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

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.

Patellar Instability in Pediatric Patients: Review of the Literature

Patellar instability is a common pathology of the knee in pediatric patients. The management of this condition can be a challenge for the orthopedic surgeon, and a comprehensive understanding of the anatomy and biomechanics of the structures around the knee is of utmost importance in formulating a treatment plan. Predisposing factors can be related to: trochlear and patellar morphological abnormalities, ligamentous stabilizers, limb geometries in the axial plane, and patellar height abnormalities. Traditionally, first-time dislocators have been treated non-operatively; however, recent evidence suggests that certain factors are related to recurrent instability, and surgical treatment may be considered even after the first dislocation. It is important to keep in mind that younger children with open physes are not suitable candidates for certain surgical techniques. In this comprehensive review, we aimed to focus on the most up-to-date information on this topic and emphasize the importance of individualizing the treatment of pediatric patients.

OSTEOCHONDRAL ALLOGRAFTING IN THE SKELETALLY IMMATURE KNEE: HIGH RATES OF INCORPORATION AND EXCELLENT EARLY OUTCOMES

Background: While an excellent option for osteochondral defects in the adult knee, outcomes following fresh osteochondral allograft (OCA) the skeletally immature are limited. Purpose: To compare radiographic and patient reported outcomes (PROs) in mature and skeletally immature adolescents following OCA of the knee. Methods: An IRB-approved review of fresh size-matched OCA treatment of knee lesions in patients aged < 19 years within a pediatric sports medicine practice from 1/2006-3/2019 was completed. Following exclusion of patients with less than 12 months follow-up, demographics, lesion characteristics, reoperations, and PROs were evaluated. A novel grading scale (k= 0.832) was utilized to evaluate radiographic OCA incorporation: A=complete, B= >50%, or C= <50% healed. Results: Forty-four patients [15.5 years (9.6-19.8) treated with OCA of the distal femur or patella (LFC= 18, MFC=17, Trochlea=6, Patella=3), 24 with open and 20 with closed physes, with 2.2 year follow up (range 1-5.3 years) were evaluated. Overall average graft size was 4.76cm2 and did not differ significantly between groups. Thirty-nine patients underwent at least one prior procedure to the ipsilateral knee, most frequently for attempted osteochondral lesion healing (77%), followed by realignment (22.7%), and meniscal pathology (15.9%). Graft failure occurred in only one skeletally immature patient with a trochlear lesion. Those with open physes were more likely to demonstrate complete graft incorporation (66.6%, p=0.001). 21(88%) patients with open physes and 17(85%) patients with closed physes had radiographic healing grades of A or B one year post-operatively. There was no difference in healing grade based on graft size, depth, or location within the knee. There was no difference in pre-operative PROs or activity scores. At final follow-up, open physes OCA patients demonstrated better KOOS scores (KOOS daily living 97.0 vs 89.5, p=0.02; KOOS pain 95.7 vs 84.6, p= 0.04; KOOS quality of life 157.2 vs 59.6, p= 0.005). Final activity scores did not vary by skeletal maturity (Pedi-IKDC 75.8 vs 77.99; Pedi-FABS 17.2 vs 13.5,) or radiographic healing grade. Daily living and pain scores were better in those with more radiographic healing (KOOS daily living 98.6 vs 86,2, p= 0.02; KOOS pain 96.7 vs 82.3, p= 0.048). Conclusion: Fresh osteochondral allograft treatment in the young knee may be expected to yield good early results. Despite relatively large graft size, when indicated for patients with open physes, equivalent or improved healing and patient reported outcomes may be expected.

Management of bilateral osteochondritis dissecans of the trochlea in a skeletally immature patient

Osteochondritis dissecans (OCD) lesions are injuries that occur more commonly in the skeletally immature population. In most cases, the aetiology is not well understood, but fortunately, many OCD lesions may heal on their own over time, particularly in skeletally immature patients with open physes. Conversely, if the lesion is considered unstable, surgical intervention may be required. This case demonstrates an especially rare presentation of bilateral OCD lesions within the lateral femoral trochlear facet. The lesions became symptomatic approximately 1 year apart without a specific injury. Non-operative treatment was not recommended in either case due to the size and instability of each lesion. The surgical treatment used an augmented microfracture technique. At 12 and 23 months after surgery, both knees remain asymptomatic and the patient has returned to their desired activities.

Transepiphyseal resection for osteosarcoma in patients with open physes using MRI assessment

Aims For paediatric and adolescent patients with growth potential, preservation of the physiological joint by transepiphyseal resection (TER) of the femur confers definite advantages over arthroplasty procedures. We hypothesized that the extent of the tumour and changes in its extent after neoadjuvant chemotherapy are essential factors in the selection of this procedure, and can be assessed with MRI. The oncological and functional outcomes of the procedure were reviewed to confirm its safety and efficacy. Methods We retrospectively reviewed 16 patients (seven male and nine female, mean age 12.2 years (7 to 16)) with osteosarcoma of the knee who had been treated by TER. We evaluated the MRI scans before and after neoadjuvant chemotherapy for all patients to assess the extent of the disease and the response to treatment. Results The mean follow-up period was 64.3 months (25 to 148) after surgery and no patients were lost to follow-up. On MRI evaluation, 13 tumours were near but not in contact with the physes and three tumours were partially in contact with the physes before neoadjuvant chemotherapy. Bone oedema in the epiphysis was observed in eight patients. After neoadjuvant chemotherapy, bone oedema in the epiphysis disappeared in all patients. In total, 11 tumours were not in contact and five tumours were in partial contact with the physes. The postoperative pathological margin was negative in all patients. At the last follow-up, 12 patients were continuously disease-free and three had no evidence of disease. One patient died due to the disease. Functionally, the patients with retained allograft or recycled autograft had a mean knee range of flexion of 126° (90° to 150°). The mean Musculoskeletal Tumor Society functional score was 27.6 (23 to 30). Conclusion TER is an effective limb-salvage technique for treating malignant metaphyseal bone tumours in paediatric and young osteosarcoma patients with open physes when a good response to chemotherapy and no progression of the tumour to the epiphysis have been confirmed by MRI. Cite this article: Bone Joint J 2020;102-B(6):772–778.