Revision ACL Reconstruction in Adolescent Patients

Abstract

Background: High failure rates have been documented after anterior cruciate ligament reconstruction (ACLR) in pediatric patients, and revision surgery is indicated due to high activity levels of children and adolescents. Purpose: To define trends in revision ACLR in patients who underwent initial ACLR at younger than 18 years. Study Design: Case series; Level of evidence, 4. Methods: An electronic medical record was used to retrospectively identify revision ACLR procedures performed by 2 surgeons between the years 2010 and 2016 in patients younger than 18 years at initial reconstruction. Descriptive information, intraoperative findings, surgical techniques, and rehabilitation data were recorded from initial and revision surgeries. Descriptive statistics were used. Results: A total of 32 patients (17 girls, 15 boys) met the inclusion criteria, with a mean age of 15.8 years at initial reconstruction. For initial reconstructions, 15 patients underwent transphyseal procedures, 3 patients underwent adult-type procedures using an anatomic reconstruction technique that did not take into account the physis, and 2 patients underwent partial intraepiphyseal procedures. Graft types included hamstring autograft (n = 17), allograft (n = 5), hybrid (n = 4), and bone–patellar tendon–bone autograft (BTB; n = 3). Average primary reconstruction graft diameter was 8.0 mm (girls, 7.72 mm; boys, 8.36 mm; P = .045). After initial reconstruction, 10 patients had postoperative protocol noncompliance, and 8 patients reported delayed recovery. Mean time to retear was 565 days (range, 25-1539 days). At revision, BTB autograft was used in 50% (n = 16), followed by hamstring autograph (31.3%; n = 10) and allograft (12.5%; n = 4); mean graft diameter was 9.05 mm. Chondral surgery was more common during revision (25% for revision vs 0% for index; P = .031). There were 4 patients who required staged reconstruction with bone grafting. At mean final follow-up of 29.5 months (SD, 22.2 months), there were 3 graft failures (9.4%) and 5 contralateral ACL ruptures (15.6%). Conclusion: Most patients with ACL graft failure were adequately treated with a single revision. Conversion from a soft tissue graft to a BTB autograft was the most common procedure. Infrequently, patients required staged reconstructions. Providers should have a high index of suspicion for associated intra-articular injuries resulting from graft failure in adolescent patients.

Unique Considerations for the Pediatric Athlete During Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction

“…16,17,103,[106][107][108] Reasons for a second ACL injury to either knee is multifactorial. Non-modifiable factors include graft type, 20,109,110 age younger than 15 to 16, 106,111 female sex, 106 and anatomic factors. [112][113][114] Modifiable factors include returning to high-risk sports 115 and biomechanical and neuromuscular factors.…”

“…16,17 Recent studies of revision ACLR in pediatric and adolescent populations have reported lower functional outcomes, lower return to sport rates, significant risk of contralateral ACL injury, and high rates of revision graft injury 18,19 compared to primary ACLR. Revision ACLR has also been associated with more meniscal and cartilage abnormalities, [18][19][20] which increases concern for long-term knee and general health.…”

Pediatric Revision Anterior Cruciate Ligament Reconstruction: Current Concepts Review

“…A return to sports rate, peaking at a rate of 68%, has been documented in the literature, with a return to previous level of play even lower at 55%. 72,[74][75][76] This can be because of fear of re-injury, highlighting the importance of continued counseling and discussion of realistic expectations. However, Webster et al noted a higher rate of a third ACL injury in those who returned to the pre-injury sport after revision ACL reconstruction than those who did not.…”

Limited evidence for graft selection in pediatric ACL reconstruction: a narrative review

“…Besides considering donor site morbidity and rupture rates in favoring HT graft over BPTB or vice-versa, skeletal maturity is another important factor to consider. Many surgeons have leaned towards the use of a HT graft to perform an ACLR in skeletally immature patients to avoid harvesting a patellar tendon from an open tibial tubercle apophysis and to avoid the bone plug or interference screw from crossing and potentially arresting the physis [ 51 ]. Additionally, a lack of understanding of growth remaining in patients with open physis influences surgeons to favour other grafts for ACLR, such as the HT autograft.…”

“…However, this may put these patients at a higher risk for graft rupture because the hamstring tendons used are thinner. Therefore, the BPTB autograft is popular in ACLR for adolescent patients nearing skeletal maturity and returning to high-risk activities [ 51 ]. In patients with closed physes, the findings discussed are inconsistent.…”