Return to Sport and Reoperation Rates in Patients Under the Age of 20 After Primary Anterior Cruciate Ligament Reconstruction: Risk Profile Comparing 3 Patient Groups Predicated Upon Skeletal Age

Background: With sports specialization and level of competition on the rise, anterior cruciate ligament reconstruction (ACLR) in athletes under the age of 20 has increased significantly in recent years. Reports have demonstrated that the revision ACLR rate is higher and return to sport (RTS) rate is lower in this population. Purpose: To evaluate the 2-year clinical outcomes of 3 cohorts of primary ACLR in pediatric and adolescent athletes under the age of 20 based on skeletal age with a focus on RTS and the incidence of second surgery. Study Design: Case series; Level of evidence, 4. Methods: This is a prospective evaluation of 324 athletes younger than 20 years of age who underwent ACLR with minimum 2-year follow-up. The surgical technique was selected predicated on skeletal age, which includes the all-epiphyseal technique with hamstring autograft in the youngest cohort in elementary and middle school (group 1), the partial transphyseal and complete transphyseal with hamstring autograft performed for athletes in the middle cohort (group 2), and bone-tendon-bone autograft in the skeletally mature high school athletes (group 3). Results: The mean chronological age of the entire cohort was 15 years (range, 8-19 years) with 55% males. The 3 cohorts included 49 patients (15%) in group 1 (mean age, 12 years), 66 (20%) in group 2 (mean age, 14.3 years), and 209 (65%) in group 3 (mean age, 16.2 years). Group 2 athletes had a significantly higher revision ACLR rate (20%) compared with group 1 (6%; P = .039) and group 3 (6%; P = .001). Similarly, group 2 athletes had significantly lower RTS rates (85%) compared with group 1 (100%) and group 3 (94%). Conclusion: The rate of revision ACLR was significantly higher and the RTS rates significantly lower in group 2 compared with groups 1 and 3. This age-related risk profile may be used to counsel athletes and parents preoperatively regarding the expectations of surgery with respect to revision ACLR and RTS rates.

Download Full-text

Return to Sport and Re-Operation Rates in Athletes Under the Age of 20 Following Primary Anterior Cruciate Ligament Reconstruction: Risk Profile Comparing Three Patient Groups Predicated Upon Skeletal Age

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118s00059 ◽

2018 ◽

Vol 6 (7_suppl4) ◽

pp. 2325967118S0005

Author(s):

Frank A. Cordasco ◽

Sheena Rachel Black ◽

Meghan Price ◽

Colleen Wixted ◽

Lori Asaro ◽

...

Keyword(s):

High School ◽

Return To Sport ◽

Risk Profile ◽

Skeletal Age ◽

Hamstring Autograft ◽

School Grade ◽

Second Surgery ◽

Group 3 ◽

Group 2 ◽

Group 1

Objectives: ACL injury in the skeletally immature athlete has become an increasingly significant clinical problem in recent years. The high-risk population of athletes less than 20 years of age has the lowest return to sport (RTS) rates and highest second surgery rates following ACL reconstruction (ACLR). The purpose of this prospective study is to evaluate the two-year clinical outcomes of three groups of primary ACLR in pediatric and adolescent athletes under the age of 20 based on skeletal age, school grade distribution and ACLR technique with a focus on RTS and incidence of second surgery. We hypothesize that the youngest (Group 1) and oldest (Group 3) cohorts will have lower revision ACL rates and higher RTS rates compared to the middle (Group 2) cohort of athletes. Methods: 306 patients less than 20 years of age underwent primary ACLR in the senior authors’ practice. Group 1 had 3-6 years of growth remaining and was comprised of lower and middle school athletes through 7th grade. Group 1 athletes received an all-epiphyseal (AE) hamstring autograft ACLR. Group 2 had 2-3 years of growth remaining and included predominantly 8th and 9th grade athletes. Group 2 was treated with either a partial transphyseal (PTP) or complete transphyseal (CT) hamstring autograft ACLR. Group 3 included skeletally mature high school & collegiate athletes treated with a CT ACLR using a bone-tendon-bone (BTB) autograft. Preoperative demographics, sport, mechanism of injury, intraoperative findings, RTS and second surgery data were collected. Athletes were followed for a minimum of 24 months with serial clinic visits. Results: The three cohorts included 47 athletes (15%) in Group 1 (mean age: 12.0 + 1.5y), 64 athletes (21%) in Group 2 (mean age: 14.3 + 1.3y), and 195 athletes (64%) in Group 3 (mean age: 16.2 + 1.8y). The rate of revision ACL was higher in Group 2 at 20% (13/64 athletes) as compared to Group 1 at 6% (3/47 athletes) and Group 3 at 6% (11/195 athletes) (p= 0.001). Group 2 athletes had a significantly lower RTS at 86% as compared to Groups 1 and 3 at 100% and 94% respectively (p=0.009). Group 2 athletes also had a significantly lower RTS at the same level 75% as compared to Groups 1 and 3 at 96% and 82% respectively (p=0.017). Using multivariate logistic regression, Group 2 athletes were nearly 5 times more likely to have a Revision ACLR compared to Group 3 BTB athletes (OR: 4.92, 95% CI: 1.19 - 20.34, p=0.028). Females were nearly 3 times more likely to have a contralateral ACLR as compared to males (OR: 2.83, 95% CI: 1.09 - 7.34, p=0.033). Conclusion: As we hypothesized, the rate of revision ACLR and overall incidence of second surgery was higher and the RTS rate lower in Group 2 athletes compared to Groups 1 and 3 athletes. Group 2 athletes may be at higher risk because upon completion of their rehabilitation and RTS clearance process they are joining a cohort of competitive, now skeletally mature high school athletes who have not lost a year of athletic competition and development of sport-specific skills. Ultimately, the athlete’s skeletal age determined the choice of surgical technique, but the grade levels noted above demarcated the three surgical cohorts with only a few outliers. We believe grade level is important as this will most often dictate the level of competition that the athlete in question is exposed to after recovery and return to sport. This age and school grade risk profile is useful to counsel athletes and parents preoperatively regarding the expectations of surgery with regard to RTS and the risk of second surgery.

Download Full-text

Septic Arthritis After Anterior Cruciate Ligament Reconstruction: How Important Is Graft Salvage?

The American Journal of Sports Medicine ◽

10.1177/0363546518782433 ◽

2018 ◽

Vol 46 (10) ◽

pp. 2376-2383 ◽

Cited By ~ 7

Author(s):

Jonas Pogorzelski ◽

Alexander Themessl ◽

Andrea Achtnich ◽

Erik M. Fritz ◽

Klaus Wörtler ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Ligament Reconstruction ◽

Cruciate Ligament ◽

Resonance Imaging ◽

Kt 1000 ◽

Graft Removal ◽

Group 2 ◽

Anterior Cruciate ◽

Group 1

Background: Septic arthritis (SA) of the knee after anterior cruciate ligament reconstruction (ACLR) is a rare but potentially devastating condition. In certain cases, graft removal becomes necessary. Purpose: To evaluate clinical, subjective, and radiologic outcomes of patients with SA after ACLR and assess whether graft retention has superior clinical results as compared with graft removal. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who were at least 12 months out from arthroscopic treatment of SA after isolated ACLR at our institution were eligible for inclusion. Patients were categorized into 2 groups: group 1, patients with initial graft retention; group 2, patients with initial graft removal. Group 2 was subdivided into 2 groups: group 2a, patients with graft reimplantation; group 2b, patients without graft reimplantation. Objective and subjective assessments were obtained at follow-up, including the International Knee Documentation Committee (IKDC) knee examination form, KT-1000 arthrometer measurements, WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score, Lysholm score, and IKDC subjective evaluation. Radiologic assessment was performed with pre- and postoperative magnetic resonance imaging. Results: Of the 41 patients included, 33 (81%) were available for follow-up at a mean ± SD 54.7 ± 24.4 months at an age of 28.4 ± 9.3 years. When compared with patients from group 2 (n = 12), patients from group 1 (n = 21) obtained significantly better results on the objective IKDC score (normal or nearly normal: group 1, 66.6%; group 2, 36.4%; P = .047) and KT-1000 measurements (group 1, 1.3 ± 1.0 mm; group 2, 2.9 ± 1.5 mm; P = .005). Group 1 also scored better than group 2 on the Lysholm ( P = .007), IKDC subjective ( P = .011), and WOMAC ( P = .069) measures. Between groups 2a (n = 4) and 2b (n = 8), no significant differences in outcomes could be detected ( P values, .307-.705), although patients with anterior cruciate ligament graft reimplantation showed a clear tendency toward better results in objective and not subjective parameters. Magnetic resonance imaging evaluation showed higher rates of cartilage damage and meniscal tears among patients with graft resection versus graft retention. Conclusion: Patients with graft retention showed superior postoperative results when compared with patients who underwent initial graft resection, although subanalysis showed comparable outcomes between graft retention and reimplantation. Thus, while graft-retaining protocols should have the highest priority in the treatment of SA after ACLR, graft reimplantation should be performed in cases where graft resection becomes necessary, to avoid future cartilage and meniscal lesions. Finally, further studies with larger numbers of patients are needed to gain a better understanding of the outcomes of patients with SA after ACLR.

Download Full-text

RETURN TO SPORT AND REOPERATION RATES IN PATIENTS UNDER THE AGE OF 20 FOLLOWING PRIMARY ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: RISK PROFILE COMPARING THREE PATIENT GROUPS PREDICATED UPON SKELETAL AGE

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119s00103 ◽

2019 ◽

Vol 7 (3_suppl) ◽

pp. 2325967119S0010

Author(s):

Frank A. Cordasco ◽

Sheena R. Black ◽

Meghan Price ◽

Colleen Wixted ◽

Michael Heller ◽

...

Keyword(s):

High School ◽

Middle School ◽

High Risk ◽

Cruciate Ligament ◽

Return To Sport ◽

Skeletal Age ◽

High Risk Population ◽

Skeletally Immature ◽

Group 3 ◽

Group 2

Background: With sports specialization and level of competition on the rise, anterior cruciate ligament reconstruction (ACLR) in skeletally immature athletes has increased significantly in recent years. Reports have demonstrated that the revision ACLR rate is higher and return to sport (RTS) rate is lower in this high-risk population. The purpose of this study is to evaluate two year clinical outcomes of three groups of primary ACLR in pediatric and adolescent athletes under the age of 20 based on skeletal age, school grade distribution, and ACLR technique with a focus on RTS and incidence of second surgery. Methods: This is a prospective evaluation of 324 athletes under 20 years of age following ACLR with minimum 2-year follow-up. The surgical technique was selected predicated upon skeletal age which includes the all-epiphyseal (AE) technique with hamstring autograft in the youngest cohort in lower and middle school (Group 1), the partial transphyseal (PTP) and complete transphyseal (CT) with hamstring autograft performed for athletes in the middle cohort (Group 2), and bone tendon bone autograft (BTB) in the skeletally mature high school athletes (Group 3). Preoperative demographics, sport, mechanism of injury, intraoperative findings, RTS, and second surgery data were collected. Athletes were followed for a minimum of 24 months with serial clinic visits. Results: The mean chronological age of the entire cohort was 15 years (range 8 to 19 years) with 55% males. The mean post-operative duration of follow-up was 3.25 years (range 2-7 years). The three cohorts included 49 patients (15%) in Group 1 (mean age: 12y), 66 (20%) in Group 2 (mean age: 14.3y), and 209 (65%) in Group 3 (mean age: 16.2y). Group 2 athletes had a significantly higher revision ACLR rate (20%) compared to Groups 1 (6%) and 3 (6%) (Table 1). When separated based on gender, there was a significantly higher rate of revision ACLR for males between groups. Post-hoc analysis revealed a significantly higher rate of revision ACLR for the males in Group 2 (24%) compared to Groups 1 (8%) and Group 3 (5%). Group 2 athletes also had significantly lower RTS rates (85%) compared to Groups 1 (100%) and 3 (94%). Multi-variate logistic regression analyses demonstrated that Group 2 athletes were more than 4 times more likely to have a revision ACLR compared to Group 3 (OR: 4.21, 95% CI: 1.09 – 16.3, p=0.037). With regard to gender, females were nearly three times more likely to have a contralateral ACLR compared to males (OR: 2.80, 95% CI: 1.11 – 7.06, p=0.029). Conclusions/Significance: The rate of revision ACLR was significantly higher and the RTS rates significantly lower in Group 2 compared to Groups 1 and 3. This age-related risk profile may be used to counsel athletes and parents preoperatively regarding the expectations of surgery with respect to revision ACLR and RTS rates. This study is unique in that it describes a particularly high-risk group of skeletally immature athletes within what is already considered to be a high-risk population of athletes less than 20 years of age. We believe this is the first report to identify a skeletally immature cohort of athletes bridging middle school and high school with higher revision ACLR and lower RTS rates compared to a younger cohort of skeletally immature lower and middle school athletes and an older group of skeletally mature high school and college adolescents. This study also reports relatively low rates of revision ACLR and high rates of RTS in the youngest cohort of skeletally immature athletes. [Table: see text]

Download Full-text

Preemptive Analgesia: Its Role and Efficacy in Anterior Cruciate Ligament Reconstruction

The American Journal of Sports Medicine ◽

10.1177/03635465980260040901 ◽

1998 ◽

Vol 26 (4) ◽

pp. 524-529 ◽

Cited By ~ 34

Author(s):

Charles J. Gatt ◽

Richard D. Parker ◽

John E. Tetzlaff ◽

Martha Zorko Szabo ◽

Audrey B. Dickerson

Keyword(s):

Postoperative Pain ◽

Ligament Reconstruction ◽

Cruciate Ligament ◽

Pain Medication ◽

Preemptive Analgesia ◽

Cruciate Ligament Reconstruction ◽

Pain Scores ◽

Group 3 ◽

Anterior Cruciate ◽

Group 1

As more outpatient orthopaedic surgical procedures are performed, postoperative pain control has gained importance. The benefits of preemptive analgesia, the use of analgesics or anesthetics or both before painful stimuli to prevent or reduce pain, have been widely published in the anesthesia and general surgery literature, but not in the orthopaedic literature. We prospectively compared the effects, on postoperative pain and narcotic use, of intraarticlar preoperative injections of 1) placebo with epinephrine, 2) bupivacaine with epinephrine, and 3) bupivacaine and morphine with epinephrine. Thirty patients (10 in each group) underwent arthroscopic anterior crucate ligament reconstruction using patellar tendon autograft under general anesthesia. Pain was assessed with a 10-point visual analog scale pre- and postoperatively, and postoperative narcotic pain medication use was recorded. Postoperative pain was significantly greater in group 1 (placebo) than in the preemptive-treatment groups (groups 2 and 3), and in group 2 than in group 3. The differences became less apparent with time, and after 1 hour, no significant differences in pain scores existed between the groups. However, intravenous narcotic pain medication was administered in the recovery room to patients with pain scores greater than 5, equalizing pain scores. Group 3 used significantly less postoperative narcotic medication than group 1. Preemptive analgesia using intraarticular bupivacaine and morphine with epinephrine resulted in lower pain scores during the 1st hour after an arthroscopic anterior cruciate ligament reconstruction than did preemptive treatment with bupivacaine and epinephrine or placebo and epinephrine.

Download Full-text

Comparative analysis of arthroscopic techniques of anterior cruciate ligament reconstruction in adolescents

Pediatric Traumatology Orthopaedics and Reconstructive Surgery ◽

10.17816/ptors34050 ◽

2020 ◽

Vol 8 (3) ◽

pp. 259-268

Author(s):

Marsel R. Salikhov ◽

Vladislav V. Avramenko

Keyword(s):

Anterior Cruciate Ligament ◽

Comparative Analysis ◽

Cruciate Ligament ◽

Rotational Stability ◽

Femoral Canal ◽

Group 3 ◽

Group 2 ◽

Anterior Cruciate ◽

Anterior Posterior ◽

Group 1

Background. According to the considerably contradictory information across the international literature, both the anatomical and transtibial reconstruction of the anterior cruciate ligament (ACL), under similar conditions, yield good functional results from treatment. Therefore, it is important to evaluate the comparative effectiveness and the prospects of certain methods of ACL reconstruction. The purpose of this study was to analyze the possibilities and advantages of anatomical technologies for the reconstruction intervention. Aim. To compare the outcomes of ACL reconstructions among adolescent children using different methods. Materials and methods. The outcomes of 94 arthroscopic reconstructions of the ACL in adolescents were analyzed. The patients were categorized into 3 groups: Group 1 included 32 patients (34%) who underwent isometric plastic surgery of the ACL, wherein the femoral canal was formed using the transtibial technique. Group 2 included 30 patients (32%) who underwent anatomical plastic surgery of the ACL, with the formation of the femoral canal through additional anteromedial arthroscopic access. Group 3 included 32 patients (34%) who underwent the all-inside anatomical reconstruction of the ACL. Results. A comparative analysis of the outcomes of reconstruction of the ACL among adolescents revealed that the anterior-posterior and rotational stability of the knee joint was better in group 3 patients than in groups 1 and 2 patients. In fact, the group 3 patients showed a significantly less positive pivot-shift (0 degree to 87.5%; I+ the extent of 12.5%) than the group 1 patients (0 degree 46.8%; I+ degree 25%; II+ degree and 21.9%; III+ degree and 6.3%), followed by the group 2 patients (0 degree to 86.6%; I+ degree 6.7%; II+ degree of 6.7%). Conclusion. Considering the safety aspects of intra-articular structures and for the better anatomical orientation of the femoral canal, the all-inside method of ACL reconstruction yielded better outcomes of postoperative anterior-posterior and rotational stability of the knee joint.

Download Full-text