An In-Depth Analysis of Graft Rupture and Contralateral Anterior Cruciate Ligament Rupture Rates After Pediatric Anterior Cruciate Ligament Reconstruction

Abstract

Background: Reported rates of graft rupture and contralateral anterior cruciate ligament (ACL) rupture after ACL reconstruction (ACLR) are higher among pediatric patients than adults. Previous series may have underestimated postoperative event risk because of small sample sizes and high proportions of dropouts. Purpose: To calculate rates of graft rupture and contralateral ACL rupture after ACLR in a large pediatric series. Study Design: Case series; Level of evidence, 4. Methods: ACLRs performed in our tertiary care children’s hospital system over a period of >7 years were identified through billing review. Cases were sorted based on operative technique, with all-epiphyseal ACLRs considered separately. Transphyseal ACLRs were divided into 2 groups based on patient age, with a cutoff of 16 years. Clinic follow-up data as well as prospectively collected survey data were used to note graft rupture and contralateral ACL rupture events. Rates of graft rupture and contralateral ACL rupture were calculated using Kaplan-Meier survival analysis. Results: The final data set included 996 patients. A total of 161 patients underwent all-epiphyseal ACLR. Of the remaining transphyseal surgeries, 504 patients were <16 years of age at the time of surgery and 331 were ≥16 years. The 4-year cumulative rate of graft rupture via Kaplan-Meier survival analysis was 19.7% among all patients. The rate was 18.2% among all-epiphyseal ACLRs, 21.6% among transphyseal ACLRs in patients <16 years, and 16.4% among transphyseal ACLRs in patients ≥16 years ( P = .855). Survival analysis estimated the 4-year cumulative rate of contralateral ACL rupture at 12.0% among all patients: 6.63% among all-epiphyseal ACLRs, 15.7% among transphyseal ACLRs in patients <16 years, and 8.05% among transphyseal ACLRs in patients ≥16 years ( P = .093). Conclusion: This is the largest series of pediatric ACLRs yet reported, and it shows that the risks of another ACL injury after first-time ACLR are higher than previously reported. The risk of contralateral ACL rupture was lower than that for graft rupture. Our methods, including prospective follow-up surveys and survival analysis to generate cumulative rate estimates, provide a best-practice example for future case series calculations. Our results provide insight into the postoperative course of pediatric patients undergoing ACLR and are crucial for preoperative patient and family counseling. Understanding these risks may also influence return-to-play decisions.

Outcomes, Including Graft Tears, Contralateral Anterior Cruciate Ligament Tears, and All-Cause Ipsilateral Knee Operations, are Similar for Adult-type, Transphyseal, and Partial Transphyseal Anterior Cruciate Ligament Reconstruction Using Hamstring Autograft in Pediatric and Adolescent Patients

“…27,41 Some data demonstrate that in an active, young population, the contralateral injury risk is not only similar, but may be even greater than the index surgical side. 45 In contrast, in the study by DeFrancesco et al, 43 there was a 4-year cumulative rate of contralateral ACL rupture of 15.7% and 8.1% in those with transphyseal reconstructions <16 and !16 years, respectively, which is lower than their ipsilateral graft rupture rates. There were no significant differences identified in contralateral ACLR in our cohort, and Cordasco et al 34 also did not find a difference in contralateral ACLRs comparing their all-epiphyseal, partial or complete transphyseal, and boneepatellar tendonebone autograft groups.…”

“…A large case series by DeFrancesco et al. 43 including 504 transphyseal surgeries in patients <16 years and 331 patients ≥16 years found graft rupture rates in these 2 groups of 21.6% and 16.4%, respectively. There is less data currently available on the partial or hybrid transphyseal technique available on reinjury rates; one prospective evaluation by Cordasco et al.…”

“…40 Barber-Westin et al 41 found in a recent systematic review of 1,239 patients undergoing transphyseal reconstruction a hamstring autograft failure rate of 15% and Pennock et al 42 found a failure rate of 21%. A large case series by DeFrancesco et al 43 including 504 transphyseal surgeries in patients <16 years and 331 patients !16 years found graft rupture rates in these 2 groups of 21.6% and 16.4%, respectively. There is less data currently available on the partial or hybrid transphyseal technique available on reinjury rates; one prospective evaluation by Cordasco et al 34 identified ACLR revision rate of 20% in 66 patients undergoing partial or complete transphyseal techniques, which was significantly greater than their all-epiphyseal (6%) and boneetendonebone autograft (6%) groups.…”

Return to Sports: A Risky Business? A Systematic Review with Meta-Analysis of Risk Factors for Graft Rupture Following ACL Reconstruction

“…Twelve of the included articles [185][186][187][188][189][190][191][192][193][194][195][196] were not eligible for meta-analysis (e.g., only one study assessing the specific risk factor or reported statistics not possible to calculate as odds ratios). individual study included in the meta-analyses).…”

Acute Management of Pediatric Knee Dislocations

“…Autograft ACL reconstruction has significantly lower rates of graft failure as compared to allograft. [47][48][49] Double-bundle or single-bundle PCL reconstruction, posterolateral corner, and posteromedial corner reconstructions can be performed with allograft in the adolescent patient population with acceptable outcomes. 6,50 PCL reconstruction is performed for those injuries with significant instability despite initial conservative management.…”