally located growth plate fusion and the iatrogenic development of a valgus knee [61]. ...
The number of publications on treatment of anterior cruciate ligament (ACL) injuries in the skeletally immature population has increased through the past decade [1–6]. However, opinions on whether pediatric ACL injuries should primarily be surgically reconstructed or conservatively treated are still divided within the pediatric orthopedic community [7, 8]. Evidence from high-level studies and randomized controlled trials is lacking [9], which leaves the field open for various treatment algorithms due to the lack of a solid scientific knowledge base. Risk factors for ACL injuries in skeletally immature patients are unknown, although it seems that boys may be more prone to rupturing their ACL before skeletal maturity, while girls have an increased risk through and after puberty [10, 11]. Many authors argue that the incidence of pediatric ACL injuries is rising. However, no epidemiological studies are available to support this statement. Increased awareness and advances in diagnostic methods, in addition to higher participation rates and earlier specialization in sports, may have led to an increase in the incidence of pediatric ACL tears.
... Surgical management, on the other hand, restores knee stability and offers the The Knee xxx (2016) xxx-xxx possibility of maintaining comparable activity levels. This intervention is advantageous in younger patients who are noncompliant with bracing, and are intolerant of reduced physical activity [3,7,8]. However, a historical analysis of ACL open repair revealed an unacceptable failure rate [9][10][11]; thus, enthusiasm for this procedure waned. ...
Background:
Anterior cruciate ligament (ACL) tears in children are increasingly common and present difficult treatment decisions due to the risk of growth disturbance. Although open primary ACL repair was abandoned in the historical literature, recent studies have suggested that there is a role for arthroscopic primary repair in patients with proximal tears.
Methods:
This is a retrospective review of five consecutive patients aged 9.2years (range 8 to 10) who underwent suture anchor ACL reinsertion. Patients were included if they were Tanner stages 1-2 and proximal ACL tears with adequate tissue quality confirmed arthroscopically. The time frame was 81days. Arthroscopic ACL reinsertion was performed with bioabsorbable suture anchor. Clinical evaluation, KT-1000™, and MRI were re-evaluated. Clinical outcomes were measured using International Knee Documentation Committee (IKDC), Lysholm and Tegner activity score.
Results:
At a mean follow-up of 43.4months (range 25 to 56), no re-injury and leg length discrepancies were observed. Four patients had negative Lachman tests. The remainder had a grade 1 Lachman test. The mean side-to-side difference was 3 (2-4mm). In MRI obtained at the last follow-up, no articular lesions or growth arrest were observed and the reinserted ACL was recognized in every exam. All patients returned to previous level of activity and presented normal and nearly normal IKDC score. The mean Lysholm score was 93.6.
Conclusion:
Arthroscopic ACL repair can achieve good short-term results with joint stability and recovery of sport activity in skeletally immature patients, with proximal ACL avulsion tear.
... Historically, mid-substance tears of the anterior cruciate ligament (ACL) were considered rare events in children. 42 However, the child athlete with a tear of the ACL is no longer an enigma. In a retrospective review of ACL injuries in adolescent soccer and basketball players, the frequency of ACL injuries over a 5-year time period correlated with an increase in the level of participation in sports over the same period. ...
Limited data exist regarding the effect of the growth process on anterior cruciate ligament (ACL) injury risk in male versus female children.
The proportion of ACL injuries/sports injuries presenting to clinic will vary by age, sex, and body mass index (BMI).
Cross-sectional epidemiologic study.
Level 3.
The study group consisted of a randomly selected 5% probability sample of all children 5 to 17 years of age presenting to a sports medicine clinic from January 1, 2000 to December 31, 2009; 2133 charts were reviewed. Data collected included demographics, height and weight, injury mechanism, diagnosis, treatment, previous injury, and organized sports.
A total of 206 ACL tears were analyzed (104 girls, 102 boys). Girls were slightly older than boys (15.1 ± 1.7 vs 14.3 ± 2.1 years; P < 0.01). Male-female comparison of ACL injury/total injury by age revealed that girls had a steeper increase by age than boys. Among 5- to 12-year-olds, boys had a higher ACL injury/total injury ratio than girls (all P < 0.01). Children 13 to 17 years of age showed no significant difference for sex in ACL injury/total injury ratio. As age advanced, the proportion of ACL injuries/total injuries increased for both girls (P < 0.01) and boys (P = 0.04). BMI was independently associated with an ACL injury (P < 0.01).
The proportion of ACL injuries/total injuries was similar for boys and girls aged 13 to 17 years. Girls showed a significantly steeper increase in ACL injury proportion versus boys through puberty.
This study will increase clinician awareness of ACL injury occurrence in young male and female athletes 5 to 12 years of age. Injury prevention efforts should target young girls before the onset of puberty and before injury occurs.
... Toujours aux États-Unis, chez des enfants âgés de cinq à 18 ans (6 millions de joueurs/an), Shea et al. [3] montrent que 6,7 % des traumatismes dans la pratique du soccer (football) touchent le ACL, près du tiers des lésions traumatiques du genou dans cette activité sportive (ces chiffres ont débouché sur des programmes de prévention associant des exercices de reprogrammation neuromusculaire, de proprioception, de pliométrie d'une rare efficacité avec diminution de cinq à sept fois le risque de lésions du ACL dans la pratique sportive, notamment du football féminin). ...
... In skeletally immature individuals, the injury pattern is somewhat different, with tibial spine avulsions and partial ACL tears predominating. [12][13][14] This pattern is most likely secondary to the greater ability of bone to deform under stress in the immature skeleton and the lack of osseous fusion of the tibial spine prior to physeal closure. As the skeleton matures, the patterns of ACL injury approach that seen in adults. ...
I njuries of the knee are common. At our institution, the Medical Univer-sity of South Carolina, trauma and sports-related activities are the most fre-quent causes of knee injuries. Second-ary to their role in maintaining stability, the ligaments of the knee are commonly involved in these injuries. To prevent long-term sequelae, early diagnosis and treatment—whether conservative or sur-gical—are key in planning management of these injuries. Because of its excellent soft-tissue contrast, magnetic resonance imaging (MRI) has proven very useful for identifying these important structures. 1-4 In the immediate postinjury period, clini-cal assessment of the knee is unreliable, which accentuates the importance of MRI as a diagnostic tool. 5 This article reviews the MRI appearance of the knee liga-ments in their normal and injured states. Basic imaging principles Because of the biochemical composi-tion of ligaments, the tightly bound hy -dro gen molecules are unavailable to participate in the magnetic moment of MRI. Therefore, under normal circum-stances, ligaments show low signal intensity on all pulse sequences. Injury allows loosely bound hydrogen atoms as well as infiltrating edema and hemor-rhage to produce signal on the various pulse se quences used to evaluate these structures. 6 MRI protocols for the knee vary by magnet and interpreter preference. Pro-tocols should include sequences ob-tained in the axial, coronal, and sagittal planes, with at least one fluid-sensitive sequence. In general, a high field-strength magnet and a dedicated knee or extremity coil is preferred, but adequate evaluation can be attained with mid-and low-field magnets. Patients are imaged supine with the knee in slight external rotation both for better visual-ization of the anterior cruciate ligament (ACL) and patient comfort. The authors do not use intravenous contrast unless evaluating for neoplasm or infection. Intra-articular contrast is used primarily in the patient who has had prior surgical meniscal repair. In general, the collateral ligaments are best evaluated in the coronal plane, and the cruciate ligaments and exten-sor mechanism are best evaluated in the sagittal plane. The coronal plane is also an important projection for the cruciate ligaments. However, visual-ization of all structures in all three imaging planes is necessary for a com-plete evaluation, which helps to avoid misdiagnosis.
... Until a few decades ago, many professionals thought midsubstance tears of the ACL were not probable in children and adolescent athletes (Angel & Hall, 1989;De Lee & Curtis, 1983); however, recent studies have reported an increased incidence ratio in young athletes disputing this claim (Bales, Guettler, & Moorman, 2004;Dorizas & Stanitski, 2003). Scholars have identified several causative factors to account for the gender difference including muscle strength, quadriceps-angle (Q-Angle), ligamentous laxity, and biomechanical analysis of movement (Shea, Apel, Pfeiffer, 2003). ...
... Toujours aux États-Unis, chez des enfants âgés de cinq à 18 ans (6 millions de joueurs/an), Shea et al. [3] montrent que 6,7 % des traumatismes dans la pratique du soccer (football) touchent le ACL, près du tiers des lésions traumatiques du genou dans cette activité sportive (ces chiffres ont débouché sur des programmes de prévention associant des exercices de reprogrammation neuromusculaire, de proprioception, de pliométrie d'une rare efficacité avec diminution de cinq à sept fois le risque de lésions du ACL dans la pratique sportive, notamment du football féminin). ...
... Injuries to the anterior cruciate ligament (ACL) are being recognized with increased frequency among youths' playing team sports such as soccer (Micheli et al., 1999). Although participation trends may contribute to these observations, these findings represent a major cause of concern (Shea et al., 2003). The exact mechanism of non-contact ACL injury remains to be elucidated (Boden et al., 2000); however, it is thought that active quadriceps pull, combined with a relative weakness in the hamstrings muscle group, may play an important role in the pathomechanism of this injury (Boden et al., 2000). ...
In this cross-sectional study, the differences in the isokinetic peak torque of the knee joint muscles (dominant and non-dominant) were investigated in three groups of youths (n=45; age, 14.9+/-1.1 years) with different soccer training backgrounds. Significant main effects were observed for training background on the functional hamstrings to quadriceps ratios for knee flexion (H(CON):Q(ECC) ratio; F(2,42)=4.023, P=0.025) and extension (H(ECC):Q(CON) ratio; F(2,42)=8.53, P<0.001) at 4.32 rad/s. Post hoc tests indicated that both ratios were significantly different between conventionally trained players compared with resistance-trained players and controls (mean+/-SD; H(ECC):Q(CON) ratio, dominant limb; 0.91+/-0.10; 1.04+/-0.12; 1.10+/-0.22; non-dominant limb; 0.89+/-0.09; 1.05+/-0.19; 1.06+/-0.15; H(CON):Q(ECC) ratio, dominant limb; 0.36+/-0.06; 0.34+/-0.07; 0.30+/-0.08; non-dominant limb; 0.33+/-0.05; 0.32+/-0.08; 0.28+/-0.07). Results suggest that the muscle-loading patterns experienced in youth soccer may alter the reciprocal balance of strength about the knee under high-velocity conditions. The findings also indicate that these balances may be improved by incorporating resistance training into the habitual exercise routines of youth soccer players.
... Sport injuries are the most common cause of acute hemarthrosis in children with the frequency of tear of the ACL to approach 33-63% of these injuries [44]. Over the past decade, mid-substance injuries to the ACL in children have been described more frequently, and now appear to be more common than avulsion fractures of the tibial spine [34,35]. The increased participation in sporting activities amongst the young, the introduction of MRI and arthroscopy, may account for the increased frequency of this injury [39]. ...
Significant controversy exists regarding the potential harm to the growth plate following reconstruction of the anterior cruciate ligament in skeletally immature patients. This study was performed to evaluate the results of a transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients.
Ninety-four skeletally immature patients (56 male and 38 female) with median age 13.7 years (range, 11.6-15.9 years) who underwent arthroscopic transphyseal reconstruction of anterior cruciate ligament with four-strand medial hamstring autograft between 1999 and 2006 were reviewed. All patients had been followed up until skeletal maturity was confirmed.
The average follow-up was 38 months (range 24-60 months). Neither leg length discrepancy nor angular deformities were noted on radiological or clinical measurement. Two patients had radiographic evidence of mild arthrosis at final follow-up. New traumatic injuries occurred in 4 patients, in whom surgical revision was performed. Ligament laxity testing with a KT 1000/2000 arthrometer showed no significant difference between the normal and the operated legs. At follow-up, the median Lysholm score was 89 (range 77-100), and the median Tegner activity score was increased from 3 to 6. The International Knee Documentation Committee score was A in 79 patients (84%) and B in 6 patients (6%) and C in 9 patients (9%). Of the 94 patients, 73 (78%) returned to their similar preoperative sport activities and 90% returned to their preoperative level of daily activities.
ACL reconstruction with medial hamstring autograft via transepiphyseal drilling and grafting yielded satisfactory clinical results with no growth defects in skeletally immature patient. The preliminary results of this series demonstrated that this surgical technique can be performed in prepubescent patients with efficacy and safety.
IV.
... In skeletally immature patients a lateral radiograph may show avulsion of the tibial eminence. MRI can be performed to depict nondisplaced avulsions, to establish whether an ACL tear has indeed occurred, and to demonstrate associated abnormalities in the joint [45, 46] (Fig. 11). Meniscal problems in this age group are unusual and are generally associated with a discoid lateral meniscus. ...
With an increasing number of paediatric and adolescent athletes presenting with injuries due to overuse, a greater demand is put on clinicians and radiologists to assess the specific type of injury. Repetitive forces applied to the immature skeleton cause a different type of injury than those seen in adults due to the differences in vulnerability of the musculoskeletal system, especially at the site of the growth cartilage. Intrinsic and extrinsic risk factors all play a role in the development of overuse injuries. MRI plays a key role in imaging overuse injuries due to its high potential for depicting cartilaginous and soft-tissue structures. Sport-specific biomechanics are described, since this knowledge is essential for adequate MRI assessment. An overview of several sport-related injuries is presented, based on anatomical location.
... 1,3,19,23,50 Further research on the appropriate treatment of ACL injury in skeletally immature athletes is necessary. 57 This study demonstrates that ACL injury occurs in skeletally immature soccer players, with a significant increase in ACL injury at age 11-12 years. Like adult female athletes, skeletally immature females also demonstrate a higher risk of ACL injury compared with their male counterparts. ...
Injury claims from an insurance company specializing in soccer coverage were reviewed for a 5-year period. A total of 8215 injury claims (3340 females, 4875 males) were divided into three categories: (1) all injury, (2) knee injury, and (3) ACL injury. Knee injuries accounted for 22% of all injuries (30% female, 16% male). ACL injury claims represented 31% of total knee injury claims (37% female, 24% males). The youngest ACL injury was age 5. The ratio of knee injury/all injury increased with age. Compared with males, females demonstrated a higher ratio of knee injury/all injury and a higher ratio of ACL injury/all injury. This study demonstrates that ACL injury occurs in skeletally immature soccer players and that females appear to have an increased risk of ACL injury and knee injury compared with males, even in the skeletally immature. Future research related to ACL injury in females will need to consider skeletally immature patients.
Objectives: There remains considerable debate regarding the optimal management of anterior cruciate ligament (ACL) injuries in skeletally immature patients. This study aims to evaluate the clinical outcomes of transphyseal ACL reconstruction in patients with open growth plates. Methods: This retrospective study included skeletally immature patients with full-thickness ACL tears and confirmed open physis. ACL reconstructions were performed using a four-strand semitendinosus autograft, with an additional gracilis tendon graft if needed. The surgical technique emphasized tibial and femoral physeal-sparing tunnel placement to minimize disruption of the growth plates. Clinical assessment included measurements for limb length discrepancy, knee stability, and growth disturbances. Functional outcomes were evaluated using IKDC 2000, Lysholm, and KOOS scores, while ligament stability was assessed with KT-1000 arthrometer measurements at routine follow-up. Results: A total of 31 consecutive patients (15 females, 16 males; mean age 13.6 ± 1.8 years, range 9–16 years) were included. Mean follow-up was 49 ± 26 months (range 18–93 months). The mean time to return to sports was 8.8 ± 4.4 months. Eight patients (26%) experienced ACL graft rupture and underwent revision ACL reconstruction. One additional patient required partial meniscectomy. The overall revision rate was 29%. The mean subjective IKDC score was 91.8 ± 7.2, with Lysholm and KOOS scores of 96.6 ± 7.9 and 94.2 ± 5.3, respectively. No significant growth disturbances were noted. The mean side-to-side difference in KT-1000 testing was 2.2 ± 1.5 mm. Patients who underwent revision ACL reconstruction showed significantly greater length growth compared with those with intact ACL reconstruction (p = 0.02). Spearman correlation revealed a significant association between length growth and anterior tibial translation (p = 0.02, r = 0.46). Conclusions: Transphyseal ACL reconstruction in skeletally immature patients provides favorable clinical and radiological outcomes, with minimal risk of growth disturbance. Most patients returned to pre-injury levels of athletic activity. However, the high revision rate emphasizes the complexity of managing ACL injuries in this population.
Background
Female athletes are four to six times more likely to sustain an anterior cruciate ligament (ACL) injury than male athletes. Jump-landing biomechanics are influenced by maturation, with post-pubertal female athletes at a heightened risk of ACL injuries.
Objective
The aim of our systematic review was to identify and summarise the current evidence regarding the changes in kinematic and kinetic risk factors associated with ACL injuries during jump-landing tasks in female athletes at various stages of maturity.
Methods
A systematic search was conducted in PubMed, CINAHL, Web of Science, SPORTDiscus, EMBASE and Scopus. Articles were included if they: (1) conducted the research on uninjured female athletes with no restriction on playing level/experience; (2) provided information regarding the stage of the maturity and the scale used for estimating the maturity status of the participants; and (3) reported a biomechanical risk factor associated with ACL injuries during jump-landing tasks across at least two different maturity groups (e.g. pre-pubertal vs post-pubertal).
Results
Sixteen articles involving 2323 female athletes were included in our review. A total of 12 kinematic and 8 kinetic variables were identified across these studies. Of the 12 kinematic variables reported in our review, we found strong evidence for higher peak knee abduction angle in post-pubertal female individuals compared with pre-pubertal girls (p < 0.05). With regard to the 8 kinetic variables, we found strong evidence for lower relative peak vertical ground reaction force, higher external knee abduction moment and internal rotation moment in post-pubertal compared with pre-pubertal athletes. The strength of evidence for the remaining kinematic and kinetic variables ranged from conflicting to moderate and, in some instances, could not be determined.
Conclusions
Our study provides an overview of the changes in biomechanical risk factors in female athletes during jump-landing tasks at various stages of maturity. We found moderate-to-limited evidence for most kinematic and kinetic variables, highlighting the need for further research.
Background
Anterior cruciate ligament (ACL) repair is increasing in frequency in younger children. Recognition of the normal development of the intercondylar notch is important for successful ACL graft placement, allowing surgeons to better understand the anatomy and risk factors related to ACL tears and its reconstruction. The purpose of this study was to compile normative data on the intercondylar notch in the pediatric population with magnetic resonance imaging (MRI), emphasizing the differences between males and females.
Methods
In this retrospective study, musculoskeletal radiologists evaluated intercondylar notch width, bicondylar distance and notch width index (NWI). A total of 253 MRI examinations (130 males and 123 females between six and 18 years of age) were included. The association between measurements, sex and age was considered. Linear and fractional polynomial regression models were used to evaluate the relationships between measurements.
Results
Intercondylar notch width increased up to 10 years of age in females and 11 years of age in males, with relative stabilization up to 13 years in girls and 14 years in boys and a slight reduction in values at subsequent ages. Bicondylar distance showed significant progressive growth with age in both sexes. NWI showed a discrete and homogenous reduction with age in both sexes.
Conclusion
Intercondylar notch width interrupts its growth around 10–11 years of age, with relative stabilization up to 13–14 years and a slight reduction in dimensions in subsequent ages. This growth pattern resembles the development of the ACL area observed in recent studies.
The increasing incidence of anterior cruciate ligament injuries in skeletally immature children demands careful attention by orthopedic surgeons. Assessing skeletal age is essential to selecting the appropriate reconstruction technique. Males with a bone age of 15 years or older and females of 13 years and older are ideal candidates for a transphyseal anterior cruciate ligament reconstruction because there is minimal risk of growth disturbance. Children with substantial growth remaining (skeletal age males ≤12 years and females ≤10 years) seem to be at risk for more significant growth disturbance, so we generally recommend physeal-sparing techniques for these younger patients.
Purpose
The aim of this study was to retrospectively compile normative data on the anterior cruciate ligament (ACL) in the paediatric population with magnetic resonance imaging, emphasizing the differences between men and women.
Methods
In this retrospective study, musculoskeletal radiologists evaluated length, area, coronal and sagittal inclination of the ACL and inclination of the intercondylar notch. A total of 253 MR examinations (130 males and 123 females between 6 and 18 years of age) were included. The association between measurements, sex and age was considered. Linear and fractional polynomial regression models were used to evaluate the relationships between measurements.
Results
ACL length showed significant progressive growth (p < 0.001) with age in men and women, without characterization of growth peaks. ACL area in women showed more pronounced growth up to 11 years, stabilized from 11 to 14 years and then sustained a slight reduction. In men, ACL area showed more pronounced growth up to 12 years, stabilized from 12 to 15 years and then sustained slight reduction. Coronal and sagittal inclination of the ACL showed a significant progressive increase (p < 0.001) with age in both sexes, progressively verticalizing. The intercondylar roof inclination angle showed significant progressive reduction (p < 0.001) with age in both sexes.
Conclusion
The area of the ACL does not accompany skeletal maturation, interrupting its growth around 11–12 years. Progressive verticalization of the ACL as well as of the intercondylar notch roof in the evaluated ages was also observed. The clinical relevance of this study is that the ACL presents different angular and morphologic changes during growth in the paediatric population. Since ACL repair is now being performed on younger children, recognition of the normal developmental changes of the ACL is of utmost importance for successful ACL graft placement.
Level of evidence
III.
The treatment of anterior cruciate ligament (ACL) injuries in skeletally immature children and adolescents requires careful consideration of skeletal age and growth remaining. The risk of physeal damage and potential to cause limb length discrepancy or angular deformity has to be weighed against the risk of nonoperative treatment or nonanatomic reconstructions. Basic science and clinical series suggest that transphyseal ACL reconstructions can be performed in a select group of patients. Boys with a bone age of 15 years or older and girls of 13 years and older are ideal candidates for transphyseal ACL reconstructions, as they have minimal growth remaining. Current evidence supports that transphyseal ACL reconstructions with soft tissue grafts are safe and effective for skeletally immature patients with a skeletal age of 13–14 years in boys and 11–12 years in females.
Children who undergo an ACL reconstruction have a unique spectrum of complications as compared to adults. The pediatric bone size, open growth plates, and extremely high activity level contribute to their high rate of complications. Children are subject to most of the same complications that are seen in adults, but they can also suffer the unique complication of a growth disturbance which can result in a shorter leg, a longer leg, or a crooked leg. Graft fixation may also be less secure and less anatomic than standard adult ACL reconstruction techniques. With the use of fluoroscopy and careful surgical technique, these complications can be minimized. Outcomes can be excellent, allowing even the very young athlete with a reconstructed ACL the safe return to cutting and pivoting sports such as football, basketball, and soccer.
Many techniques for reconstruction of pediatric and adolescent anterior cruciate ligament (ACL) ruptures have been described, yet the best technique to reproduce normal kinematics of the knee while causing minimal growth disturbance is not definitively determined. We describe a technique which adapts the Allen Anderson technique for all-inside, all-epiphyseal, anatomic ACL reconstruction. However, this technique uses a novel quadriceps tendon - patellar bone - autograft to provide the best-possible patient outcomes. ACL reconstruction advancement in pediatrics is important as an increasing number of adolescent athletes experience ACL rupture and desire to return to sport.
Currently, it is estimated that 400,000 anterior cruciate ligament (ACL) surgeries are performed in the USA. About half of those patients are children and adolescents [26, 65]. The most common injury patterns are midsubstance tears or tibial eminence avulsions. Treatment of a tibial eminence avulsion is done with closed reduction and immobilization (Meyers and McKeever types I and II) or refixation with sutures, pins, or screws (type III) and will not be discussed in this chapter.
A lesão do ligamento cruzado anterior (LCA) na criança e no adolescente assume uma importância crescente, considerando a elevada participação destes grupos em atividades desportivas e a gravidade potencial da lesão. A decisão terapêutica é difícil e a evidência das diferentes opções é muito baixa. Este artigo pretende apresentar as principais fases do programa de reabilitação após reconstrução do LCA e formular elementos de prognóstico. The issue of the anterior cruciate ligament (ACL) injury in children and adolescents is becoming more and more important considering the high participation of these groups in sports activities and the potential severity of the injury. Therapeutic decision-making is difficult and the evidence for different options is very low. This article aims to present the main stages of the rehabilitation program after ACL reconstruction and formulate considerations about prognosis.
This article summarises lower limb pathology, which results in lower limb pain. It mainly addresses injuries and deliberately omits osteoarthritis and rheumatoid arthritis, since these entities are described in detail in other chapters in this volume. As major trauma is not a focal point for rheumatologists and repetitive strain injuries of the lower limb are rare, sports and leisure injuries are the main focus. Regarding lower limb pain, this chapter describes the most important problems and quantifies the size of the problem. Furthermore, it informs the reader about different treatment modalities, their goals and methods of measuring the effectiveness of the treatment. Evidence is given for different interventions, such as lifestyle, pharmacological, surgery and rehabilitation. In addition, opportunities to apply these interventions for prevention and treatment to those who will potentially benefit most are shown. Finally, strategies (care pathways) are given for prevention and treatment based on this evidence.
Approximately 25% of fractures in children occur in the lower limb. The injury and fracture pattern vary with age and skeletal
maturity. The peak incidence is bimodal, with high energy trauma (falls from height or motor vehicle accidents) peaking in
preadolescents and sporting injuries peaking in adolescents
Purpose:
The objective of this study was to assess the effect of absorbable or nonabsorbable sutures in bioenhanced anterior cruciate ligament (ACL) repair in a skeletally immature pig model on suture tunnel and growth plate healing and biomechanical outcomes.
Methods:
Sixteen female skeletally immature Yorkshire pigs were randomly allocated to receive unilateral, bioenhanced ACL repair with an absorbable (Vicryl) or nonabsorbable (Ethibond) suture augmented by an extracellular matrix-based scaffold (MIACH). After 15 weeks of healing, micro-computed tomography was used to measure residual tunnel diameters and growth plate status, and biomechanical outcomes were assessed.
Results:
At 15 weeks postoperatively, there was a significant difference in tunnel diameter with significantly larger diameters in the nonabsorbable suture group (4.4 ± 0.3 mm; mean ± SD) than in the absorbable group (1.8 ± 0.5 mm; P < .001). The growth plate showed a significantly greater affected area in the nonabsorbable group (15.2 ± 3.4 mm(2)) than in the absorbable group (2.7 ± 0.8 mm(2), P < .001). There was no significant difference in the linear stiffness of the repairs (29.0 ± 14.8 N/mm for absorbable v 43.3 ± 28.3 N/mm for nonabsorbable sutures, P = .531), but load to failure was higher in the nonabsorbable suture group (211 ± 121.5 N) than in the absorbable suture group (173 ± 101.4 N, P = .002). There was no difference between the 2 groups in anteroposterior laxity at 30° (P = .5117), 60° (P = .3150), and 90° (P = .4297) of knee flexion.
Conclusions:
The use of absorbable sutures for ACL repair resulted in decreased physeal plate damage after 15 weeks of healing; however, use of nonabsorbable sutures resulted in 20% stronger repairs.
Clinical relevance:
Choice of suture type for ACL repair or repair of tibial avulsion fractures may depend on patient skeletal age and size, with absorbable sutures preferred in very young, small patients at higher risk with physeal damage and nonabsorbable sutures preferred in larger, prepubescent patients who may place higher loads on the repair.
In anterior cruciate ligament (ACL) injury, conventional adult reconstruction techniques have to face the potential risk of growth disturbance or angular deformities in skeletally immature patients. The aim of this study was to evaluate the clinical outcomes of ACL reconstruction by conventional transphyseal tunnel technique.
On a retrospective basis, we reviewed 25 skeletally immature patients; all the patients showed skeletal maturity at last follow-up, and the mean age was 16.4 years. The average injury to surgery interval was 12.6 months. Clinical outcomes were assessed at a mean of 74.4 months postoperatively using the Lysholm Knee Scoring Scale, the Tegner activity level, the International Knee Documentation Committee (IKDC), and plain radiographs.
All the patients had undergone transphyseal reconstruction of ACL. The mean Lysholm score was 48.36 points preoperatively and 93.32 points postoperatively; the mean Tegner activity level was changed from 3.0 points to 5.6 points. The mean IKDC level was categorized as C preoperatively and changed to A postoperatively.
Our midterm outcome at an average 6 years after surgery was satisfactory without significant leg length discrepancies or abnormal alignment of the knee joint. Transphyseal reconstruction of ACL is a good treatment modality in the skeletally immature patient.
Soccer young player’s injuries differ from those in adults players. Adolescents and indoor players have marked increased risk.
Is a predominant contact sport and therefore macrotrauma lesions are more frequent than overuse injuries, the latter being
related to intense training programs. Macrotrauma lesions are fractures, sprains, contusions and joint rotation injuries.
The lower limb is most frequently involved and only goalkeepers have tendency for developing upper limb injuries. The high
frequency of avulsion fractures is due to the growing skeleton peculiarities where the epiphyseal plate is weaker than ligament
and tendons. Muscles lesions might be strains (hamstrings, quadriceps, adductor or gastrocnemius) or direct contusions. Anterior
cruciate ligament rupture or avulsion is the most common serious injury, more common in females.
Revision ACL reconstruction poses several challenges for the surgeon in terms of the timing of surgery and the limited graft choices. To our knowledge, there is currently no published data with regards to revision ACL reconstruction in a child. We describe the case of a 12-year-old girl who had a re-injury 4.5 months after her index primary ACL reconstruction at the age of 11 years. She sustained a repeat injury to the reconstructed knee following a road traffic accident and developed significant instability despite an intensive rehabilitation program. After careful consideration of the available graft materials--known all the advantages and disadvantages of the autografts, allografts and synthetic materials--we decided to use the patient's mother's hamstrings as a graft. The parents of our patient refused the use of allograft and synthetic materials. We discuss our management of this case, the reasons for our revision graft choice, and the theoretical disadvantages of some of the alternative graft choices available in this scenario. We believe in such cases, performing ACL revision with a donor graft of the patient's mother could be good alternative to allografts or synthetic grafts.
To systematically review the current evidence for conservative and surgical treatment of anterior cruciate ligament (ACL) tears in skeletally immature patients.
A systematic search of PubMed, CINAHL, EMBASE, CCTR, and CDSR was performed for surgical and/or conservative treatment of complete ACL tears in immature individuals. Studies with less than six months of follow-up were excluded. Study quality was assessed and data were collected on clinical outcome, growth disturbance, and secondary joint damage.
We identified 48 studies meeting the inclusion criteria. Conservative treatment was found to result in poor clinical outcomes and a high incidence of secondary defects, including meniscal and cartilage injury. Surgical treatment had only very weak evidence for growth disturbance, yet strong evidence of good postoperative stability and function. No specific surgical treatment showed clearly superior outcomes, yet the studies using physeal-sparing techniques had no reported growth disturbances at all.
The current best evidence suggests that surgical stabilization should be considered the preferred treatment in immature patients with complete ACL tears. While physeal-sparing techniques are not associated with a risk of growth disturbance, transphyseal reconstruction is an alternative with a beneficial safety profile and a minimal risk of growth disturbance. Conservative treatment commonly leads to meniscal damage and cartilage destruction and should be considered a last resort.
Level IV, systematic review of Level II, III, and IV studies.
The objective of this work is to assess the feasibility of successfully repairing the torn anterior cruciate ligament (ACL). Two major motivators for developing a new treatment for ACL injuries are the recently reported high rates of osteoarthritis, after conventional ACL reconstruction, and the problem of how to safely treat skeletally immature patients. A key factor in developing such a technique was the identification of the main inhibitor of intrinsic ACL healing-the lack of clot formation between the 2 torn ends of the ligament. A bioactive and biocompatible scaffold, which could be placed in the wound site to enhance cellular proliferation and biosynthesis, was developed. This biomaterial has shown promising functional outcomes in several large animal models of primary repair of partial and complete ACL transection over 4 to 14 weeks, suggesting potential for a successful, future clinical application.
An ACL injury in a child or adolescent is a major risk factor for the development of early-onset osteoarthritis. Although definitive evidence for recommending surgical management of these injuries is lacking, aggressive surgical treatment appears to provide the best outcome due to meniscal-salvage opportunities, especially in those who remain physically active.
The knee is the joint which is most commonly imaged by MRI in children. With increasing participation in competitive sports at younger ages, knee injuries are common in children. While older adolescents have patterns of injury similar to those seen in adults, injuries seen in skeletally immature patients differ. In this essay, the MR findings of injuries of the skeletally immature knee are highlighted.
There is a lot of controversy in the recent literature with regard to the optimal treatment of anterior cruciate ligament (ACL) injuries during growth. Iatrogenic growth disturbance due to physeal damage is a potential complication, forcing many orthopaedic surgeons to treat these injuries conservatively.
It is possible to perform a fully transphyseal ACL reconstruction in an ovine model with wide-open physes without creating growth disturbances.
Descriptive laboratory study.
Four-month-old skeletally immature sheep underwent a transphyseal ACL reconstruction of the right knee. The surgical technique followed the criteria known to be essential to avoid growth disturbances in humans; the tibial tuberosity was spared to prevent a genu recurvatum, thermal damage to the growth plates was avoided, the physes were perforated with a small-diameter drill in the center of the growth plate, a soft tissue graft was used, graft fixation was achieved far away from the growth plates, the perforated growth plates were filled by the soft tissue graft, and the graft was moderately pretensioned before fixation. The left knee served as a control. A computer-assisted evaluation of long radiographs (frontal and sagittal plane) of the exarticulated hindlimbs was performed to exactly evaluate the limb alignment, joint orientation, and leg length. The animals were sacrificed in groups of 6 after 3, 6, 12, and 24 weeks.
No angular deformities or leg-length discrepancies occurred after this transphyseal ACL reconstruction procedure throughout the remaining growth.
This large-animal study supports the clinical observation that it is possible to perform an ACL reconstruction without creating growth disturbances as long as a number of key principles are followed.
Previous animal studies argued against ACL reconstruction in skeletally immature patients. This large-animal study provides support for early operative treatment of ACL ruptures even in young patients with open physes.
Musculoskeletal injuries are a frequent consequence of physical activity and sports participation. Many injuries are predictable based on the physical demands of the sport or the inherent risk of the participant. Injuries also tend to follow characteristic patterns because of vulnerabilities dictated by anatomy or skeletal immaturity. Familiarity with injury patterns and injury risks can help correctly diagnose and treat injuries. The patterns and predictabilities of injury also serve as the basis for injury prevention. The clinical approach to acute and overuse injuries varies because the nature of information that is most useful for treatment varies. In acute injuries, the effects of the injury determine treatment. Therefore, the history, physical examination, and imaging studies must be oriented toward assessing what was damaged and how much damage occurred. For overuse injuries, the effects of injury are subtle, nonspecific, and not particularly useful in planning treatment. However, if the extrinsic and intrinsic causes of injury are identified, treatment can address the cause of problem rather than just the symptoms. When the cause of an injury is addressed, the patient has a far greater chance of returning to the activity that prompted the injury - without reurrence of symptoms. Fortunately, most of the sports injuries that affect children and adole scents are not severe, do not require surgery, and do not have adverse long-term consequences. As a result, the majority of injuries do not require consultation or subspecialty care. This creates a responsibility and an opportunity for primary care physicians to care for the majority of injuries that occur. By doing so, physicians can also promote the health benefits of lifelong physical activity.
In the last two decades there has been an increase in the incidence of anterior cruciate ligament (ACL) injuries in children. This may be due to increased awareness, more participation in high demand contact and non-contact sports at an earlier age and better diagnosis as a result of better imaging. A review of the literature suggests that the long-term results of non-operative treatment are poor. While the short to medium-term results of ACL reconstruction in children are encouraging, the long-term results are unknown. In this review, the current trends in the management of paediatric ACL injuries are discussed with particular emphasis on the natural history, surgical techniques, the effect of surgery on the growth plate and complications.
Traumatic rupture of the anterior cruciate ligament (ACL) in adulthood is relatively common and surgical reconstruction is frequently required to allow return to high-level activities. There is growing evidence to suggest that ACL rupture in children is more common than previously thought and a poor outcome is associated with conservative management. The site of rupture in childhood is predominantly tibial avulsion, but mid-substance tears have also been reported. We report a case of a proximal ACL avulsion in an 11-year-old athlete and discuss a method of extra-physeal repair. There are very few previous reports of proximal avulsion fractures in skeletally immature patients.
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