Intact PCL is a potential predictor of ACL graft size in the skeletally immature knee and other anatomic considerations for ACL reconstruction

Purpose To develop a method for using an intact posterior cruciate ligament (PCL) as a predictor of anterior cruciate ligament (ACL) graft size and examine possible differences in tunnel length based on all-epiphyseal drilling method. Methods One hundred one patients 5–18 years of age with magnetic resonance imaging (MRI) of the knee at an outpatient pediatric orthopaedic clinic from 2008 to 2020 were included. ACL and PCL coronal, sagittal, and length measurements were made in all patients. Tunnel length measurements were made in patients with open physes. Statistical analyses were performed to evaluate potential associations in patient bony or ligamentous measurements. Results PCL sagittal width and PCL coronal width were statistically significant predictors of ACL sagittal width and ACL coronal width, respectively (p = 0.002, R = 0.304; p = 0.008, R = 0.264). The following equations were developed to calculate ACL coronal and sagittal width measurements from the corresponding measurement on an intact PCL; ACL Coronal Width (mm) = 6.23 + (0.16 x PCL Coronal Width); ACL Sagittal Width (mm) = 5.85 + (0.53 x PCL Sagittal Width). Mean tibial maximum oblique length (27.8 mm) was longer than mean tibial physeal sparing length (24.9 mm). Mean femoral maximum oblique length (36.9 mm) was comparable to mean femoral physeal sparing length (36.1 mm). Both were longer than mean femoral straight lateral length (32.7 mm). Conclusion An intact PCL is a predictor of native ACL size. Tunnel length differs based on chosen drilling method in all-epiphyseal technique. Level of evidence Diagnostic Level III.

Tratamento cirúrgico de lesão do ligamento cruzado anterior em paciente com imaturidade esquelética pela técnica de Kocher, com seguimento pós operatório de 6 anos: relato de caso / Surgical treatment of anterior cruciate ligament injury in a patient with skeletal immaturity by the Kocher technique, with a postoperative follow-up of 6 years: case report

Introdução: No tratamento cirúrgico da lesão do ligamento cruzado anterior (LCA) em pacientes pediá-tricos, é necessário o equilíbrio entre a restauração da anatomia, e o risco de dano à fise de crescimento durante o ato operatório. Objetivo: Relatar caso de paciente com 9 anos, de-senvolvimento puberal de Tanner I, submetido a reconstrução do LCA pela técnica de Ko-cher, técnica de reconstrução extra fisária com enxerto de trato iliotibial autólogo.Palavras chave: Joelho, Reconstrução do ligamento cruzado anterior, Maturidade sexual AbstractIntroduction: In the surgical treatment of anterior cruciate ligament (ACL) injury in pediatric patients, a balance between anatomical restoration and the risk of damage to the growth plate during the surgery is necessary. Objective: Report a case of a 9-year-old patient, pubertal development of Tanner I, underwent ACL reconstruction using the technique of Kocher et al., a physeal-sparing reconstruction technique with autologous iliotibial tract graft.Keywords: Knee, Anterior cruciate ligament reconstruction, Sexual maturation

CLEARANCE BASED ON STANDARDIZED RETURN TO SPORTS ASSESSMENT FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN PEDIATRIC AND ADOLESCENT PATIENTS

Background: Return to sports (RTS) is often the primary concern of patients following anterior cruciate ligament reconstruction (ACLR). Unfortunately, RTS at the preinjury level is not commonplace in pediatric patients despite advances in rehabilitation and measures of recovery, and second injury rates are highest among the young adolescent population. RTS criteria have become more rigorous in recent years. The impact of these new RTS assessments (RTSA) is still unfolding, and their application in a mixed pediatric and adolescent population is unclear. Purpose: To assess whether adolescent patients who undergo standard ACLR pass a rigorous RTSA sooner than those undergoing pediatric ACLR. Methods: This study was a retrospective chart review of patients ages >5 and <18 with primary, unilateral ACL tear who underwent ACLR from January 2017 to December 2019. Subjects were identified using current procedural terminology codes from the hospital electronic medical record then grouped based on ACL reconstruction technique: Adolescent (transphyseal approach) and Pediatric (complete or partial physeal-sparing approach). All subjects underwent a rigorous and standardized RTSA used by the operating surgeons to guide clearance to RTS. The primary outcome measure was post-operative time to clearance for RTS, with secondary analyses controlling for sex, concomitant pathology at the time of ACLR, number of RTSAs prior to clearance, and physical therapy provider. Parametric and nonparametric statistical comparisons were respectively performed via unpaired Student t-tests and Mann-Whitney U tests (p<0.05). Results: Of 426 identified ACLR patients, 97 (84 Adolescent, 13 Pediatric) met the inclusion criteria for the final analysis (39 M, 58 F; Adolescent mean age 16.44 ± 1.7 years, Pediatric mean age 13.21 ± 1.4 years). There were no significant differences in gender distribution or concomitant pathology between the groups. Median post-operative time to clearance for RTS was 12.2 months in the Pediatric group (95% CI: 10.9-12.7) and 9.3 months in the Adolescent group (95% CI: 8.9-9.8) (p<0.001). This difference in time to RTS between groups remained statistically significant after adjusting for the secondary variables described above (all p≤0.002). Conclusions: When applying a rigorous and standardized RTSA to determine readiness for RTS, Pediatric subjects who underwent a partial or complete physeal-sparing technique took nearly 3 months longer to be cleared than Adolescent subjects who underwent a standard transphyseal approach. Notably, Adolescent subjects averaged more than 9 months of rehabilitation prior to RTS. These findings help inform patient expectations for a safe recovery period following ACLR.

Physeal-Sparing Anterior Cruciate Ligament Reconstruction for Skeletally Immature Patients: All-Epiphyseal Technique Using Quadricep Tendon Autograft

The anterior cruciate ligament (ACL) is a major stabilizing structure of the knee and one of the most common injured structures. The true incidence of ACL injury in children and adolescents is unknown, but recent studies suggest increased ACL injury rates, especially in the sports-participating population. The mechanism of injury, clinical examination, and diagnosis of ACL injury in children is the same as in adults. The main concerns in the management of pediatric ACL injuries are the open physes and the eventual long-term consequences of the ACL deficient knee. The ideal treatment strategy of pediatric ACL injuries is still controversial, because there is still no universal consensus for techniques, graft choices, and postoperative rehabilitation. We present a case of a 12-year-old male patient who underwent ACL reconstruction using an all-inside, physeal-sparing technique with a quadriceps tendon autograft and discuss the current treatment strategies.