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      Return to sport activity after anterior cruciate ligament reconstruction in skeletally immature athletes with manual drilling original all inside reconstruction at 8 years follow-up


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          Anterior cruciate ligament (ACL) tears are common injuries in adolescent athletes, especially in those who bear high stress on their knees due to shearing forces. The goal of the surgical procedures in skeletally immature patients is to restore joint stability avoiding the adverse effects on the growth process.

          The aim of this study was to verify the return of the skeletally immature professional athletes to sports in the long-term, following ACL reconstruction with the original all-inside technique and with manual drilling.


          This study included 24 athletes (14 boys, 10 girls; mean age: 13.15 years, range: 9–14 years) who had radiographic evidence of open physes, were less than 14 years of age at the time of surgery and those with a minimum follow-up of eight years. All patients completed a questionnaire, the IKDC subjective knee evaluation form, and Tegner Activity Scale. Biomechanical outcomes of the KT-1000 arthrometer, gait analysis, and stabilometric and isokinetic results were also evaluated. A plain radiograph of both lower limbs was taken to obtain a precise measurement of the limb length and mechanical axis angles.


          The patients returned to sport activities in a mean time of 6.43 months. No rerupture or resurgery due to growth abnormalities was observed. The mean difference in length between the operated and contralateral legs was 0.4 (range: −0.2 to 0.7) cm. The mean side-to-side difference measured with the KT-1000 arthrometer was 5.2 (range: 3.5 to 7) mm in the preoperative and 0.8 (range: 0 to 2.5) mm in the postoperative measurements.


          In conclusion, the original all-inside technique with manual drilling with a half tunnel and short graft seems to be a very effective technique for the surgical management of ACL injuries in pediatric/adolescent athletes. A good rate of return to sports at pre-injury levels or higher, high patient satisfaction and a decent motor and proprioceptive function is possible as shown by our analysis.

          Level of evidence

          Level IV, Therapeutic study.

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          Most cited references22

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          Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and The ACL Study Group.

          Expert opinion regarding experience with the management and complications of pediatric anterior cruciate ligament (ACL) injuries was studied by surveying members of The Herodicus Society and The ACL Study Group. There was large practice variation in initial management and ACL reconstruction technique. There were 15 reported cases of growth disturbance: 8 cases of distal femoral valgus deformity with arrest of the lateral distal femoral physis, 3 cases of tibial recurvatum with arrest of the tibial tubercle apophysis, 2 cases of genu valgum without arrest, and 2 cases of leg length discrepancy. Associated factors included fixation hardware across the lateral distal femoral physis in 3 cases, bone plugs of a patellar tendon graft across the distal femoral physis in 3 cases, large (12 mm) tunnels in 2 cases, fixation hardware across the tibial tubercle apophysis in 3 cases, lateral extra-articular tenodesis in 2 cases, and over-the-top femoral position in 1 case. Based on this experience, we recommend a guarded approach to ACL reconstruction in the skeletally immature patient with careful attention to technique and follow-up.
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            Outcomes and risks of operative treatment of rupture of the anterior cruciate ligament in children and adolescents.

            The aim of this meta-analysis was to evaluate the clinical outcomes and risks of anterior cruciate ligament (ACL) surgery in children and adolescents. We electronically searched Medline, the Cochrane Controlled Trial Database, Embase, and Medpilot for studies on surgical treatment for ACL ruptures in skeletally immature patients. We extracted baseline demographics, follow-up intervals, surgical details (i.e., ligament suture or reconstruction, physeal-sparing or transphyseal techniques, type of transplant, and methods of fixation). Endpoints comprised rates of growth disturbances and reruptures, as well as knee function (measured by the International Knee Documentation Committee's documentation system and the Lysholm score). Unweighted overall effect sizes (risks, risk ratios [RRs], and means of functional scores) were estimated by use of crude nominators and denominators, and random-effects meta-regression analysis was used for weighted data synthesis. A total of 55 articles reporting on 935 patients (median age, 13 years; range, 1.5 to 16 years) were suitable for the study. After a median follow-up of 40 months (range, 14 to 89 months), the weighted rate of leg-length differences or axis deviations was 1.8% (95% confidence interval [CI], 0% to 3.9%] and that of reruptures was 4.8% (95% CI, 2.9% to 6.7%). Excellent or good function (International Knee Documentation Committee grade A or B) was achieved in 84.2% (95% CI, 75.8% to 92.6%) of all knees, and Lysholm scores averaged 96.3 (95% CI, 95.5 to 97.2). Transphyseal reconstruction was associated with a significantly lower risk of leg-length differences or axis deviations compared with physeal-sparing techniques (1.9% v 5.8%; RR, 0.34; 95% CI, 0.14 to 0.81) but had a higher risk of rerupture (4.2% v 1.4%; RR, 2.91; 95% CI, 0.70 to 12.12). Sutures did not result in any growth disturbances, with a weighted rerupture rate of 4.6% (95% CI, 2.6 to 6.7). Fixation far from the joint line fared better than close fixation with regard to this endpoint (1.4% v 3.2%; RR, 0.42; 95% CI, 0.09 to 1.93). Bone-patellar tendon-bone grafts, which are also less likely to fail, were associated with higher risks of leg-length differences or axis deviations than were hamstrings (3.6% v 2.0%; RR, 1.82; 95% CI, 0.66 to 5.03). Meta-regression did not show a significant impact of the publication year on event rates. This meta-analysis showed low rates of leg-length differences or axis deviations and graft failures after ACL reconstruction in skeletally immature patients. Hamstring transplants may lower the risk of leg-length differences or axis deviations, and physeal-sparing techniques may increase the risk. Randomized controlled trials are needed to clarify important issues in managing ACL ruptures in children and adolescents. Level IV, meta-analysis of case series. Copyright © 2010 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
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              Treating anterior cruciate ligament tears in skeletally immature patients.

              To systematically review the current evidence for conservative and surgical treatment of anterior cruciate ligament (ACL) tears in skeletally immature patients. A systematic search of PubMed, CINAHL, EMBASE, CCTR, and CDSR was performed for surgical and/or conservative treatment of complete ACL tears in immature individuals. Studies with less than six months of follow-up were excluded. Study quality was assessed and data were collected on clinical outcome, growth disturbance, and secondary joint damage. We identified 48 studies meeting the inclusion criteria. Conservative treatment was found to result in poor clinical outcomes and a high incidence of secondary defects, including meniscal and cartilage injury. Surgical treatment had only very weak evidence for growth disturbance, yet strong evidence of good postoperative stability and function. No specific surgical treatment showed clearly superior outcomes, yet the studies using physeal-sparing techniques had no reported growth disturbances at all. The current best evidence suggests that surgical stabilization should be considered the preferred treatment in immature patients with complete ACL tears. While physeal-sparing techniques are not associated with a risk of growth disturbance, transphyseal reconstruction is an alternative with a beneficial safety profile and a minimal risk of growth disturbance. Conservative treatment commonly leads to meniscal damage and cartilage destruction and should be considered a last resort. Level IV, systematic review of Level II, III, and IV studies.

                Author and article information

                Acta Orthop Traumatol Turc
                Acta Orthop Traumatol Turc
                Acta Orthopaedica et Traumatologica Turcica
                Turkish Association of Orthopaedics and Traumatology
                03 November 2016
                December 2016
                03 November 2016
                : 50
                : 6
                : 635-638
                [a ]Institute of Orthopedics and Traumatology, Catholic University of the Sacred Heart, ‘Agostino Gemelli’ Hospital, Largo Agostino Gemelli 8, 00168 Rome, Italy
                [b ]Royal National Orthopaedi Hospital, Stanmore, London, UK
                Author notes
                []Corresponding author. Let People Move, via G.B. Pontani, 9, Italy. Fax: +39 075 5292165. giacomo.placella@ 123456gmail.com
                © 2016 Turkish Association of Orthopaedics and Traumatology. Publishing services by Elsevier B.V.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                Original Article

                all-inside, acl, athlete, sports, adolescent


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