Outcomes of Pediatric Posterior Cruciate Ligament Reconstruction: A Systematic Review

Abstract

Background: Little has been reported in the literature regarding surgical treatment of posterior cruciate ligament (PCL) injuries in pediatric patients. Purpose/Hypothesis: The purpose was to evaluate presentation, injury pattern, outcomes, and complications of surgically managed PCL injuries in pediatric patients. It was hypothesized that pediatric patients would have good patient-reported outcomes and no significant radiographic changes or complications. Study Design: Systematic review; Level of evidence, 4. Methods: A literature search was performed using PubMed, Medline, EMBASE, Scopus, and Cochrane databases between 1975 and December 16, 2019. Search terms included “posterior cruciate ligament,” “peel-off injury,” “avulsion,” “PCL,” “pediatric,” “skeletally immature,” and “adolescent.” Included were studies on pediatric patients with PCL injuries managed operatively. Exclusion criteria included case reports, studies not reporting clinical results, reviews, abstract or conference papers, or papers not in the English language. Quality assessment was performed on all included studies using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Results: Four articles comprising 43 knees in 42 patients met the criteria and were included. Motor vehicle accidents were the most common mechanism of injury (39.5%; n = 17/43), followed by sports-related injuries (35%; n = 15/43). All studies commented on tear pattern, with the following distribution: 42% (n = 18/43) midsubstance tears, 37% (n = 16/43) tibial avulsions, and 21% (n = 9/43) femoral avulsions. Overall, good patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score and Pediatric International Knee Documentation Committee, Tegner, and Lysholm scores) and return to activity, as well as satisfactory posterior stability (KT-1000 arthrometer, posterior drawer test, and kneeling radiographs) and range of motion, were reported. There was no significant leg-length discrepancy or angular deformity reported. Arthrofibrosis was reported in 7% of postoperative knees and was the most commonly reported complication. Osteoarthritis was reported in 21% (n = 9/43) of knees. The average MINORS score was 7 (range, 6-8) for noncomparative studies and 10 for comparative studies. Conclusion: Good patient-reported outcomes and return to activity can be obtained using repair or reconstruction. This evidence was limited by the quality of the included studies and overall small sample size; however, this review serves as a baseline for futures studies on PCL repair/reconstruction in pediatric patients.

Treatment of a Failed Posterior Cruciate Ligament Avulsion Fracture Fixation in a Skeletally Immature Patient

“…Scarcella et al conducted a systematic review and reported on 42 pediatric patients who underwent either PCL repair or reconstruction, with only 1 patient experiencing a graft failure after a primary PCL reconstruction. This patient subsequently underwent a revision reconstruction with a bone-patellar-bone autograft with no growth-related complications 3 . By contrast, our patient experienced failure after a primary PCL repair and was subsequently treated with 2 years of rebound bracing and a revision reconstruction once skeletally mature to mitigate further risk of any physis-related growth disturbances, specifically when drilling the tibial tunnel during the reconstruction.…”

“…Treatment guidelines and clinical outcomes on skeletally immature patients who experience PCL repair failure are also limited 3,4 . Scarcella et al conducted a systematic review and reported on 42 pediatric patients who underwent either PCL repair or reconstruction, with only 1 patient experiencing a graft failure after a primary PCL reconstruction.…”

“…In comparison with adults, pediatric PCL injuries are even more uncommon, which may be attributed to the ligament being stronger and more resilient than epiphyseal bone in children and adolescents with open physes 2 . Although most isolated PCL tears in pediatric patients can be treated nonoperatively, reported outcomes for those who require surgical management are limited and confined to case reports and small case series 3,4 .…”

Posterior Cruciate Ligament Femoral Avulsion Fractures in Pediatric Patients

“…In 2021, Pacull et al identified 14 patients younger than 9 years with PCL cartilaginous injuries (cartilaginous avulsion or intrasubstance tear) 8 . In pediatric and adolescent patients, tibial PCL avulsions are more common than femoral PCL avulsions 6 . There are only 5 cases demonstrated in the literature of bony femoral PCL avulsions in patients 12 years and younger, in addition to the first case in this report (Table I).…”

“…PCL avulsions are reported more frequently off the tibial side. 6 PCL avulsion fractures can be treated nonoperatively, arthroscopically, or with arthrotomy and open surgery 5 . The timing of presentation affects the treatment selection, with delays in treatment being linked to malunion, nonunion, and instability 5 .…”