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The aim is to present a technique for pediatric and adult ACL reconstruction using an intraosseous suspensory fixation. This technique uses a 4-strands hamstring graft fixed in the femoral tunnel, with a loop locked in a polyetheretherketone (PEEK) cage. The ACLip® device offers an inside-out drilling system and a closer fixation to the joint than an extracortical button fixation. The technique can be easily used both in adults and in skeletally immature patients. The first practical experience shows promising results regarding the safety and the effectiveness of the technique. Level of evidence: IV.

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BACKGROUND: Pediatric athletes who undergo anterior cruciate ligament reconstruction are at risk for a growth deformity if the surgery violates the physes. CASE: A 12-year-old African American boy underwent anterior cruciate ligament reconstruction using a hamstring autograft. The procedure violated the distal femoral growth plate and the perichondrial ring of LaCroix, resulting in a distal femoral lateral physeal growth arrest. Three years later, he had developed a 15° valgus deformity, an increased quadriceps angle and patellofemoral instability. He was able to return to sports after undergoing a distal femoral osteotomy to correct the valgus and medial patellofemoral ligament reconstruction to stabilize the patella. CONCLUSION: Anterior cruciate ligament reconstruction in athletes with open physes has the potential to cause distal femoral valgus deformity, an increased quadriceps angle, and subsequent patellofemoral instability.

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BACKGROUND: Posterior hamstring harvest has been described in the adult population in a limited fashion, but no study is available describing the use of posterior hamstring harvest in an active pediatric and adolescent cohort. At times, surgeons may be faced with a challenging anterior harvest due to patient anatomic characteristics, particularly the anatomic features and size of the pes tendons. Clinicians need to have multiple harvest approaches at their disposal. Complications with hamstring harvest such as premature graft transection are more problematic in this population due to higher failure rates with allograft tissue. The posterior harvest via its more proximal location may allow for easier tendon identification, visualization of the accessory attachments, and longer preserved tendon length if transection error occurs when the anterior approach is avoided based on surgical technique, patient anatomic characteristics, and surgeon and patient preference. PURPOSE: To describe the technique of a posterior hamstring harvest in pediatric and adolescent patients and to analyze complications. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study was a retrospective review of a consecutive series of pediatric and adolescent patients who underwent posterior hamstring harvest. During surgery, the patient's leg was abducted and externally rotated to expose the posteromedial aspect of the knee. A 2-cm incision was made overlying the palpable medial hamstring at the popliteal crease. The posterior hamstring tendons were first harvested proximally with an open tendon stripper and distally with a closed stripper. Preoperative, intraoperative, and postoperative findings and complications were analyzed. RESULTS: A total of 214 patients (mean ± SD age, 15.7 ± 4.1 years; range, 8.0-19.8 years) underwent posterior harvest, with a mean ± SD follow-up of 1.83 ± 1.05 years. No complications occurred in our series related to graft harvest-no graft transections, neurovascular injuries, secondary procedures for wound healing or closure, cosmetic concerns, or limitations in return to activity due to the posterior incision. CONCLUSION: The posterior hamstring harvest is a safe and reliable technique to harvest autograft tendon in pediatric and adolescent anterior cruciate ligament reconstructions. The posterior technique entailed no complications related to harvest. No patients expressed any cosmetic concerns about their incision or had limitations in return to sport due to the posterior harvest.

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BACKGROUND: Anterior cruciate ligament reconstruction is becoming more common in skeletally immature individuals, and it may be performed with transphyseal or physeal-sparing techniques. A number of studies have assessed the outcomes of these techniques, but there is a need to systematically evaluate the pooled data from these studies. PURPOSE: To compare the differences in demographics and outcomes of transphyseal and physeal-sparing techniques by assessing (1) demographics, (2) incidence of growth disturbances, and (3) graft survivorship in the pediatric population. STUDY DESIGN: Systematic review. METHODS: A thorough review of 3 databases was performed to identify all studies that evaluated outcomes after pediatric reconstruction based on transphyseal or physeal-sparing techniques. After completing our search and cross-referencing for additional sources, 43 reports were identified for this review. Reports were analyzed for differences in demographics as well as incidence of leg-length discrepancies, angular deformities, and graft survivorship. After review of manuscripts, 27 studies were included for review (21 transphyseal and 6 physeal-sparing studies). RESULTS: Those who had transphyseal reconstruction were more likely to be female (39% vs 20%; P = .0001), while those with the physeal-sparing surgery were younger (12 vs 13.5 years of age; P = .0001). The transphyseal and physeal-sparing cohorts demonstrated similar incidence rates of leg-length discrepancies (0.81% vs 1.2%, respectively; P = .64) and angular deformities (0.61% vs 0%, respectively; P = .36). The transphyseal and physeal-sparing cohorts also showed similar rates of rerupture (6.2% vs 3.1%, respectively; P = .11). CONCLUSION: Although the study groups were not well matched with regard to age and sex, our results show that these surgical techniques have no differences in incidence of growth disturbances or graft survivorship. Younger males tend to undergo physeal-sparing reconstruction. Future research should focus on long-term outcome metrics with the physeal-sparing techniques, as there remains a paucity of studies regarding them.

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BACKGROUND: There have been no population-based studies to evaluate the rate of pediatric anterior cruciate ligament (ACL) reconstruction. PURPOSE: The primary aim of the current study was to determine the yearly rate of ACL reconstruction over the past 20 years in New York State. Secondary aims were to determine the age distribution for ACL reconstruction and determine whether patient demographic and socioeconomic factors were associated with ACL reconstruction. STUDY DESIGN: Descriptive epidemiology study. METHODS: The Statewide Planning and Research Cooperative System (SPARCS) database contains a census of all hospital admissions and ambulatory surgery in New York State. This database was used to identify pediatric ACL reconstructions between 1990 and 2009; ICD-9-CM (International Classification of Diseases, 9 Revision, Clinical Modification) and CPT-4 (Current Procedural Terminology, 4th Revision) codes were used to identify reconstructions. Patient sex, age, race, family income, education, and insurance status were assessed. RESULTS: The rate of ACL reconstruction per 100,000 population aged 3 to 20 years has been increasing steadily over the past 20 years, from 17.6 (95% confidence interval [CI], 16.4-18.9) in 1990 to 50.9 (95% CI, 48.8-53.0) in 2009. The peak age for ACL reconstruction in 2009 was 17 years, at a rate of 176.7 (95% CI, 160.9-192.5). In 2009, the youngest age at which ACL reconstruction was performed was 9 years. The rate of ACL reconstruction in male patients was about 15% higher than in females, and ACL reconstruction was 6-fold more common in patients with private health insurance compared with those enrolled in Medicaid. CONCLUSION: This study is the first to quantify the increasing rate of ACL reconstructions in the skeletally immature. Only ACL reconstructions were assessed, and it is possible that some ACL tears in children are not diagnosed or are treated nonoperatively. The rate of ACL tears in New York State is likely higher than the rate of reconstructions reported in this study. SIGNIFICANCE: This study quantifies the increasing rate of ACL reconstruction in the skeletally immature and suggests that there may be some disparities in care based on insurance status.

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BACKGROUND: Debate regarding the optimal initial treatment for anterior cruciate ligament (ACL) injuries in children and adolescents has not resulted in a clear consensus for initial nonoperative treatment or operative reconstruction. HYPOTHESIS/PURPOSE: The purpose of this meta-analysis was to systematically analyze aggregated data from the literature to determine if a benefit exists for either nonoperative or early operative treatment for ACL injuries in the pediatric patient. The hypothesis was that combined results would favor early operative reconstruction with respect to posttreatment episodes of instability/pathological laxity, symptomatic meniscal tears, clinical outcome scores, and return to activity. STUDY DESIGN: Meta-analysis. METHODS: A literature selection process included the extraction of data on the following clinical variables: symptomatic meniscal tears, return to activities, clinical outcome scores, return to the operating room, and posttreatment instability/pathological laxity. A symptomatic meniscal tear was defined as occurring after the initial presentation, limiting activity, and requiring further treatment. Instability/pathological laxity was defined for the sake of this study as having an episode of giving way, a grade ≥2 Lachman/pivot-shift test result, or a side-to-side difference of >4 mm as measured by the KT-1000 arthrometer. All studies were evaluated using a formal study quality analysis. Meta-analysis was conducted for aggregated data in each category. RESULTS: Six studies (217 patients) comparing operative to nonoperative treatment and 5 studies (353 patients) comparing early to delayed reconstruction were identified. Three studies reported posttreatment instability/pathological laxity; 13.6% of patients after operative treatment experienced instability/pathological laxity compared with 75% of patients after nonoperative treatment (P < .01). Two studies reported symptomatic meniscal tears; patients were over 12 times more likely to have a medial meniscal tear after nonoperative treatment than after operative treatment (35.4% vs 3.9%, respectively; P = .02). A significant difference in scores between groups was noted in 1 of 2 studies reporting International Knee Documentation Committee (IKDC) scores (P = .002) and in 1 of 2 studies reporting Tegner scores (P = .007). Two studies reported return to activity; none of the patients in the nonoperative groups returned to their previous level of play compared with 85.7% of patients in the operative groups (P < .01). Study quality analysis revealed that the majority of the studies were inconsistent in reporting outcomes. CONCLUSION: Meta-analysis revealed multiple trends that favor early surgical stabilization over nonoperative or delayed treatment. Patients after nonoperative and delayed treatment experienced more instability/pathological laxity and inability to return to previous activity levels than did patients treated with early surgical stabilization.

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