PREVALENCE OF CONCOMITANT PATHOLOGY IN SKELETALLY IMMATURE PATIENTS WITH ANTERIOR CRUCIATE LIGAMENT TEARS

Background: Historically, anterior cruciate ligament (ACL) injuries in children were treated non-operatively with delayed surgical reconstruction. More recently, there has been increasing literature that suggests delaying surgical reconstruction after ACL injury results in inferior outcomes and increased secondary meniscal and chondral injury in young athletes. Multiple studies have focused on the rates of these concomitant injuries in young athletes, but many of these studies include older athletes nearing or at the point of skeletal maturity and few include skeletal bone age determination. Thus, the rates of concomitant pathology in skeletally immature patients is unknown. The purpose of this study was to describe the prevalence of concomitant pathology found in a group of skeletally immature and compare them to a similar group of skeletally mature patients undergoing ACL reconstruction. Methods: The surgical case log for four orthopaedic surgeons within the sports medicine department of a children’s hospital were reviewed over a ten-year period. Patients were grouped based on skeletal maturity; skeletally immature (SI), approaching skeletal maturity (AM), and skeletally mature (SM). Operative diagnoses were obtained from the operative reports. Patient demographics including sex, bone and chronological age as well as injury and surgical dates were collected from clinical notes. Descriptive statistics were computed for patient demographics and surgical findings. A chi square analysis was completed to understand the prevalence rate among the three groups and a logistical regression was conducted to understanding the association between timing from injury to surgery and presence of concomitant pathology. Results: Our cohort consisted of 535 patients, 66 SI patients (46 males, 20 females; avg chronological age 12.9±1.6 years; avg bone age 13.2 years), 276 AM patients (118 males, 158 females; avg chronological age 15.2±1.2 years; avg bone age 14.9 years), 193 SM patients (107 males, 86 females; avg chronological age 20.3±6.0 years). All patients in the SI group were treated with a physeal sparing technique (61 patients - hybrid sparing technique, 4 patients - femoral and tibial sparing technique, 1 patient - extra-articular reconstruction). Concomitant pathology was present in 38% of SI patients compared to 52% of AM patients and 57% of SM patients. Meniscal injury was the predominant concomitant pathology in the SI group (37.9%); only a single patient had a second ligament reconstructed in addition to their ACL. In comparison, meniscal pathology was also the predominant concomitant pathology in both the AM (48.9%) and SM (51.8%) groups along with chondral lesions (AM 2.2%, SM 3.1%) and multi-ligament injuries (AM 0.4%, SM 4.1%). Lateral meniscal injuries were seen more often than medial meniscal injuries for all groups. A statistical difference was found between groups for the prevalence of concomitant pathology, with the SI group having less than the AM group (p = 0.042) and SM group (p = 0.007). The average time from injury to surgery was shorter for SI patients, 60±43 days compared to 105±208 days (AM group) and 123±185 days (SM group). The results of the logistical regression did not show an association between days from injury to surgery and presence of concomitant pathology in the SI group, but did reveal an association for the AM (p = 0.004; OR 1.004) and SM (p = 0.013; OR 1.002) groups. Conclusion: This is the first article that compares the rates of concomitant pathology in a well-defined group of skeletally immature patients undergoing ACL reconstruction surgery to a skeletally mature cohort. We found that skeletally immature patients had less concomitant pathology than skeletally mature patients.

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Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Early Results Using a Hybrid Physeal-Sparing Technique

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118755330 ◽

2018 ◽

Vol 6 (2) ◽

pp. 232596711875533 ◽

Cited By ~ 5

Author(s):

Robert G. Willson ◽

Regina O. Kostyun ◽

Matthew D. Milewski ◽

Carl W. Nissen

Keyword(s):

Anterior Cruciate Ligament ◽

Skeletal Maturity ◽

Cruciate Ligament ◽

Return To Play ◽

Hybrid Technique ◽

Skeletally Immature ◽

Acl Injuries ◽

Outcome Scores ◽

Anterior Cruciate ◽

Physeal Sparing

Background: Reconstruction of the anterior cruciate ligament (ACL) in the skeletally immature patient is frequently performed in hopes of preventing new or additional chondral damage and meniscal injuries. Patients within a few years of skeletal maturity are more at risk for ACL injuries than prepubescent patients, about whom several physeal-sparing techniques have been described. Reconstruction techniques in the former higher risk group need to be better understood. Purpose: To review a series of adolescent patients with ACL injuries surgically treated with the hybrid physeal-sparing technique. Study Design: Case series; Level of evidence, 4. Methods: Surgical logs of ACL reconstructions (ACLRs) performed at a single pediatric/adolescent sports medicine center over a 6-year period were reviewed. Patients with open physes who had undergone ACLR with a femoral physeal-sparing tunnel and transphyseal tibial tunnel were identified. Their demographics, operative reports, rehabilitative course, time to return to play, outcome scores, and postoperative radiographs were collected and analyzed. Results: Twenty-three patients with a mean chronological age and bone age of 13.0 and 13.6 years, respectively, were identified. Examination and subjective outcome scores were obtained at a mean of 19 months and overall demonstrated positive results, with a mean Pediatric International Knee Documentation Committee (Pedi-IKDC) score of 96.0 and a mean Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) score of 89.1. Full-length mechanical axis films obtained at a mean 21 months postoperatively demonstrated no leg-length discrepancies or angular deformities in 21 of 23 patients. Two patients had an identified growth disturbance in the form of femoral and tibial growth acceleration on the ACL-reconstructed limb. Conclusion: The femoral physeal-sparing with transphyseal tibial drilling “hybrid” technique in skeletally maturing patients appears to have a high rate of success with low morbidity. However, the possibility of physeal abnormalities does exist, which demonstrates the importance of a close postoperative follow-up and evaluation until skeletal maturity is achieved. ACLR in skeletally immature patients is performed on an increasingly regular basis. Establishing the best and safest technique to do so is therefore important.

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Degeneration of the Knee Joint in Skeletally Immature Patients With a Diagnosis of an Anterior Cruciate Ligament Tear

The American Journal of Sports Medicine ◽

10.1177/0363546511420818 ◽

2011 ◽

Vol 39 (12) ◽

pp. 2582-2587 ◽

Cited By ~ 186

Author(s):

J. Todd R. Lawrence ◽

Nina Argawal ◽

Theodore J. Ganley

Keyword(s):

Anterior Cruciate Ligament ◽

Odds Ratio ◽

Cruciate Ligament ◽

Lateral Compartment ◽

Surgical Reconstruction ◽

Skeletally Immature ◽

Meniscal Tears ◽

Cartilage Injuries ◽

Anterior Cruciate ◽

Time From Injury

Background: In skeletally immature patients with an anterior cruciate ligament (ACL) tear and significant growth remaining, the risk of inducing a growth disturbance with early reconstruction must be balanced against the risk of further intra-articular damage by delaying treatment until closer to skeletal maturity. Hypothesis: Increased time from injury to ACL reconstruction in children ≤14 years of age will be associated with increased meniscal and chondral injuries at the time of reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: With institutional review board approval, the records of a consecutive series of patients 14 years of age and younger who underwent ACL reconstruction between 1991 and 2005 were reviewed. Demographic, magnetic resonance imaging (MRI), and intraoperative findings were analyzed. Meniscal and articular cartilage injuries were graded. Logistic regression models using both univariable and multivariable regression procedures were used to identify factors independently associated with intra-articular lesions. Fisher exact test and Kaplan-Meier analysis were used to test for differences in intra-articular injuries by time from injury to surgery. Results: Seventy patients were identified. Twenty-nine patients (41%) underwent reconstruction more than 12 weeks from the time of injury. Logistic regression analysis revealed time to surgical reconstruction (odds ratio, 4.1) and a history of a sense of knee instability (odds ratio, 11.4) to be independently associated with medial meniscal tears. Time to surgical reconstruction was also independently associated with medial and lateral compartment chondral injuries (odds ratios, 5.6 and 11.3, respectively). Testing time as a continuous variable, survivorship analysis also confirmed a significant association of time to reconstruction with medial meniscal injury as well as lateral and patellotrochlear cartilage injuries. When present, a delay in treatment of over 12 weeks (29 patients) was associated with an increase in the severity of medial meniscal tears ( P = .011) and higher grade lateral and patellotrochlear chondral injuries ( P = .0014 and P = .038, respectively). Conclusion: Young patients who underwent surgical reconstruction of an acute ACL tear >12 weeks after the injury were noted to have a significant increase in irreparable medial meniscal tears and lateral compartment chondral injuries at the time of reconstruction. When a subjective sense of knee instability was present, this association was even stronger.

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Assessment of Skeletal Maturity and Postoperative Growth Disturbance After Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: A Systematic Review

The American Journal of Sports Medicine ◽

10.1177/03635465211008656 ◽

2021 ◽

pp. 036354652110086

Author(s):

Matthew S. Fury ◽

Nikolaos K. Paschos ◽

Peter D. Fabricant ◽

Christian N. Anderson ◽

Michael T. Busch ◽

...

Keyword(s):

Systematic Review ◽

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Skeletal Maturity ◽

Cruciate Ligament ◽

Angular Deformity ◽

Skeletally Immature ◽

Growth Modulation ◽

Growth Disturbance ◽

Anterior Cruciate

Background: Growth disturbance is an uncommon but potentially serious complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients. Purpose: To describe how the pediatric ACL literature has assessed preoperative skeletal maturity and the amount of growth remaining and to comprehensively review the incidence, reporting, and monitoring of postoperative growth disturbance. Study Design: Systematic review; Level of evidence, 4. Methods: This review included studies reporting original research of clinical outcomes of skeletally immature patients after ACL reconstruction. Patient characteristics, surgical techniques, preoperative assessments of skeletal maturity or growth remaining, and postoperative assessments of growth disturbances were extracted. Results: A total of 100 studies met inclusion criteria. All studies reported chronological age, and 28 studies (28%) assessed skeletal age. A total of 44 studies (44%) used Tanner staging, and 12 studies (12%) obtained standing hip-to-ankle radiographs preoperatively. In total, 42 patients (2.1%) demonstrated a leg length discrepancy (LLD) >10 mm postoperatively, including 9 patients (0.5%) with LLD >20 mm; furthermore, 11 patients (0.6%) with LLD underwent growth modulation. Shortening was the most common deformity overall, but overgrowth was reported more frequently in patients who had undergone all-epiphyseal techniques. Most LLDs involved the femur (83%). A total of 26 patients (1.3%) demonstrated a postoperative angular deformity ≥5°, and 9 of these patients underwent growth modulation. The most common deformities were femoral valgus (41%), tibial recurvatum (33%), and tibial varus (22%). Although standing hip-to-ankle radiographs were the most common radiographic assessment of growth disturbance, most studies inadequately reported the clinical and radiographic methods of assessment for growth disturbance. Additionally, only 35% of studies explicitly followed patients to skeletal maturity. Conclusion: This systematic review described significant variability in the reporting and monitoring of growth-related complications after ACL reconstruction in skeletally immature patients. The incidence of LLD and angular deformity appeared to be low, but the quality of research was not comprehensive enough for accurate assessment. Registration: CRD42019136059 (PROSPERO)

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EFFECT OF SKELETAL MATURITY ON INCIDENCE OF ASSOCIATED MENISCAL AND CHONDRAL INJURIES IN ANTERIOR CRUCIATE LIGAMENT INJURED KNEES

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967121s00105 ◽

2021 ◽

Vol 9 (7_suppl3) ◽

pp. 2325967121S0010

Author(s):

Brett Heldt ◽

Elsayed Attia ◽

Raymond Guo ◽

Indranil Kushare ◽

Theodore Shybut

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Medial Meniscus ◽

Skeletal Maturity ◽

Cruciate Ligament ◽

Demographic Data ◽

Meniscal Tear ◽

Lateral Meniscus ◽

Meniscus Tears ◽

Anterior Cruciate

Background: Acute anterior cruciate ligament(ACL) rupture is associated with a significant incidence of concomitant meniscal and chondral injuries. However, to our knowledge, the incidence of these concomitant injuries in skeletally immature(SI) versus skeletally mature(SM) patients has not been directly compared. SI patients are a unique subset of ACL patients because surgical considerations are different, and subsequent re-tear rates are high. However, it is unclear if the rates and types of meniscal and chondral injuries differ. Purpose: The purpose of this study is to compare associated meniscal and chondral injury patterns between SI and SM patients under age 21, treated with ACL reconstruction for an acute ACL tear. We hypothesized that no significant differences would be seen. Methods: We performed a single-center retrospective review of primary ACL reconstructions performed from January 2012 to April 2020. Patients were stratified by skeletal maturity status based on a review of records and imaging. Demographic data was recorded, including age, sex, and BMI. Associated intra-articular meniscal injury, including laterality, location, configuration, and treatment were determined. Articular cartilage injury location, grade, and treatments were determined. Revision rates, non-ACL reoperation rates, and time to surgery were also compared between the two groups. Results: 785 SM and 208 SI patients met inclusion criteria. Mean BMI and mean age were significantly different between groups. Meniscal tear rates were significantly greater in SM versus SI patients in medial meniscus tears(P<.001), medial posterior horn tears(P=.001), medial longitudinal tears configuration(P=.007), lateral Radial configuration(P=.002), and lateral complex tears(P=.011). Medial repairs(P<.001) and lateral partial meniscectomies(P=.004) were more likely in the SM group. There was a significantly greater number of chondral injuries in the SM versus SI groups in the Lateral(p=.007) and medial compartments(P<.001). SM patients had a significantly increased number of outerbridge grade 1 and 2 in the Lateral(P<.001) and Medial Compartments(P=.013). ACL revisions(P=.019) and Non-ACL reoperations(P=.002) were significantly greater in the SI patients compared to SM. No other significant differences were noted. Conclusion: SM ACL injured patients have a significantly higher rate of medial meniscus tears and medial longitudinal configurations treated with repair, and a significantly higher rate of radial and/or complex lateral meniscus tears treated with partial meniscectomy compared to the SI group. We also found a significantly higher rate of both medial and lateral compartment chondral injuries, mainly grades 1 and 2, in SM compared to SI patients. Conversely, SI ACL reconstruction patients had higher revision and subsequent non-ACL surgery rates.

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