Lindsay Schlichte MS, Colleen Wixted BS, and Daniel Green MD MS FACS Department of Orthopedic Surgery, Pediatrics, Hospital for Special Surgery, New York, NY, USA Children and adolescents with ACL tears are indicated for anterior cruciate ligament reconstruction (ACLR) shortly after initial presentation. Historically, these patients were definitively prescribed activity restriction, bracing, and physical therapy. However, these patients showed early, severe meniscal degeneration and cartilage defects that eventually required surgical intervention.1 Pediatric ACLR techniques have advanced significantly in recent years. There are multiple physical sparing techniques and advanced rehabilitation protocols to prevent arthrofibrosis. What is the ideal timing for pediatric ACLR? Is this patient at risk for developing arthrofibrosis if ACLR is preformed too soon? Current literature consistently agrees that indefinite delay to surgical intervention when treating ACL injuries in pediatric patients will result in further meniscal damage.1–3 In a group of 370 pediatric patients with ACL tears, those with surgical treatment ≥150 days after injury had a significantly higher incidence of meniscus tears compared to those treated surgically ≤150 days postinjury.4 Furthermore, multiple meta‐analyses have demonstrated that nonoperative management equates to a 12‐fold greater risk of developing a meniscal tear.2,3 There is an increased meniscal injury prevalence of 6% for every month that surgery is delayed.5 If surgery is delayed for over three months, patients are 3.5–4.8 times more likely to present with an additional or more severe medial meniscal tear.6 Guenther et al. reviewed 112 patients (mean age: 15.4 years) in which 51% of those who underwent surgery >1 year postinjury presented with a new or higher‐grade medial meniscal tear versus only 20% of those who had surgery <1 year postinjury.7 Comparing a group who underwent ACLR at a mean interval of 11.5 months to a group who underwent ACLR at a mean interval of 30.3 months, findings revealed that the group with a longer time to surgery presented with a significantly higher medial meniscal tear rate.8 Some authors have also hypothesized the risk of arthrofibrosis as a function of time interval from ACL injury to surgery, making this another relevant concern in surgical planning. In an attempt to understand this potential risk in the pediatric population, Nwachukwu et al. retrospectively reviewed 933 ACL reconstructions with an average follow‐up of 6.3 years. Arthrofibrosis was defined as loss of 5° or more extension that required a follow‐up procedure, or a loss of 15° or more extension that required a follow‐up procedure. The prevalence of arthrofibrosis was 8.3%.9 Prior knee surgery and ACL reconstruction within one month of injury were not significantly associated with postoperative arthrofibrosis. Females, patients aged ≥16, patellar tendon autograft, and concomitant meniscal repair were associated with a higher incidence of arthrofibrosis.9 Some practitioners advocate for the use of postoperative continuous passive motion (CPM) machine protocols to reduce the risk of arthrofibrosis. A recent retrospective review compared the postoperative rates of MUA for arthrofibrosis among pediatric ACLR patients treated with or without postoperative CPM protocol. The no‐CPM cohort has a 7.4% rate of MUA for arthrofibrosis while no patients in the CPM cohort required MUA. Future work may better define the clinical utility and cost effectiveness of CPM in rehabilitation.10 ACLR is recommended for the current clinical scenario at the patient’s and family’s earliest convenience. Current research does not suggest an increased risk of arthrofibrosis with early ACLR. However, if ACLR is delayed, the patient is at high risk of further internal derangement of the knee, and should adhere to activity restrictions. A variety of surgical techniques for ACLR have been developed to restore knee stability while minimizing the risk of physeal injury in young patients. These techniques include the all‐epiphyseal (AE) reconstruction, the pediatric extra‐articular ACLR with iliotibial band (ITB) autograft, and the complete transphyseal (CT) reconstruction with soft tissue graft. Of note, the bone tendon bone (BTB) autograft is an adult‐type reconstruction for school‐ and college‐aged patients at or near skeletal maturity due to its risk to physeal injury. As the focus of this chapter is the pediatric ACLR; BTB autograft will not be discussed further. The elected procedure should minimize the risk of postoperative growth arrest and/or angular deformity while maximizing the opportunity to RTS and daily activities. Of the three available techniques for ACLR in skeletally immature patients, is there one that has been shown to be superior to the others? Are there specific indications for each procedure that produce the best outcomes? The surgical technique is generally based upon the patient’s skeletal age, predicted growth remaining, and surgeon preference. The pediatric extra‐articular ACLR with ITB autograft and AE reconstructions are generally reserved for patients with approximately 3–6 years of growth remaining, while the transphyseal reconstruction is for young adolescents with approximately 2–3 years of growth remaining.11,12,14–17,19,20,27–29 Micheli et al. reported on a series of eight patients (mean age: 11 years) who underwent this modified intra‐ and extra‐articular extraphyseal reconstruction originally described by MacIntosh and Darby.18 The technique was performed with ITB autograft and the patients were followed for an average of 5.5 years after surgery. At latest follow‐up, none of the patients experienced any complications or required revision surgery, and they were able to return to activities with a mean Lysholm score of 97.4.18 Further studies similarly found satisfactory results with this procedure. Out of 237 patients (mean age: 11.2 years), Kocher et al. found at mean follow‐up 25.8 months, 96.8 and 98.9% of patients were grade A on the Lachman and pivot‐shift test, respectively. At an average 33.5 months postoperatively, graft rupture occurred in nine (6.6%) of 137 knees. For patients who did not sustain a graft rupture, the mean Pedi‐IKDC score was 93.3, the mean Lysholm score was 93.4, and the mean score on the Tegner Activity Scale was 7.8. No cases of limb‐length discrepancy or angular deformity were observed.23 Anderson described a transepiphyseal ACLR for pediatric patients that mitigates the risk of iatrogenic growth disturbance by avoiding graft fixation that violates the tibial or femoral physis.24 In a preliminary report of 12 patients (mean age: 13.3 years), Anderson reported no instances of growth disturbance.25
186 Pediatric Anterior Cruciate Ligament Injuries
Clinical scenario
Top three questions
Question 1: In a child or teenager with acute ACL tear, what are the effects on cartilage and meniscus with delayed reconstruction compared to acute reconstruction?
Rationale
Clinical comment
Available literature and quality of the evidence
Findings
Resolution of clinical scenario
Question 2: In children/adolescents with acute ACL tear, is one surgical technique superior to others with respect to ACL re‐rupture rates, pain, or return to sport (RTS)?
Rationale
Clinical comment
Available literature and quality of the evidence
Findings
The pediatric extra‐articular ACLR with ITB autograft
All‐epiphyseal (AE)
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