J. Todd R. Lawrence

Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft.

PURPOSE To evaluate whether decreased hamstring autograft size and decreased patient age are predictors of early graft revision. METHODS Of 338 consecutive patients undergoing primary anterior cruciate ligament (ACL) reconstruction with hamstring autograft, 256 (75.7%) were evaluated. Graft size and patient age, gender, and body mass index at the time of ACL reconstruction were recorded, along with whether subsequent ACL revision was performed. RESULTS The 256 patients comprised 136 male and 120 female patients and ranged in age from 11 to 52 years (mean, 25.0 years). The mean follow-up was 14 months (range, 6 to 47 months). Revision ACL reconstruction was performed in 18 of 256 patients (7.0%) at a mean of 12 months after surgery (range, 3 to 31 months). Revision was performed in 1 of 58 patients (1.7%) with grafts greater than 8 mm in diameter, 9 of 139 patients (6.5%) with 7.5- or 8-mm-diameter grafts, and 8 of 59 patients (13.6%) with grafts 7 mm or less in diameter (P = .027). There was 1 revision performed in the 137 patients aged 20 years or older (0.7%), but 17 revisions were performed in the 119 patients aged under 20 years (14.3%) (P < .0001). Most revisions (16 of 18) were noted to occur in patients aged under 20 years with grafts 8 mm in diameter or less, and the revision rate in this population was 16.4% (16 of 97 patients). Age less than 20 years at reconstruction (odds ratio [OR], 18.97; 95% confidence interval [CI], 2.43 to 147.06; P = .005), decreased graft size (OR, 2.20; 95% CI, 1.00 to 4.85; P = .05), and increased follow-up time (OR, 1.07; 95% CI, 1.02 to 1.12) were associated with increased risk of revision. CONCLUSIONS Decreased hamstring autograft size and decreased patient age are predictors of early graft revision. Use of hamstring autografts 8 mm in diameter or less in patients aged under 20 years is associated with higher revision rates. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Degeneration of the Knee Joint in Skeletally Immature Patients With a Diagnosis of an Anterior Cruciate Ligament Tear Is There Harm in Delay of Treatment

Background: In skeletally immature patients with an anterior cruciate ligament (ACL) tear and significant growth remaining, the risk of inducing a growth disturbance with early reconstruction must be balanced against the risk of further intra-articular damage by delaying treatment until closer to skeletal maturity. Hypothesis: Increased time from injury to ACL reconstruction in children ≤14 years of age will be associated with increased meniscal and chondral injuries at the time of reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: With institutional review board approval, the records of a consecutive series of patients 14 years of age and younger who underwent ACL reconstruction between 1991 and 2005 were reviewed. Demographic, magnetic resonance imaging (MRI), and intraoperative findings were analyzed. Meniscal and articular cartilage injuries were graded. Logistic regression models using both univariable and multivariable regression procedures were used to identify factors independently associated with intra-articular lesions. Fisher exact test and Kaplan-Meier analysis were used to test for differences in intra-articular injuries by time from injury to surgery. Results: Seventy patients were identified. Twenty-nine patients (41%) underwent reconstruction more than 12 weeks from the time of injury. Logistic regression analysis revealed time to surgical reconstruction (odds ratio, 4.1) and a history of a sense of knee instability (odds ratio, 11.4) to be independently associated with medial meniscal tears. Time to surgical reconstruction was also independently associated with medial and lateral compartment chondral injuries (odds ratios, 5.6 and 11.3, respectively). Testing time as a continuous variable, survivorship analysis also confirmed a significant association of time to reconstruction with medial meniscal injury as well as lateral and patellotrochlear cartilage injuries. When present, a delay in treatment of over 12 weeks (29 patients) was associated with an increase in the severity of medial meniscal tears (P = .011) and higher grade lateral and patellotrochlear chondral injuries (P = .0014 and P = .038, respectively). Conclusion: Young patients who underwent surgical reconstruction of an acute ACL tear >12 weeks after the injury were noted to have a significant increase in irreparable medial meniscal tears and lateral compartment chondral injuries at the time of reconstruction. When a subjective sense of knee instability was present, this association was even stronger.

Return to Competitive Sports After Medial Epicondyle Fractures in Adolescent Athletes: Results of Operative and Nonoperative Treatment

Background: The optimal treatment of medial epicondyle fractures in pediatric athletes remains unclear. Purpose: To evaluate the outcomes of operative and nonoperative management of medial epicondyle fractures in young athletes. Study Design: Case series; Level of evidence, 4. Methods: The records of all children with fractures of the medial epicondyle over a 5-year period, with a minimum 2 years of follow-up at a pediatric tertiary referral center, were reviewed. Patients with intra-articular entrapment of the fracture fragment or ulnar nerve entrapment were excluded. Treatment decisions were made primarily based on injury mechanism and elbow laxity or instability. Patients were contacted and asked to complete a modified Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Results: Complete data with 2-year follow-up were available for 20 athletes: 6 treated nonoperatively and 14 treated operatively. At the latest follow-up, both groups achieved excellent DASH scores. Half of each cohort required physical therapy, and 6 of 14 patients who received operative treatment reported numbness. All patients were either very or completely satisfied with their treatment. Fourteen patients were overhead athletes (8 treated operatively, 6 nonoperatively). Excellent DASH scores were achieved in both groups, and all overhead athletes were able to return to their sport at the next appropriate level. Seven patients were baseball pitchers and sustained a fracture while throwing (4 treated operatively, 3 nonoperatively). None felt their performance was limited after treatment, and excellent DASH scores were achieved in both groups. Conclusion: These data demonstrate that nonoperative treatment can be successful in young athletes with low-energy medial epicondyle avulsions, a stable elbow, and minimal fracture displacement. Surgical management can be successful in athletes who sustain more significant trauma, who have elbow laxity or instability, or who have significant fracture fragment displacement after a fracture of the medial epicondyle.

Sport-Specific Yearly Risk and Incidence of Anterior Cruciate Ligament Tears in High School Athletes A Systematic Review and Meta-analysis

Background: Anterior cruciate ligament (ACL) injury rates are affected by frequency and level of competition, sex, and sport. To date, no study has sought to quantify sport-specific yearly risk for ACL tears in the high school (HS) athlete by sex and sport played. Purpose: To establish evidence-based incidence and yearly risk of ACL tears in HS athletes by sex for sports performed at the varsity level across the majority of US high schools. Study Design: Meta-analysis. Methods: PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched to identify all articles reporting ACL tears per athletic exposure in HS athletes. ACL injury incidence rates (IRs) by sex and sport were calculated via meta-analysis. State athletic association guidelines were used to determine the number of exposures per season to calculate yearly risk of ACL tears. Results: The search recovered 3779 unique articles, of which 10 met our inclusion criteria, for a total of 700 ACL injuries in 11,239,029 exposures. The IR was 0.062 injuries per 1000 exposures (95% CI, 0.058-0.067). Although more injuries were recorded in males than females, females had a higher rate of injury per exposure (relative risk, 1.57; 95% CI, 1.35-1.82). Relative risk was highest in basketball (3.80; 95% CI, 2.53-5.85) and soccer (3.67; 95% CI, 2.61-5.27). While boys’ football had the highest number of ACL injuries at 273, girls’ soccer had the highest IR (0.148; 95% CI, 0.128-0.172). In girls, the highest injury risks per season were observed in soccer (1.11%; 95% CI, 0.96%-1.29%), basketball (0.88%; 95% CI, 0.71%-1.06%), and lacrosse (0.53%; 95% CI, 0.19%-1.15%). In comparison, the highest risks for boys were observed in football (0.80%; 95% CI, 0.71%-0.91%), lacrosse (0.44%; 95% CI, 0.18%-0.90%), and soccer (0.30%; 95% CI, 0.22%-0.41%). Conclusion: There is an approximately 1.6-fold greater rate of ACL tears per athletic exposure in HS female athletes than males. However, there is significant risk in both sexes, particularly in high-risk sports such as soccer, football, basketball, and lacrosse. Knowledge of sport-specific risk is essential for future injury reduction programs, parent-athlete decision making, and accurate physician counseling.

Growth Disturbance Following ACL Reconstruction with Use of an Epiphyseal Femoral Tunnel

Anterior cruciate ligament (ACL) tears in skeletally immature patients are increasing in prevalence. This appears to be the result of a heightened suspicion for such injuries, more readily available imaging, and the ever-increasing physical demands and competitiveness of organized youth sports1. As a result, there is increased interest in early ACL reconstruction to potentially prevent further intra-articular damage to the knee2-4. Multiple surgical techniques for ACL reconstruction described for adults are not appropriate in skeletally immature patients because they involve large drill holes across the physis, fixation or bone blocks that cross the physis, or tensioning of a graft across the physis, all of which have been shown to result in growth disturbances5-13. Because of these concerns, multiple surgical techniques to address ACL tears in patients with open physes have been described, including primary repair, extra-articular tenodesis, transphyseal reconstruction, partial transphyseal reconstruction, and physeal sparing techniques. Growth disturbances have been reported with the use of most of these techniques12-14. Anderson described a technique of ACL reconstruction that avoids drilling tunnels across the physis15,16. Theoretically, this should decrease the incidence of growth disturbance following ACL reconstruction in skeletally immature patients. With this technique, both the femoral and the tibial tunnels are drilled entirely within the epiphysis, and an all-soft-tissue graft is used for the reconstruction. Good results were found in twelve patients at the time of follow-up, two to eight years postoperatively15, and to our knowledge a growth disturbance has never been reported after the use of this technique. Here, we describe a case of distal femoral valgus angulation associated with use of an epiphyseal femoral tunnel for a revision ACL reconstruction in an immature patient. The patient and his family …

Anterior Cruciate Ligament Reconstruction in the Young Athlete: A Treatment Algorithm for the Skeletally Immature

Injury to the anterior cruciate ligament (ACL) in the skeletally immature was once considered rare, and it was widely held that tibial spine avulsions rather than ligament ruptures occur in this young population. The incidence of ACL rupture in skeletally immature individuals sustaining a knee injury has historically been reported as 1% to 3.4%. In young athletes presenting with hemarthrosis, however, the incidence of CL rupture has been reported to be between 26% and 65%. As imaging and clinical awareness of injuries in young athletes has improved, the diagnosis and reported incidence of ACL injury has increased. The rate of ACL injury in patients with open physes has recently been shown to approach the rate of tibial spine fractures and traumatic ACL disruption has also been described in children as young as 4 years of age.

The Future of the Orthopaedic Clinician- Scientist Part II: Identification of Factors That May Influence Orthopaedic Residents' Intent to Perform Research

BACKGROUND The successful incorporation of research into the future careers of residents provides tremendous potential for increasing scientific orthopaedic inquiry and improving musculoskeletal care. Therefore, we sought to assess resident opinions regarding plans and incentives for future research and the opinions of academic chairs who must support them. METHODS Residents from sixteen departments were surveyed with a twenty-four-question online survey. Similar surveys were sent to chairs of all residency-sponsoring departments. RESULTS The response rate was 44% (183) for the residents and 60% (eighty-six) for the chairs. Forty-two percent of the residents felt certain or likely that they would perform research during their careers, and 28% were undecided. Ninety-nine percent thought that orthopaedic surgeons performing research is important to clinical orthopaedics. Ninety-three percent of the residents expressed the need for monetary incentives for research, but only 40% would help to provide it. Chairs similarly noted the importance of research subsidization (92%) and a willingness to support it (70%). Residents indicated that increased funding and protected time would provide the greatest incentives for research during residency; chairs agreed. After training, debt relief and salary support were most important for residents; chairs chose protected time and a chair who is supportive of research as most important. Primary authorship on a prior manuscript and past research experience were found to be associated with greater future research interest in univariate analyses; primary authorship maintained an independent association in multivariate analysis. Younger residents and women were more likely to be unsure of their research interest. CONCLUSIONS Many orthopaedic residents in training have interest in integrating research into their future practice and support the research mission of orthopaedic surgeons. Our results may aid in identifying residents with high research interest (and those unsure) and help to guide the provision of incentives to actuate those interests.

Strength and Functional Performance Recovery After Anterior Cruciate Ligament Reconstruction in Preadolescent Athletes

Background: In the skeletally immature population, the incidence of anterior cruciate ligament (ACL) injuries and ACL reconstructions appears to be increasing. Differences in surgical techniques, physiology, and emotional maturity may alter the rehabilitation progression and impact the outcomes when compared with adults. Reports of objective strength recovery and performance-based outcome measures after pediatric ACL reconstruction (ACLR) are limited. Study Design: Retrospective case series. Level of Evidence: Level 4. Methods: All patients that underwent all-epiphyseal ACLR from January 2008 to August 2010 were identified. Isokinetic peak quadriceps/hamstring torque values and functional performance measures in unilateral hopping tasks were extracted and compared with the noninjured limb. A limb symmetry index (LSI) of ≥90% was considered satisfactory. Results: Complete data were available for 16 patients (mean age, 12.28 years; range, 8.51-14.88 years). By a mean 7 months (range, 3.02-12.56 years) postoperatively, only 9 of 16 (56%) were able to achieve a satisfactory LSI for quadriceps strength. For hamstring strength, 15 of 16 (94%) were able to achieve satisfactory LSI. By a mean of 12 months (range, 5.39-24.39 months) postoperatively, only 6 of 16 subjects (38%) were able to achieve satisfactory performance on all functional hop tests. At a mean 15.42 months (range, 8.58-24.39 months) postsurgery, only 4 of 16 (25%) subjects were able to achieve an LSI of ≥90% on all testing parameters. Conclusion: For some pediatric patients, significant strength and functional deficits may be present at greater than 1 year after ACLR. This population may require more prolonged rehabilitation programs to allow for adequate recovery of strength and function because of unique characteristics of normal growth and development.

Change in Size of Hamstring Grafts During Preparation for ACL Reconstruction: Effect of Tension and Circumferential Compression on Graft Diameter.

BACKGROUND There is good consensus that anterior cruciate ligament (ACL) grafts should be pretensioned to remove creep prior to implantation, but the literature contains little information on the influence of graft preparation or circumferential compression on graft size. The purpose of this study was to investigate how the size of hamstring allografts changes as they are prepared for ACL reconstruction. We hypothesized that grafts decrease in diameter as they are prepared with both tension and circumferential compression. We also investigated the interrater reliability of graft diameter measurements during each step of graft preparation. METHODS Twenty pairs of fresh-frozen human hamstring tendons obtained from an allograft supplier were prepared in a standardized fashion for ACL reconstruction (suturing followed by longitudinal tensioning followed by circumferential compression followed by relaxation). Four blinded raters measured each graft in a sequential manner after each graft preparation step. Interrater reliability was assessed using the intraclass correlation coefficient ICC(2,1). The mean allograft diameter at each time point was calculated and compared across all time points using repeated-measures analysis of variance (ANOVA). RESULTS Subjecting the grafts to both tension and circumferential compression significantly decreased their mean diameter (to 7.38 mm compared with 8.28 mm at baseline; p = 0.044). Interrater reliability revealed almost perfect agreement at each measurement interval, with the ICC ranging from 0.933 to 0.961. CONCLUSIONS The average diameter of hamstring ACL grafts decreases by almost 1 mm after they are subjected to both tension and circumferential compression within a standard cylindrical sizing block. CLINICAL RELEVANCE Because ACL bone tunnels are drilled in 0.5-mm increments, preparing soft-tissue grafts with circumferential compression in addition to tension may allow creation of tunnels that are one to two incremental sizes smaller. This could permit less bone removal, which may be particularly applicable for certain reconstruction techniques such as pediatric, double-bundle, or revision ACL reconstruction, in which limited space is available for tunnel drilling.

Early ACL reconstruction in children leads to less meniscal and articular cartilage damage when compared with conservative or delayed treatment

Background Anterior cruciate ligament (ACL) tears are being seen and treated with increasing frequency in children and adolescent athletes. The superiority of treating ACL tears in children and adolescents with acute reconstruction, delayed reconstruction or non-operative treatment remains controversial. Objectives To perform a systematic literature review to investigate for any associations between progressive intra-articular joint damage (increasing rates of meniscal and cartilage injury) with delayed or non-operative treatment of ACL tears in children and adolescents under age 18 when compared with acute ACL reconstruction (ACLR). Data sources PubMed, EMBASE and Cochrane computerised databases. Study eligibility criteria Inclusion criteria: (1) paediatric patient population (defined as <18 years of age), (2) investigated association between operative or non-operative treatment and consequent meniscal/chondral injury rates, (3) original research article, rather than a review, case report or meta-analysis. Exclusion criteria: (1) revision ACL cohort, (2) full-text article in a language other than English and (3) not a human clinical study. Participants Youth aged <18 years with ACL tears. Interventions Acute ACLR, delayed ACLR, non-operative management. Synthesis methods Qualitative synthesis. Results 17 studies were included in the final analysis, all of which reported on medial meniscal injuries, of which 8 (47%) favoured acute reconstruction. 10 of 17 reported on cartilage injuries, of which 4 (40%) favoured acute ACLR. No study concluded that delayed reconstruction or non-operative management was associated with fewer cartilage or meniscus injuries. Limitations While the included studies provided patient age data, not all provided details about distribution of skeletal maturity. Furthermore, the majority of studies were retrospective and subject to selection bias, measurement bias and design bias (eg, surgical decision-making may have accounted for intra-articular pathology sustained at the time of injury). Constituent study heterogeneity with regard to ACLR techniques, definitions of surgical delay and variable length of follow-up precluded combining results in quantitative meta-analysis. Conclusions and implications of key findings On the basis of the available published literature which is largely retrospective, acute reconstruction for ACL tears appears to be associated with fewer medial meniscal injuries and articular cartilage lesions when compared with delayed or non-operative management. Several studies that were equivocal showed clinically relevant effect sizes but were underpowered to detect statistical differences between groups. Future prospective research in a large uniform cohort of skeletally immature patients with ACL tears may provide more answers to this important clinical question. Trial registration number CRD42015027614.