Risk Factors for Failure After Anterior Cruciate Ligament Reconstruction in a Pediatric Population: A Prediction Algorithm

Abstract

Background: Anterior cruciate ligament reconstruction (ACLR) in pediatric patients is becoming increasingly common. There is growing yet limited literature on the risk factors for revision in this demographic. Purpose: To (1) determine the rate of pediatric revision ACLR in a nationally representative sample, (2) ascertain the associated patient- and injury-specific risk factors for revision ACLR, and (3) examine the differences in the rate and risks of revision ACLR between pediatric and adult patients. Study Design: Case-control study; Level of evidence, 3. Methods: The PearlDiver patient record database was used to identify adult patients (age ≥20 years) and pediatric patients (age <20 years) who underwent primary ACLR between 2010 and 2015. At 5 years postoperatively, the risk of revision ACLR was compared between the adult and pediatric groups. ACLR to the contralateral side was also compared. Multivariate logistic regression was used to determine the significant risk factors for revision ACLR and the overall reoperation rates in pediatric and adult patients; from these risk factors, an algorithm was developed to predict the risk of revision ACLR in pediatric patients. Results: Included were 2055 pediatric patients, 1778 adult patients aged 20 to 29 years, and 1646 adult patients aged 30 to 39 years who underwent ACLR. At 5 years postoperatively, pediatric patients faced a higher risk of revision surgery when compared with adults (18.0 % vs 9.2% [adults 20-29 years] and 7.1% [adults 30-39 years]; P < .0001), with significantly decreased survivorship of the index ACLR ( P < .0001; log-rank test). Pediatric patients were also at higher risk of undergoing contralateral ACLR as compared with adults (5.8% vs 1.6% [adults 20-29 years] and 1.9% [adults 30-39 years]; P < .0001). Among the pediatric cohort, boys (odds ratio [OR], 0.78; 95% CI, 0.63-0.96; P = .0204) and patients >14 years old (OR, 0.62; 95% CI, 0.45-0.86; P = .0035) had a decreased risk of overall reoperation; patients undergoing concurrent meniscal repair (OR, 1.84; 95% CI, 1.43-2.38; P < .0001) or meniscectomy (OR, 2.20; 95% CI, 1.72-2.82; P < .0001) had an increased risk of revision surgery. According to the risk algorithm, the highest probability for revision ACLR was in girls <15 years old with concomitant meniscal and medial collateral ligament injury (36% risk of revision). Conclusion: As compared with adults, pediatric patients had an increased likelihood of revision ACLR, contralateral ACLR, and meniscal reoperation within 5 years of an index ACLR. Families of pediatric patients—especially female patients, younger patients, and those with concomitant medial collateral ligament and meniscal injuries—should be counseled on such risks.

Combining Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Procedures in Skeletally Immature Patients Is Safe and Associated With a Low Failure Rate

“…ACL reconstruction in young patients remains linked to a high rate of graft failure 15 , 16 , 17 and to potential growth disorders 18 , 19 : being a child has been described as a major risk factor for graft failure in comparison with an adult population in a large cohort of 5,479 patients (18.0% [pediatric <20 years old] vs 9.2% [adults 20-29 years old] and 7.1% [adults 30-39 years old]; P < .0001 at 5 years postoperatively). 20 …”

Risk Factors for Revision or Rerupture After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

“…However, it is worth noting that there was high heterogeneity between studies in the pediatric and adolescent populations. Lemme et al 69 suggested that both meniscal injury and surgery significantly increased postoperative revision or rerupture. This study 69 , however, included multiligamentous knee reconstruction, and there was a lack of corresponding data in terms of graft types and surgical techniques.…”

“…Lemme et al 69 suggested that both meniscal injury and surgery significantly increased postoperative revision or rerupture. This study 69 , however, included multiligamentous knee reconstruction, and there was a lack of corresponding data in terms of graft types and surgical techniques. In contrast, the study of Cordasco et al 24 excluded multiligamentous knee reconstruction.…”

“…Considerably high heterogeneity was found in the outcome. Sensitivity analysis found that the studies of Cordasco et al, 24 Lemme et al, 69 and Pullen et al 105 were the main sources of heterogeneity. I 2 could be reduced to 0% after the studies were removed, and pooled analysis of the remaining studies still showed no significant differences and no significant change from the original result (OR, 1.10; 95% CI, 0.86-1.39; P = .45), indicating the robustness of the final outcome.…”

Reliability of MRI Detection of Kaplan Fiber Injury in Pediatric and Adolescent Patients with ACL Tears

“…Although the rates of concomitant ligament tears for pediatric patients may be lower in the setting of ACL injuries, pediatric and adolescent patients undergoing ACL reconstruction have been shown to have significantly higher rates of retear compared with adults. 15 Wasserstein et al 28 analyzed more than 12,000 ACL reconstruction procedures and found that young age (15-19 years) was a significant independent risk factor for failure. Asai and colleagues 1 reported that 14.8% of skeletally immature patients required revision compared with 2.9% of adults.…”