Anatomic all-epiphyseal ACL reconstruction with “inside-out” femoral tunnel placement in immature patients yields high return to sport rates and functional outcome scores a minimum of 24 months after reconstruction

Abstract

PurposeTo understand if anatomic physeal‐sparing ACL reconstruction in the immature host preserves range of motion, permits a return to sports, and avoids limb length discrepancy and accelerated intra‐articular degeneration with a cross‐sectional radiographic, physical examination and patient‐reported outcomes analysis. MethodsA cross‐sectional recall study included 38 patients aged 7–15 who underwent all‐epiphyseal ACL reconstruction with hamstring allograft performed by a single surgeon at a large academic medical center. All‐epiphyseal reconstructions were performed using a modified Anderson physeal‐sparing technique, with the femoral tunnel placed using an “inside‐out” technique. Assessments consisted of a physical exam, long leg cassette radiographs, KT‐1000 measurements, subjective patient metrics, and magnetic resonance imaging. ResultsThirty‐eight (56.7%) of 66 eligible patients returned for in‐person clinical and radiographic exams. Patients were 11.4 ± 1.8 years at the time of surgery. Five patients were females (13.2%). Mean follow‐up was 5.5 ± 2.4 years. ACL re‐injuries occurred in four patients (10.5%), all of whom underwent revision reconstructions. Thirty‐three of the remaining 34 (97.1%) patients returned to sports following their reconstruction, and 24 (70.6%) returned to their baseline level of competition. Mean limb length discrepancy (LLD) was 0.2 ± 1.4 cm. Nine patients had an LLD of > 1 cm (26.5%), which occurred at an equivalent age as those with < 1 cm LLD (10.8 ± 2.0 vs. 11.7 ± 1.7, n.s.). Pre‐operative Marx scores (13.1 ± 3.5) were not significantly different from post‐operative values (12.3 ± 5.1, n.s.). Patients who required ACL revisions had significantly lower Marx scores than those with intact primary grafts (8.3 ± 7.1 vs. 13.4 ± 4.5, p = 0.047). Cohort mean International Knee Documentation Committee (IKDC) score was 89.7 ± 12.7. ConclusionAnatomic all‐epiphyseal anatomic ACL reconstruction appears to be useful in patients with significant projected remaining growth, with good return‐to‐sport outcomes and minimal risk of clinically significant physeal complications. However, given the limited patient recall possible in the present study, further large sample size, high‐quality works are necessary to validate our findings. Level of evidenceLevel IV.

Combining Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Procedures in Skeletally Immature Patients Is Safe and Associated With a Low Failure Rate

“…ACL reconstruction associated with the lateral extra-articular procedure in our series was associated with a low graft rupture rate. Table 7 33 , 34 , 35 , 36 , 37 , 50 , 51 , 52 , 53 , 54 , 55 , 56 compares our results with those in the literature. Similar series with lateral extra-articular procedure in the pediatric population reported graft failure rates from 0% to 6.6% with similar follow-up.…”

“…The addition of lateral extra-articular procedure was not done at the expense of clinical results. In the literature, the combination has led to good-to-excellent clinical outcomes 33 , 34 , 35 , 36 comparable with classical methods 50 , 51 , 53 , 55 , 56 , 60 regarding the mean scores ( Table 7 ) and regarding MCID and PASS. The MCIDs presented in this study showed an excellent improvement in the scores most affected by ACL rupture (Pedi-IKDC, KOOS sport, KOOS quality of life and Lysholm).…”

Criteria Used to Determine Unrestricted Return to Activity After ACL Reconstruction in Pediatric and Adolescent Patients: A Systematic Review

“…Of the 27 studies included, 13 studies ¶ only used 1 criterion when determining RTA, 2 studies 70,74 used 2 different criteria, and 12 studies # used ≥3 criteria. In addition, 8 studies 3,23,25,60,70,73,80,85 used elapsed time postoperatively, 11 studies ** used subjective criteria, and 17 studies †† used objective criteria as one of the components when determining RTA (Figure 2). The graft failure rates for the ACLR ranged from 0% 25 to 39%, 70 and injuries to the contralateral ACL ranged from 0% 6 to 19.2%.…”

“…Time after ACLR surgery was the only criterion for determining RTA in 6 studies, 3,23,25,60,73,80 while 1 study 70 used time postoperatively in combination with a subjective criterion and 1 study 85 used time postoperatively in combination with subjective and objective criteria. The time points used to release patients to full activity ranged from 6 months to 12 months post-ACLR, with the most common time point being 6 months (5 studies 23,60,70,73,85 ).…”

“…{References 3,6,14,23,25,44,45,60,[71][72][73]76,80. #References 24, 29, 41, 46, 53, 67, 68, 75, 81, 82, 84, 85.…”