All-Inside, All-Epiphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Athletes: Return to Sport, Incidence of Second Surgery, and 2-Year Clinical Outcomes

Cordasco, Frank A.; Mayer, Stephanie W.; Green, Daniel W.

doi:10.1177/0363546516677723

Cited by 84 publications

(91 citation statements)

References 43 publications

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“…28,32 With sports specialization on the rise, intrasubstance tears of the ACL in skeletally immature athletes have increased dramatically. 410,23,36 In addition, return-to-play rates are low and second injury rates are highest among this population. 1,22,37 Young athletes are 15 times more likely to reinjure their ACLs within the first year, 6 times more likely within 2 years after returning to sports activity, and only 43% return to their preinjury level.…”

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confidence: 97%

Return to Sport for Skeletally Immature Athletes After ACL Reconstruction: Preventing a Second Injury Using a Quality of Movement Assessment and Quantitative Measures to Address Modifiable Risk Factors

Graziano

Chiaia

Mille

et al. 2017

Orthopaedic Journal of Sports Medicine

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Background:Reinjury rates after anterior cruciate ligament reconstruction (ACLR) are highest among young athletes, who consequently suffer from low rates of return to play. Historically, quantitative measures have been used to determine readiness to return to sport; however, they do not assess modifiable risk factors related to the quality of movement.Purpose:To determine the effectiveness of a criteria-based rehabilitation progression and return-to-sport criteria on efficient return to activity and prevention of second injury in young athletes post-ACLR.Study Design:Case series; Level of evidence, 4.Methods:Between December 2010 and 2013, 42 skeletally immature athletes (mean chronologic age, 12 years; range, 10-15 years) who underwent ACLR using ipsilateral hamstring tendon autograft were prospectively evaluated. All athletes progressed through a criteria-based rehabilitation progression; were assessed at specific time frames for strength, biomechanical, and neuromuscular risk factors predictive of injury; and were provided targeted interventions. The final return to sport phase consisted of quantitative testing as well as a quality of movement assessment of several functional movements with progressive difficulty and sports-specific loading. Clearance for unrestricted activity was determined by achieving satisfactory results on both qualitative and quantitative assessments with consideration for the demands of each sport.Results:The mean time for return to unrestricted competitive activity was 12 months. All but 3 (7%) athletes returned to their primary sport. Thirty-five athletes (83%) returned to unrestricted activity. Of the 6 (14%) who sustained a second injury, 3 (50%) were injured in sports they were not cleared for. All ACL reinjuries occurred in a cutting sport. Half of reinjuries occurred within 1 year of surgery, while the remaining occurred between 1 and 2 years. Eighty-three percent of reinjuries involved highly competitive cutting athletes.Conclusion:In our cohort, the combination of qualitative and quantitative data served as a good indicator for reducing risk and determining readiness to return to sport.

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confidence: 97%

Return to Sport for Skeletally Immature Athletes After ACL Reconstruction: Preventing a Second Injury Using a Quality of Movement Assessment and Quantitative Measures to Address Modifiable Risk Factors

Graziano

Chiaia

Mille

et al. 2017

Orthopaedic Journal of Sports Medicine

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“…Cassard et al 108 , in a series of 28 subjects at a mean follow-up of 2.8 years, noted a 100% return to activities; however, as far as we know, this outcome was not reported in other studies. Complications have been reported in the orthopaedic literature; in small and short-term series, graft rupture rates of 4% to 17% have been noted [24][25][26]108,109 . An MRI-based investigation noted physeal compromise in 10 of 15 tibiae and 1 (4%) of 23 femora, without clinical growth disturbances at 1 year 110 .…”

Section: Physeal Sparing: All-epiphyseal Techniquementioning

confidence: 99%

Management of ACL Injuries in Children and Adolescents

Fabricant

Kocher

2017

The Journal of Bone and Joint Surgery

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ä Children and adolescent athletes constitute the largest demographic of patients who sustain anterior cruciate ligament (ACL) tears, and the frequency is increasing. ä In ACL-deficient children and adolescents, continued symptoms of instability can result in progressive meniscal and cartilage damage as well as arthritic changes. ä Growth disturbance can occur after ACL surgery in children, and includes tibial recurvatum due to tibial tubercle apophyseal arrest as well as limb-length discrepancy and/or angular deformity due to physeal arrest or overgrowth. ä Several "physeal sparing" and "physeal respecting" ACL reconstruction techniques have been developed for use in skeletally immature patients to minimize the risk of growth disturbance, with favorable clinical outcomes. ä ACL injury prevention strategies include neuromuscular conditioning and may be performed to prevent both initial ACL injury as well as reinjury and injury of the contralateral ACL after reconstruction. Disclosure: No internal or external funding was provided for this project. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked "yes" to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/B603).

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“…As a result, I have concluded based on the compelling data available in the literature that ACLR is the conservative treatment in the majority of skeletally immature athletes. [2][3][4][5] Nevertheless, the greatest concern regarding the surgical treatment of ACL injury in this cohort of young athletes is the development of a growth disturbance in the form of malalignment (valgus on the femoral side or recurvatum on the tibial side) and/or leg length discrepancy including overgrowth. 4,[6][7][8] The literature is replete with descriptions of several surgical approaches used to treat ACL injury in the skeletally immature athlete.…”

Section: See Related Article On Page 1570mentioning

confidence: 99%

“…Our group's clinical experience supports this concept of excellent tendon-bone incorporation within sockets in that our 2-year clinical outcomes after all-epiphyseal ACLR in athletes resulted in 4.3% revision ACLR and 96% return to sport. 4 The secondary concerns are related to the potential for damage of the lateral femoral condyle structures, which include the posterior articular cartilage, LCL and ALL footprints, and popliteus tendon insertion. This potential risk could also be minimized with the use of sockets rather than tunnels for the distal femoral approach as the diameter of lateral cortical violation is diminished with a smaller diameter drill hole used to prepare the socket with a retro-cutter device compared with a larger diameter reamer used to prepare the outside-in tunnel.…”

Section: See Related Article On Page 1570mentioning

confidence: 99%

Editorial Commentary: The All-Epiphyseal Anterior Cruciate Ligament Distal Femoral Approach: Sockets or Tunnels?

Cordasco

2018

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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I believe that the distal femoral approach for anterior cruciate ligament reconstruction in the skeletally immature athlete with 3 to 6 years of remaining growth is best performed with an all-inside, all-epiphyseal technique using sockets rather than an outside-in approach creating tunnels. A shorter socket rather than a longer tunnel exposes a smaller surface area of the lateral distal femoral physis to potential compromise and resultant valgus malalignment. In addition, exiting the lateral femoral aspect of the epiphysis with a full-diameter tunnel as compared with a smaller diameter drill hole used to prepare a socket places the posterior articular cartilage, the lateral collateral ligament and anterolateral ligament footprints, and the popliteus tendon insertion at risk. My preference for sockets is also related to my belief that they provide a superior biologic milieu for graft incorporation compared with a full-length tunnel with the attendant violation of the lateral femoral cortex of the epiphysis.

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All-Inside, All-Epiphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Athletes: Return to Sport, Incidence of Second Surgery, and 2-Year Clinical Outcomes

Abstract: The all-inside, all-epiphyseal ACL reconstruction technique using a hamstring autograft demonstrates excellent subjective and objective clinical outcomes in skeletally immature athletes without physeal arrest.

Cited by 84 publications

References 43 publications

Return to Sport for Skeletally Immature Athletes After ACL Reconstruction: Preventing a Second Injury Using a Quality of Movement Assessment and Quantitative Measures to Address Modifiable Risk Factors

Return to Sport for Skeletally Immature Athletes After ACL Reconstruction: Preventing a Second Injury Using a Quality of Movement Assessment and Quantitative Measures to Address Modifiable Risk Factors

Management of ACL Injuries in Children and Adolescents

Editorial Commentary: The All-Epiphyseal Anterior Cruciate Ligament Distal Femoral Approach: Sockets or Tunnels?

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