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Purpose: To compare the clinical and patient-reported outcomes of adolescent patients who underwent anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) versus hamstring tendon (HT) autograft., Methods: This was a retrospective cohort study of adolescent patients aged 18 years or younger treated at a single tertiary care children's hospital who underwent primary transphyseal ACLR using QT or HT between January 2018 and December 2019. All patients had minimum 6-month follow-up. Outcomes included isokinetic strength testing, postoperative Patient-Reported Outcomes Measurement Information System and International Knee Documentation Committee scores, and complications; these were compared between the QT and HT cohorts., Results: A total of 84 patients (44 HT and 40 QT patients) were included. The QT cohort had a higher proportion of male patients (62.5% vs 34.1%, P = .01). At 3 months, HT patients had a lower hamstring-quadriceps (H/Q) strength ratio (60.7 ± 11.0 vs 79.5 ± 18.6, P < .01) and lower Limb Symmetry Index in flexion (85.6 ± 16.1 vs 95.5 ± 15.7, P = .01) whereas QT patients had a lower Limb Symmetry Index in extension (67.3 ± 9.5 vs 77.4 ± 10.7, P < .01). The H/Q ratio at 6 months was lower in HT patients (59.4 ± 11.5 vs 66.2 ± 7.5, P < .01). Patient-Reported Outcomes Measurement Information System and International Knee Documentation Committee scores were not different at 3 months or latest follow-up. QT patients had more wound issues (20.0% vs 2.3%, P = .01). Patients receiving HT autograft had more ipsilateral knee injuries (18.2% vs 2.5%, P = .03), but there was no difference in graft failure for ACLR using HT versus QT (9.1% vs 2.5%, P = .36)., Conclusions: There were no differences in patient-reported outcome measures between patients receiving QT autografts and those receiving HT autografts. Patients with QT grafts had more postoperative wound issues but a lower rate of ipsilateral knee complications (graft failure or meniscal tear). Differences in quadriceps and hamstring strength postoperatively compared with the contralateral limb were observed for adolescent ACLR patients receiving QT and HT autografts, respectively. This contributed to higher H/Q ratios seen at 3 and 6 months postoperatively for patients receiving QT autografts., Level of Evidence: Level III, retrospective comparative therapeutic study., Competing Interests: Disclosures The authors report the following potential conflicts of interest or sources of funding: I.G. receives travel support from Stryker and receives educational support from Liberty Surgical, outside the submitted work. R.L.P. receives educational support from Gotham Surgical Solutions and Devices and receives personal fees from Stryker and DePuy Synthes Sales, outside the submitted work. T.J.G. receives grant support for unrelated research from Vericel and receives personal fees from Arthrex, outside the submitted work. All other authors (J.T.B., A.C.S., E.G., and C.J.D.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Full ICMJE author disclosure forms are available for this article online, as supplementary material., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Objective: To identify associations between race or insurance status and preoperative, intraoperative, and postoperative findings in a large cohort of pediatric anterior cruciate ligament (ACL) reconstructions., Design: Retrospective cohort study., Setting: Division of Orthopaedics at an urban tertiary care children's hospital., Patients: 915 pediatric (<21) patients undergoing primary ACL reconstruction between January 2009 and May 2016., Independent Variables: Insurance status and race., Main Outcome Measures: Delay to surgery, concurrent meniscal injury, sports clearance, postoperative complications, physical therapy, range of motion, and isokinetic strength reduction., Results: Multivariate analysis revealed a significantly longer delay to surgery for black/Hispanic and publicly insured children compared to their counterparts (P = 0.02 and P = 0.001, respectively). Black/Hispanic patients were more likely to sustain irreparable meniscus tears resulting in meniscectomy than white/Asian patients (odds ratio 2.16, 95% confidence interval, 1.10-2.29, P = 0.01). Black/Hispanic and publicly insured children averaged fewer physical therapy (PT) visits (P < 0.001 for both). Nine months after surgery, black/Hispanic patients had significantly greater strength reduction than white/Asian patients. There were no differences in postoperative complications, including graft rupture, contralateral ACL injury, or new meniscus tear along the lines of race, although privately insured patients were more likely to suffer a graft rupture than publicly insured patients (P = 0.006)., Conclusions: After ACL rupture, black/Hispanic children and publicly insured children experience a greater delay to surgery. Black/Hispanic patients have more irreparable meniscus tears and less PT visits. Black/Hispanic patients have greater residual hamstrings and quadriceps weakness 9 months after surgery.

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.

Background: Following anterior cruciate ligament (ACL) reconstruction, children are at significant risk for complications, including contralateral ACL rupture. The purpose of this study is to determine which children are at risk for a contralateral ACL tear after ipsilateral reconstruction., Methods: After review of medical records, we contacted patients who underwent primary ACL reconstruction between 2009 and 2016. Patients were included in the study if they were able to provide follow-up data either in person or remotely at least 2 years after surgery. Demographic data, sports participation, and intraoperative findings and techniques were recorded. All patients were also asked to confirm returning to sport information and postoperative complications (including contralateral ACL tear). Univariate analysis consisted of χ and independent samples t tests. Purposeful entry logistic regression was then conducted to control for confounding factors. Kaplan-Meier analysis was performed to assess contralateral ACL survival., Results: A total of 498 children with average follow-up of 4.3±2.1 years were included in the analysis. The mean age was 15.0±2.3 years and 262 patients (52.6%) were female. Thirty-five subjects (7.0%) sustained a contralateral ACL tear at a mean of 2.7±1.7 years following index reconstruction. Kaplan-Meier analysis revealed the median contralateral ACL survival time to be 8.9 years [95% confidence interval (CI): 8.3, 9.5 y]. In univariate analysis, 11.5% of female patients had a contralateral rupture compared with 2.1% of male patient (P<0.001). Patients with a contralateral tear had a mean age of 14.4±2.0 years compared with 15.1±2.3 years for those without an ACL injury in the opposite knee (P=0.04). After controlling for numerous factors in a multivariate model, female patients had 3.5 times higher odds of sustaining a contralateral ACL tear than male patients (95% CI: 1.1, 10.6; P=0.03). Each year of decreasing age raised the odds of contralateral injury by a factor of 1.3 (95% CI: 1.1, 1.6; P=0.02). Furthermore, children younger than 15 years had 3.1 times higher odds of contralateral rupture than those aged 15 and older (95% CI: 1.3, 7.2; P=0.01)., Conclusions: After adjusting for confounding factors in a multivariate model, female patients were at increased risk of contralateral ACL tear following ipsilateral reconstruction, as were younger children. Specifically, ACL rupture in the opposite knee was more likely in patients below the age of 15 years., Level of Evidence: Level III-prognostic study.

Introduction: Complication rates after physeal-sparing anterior cruciate ligament reconstruction (ACLR) are known to be high in the paediatric population compared with the adult population. However, the outcomes of these skeletally immature patients after all-epiphyseal reconstruction have not been compared with those after transphyseal reconstructions in a more similar age group. This study compares clinical outcomes and complications between all-epiphyseal and pediatric transphyseal ACLR., Methods: We retrospectively reviewed 1,056 pediatric patients undergoing primary ACLR between 2000 and 2015. Of these, 51 were excluded (5 extra-articular and 46 partial transphyseal reconstructions). Demographic data, intraoperative findings and techniques, postoperative complications (including graft rupture, contralateral anterior cruciate ligament [ACL] tear, and meniscus injuries), clearance for sports, range of motion (ROM), and isokinetic strength testing were recorded. Univariate analysis was followed by stepwise, binary logistic regressions to control for confounding factors., Results: During the study period, 162 patients underwent all-epiphyseal reconstruction (mean age, 12.1 ± 1.8 years) and 843 underwent transphyseal ACLR (mean age, 15.8 ± 1.9 years). At the time of surgery, more meniscus tears were found in the transphyseal group (76% versus 60%; P < 0.01). These patients also had more irreparable meniscus tears requiring partial meniscectomy (35% versus 18%; P < 0.01). Overall, the rates of graft failure, contralateral ACL injury, and new meniscus tears were 10.3%, 6.1%, and 14.2%, respectively. After controlling for confounders in a multivariate model, no difference was found in these postoperative complications between all-epiphyseal and transphyseal ACLR. Furthermore, no clinically significant difference was observed in postoperative ROM or isokinetic strength testing., Discussion: Skeletally immature patients undergoing all-epiphyseal ACLR had less irreparable meniscus tears than older children undergoing transphyseal reconstruction. After adjusting for age and other confounders, there was no difference in postoperative ROM or strength, nor an increased risk of graft rupture, contralateral ACL injury, or new meniscus tear in these young patients compared with older adolescents undergoing transphyseal ACLR., Level of Evidence: Level III.

Joint immobilization after anterior cruciate ligament (ACL) reconstruction may lead to intra-articular adhesions and range of motion deficits. Some practitioners thus advocate for the use of postoperative continuous passive motion (CPM) machine protocols. However, previous studies have failed to show CPM to be effective in increasing postoperative range of motion. Continuous passive motion has, however, been shown to reduce rates of arthrofibrosis requiring manipulation under anesthesia (MUA) in adult populations. To date, there has been no study of the efficacy of CPM after ACL reconstruction in a pediatric population. This was a retrospective cohort study of pediatric patients (age <20 years) who underwent primary ACL reconstruction at an urban tertiary care children's hospital. Clinically significant arthrofibrosis was defined as reduced knee flexion requiring MUA within 6 months of surgery. The final dataset included 163 patients. There was no significant difference between cohorts in range of motion at the 1-week, 1-month, 3-month, and 6-month time points (P=.137, .695, .897, and .339, respectively). The 2 cohorts also did not differ significantly in pain scores at these time points (P=.684, .623, .507, and 1.000, respectively). At 3 and 6 months, neither quadriceps nor hamstrings strength differed significantly between cohorts. Four patients (7.4%) in the no-CPM cohort required MUA for arthrofibrosis within 6 months of surgery, while no patients in the CPM cohort required MUA (P=.023). This suggests that CPM use reduces arthrofibrosis requiring MUA in pediatric patients after ACL reconstruction. Future work may better define the clinical utility and cost-effectiveness of CPM in rehabilitation after these surgeries. [Orthopedics. 2019; 42(1):e81-e85.]., (Copyright 2018, SLACK Incorporated.)

Purpose: To assess the relationship of elevated body mass index (BMI) on postoperative outcomes, including graft rupture, contralateral anterior cruciate ligament (ACL) tear, new meniscus injuries, isokinetic strength testing, and range of motion (ROM) in a large group of pediatric patients. We also sought to calculate the risk of graft rupture in overweight patients with small femoral or tibial tunnels. The secondary objective was to evaluate the association between BMI and concurrent meniscus tears and the need for meniscectomy at the time of primary ACL reconstruction., Methods: We retrospectively reviewed all pediatric patients undergoing primary ACL reconstruction at our institution. BMI percentile for age was used to categorize children as having normal BMI or being overweight or obese per Centers for Disease Control and Prevention guidelines. Demographic data, intraoperative findings and techniques, postoperative complications (including graft rupture, contralateral ACL tear, and meniscus injuries), ROM, and isokinetic strength testing were recorded. Univariate analysis was followed by stepwise, logistic regression to control for confounders., Results: Of the 1,056 patients included, 535 (50.7%) were male and 521 were (49.3%) female, with a mean age of 15.1 ± 2.4 years. The average BMI was 23.1 ± 4.7. There were 675 (63.9%) children with normal BMI, 228 (21.6%) who were overweight, and 153 (14.5%) who were obese. In multivariate analysis, children with elevated BMI had a higher rate of concurrent meniscus tears compared with those with normal BMI (76.3% vs 70.2%; P = .02) and 1.6 times higher odds of requiring a meniscectomy (95% confidence interval, 1.2-2.2; P < .01). The 723 patients included in the analysis of postoperative complications had a mean follow-up duration of 26.2 ± 3.3 months Postoperatively, BMI did not impact the rate of graft rupture, contralateral ACL injury, or new meniscus tears. There was no increased risk of graft failure in overweight children with smaller graft size (≤8 mm). There was no clinically relevant difference in postoperative ROM or isokinetic strength testing., Conclusions: After ACL rupture, overweight and obese children sustained more overall meniscus tears and more irreparable meniscus tears than those with normal BMI. Graft size did not impact the risk of early graft failure in overweight patients. With an appropriate rehabilitation protocol, there was no increased risk of graft rupture, contralateral ACL injury, or new meniscus tear in early follow-up., Level of Evidence: Level III, retrospective comparative study., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)