Abstract
Background
Indications and outcomes of anterior cruciate ligament (ACL) reconstruction in children and adolescents is still controversial. It was the aim of this study to analyze outcomes of anterior cruciate ligament reconstruction in this special age group.
Methods
Retrospectively, we analyzed 62 consecutive cases of ACL reconstruction using a physis crossing technique in six to 16-year-old patients with a mean follow-up of 69 months.
Results
Cases operated later than six weeks after trauma had significantly more meniscal lesions than patients operated within six weeks of trauma. At last follow-up, we found good or very good subjective and objective results in 71% of the patients.
Conclusion
In active and healthy children with anterior knee instability after ACL tear, ligament reconstruction is a safe and successful procedure and should be considered within six weeks of trauma because instability seems to promote secondary meniscal lesions.
Keywords: Knee, ACL tear, Instability, Meniscal tear, Osteoarthritis
Abbreviations: ACL, anterior cruciate ligament
1. Introduction
In young and active patients, conservative treatment of anterior cruciate ligament (ACL) tears often leads to bad results.1 Secondary meniscal lesions and the development of posttraumatic osteoarthritis of the ACL-deficient unstable knee are common in this population.2 We conducted a retrospective cohort study to evaluate outcomes of ACL reconstruction in children and adolescents using an autologous semitendinosus graft. We hypothesize that in immature patients with ACL tear early ligament reconstruction with autologous semitendinosus tendon is a safe treatment leading to good subjective and objective outcomes.
2. Patients and methods
From our database, we identified all 62 primary ACL reconstructions performed consecutively in patients aged 6–16 years in our department between January 2008 and December 2016. Mean patient age was 13.8 years. 54% were girls, 46% were boys. 33 left knees and 29 right knees were injured.
Inclusion criteria included complete tear of the ACL and patient age under 17 years at time of surgery. Exclusion criteria included multiligament injuries and fractures. The study was approved by the local ethic committee of the Eberhard Karls University Tübingen, Germany (No. 113/2020BO2).
All patients underwent ACL reconstruction using an autologous ipsilateral three- or four-fold semitendinosus tendon graft by 3 surgeons with extraarticular fixation (physis crossing): femoral with an endobutton, tibial with a suture disc (Fig. 1). The bone tunnels had the same diameter as the graft. This was 6 mm on average. The graft was tensioned by the primary surgeon with about 60 N.
Fig. 1.
ACL reconstruction in a 12-year old boy. a Preoperative radiograph, b Postoperative radiograph, c Intraoperative arthroscopic image.
Patients were treated either immediately within the first week of injury or delayed after 6 weeks, depending on the time of presentation.
Postoperatively for 6 weeks, patients were allowed full weight bearing when standing and partial weight bearing with 20 kg during walking with a knee brace. Range of motion was limited to 90° of flexion. Isometric training of the active dynamic knee stabilizing muscles was performed. At clinical follow-up 6 weeks postoperatively, patients were allowed full weight bearing without a knee brace and full mobilization. Return to competitive sports was allowed after 9 months, if muscle strength and neuromuscular control were reestablished.
Out of 62 patients eligible for the retrospective cohort study, we received completely answered questionnaires by 52 (84%) patients and we had been able to fully follow-up 48 patients (77%) also clinically and radiographically. The remaining patients were not available for follow-up exam.
At final follow-up in our outpatient clinic 69 (min. 26, max. 130) months postoperatively, we performed a standardized clinical investigation including Lachman test, pivot-shift test, range of motion, thigh circumference measure (measured 10 cm proximal to the lateral knee joint line), single-leg hop test,3 and instrumental translation measure with the KT-1000 arthrometer (MEDmetric, San Diego, CA, USA).4 The coronal alignment was measured clinically to avoid long leg radiographs in this young group of patients for ethical reasons. Additionally, we used the visual analog pain scale (VAS),5 IKDC score,6, 7, 8, 9, 10 and standard X-rays of the knee. For radiological evaluation during follow-up, we used the score of Sherman.11,12 For analyzing subjective patient outcomes, we determined the score of Flandry using the validated German version of Flandry’s questionnaire.13,14
SPSS 19.0 (SPSS Inc., USA) was used for statistical analysis. After testing for normal distribution with the Kolmogorow-Smirnow-Test, we used the paired t-test and the Spearman rank correlation. A p-value of <0.05 was considered statistically significant.
3. Results
At the time of surgery, 13% (n = 8) of the patients were in Tanner stage I, 16% (n = 10) were in Tanner stage II, 36% (n = 22) were in Tanner stage III, 13% (n = 8) were in Tanner stage IV, and 22% (n = 14) were in Tanner stage V. Intraoperatively, concomitant meniscal injuries were found in 40% (n = 25) of cases. 47% (n = 29) of the patients underwent surgical treatment within the first week of trauma. In cases of delayed ACL reconstruction, more meniscal tears were present (Fig. 2). Lateral or medial partial meniscal tears were found most often (Table 1).
Fig. 2.
Relative frequency of medial and lateral meniscal tears in dependence of time between anterior cruciate ligament tear and reconstruction (n = 62).
Table 1.
Intraoperative management of accompanying meniscal lesions.
| Meniscal lesion | n | No intervention | Suture | Resection |
|---|---|---|---|---|
| Medial partial | 5 | 2 | 3 | |
| Medial complete | 2 | 1 | 1 | |
| Lateral partial | 8 | 5 | 3 | |
| Lateral complete | 3 | 2 | 1 | |
| Medial + lateral partial | 3 | 2 | 1 | |
| Medial + lateral complete | 2 | 2 | 1 | |
| Medial complete + lateral partial | 1 | 1 | ||
| Total | 24 | 7 | 10 | 8 |
At follow-up examinations 69 months after ACL reconstruction, no effusion in the operated knees was found. Circumferential thigh measures 10 cm proximal of the knee joint line showed very little atrophy of the operated thigh (45.8 versus 47.4 ± 5.5, p = 0.46). Muscle atrophy was not different between patients, who received early or late operative treatment. One patient had a slight extension deficit (0/5/130°) in the operated knee. All other knees (operated or contralateral) showed free active and passive range of motion. No (partial) growth arrest of the physes on X-rays or clinical coronal malalignment after ACL reconstruction in comparison with the other leg was found. Collateral ligaments were stable in extension and flexion. We found a significant difference between the operated and contralateral knees in the Lachman test (Table 2), p = 0.027. We found a slightly positive (+) pivot shift test in four operated knees. The instrumental translation measure with the KT-1000 arthrometer showed a mean anterior translation of the tibial head of 7.5 (min. 6.0, max. 9.5) mm in the operated knees versus 6.0 (min. 4.3, max. 6.7) mm in the contralateral knees. In the one-leg jump test, we found a tendency for better performance in the contralateral leg (Fig. 3), p = 0.39. Bone tunnels were between 5 and 8 mm in diameter. 71% of the patients subjectively rated their outcome as good or very good according to the score of Flandry (Fig. 4). We found a mean IKDC score of 85.3 ( ±15.5), see Fig. 5. The Sherman scores were almost identical preoperatively and at follow-up examinations (Table 3), p = 0.97.
Table 2.
Lachman test 69 months after anterior cruciate ligament reconstruction in operated and contralateral knees (p = 0.027).
| Lachman test [mm] | Operated (%) | Contralateral (%) |
|---|---|---|
| 0-2 (negative) | 27 (56.3) | 48 (100) |
| 3-5 (+) | 15 (31.3) | 0 (0) |
| 6-10 (++) | 5 (10.4) | 0 (0) |
| >10 (+++) | 1 (2.1) | 0 (0) |
Fig. 3.
One-leg jump test comparing operated and contralateral knees 69 months after anterior cruciate ligament reconstruction (n = 48), p = 0.39.
Fig. 4.
Flandry score 69 months after anterior cruciate ligament reconstruction (n = 52).
Fig. 5.
IKDC score 69 months after anterior cruciate ligament reconstruction (n = 52).
Table 3.
Sherman scores preoperatively and 69 months after anterior cruciate ligament reconstruction (n=52).
| Sherman score | Before surgery | At follow-up | p-value |
|---|---|---|---|
| P-score | 10.0 (±0.6) | 09.6 (±0.9) | 0.96 |
| D-score | 16.0 (±0.4) | 15.4 (±0.9) | 0.96 |
| T-score | 26.0 (±0.4) | 25.6 (±0.9) | 0.98 |
4. Discussion
The results of the current study showed ACL reconstruction with autologous semitendinosus tendon graft in transphyseal technique to be safe with overall good subjective and objective outcomes in immature patients. Most importantly, we found a significant increase of meniscal lesions at time of ACL reconstruction in cases with delayed surgery. This is in line with other studies.15, 16, 17 So especially in this young and active population of children and adolescents aged six to 16 we should stabilize the knee as soon as possible after indicating ACL-reconstruction to prevent secondary meniscal tears. We should sensitize coaches and physiotherapist to send young patients with swelling of the knee after trauma to an orthopaedic surgeon for further diagnostics. ACL reconstruction should be indicated in those young and active patients to prevent secondary meniscal lesions. From other studies in adults we know that patients develop osteoarthritis after ACL tear with or without reconstruction, probably due to persistent instability after reconstruction.18, 19, 20, 21 We couldn’t confirm these findings in this current study. However, the follow-up was limited. One long-term study demonstrated the development of posttraumatic osteoarthritis in twelve to 16-year-old patients after delayed ACL reconstruction. Clinical outcomes and health related quality of life still were good after ten to 20 years.22 To gain more knowledge about the possible development of arthritis after tear of the ACL in children and adolescents, more evidence from long-term outcome studies around this patient group are needed.
5. Conlcusion
ACL reconstruction with autologous semitendinosus tendon and extraarticular fixation is a safe procedure, which can lead to good and very good subjective and objective mid-term outcomes in children and adolescents. Because of the high incidence of secondary meniscal lesions in this young and active population, ligament reconstruction should be considered as soon as possible after ACL tear with anterior instability.
Author contributions
CK developed the study design, interpreted the data, and wrote the manuscript. SD and AA supervised the project and revised the manuscript. SSA collected the data, performed statistical data analysis, and revised the manuscript. All authors read and approved the final manuscript.
Declaration of competing interest
None.
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