ACL Reconstruction with Open Physes

Introduction: It is unknown whether functional and isokinetic testing at 6 months following ACL reconstruction in patients with open-physes correlates with longer term outcomes. The purpose of this study was to compare subsequent ACL rupture risk, knee function, and activity level in patients with open-physes who had excellent 6-month testing to those who did not. Methods: Between the years of 2000 and 2015, 86 patients with open-physes underwent ACL reconstruction and had functional and isokinetic testing performed at 6-months post-operatively. Thirty-four (40%) tested in the excellent range in all categories of both functional and isokinetic testing and were labeled the excellent group. The remaining 52 (60%) patients were labeled the delayed testing group. Data regarding patient, injury, and surgical characteristics were retrospectively collected. The rate of second ACL injury as well as clinical outcome scores were collected postoperatively. Results: Graft rupture rate was 23.4% (n = 8) in the excellent group and 15.4% (n = 8) in the delayed group (p = 0.51). In the excellent group, 20.5% (n = 7) had a contralateral ACL tear versus 11.5% (n = 6) in the delayed group (p = 0.40). Five patients in the excellent group and 4 patients in the delayed group sustained both graft failure and contralateral ACL tear. The overall prevalence of second ACL injury was 29% in the excellent group and 23% in the delayed group. The delayed group returned to sport at an average of 8.8 months whereas the excellent group returned at an average of 6.6 months (p < 0.01). At mean follow up of 3.59 years, the excellent group had a higher Tegner activity level (8.9 versus 8.3) than the delayed group (p < 0.02). Conclusion: Pediatric patients with open-physes who had excellent isokinetic strength and functional testing 6-months postoperatively returned to sport sooner than those who did not. There was no statistical difference in either graft failure or contralateral ACL disruption between these groups. However, both groups had unacceptably high rates of second ACL injury (29% for the excellent group and 23% for the delayed group). Significance: Excellent 6 month return of strength and function was not protective of subsequent ACL disruption, the rate of which remains dismal within this pediatric population. Development of more sensitive functional measures for children could help to change these poor outcomes and guide clinicians when to allow return to sport.

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Mid-Term Patient Reported Outcomes and Return to Sport for Physeal Sparing ACL Reconstruction in Skeletally Immature Patients

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119s00330 ◽

2019 ◽

Vol 7 (7_suppl5) ◽

pp. 2325967119S0033

Author(s):

Lauren K. Szolomayer ◽

Carl W. Nissen ◽

Christine Mary Kelly ◽

Regina Kostyun

Keyword(s):

Acl Reconstruction ◽

Patient Reported Outcomes ◽

Return To Sport ◽

Chronological Age ◽

Open Physes ◽

Recreational Athletes ◽

Patient Reported ◽

Competitive Athletes ◽

Physeal Sparing

Objectives: Physeal-sparing techniques for anterior cruciate ligament (ACL) reconstruction have previously been described as safe treatment for adolescent ACL tears in patients with open physes, however few studies to date have reported on return-to-sport or patient reported outcome scores for this specific patient population. This study examined patient reported outcomes in children who underwent a physeal-sparing ACL reconstruction with a minimum of two-year follow-up. Methods: Surgical logs of ACLR performed at a single pediatric/adolescent sports medicine center from 2011 to 2016 were reviewed. Patients with open physes who had ACLR with a hybrid physeal sparing or all-epiphyseal technique were identified. Patients were treated by one of two pediatric sports trained orthopedic surgeons. Their demographics, operative reports, rehabilitative course, time to return-to-play, and post-operative course were retrospectively reviewed. Prospective patient reported outcomes scores, ACL-Return to Sport after Injury (ACL-RSI) and International Knee Documentation Committee (IKDC) or Pediatric IKDC (Pedi-IKDC) and return to sport questionnaire including pre-injury primary sport and competition level, ability to return to pre-injury level of competition following ACLR and subsequent ACL injury were collected. Results: There were 49 patients who met inclusion criteria. Prospectively collected data was obtained for 25 patients at an average of 4.6 (range 2.1-8.0) years following surgery. The average chronological age of patients at time of surgery was 12.8 ± 1.4 years with an average bone age of 13.5 ± 1.3 years. At mid-term follow-up, the average chronological age was 17.2 ± 2.0 years. Average Pedi-IKDC or IKDC score was 94.2 ± 9.2 and ACL-RSI Score was 89.2 ± 18.3. There were 23 patients who considered themselves athletes prior to surgery, 8 patients identifying as recreational athletes competing in town or school leagues and 15 patients identifying as competitive athletes participating on youth travel or club leagues. All patients reported the ability to return to their primary sport following ACLR, with 74% returning to the same or higher level of competition, of which 6 were recreational athletes and 11 were competitive athletes. In addition, 6 patients did not complete outcomes data, but had suffered tear of their ipsilateral (3) or contralateral (3) side and were treated at the same facility. These patients were included in calculation of overall re-tear rate of 12.5% (5 patients) and contralateral tear of 25% (8 patients). Conclusion: Mid-term results of patients treated with a hybrid physeal-sparing or all-epiphyseal ACLR were favorable, with adolescents reporting a high level of functional ability and strong psychological readiness to engage in athletic activities. Re-tear and contralateral tear rates were equivalent to other reported studies. These physeal-sparing techniques demonstrate the ability for young athletes to successfully remain physically active and involved in their sports several years following surgery.

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INCONSISTENT 6-MONTH FUNCTION AND ISOKINETIC TEST RESULTS FOLLOWING ACL RECONSTRUCTION IN A GROUP OF SKELETALLY IMMATURE PEDIATRIC PATIENTS

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119s00101 ◽

2019 ◽

Vol 7 (3_suppl) ◽

pp. 2325967119S0010

Author(s):

Brian T. Samuelsen ◽

Heath P. Melugin ◽

Mario Hevesi ◽

Bruce A. Levy ◽

Diane L. Dahm ◽

...

Keyword(s):

Acl Reconstruction ◽

Nerve Block ◽

Pediatric Patients ◽

Cartilage Damage ◽

Meniscal Tear ◽

Univariate Analysis ◽

Test Results ◽

Open Physes ◽

Factors Associated ◽

Isokinetic Test

Purpose: The goal of this study was to evaluate patient and surgical factors predictive of excellent functional and isokinetic test results 6-months following anterior cruciate ligament (ACL) reconstruction in a group of pediatric patients with open physes. Methods: We retrospectively reviewed the records of all patients 14 years of age or younger that underwent ACL reconstruction from 2000 to 2015. An excellent 6-month outcome was defined as greater than 85% in isokinetic strength and greater than 90% in functional tests when compared to the non-operative extremity. We then utilized univariate and multivariate statistical models to identify patient and/or surgical factors associated with excellent 6-month outcomes. Results: Eighty-six patients (46 male, 42 female) with open physes on preoperative radiographs were included in the study, with a mean age of 13.6 (range, 8.4-14.9), body mass index (BMI) of 22.1 (range, 15.6-36.0), Tegner activity score of 8.8 (6.0-9.0). Thirty-four patients (40%) met the criteria for the excellent 6-month group, which left 52 (60%) in the delayed 6-month group. In univariate analysis, no single preoperative factor correlated with excellent 6-month outcome. The two groups were statistically similar in terms of age, BMI, time to surgery, preoperative arc of motion, presence of concomitant meniscal tear, cartilage damage, graft size, use of a nerve block or tourniquet, operative time, and tourniquet time. Use of a nerve block trended towards delayed outcomes (p = 0.051). Conclusion: Children undergoing ACL reconstruction only have a 40% chance of achieving an excellent rehabilitation result at 6 months. We found no statistically significant patient or surgical characteristics that could predict this outcome. Utilizing a nerve block is a factor which will need to be further evaluated. Significance: Studies in the adult population have identified preoperative patient and surgical factors associated with excellent 6-month isokinetic and functional test results. This pediatric cohort did not find similar results as many of these children were young, healthy and fit. However, the variability of the outcome casts doubts on applying adult rehabilitation protocols to children.

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Clinical Outcomes and Postoperative Complications After All-Epiphyseal Double-Bundle ACL Reconstruction for Skeletally Immature Patients

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211051308 ◽

2021 ◽

Vol 9 (11) ◽

pp. 232596712110513

Author(s):

Shizuka Sasaki ◽

Eiji Sasaki ◽

Yuka Kimura ◽

Yuji Yamamoto ◽

Eiichi Tsuda ◽

...

Keyword(s):

Postoperative Complications ◽

Positive Result ◽

Clinical Outcomes ◽

Acl Reconstruction ◽

Pivot Shift ◽

Double Bundle ◽

Conventional Group ◽

Angular Deformity ◽

Skeletally Immature ◽

Open Physes

Background: The treatment strategy for pediatric anterior cruciate ligament (ACL) tears, especially in patients with open physes, remains controversial. Purpose: To assess clinical outcomes and postoperative complications after all-epiphyseal double-bundle ACL (DB-ACL) reconstruction for patients with open physes. Study Design: Cohort study; Level of evidence, 3. Methods: Included were 102 patients aged ≤15 years who underwent ACL reconstruction at a single institution and had a minimum of 2 years of follow-up. Of these patients, 18 had undergone all-epiphyseal DB-ACL reconstruction (mean age, 12.4 ± 1.2 year) and 84 had undergone conventional DB-ACL reconstruction (mean age, 14.1 ± 0.9 year). The outcomes of the all-epiphyseal group were compared with those of the conventional group. Objective clinical outcomes included KT-1000 arthrometer measurements of side-to-side difference in anterior tibial translation, Lachman test grade, and pivot-shift test grade. Radiographic angular deformity (defined as >3° of the side-to-side difference in femorotibial angle) and incidence of second ACL injury were also compared. Results: The postoperative side-to-side difference in laxity significantly improved from 6.1 ± 2.4 to 0.6 ± 0.9 mm in the all-epiphyseal group ( P = .001), and postoperative laxity was similar to that of the conventional group (0.4 ± 0.8 mm; P = .518). A Lachman grade 1 positive result was observed in 20% of the all-epiphyseal group and 3% of the conventional group ( P = .042), and a pivot-shift grade 1 positive result was observed in 22% of the all-epiphyseal group and 4% of the conventional group ( P = .074). A total of 4 patients (26.7%) in the all-epiphyseal group and 4 (6.1%) in the conventional group demonstrated angular deformity ( P = .035). The incidence of postoperative ipsilateral ACL tear was 16.7% in the all-epiphyseal group and 23.8% in the conventional group ( P = .757). The incidence of contralateral ACL tear was 11.1% in the all-epiphyseal group and 14.3% in the conventional group ( P ≥ .999). Conclusion: All-epiphyseal DB-ACL reconstruction for skeletally immature patients achieved satisfactory clinical outcomes compared with conventional DB-ACL reconstruction. The incidence of ipsilateral graft rupture was relatively high in both groups. The all-epiphyseal group had a significantly higher incidence of angular deformity.

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Intraarticular hamstring graft diameter decreases with continuing knee growth after ACL reconstruction with open physes

Knee Surgery Sports Traumatology Arthroscopy ◽

10.1007/s00167-016-4030-4 ◽

2016 ◽

Vol 24 (3) ◽

pp. 792-795 ◽

Cited By ~ 14

Author(s):

Diego Costa Astur ◽

Gustavo Gonçalves Arliani ◽

Pedro Debieux ◽

Camila Cohen Kaleka ◽

Joicemar Tarouco Amaro ◽

...

Keyword(s):

Acl Reconstruction ◽

Hamstring Graft ◽

Open Physes ◽

Graft Diameter

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Twin athlete brothers with open physes operated for ACL reconstruction on the same day, but with different elapsed times after injury: a 5-year follow-up

BMJ Case Reports ◽

10.1136/bcr-2013-202650 ◽

2014 ◽

Vol 2014 (feb06 2) ◽

pp. bcr2013202650-bcr2013202650 ◽

Cited By ~ 2

Author(s):

D. C. Astur ◽

D. Lauxen ◽

B. Ejnisman ◽

M. Cohen

Keyword(s):

Acl Reconstruction ◽

Open Physes

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Hindlimb Growth after a Transphyseal Reconstruction of the Anterior Cruciate Ligament

The American Journal of Sports Medicine ◽

10.1177/0363546508322884 ◽

2008 ◽

Vol 36 (12) ◽

pp. 2437-2443 ◽

Cited By ~ 37

Author(s):

Rupert Meller ◽

Daniel Kendoff ◽

Stefan Hankemeier ◽

Michael Jagodzinski ◽

Martin Grotz ◽

...

Keyword(s):

Acl Reconstruction ◽

Cruciate Ligament ◽

Large Animal ◽

Leg Length ◽

Growth Plates ◽

Open Physes ◽

Growth Disturbances ◽

Soft Tissue Graft ◽

Anterior Cruciate ◽

Large Animal Study

Background 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. Hypothesis It is possible to perform a fully transphyseal ACL reconstruction in an ovine model with wide-open physes without creating growth disturbances. Study Design Descriptive laboratory study. Materials and Methods 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. Results No angular deformities or leg-length discrepancies occurred after this transphyseal ACL reconstruction procedure throughout the remaining growth. Conclusion 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. Clinical Relevance 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.

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