Youth soccer players: patterns of injury involving the primary growth plates of epiphyses.

Youth soccer (football) is immensely popular internationally. Earlier participation, sport sub-specialization, and year-around practice have led to an increased incidence of injury from both acute trauma and repetitive overuse. The growth plates (physes) of the immature skeleton are particularly vulnerable to injury and delayed diagnosis can lead to future growth disturbance and long-term morbidity. Familiarity with the various components of the growth plate complex necessary for ensuring normal endochondral ossification is fundamental in understanding the various patterns of imaging findings following injury. This review discusses the zonal columnar arrangement of the growth plate proper and the contrasting function of the vasculature within the subjacent epiphysis and metaphysis. This is followed by an evidence-based discussion of the common patterns of injury involving the epiphyseal primary growth plate observed among youth soccer players: subcategorized into physeal fractures (direct injury) and physeal stress injuries (indirect insult to subjacent metaphysis). In this section, the role of imaging and characteristic imaging features will be discussed. While the normal physiologic and pathophysiologic mechanisms can be applied to other growth plates, such as primary growth plates underlying the apophyses and secondary growth plates surrounding the secondary ossificiation centers, which also undergo endochondral ossification, the current review is focused on injuries involving the primary growth plates underlying epiphyses.

Anterior cruciate ligament reconstruction in skeletally immature patients is effective: A systematic review.

PURPOSE: The present study evaluated the outcomes of anterior cruciate ligament (ACL) reconstruction in children with open physes. The outcomes of interest were to compare the increase in joint laxity and PROMs from baseline to the last follow-up, the rate and features of the return to sport and the rate of complications. METHODS: This study was conducted according to the 2020 PRISMA guidelines. In October 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles which clearly stated that surgeries were conducted in children with open physis were eligible. RESULTS: Data from 53 studies (1691 procedures) were collected. 35% (597 out of 1691 patients) were women. The mean length of the follow-up was 44.7 ± 31.3 months. The mean age of the patients was 12.7 ± 1.1 years old. All PROMs significantly improved from the baseline values to those at the last follow-up. The mean time to return to sport was 8.3 ± 1.9 months. 89% (690 out of 771 patients) returned to sports, 15% (109 out of 721 patients) reduced their level of sports activity or league, and 84% (651 out of 771 patients) returned to their previous level of sport. 9% (112 out of 1213) of patients experienced re-tear of the reconstructed ACL, and 11% (75 out of 660) of patients underwent a further ACL reoperation. No patients (0 out of 83) demonstrated increased laxity at the last follow-up, and persistent sensation of instability was reported by 5% (11 out of 235) of patients. CONCLUSION: ACL reconstruction in skeletally immature patients is effective and safe, and is associated with fast recovery and a high rate of return to sport. LEVEL OF EVIDENCE: Level IV.

The posterior condyle grows in the direction of the increasing posterior condylar offset and the inclination angle of the ACL changes accordingly.

PURPOSE: The purpose of this study was to reveal the changes in the shape of the posterior femoral condyle and the morphology of the ACL, both before and after epiphyseal closure. The hypothesis of this study is that the morphological change of the posterior femoral condyle and that of the ACL may be correlated to some extent. METHODS: Eighty-one patients who underwent surgery for the knee joint (meniscal repair, arthroscopic synovectomy, medial patellofemoral ligament reconstruction) between 2016 and 2021 were included in this study, 48 patients aged 13 years or under (before epiphysis closure; mean age: 10.9 (range: 7-13) and 33 patients aged over 18 years or over (after epiphysis closure; mean age: 21.7 (range: 18-30). The shape of the posterior femoral condyle was evaluated via lateral view radiographs, and the morphology of the ACL was measured via sagittal and coronal magnetic resonance imaging (MRI) images. RESULTS: The morphology of the posterior condyle in the lateral view radiograph in patients aged 13 and under was larger in the direction of the short axis of the femur compared with that in those aged 18 and over (p < 0.001). The mean value of the inclination angle of the anterior cruciate ligament (ACL) in the sagittal plane was significantly smaller in patients aged 13 and under (41.7° ± 3.7) than in those aged 18 and over (48.5° ± 4.2) (p < 0.001). The mean values of the inclination angle of the ACL in the coronal plane were significantly smaller in patients aged 13 and under (55.7° ± 6.4) than in those aged 18 and over (63.4° ± 4.4) (p < 0.001). CONCLUSION: This study evaluates and compares the shape of the posterior femoral condyle and the morphology of the ACL fiber before and after epiphyseal closure. The posterior femoral condyle grew posteriorly rather than longitudinally, and the inclination of the ACL fibers was thought to change accordingly. LEVEL OF EVIDENCE: Level Ⅲ.

All-epiphyseal anterior cruciate ligament reconstruction yields superior sports performances than the trans-epiphyseal technique in skeletally immature patients: a systematic review.

BACKGROUND: Anterior cruciate ligament (ACL) tears in skeletally immature patients are increasingly common. Evidence comparing the outcomes of all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients is limited, and the current literature could benefit from a comprehensive systematic review. The present study compared all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients. The outcomes of interest were to compare joint laxity, patient-reported outcome measures (PROMs), return to sport, and complications. METHODS: This study was conducted according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. In November 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. No additional filters were used in the database search. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles that clearly stated the surgical technique (all- or trans-epiphyseal) were eligible. Only articles with a minimum of 6 months of follow-up were included. Only articles that clearly stated that surgeries were conducted in children with open physis were eligible. RESULTS: Data from 1489 patients (1493 procedures) were collected, of which 32% (490 of 1489 patients) were female. The mean length of follow-up was 46.6 months. The mean age of the patients was 12.7 years. No difference was found in joint laxity (Table 3): positive pivot shift (P = 0.4), positive Lachman test (P = 0.3), and mean arthrometer laxity (P = 0.1). No difference was found in PROMs (Table 4): International Knee Documentation Committee (IKDC) (P = 0.3), Lysholm (P = 0.4), and Tegner (P = 0.7). The trans-epiphyseal technique was associated with a greater rate of patients unable to return to sports (1% versus 7%, P = 0.0001) and with a longer time to return to sports (7.7 versus 8.6 months, P = 0.01). Though the trans-epiphyseal technique was associated with a lower rate of return to sport, this difference was not statistically significant (P = 0.8). No difference was evidenced in the rate of patients who had reduced their league or level of sports activity (P = 0.6) or in the rate of patients who had returned to their previous league or level of sports activity (P = 0.7). No difference was found in the rate of complication: re-tear (P = 0.8), reoperation (P = 0.7), increased laxity (P = 0.9), and persistent instability sensation (P = 0.3). CONCLUSION: Trans-epiphyseal ACL reconstruction was associated with a greater rate of patients unable to return to sport and with a longer time to return to sport compared with the all-epiphyseal technique in skeletally immature patients. Level of evidence Level III, systematic review.

Clinical outcomes of different autografts used for all-epiphyseal, partial epiphyseal or transphyseal anterior cruciate ligament reconstruction in skeletally immature patients - a systematic review.

BACKGROUND: Different types of grafts can be used for anterior cruciate ligament reconstruction (ACLR). There is little published data regarding skeletally immature patients. The purpose of this systematic review was to assess the clinical outcomes and complications for different autograft types used in all-epiphyseal, transphyseal and partial epiphyseal/hybrid ACLR in skeletally immature children and adolescents. METHODS: PubMed, Embase and Cochrane databases were systematically searched for literature regarding ACLR using hamstrings, quadriceps or bone-patellar-tendon-bone (BPTB) autografts in skeletally immature patients. Studies were included if they examined at least one of the following outcomes: graft failure, return to sport(s), growth disturbance, arthrofibrosis or patient reported outcomes and had a minimum follow-up of 1 year. Case reports, conference abstracts and studies examining allografts and extra-articular or over-the-top ACL reconstruction techniques were excluded. Graft failure rates were pooled for each graft type using the quality effects model of MetaXL. A qualitative synthesis of secondary outcomes was performed. RESULTS: The database search identified 242 studies. In total 31 studies were included in this review, comprising of 1358 patients. Most patients (81%) were treated using hamstring autograft. The most common used surgical technique was transphyseal. The weighted, pooled failure rate for each graft type was 12% for hamstring tendon autografts, 8% for quadriceps tendon autografts and 6% for BPTB autografts. Confidence intervals were overlapping. The variability in time to graft failure was high. The qualitative analysis of the secondary outcomes showed similar results with good clinical outcomes and low complication rates across all graft types. CONCLUSIONS: Based on this review it is not possible to determine a superior graft type for ACLR in skeletally immature. Of the included studies, the most common graft type used was the hamstring tendon. Overall, graft failure rates are low, and most studies show good clinical outcomes with high return to sports rates.

Giant cell tumor of bone in the pediatric population: a retrospective study highlighting cases of metaphyseal only location and increased local recurrence rates in skeletally immature patients.

OBJECTIVE: To describe the presentation of giant cell tumors (GCT) of the bone in the pediatric population to (1) improve the differential diagnosis of pediatric bone tumors and (2) identify the origin of GCT. Understanding the origin of bone tumors assists in establishing appropriate diagnoses and recommending treatment options. This is particularly important in children, where evaluating the need for invasive procedures is balanced with the desire to avoid overtreatment. GCT have historically been considered epiphyseal lesions with potential metaphyseal extension. Therefore, GCT may be inappropriately excluded from the differential diagnosis of metaphyseal lesions in the skeletally immature. MATERIALS AND METHODS: We identified 14 patients from 1981 to 2021 at a single institution who had histologic confirmation of GCT and were less than 18 years old at diagnosis. Patient characteristics, tumor location, surgical treatment, and local recurrence rates were collected. RESULTS AND CONCLUSIONS: Ten (71%) patients were female. Eleven (78.6%) were epiphysiometaphyseal (1 epiphyseal, 4 metaphyseal, 6 epiphysiometaphyseal). Five patients had an open adjacent physis, of which three (60%) had tumors confined solely to the metaphysis. Of the five patients with open physis, four (80%) developed local recurrence while only one patient (11%) with a closed physis had local recurrence (p value = 0.0023). Our results illustrate that for the skeletally immature, GCT can (and in our results more commonly did) occur in the metaphyseal location. These findings suggest that GCT should be included in the differential diagnosis of primary metaphyseal-only lesions in the skeletally immature.

Autologous chondrocyte implantation in the knee is effective in skeletally immature patients: a systematic review.

PURPOSE: This systematic review evaluated the efficacy and safety of autologous chondrocyte implantation (ACI) for chondral defects of the knee in skeletally immature patients. Current available data from patients reported outcome measures (PROMs) and complications were collected, analyzed, and discussed. METHODS: This systematic review was conducted according to the PRISMA guidelines. The following databases were accessed in May 2022: PubMed, Google scholar, Embase, and Scopus. All the clinical studies investigating the efficacy of ACI to manage chondral defects of the knee in skeletally immature patients were accessed. Articles treating patients with surgical procedures other than ACI were not eligible, nor were studies with a follow-up shorter than 12 months. RESULTS: Data from 9 studies (251 procedures) were collected. 32% (80 of 251) of patients were females. The mean length of follow-up was 44.2 ± 29.4 (range, 12-115) months. The mean age of the patients was 16.4 ± 0.7 (range, 15-17) years. The Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Document Committee (IKDC) increased of + 41.9/100 (P = 0.003) and + 33.2/100 (P = < 0.0001) points, respectively. The Lysholm Knee Score improved of + 20.6/100 (P = 0.02) points. The Visual Analogue Scale (VAS) for pain reduced of - 3.6/10 (P = 0.004) points. The Tegner scale did not show any statistically significant improvement from baseline to follow-up (P = n.s.). The rate of graft hypertrophy was 12.5% (5 of 40 patients), and the rate of failure 5.6% (8 of 142 patients). CONCLUSION: ACI for chondral defects of the knee is effective to improve PROMs in skeletally immature patients. The safety profile of ACI still remains controversial. LEVEL OF EVIDENCE: III.

Differences in the microstructural and mechanical qualities of semitendinosus tendon grafts between skeletally immature and mature patients in anterior cruciate ligament reconstruction.

BACKGROUND: This study aimed to investigate the microstructural and mechanical properties of semitendinosus tendon graft tissues during anterior cruciate ligament reconstruction and the clinical outcomes in skeletally immature and mature patients. METHODS: Twenty-two patients who underwent primary anterior cruciate ligament reconstruction using a hamstring tendon graft were analyzed and divided into skeletally immature (n = 7) and mature groups (n = 15) based on magnetic resonance imaging findings of the epiphyseal plate of the distal femur. Tissue samples were collected from the mid-portion of the semitendinosus tendon. The collagen fibril diameter, maximum stress, and strain at maximum stress point in the semitendinosus tendon tissues were calculated for comparison of the microstructural and mechanical properties between the two groups. Postoperative outcomes were also assessed between the two groups. RESULTS: The mean and 60th and 80th percentiles of fibril diameters in the skeletally immature group were significantly smaller than those in the mature group (65.9 ± 13.0, 73.5 ± 19.3, and 91.3 ± 27.4 nm in the skeletally immature group; and 90.3 ± 14.7, 94.0 ± 18.4, and 125.3 ± 19.9 nm in the skeletally immature group; p = 0.001, 0.024, and 0.004, respectively). Additionally, the strain at maximum stress was higher in the skeletally immature group (237.2 ± 102.4% vs. 121.5 ± 51.9%, p = 0.024). However, there was no difference in maximum stress between the skeletally immature and mature groups (19.9 ± 14.3 MPa vs. 24.5 ± 23.4 MPa, p = 0.578). Strain was negatively correlated with the mean fibril diameter and the 60th and 80th percentiles of fibril diameters, whereas stress was positively correlated with the mean fibril diameter. The skeletally immature group had a higher pivot shift test-positive rate than the mature group at the last follow-up (p = 0.023). CONCLUSION: Semitendinosus tendon graft tissues differed microstructurally and mechanically between skeletally immature and mature patients. LEVEL OF EVIDENCE: Level Ⅳ.

Postoperative radiographic observations following transphyseal anterior cruciate ligament reconstruction in skeletally immature patients.

OBJECTIVE: To characterize the changes to bone tunnels, graft fixation devices, and physes that occur on radiographs of skeletally immature individuals at least 2 years after transphyseal anterior cruciate ligament reconstruction (ACLR). MATERIALS AND METHODS: Skeletally immature patients who underwent transphyseal ACLR were recruited to complete postoperative assessment at ≥ 2 years. The dimensions of tibial and femoral bone tunnels, position of graft fixation devices, and presence of growth arrest were assessed on radiographs, and pain visual analog and International Knee Documentation Committee scores were obtained. Paired t tests were used for comparisons. RESULTS: Nine patients were included with an average follow-up of 4.6 years postoperatively. There were no cases of premature physeal closure postoperatively and clinical outcome measures were excellent in all patients. The length of the intra-articular portion of anterior cruciate ligament graft increased postoperatively (P = 0.01). Distance between the tibial hardware and proximal tibial physis also increased over time on anteroposterior (P = 0.001) and lateral (P = 0.003) radiographs. However, the distance between the femoral hardware and distal femoral physis was unchanged and in five patients was associated with proximal femoral tunnel enlargement. CONCLUSION: Proximal femoral tunnel expansion and lack of proximal migration of the femoral button were seen in more than half of our patients. However, these findings had no detrimental effects on clinical outcome measures or remaining skeletal growth.

Recurrent patellofemoral instability rates after MPFL reconstruction techniques are in the range of instability rates after other soft tissue realignment techniques.

PURPOSE: Recurrent patellofemoral instability is a common knee injury in skeletally immature patients. Many surgical techniques have been described in the literature, all with different success rates. Purpose of this study was to perform a systematic review and meta-analysis of the available literature to assess recurrent patellofemoral instability rates after surgical treatment using MPFL reconstruction techniques and other soft tissue realignment techniques in skeletally immature patients. METHODS: PubMed, Embase, Web of Science, and The Cochrane Library were searched to identify all original articles concerning the surgical treatment for patellofemoral instability in skeletally immature patients and that reported post-operative recurrent patellofemoral instability rates. Subsequently a risk of bias assessment was conducted and a meta-analysis was performed on reported post-operative recurrent patellofemoral instability rates after MPFL reconstruction techniques and other soft tissue realignment techniques. RESULTS: Of the 21 eligible studies (448 knees in 389 patients), 10 studies reported on MPFL reconstruction techniques using different grafts and fixation techniques and 11 reported on other soft tissue realignment procedures. In total, 62 of the 448 (13.8%) treated knees showed recurrent patellofemoral instability during follow-up. The overall pooled recurrent patellofemoral instability rate was estimated to be 0.08 (95% CI 0.02-0.16). For MPFL reconstruction techniques, the pooled recurrent patellofemoral instability rate was estimated to be 0.02 (95% CI 0.00-0.09). For the other soft tissue realignment techniques, the pooled rate was estimated to be 0.15 (95% CI 0.04-0.31). No statistically significant difference in recurrent patellofemoral instability rates between MPFL reconstruction techniques and other soft tissue realignment techniques were found (n.s.). There was a large variation in treatment effects over different settings, including what effect is to be expected in future patients. CONCLUSION: This systematic review and meta-analysis found that recurrent patellofemoral instability rates after MPFL reconstruction techniques are in the range of instability rates after other soft tissue realignment techniques. The clinical relevance of this study is that it provides clinicians with the best currently available evidence on recurrent patellofemoral instability rates after surgical treatment for patellofemoral instability in skeletally immature patients. LEVEL OF EVIDENCE: IV.

Over the top anterior cruciate ligament reconstruction in patients with open physes: a long-term follow-up study.

INTRODUCTION: Anterior cruciate ligament (ACL) rupture in skeletally immature athletes is becoming an injury with increasing incidence. Choices of treatment are still debated, including conservative management vs. various surgical techniques. The lack of long-term reports has been highlighted in the literature. AIM: To evaluate long-term results of ACL reconstructions performed in skeletally immature patients using the Over the Top technique with lateral extra-articular tenodesis. METHODS: Retrospective study. All surgeries performed by same surgeon. A total of 42 patients included. All patients had pre-operative radiological studies. SUBJECTS: 30 males and 12 females. Average age: 12.5 years (range 11-14 years). Average follow-up: 96.1 months. Clinical evaluation: Pedi-IKDC, Tegner-Lysholm, KT-1000 and plain radiographs. Standardized rehabilitation protocol. RESULTS: No instability or leg length discrepancy was recorded. Average pre-operative Tegner-Lysholm and Pedi-IKDC scores were 55 and 40, respectively, with a score of 94.8 (p < 0.05) and 94.78, respectively, at final follow-up (p < 0.05). Average post-operative (1 month) Tegner-Lysholm score: 75 (range: 62-79). Median post-operative Tegner activity: 8. Mean side-to-side (KT-1000): 1.2 mm. A total of 22 patients could go back to pre-injury sport activity, with an average rehabilitation of 7.3 months. DISCUSSION: A significant number of cases were included in our structured standardized study and follow-up. Functional scores were excellent overall. Excellent results are testified by a final achievement of 22 patients going back to pre-injury sport activity, which is in keeping with the literature. Our experience exhibited a low complication rate and no metalwork failure. We correlate our results to the use of the Over the Top technique with lateral extra-articular tenodesis. CONCLUSION: The studied procedure seems to be an excellent option and an effective, feasible and safe technique when treating ruptured ACLs in skeletally immature patients.

ACL injuries before 15 years of age: could the young become an athlete?

PURPOSE: The purpose of this study was to systematically assess the possibility for a patient younger than 15 to return to a competitive level of sport following an ACL injury. METHODS: Four databases were analyzed (PubMed, MedLine, Cinahl, Cochrane Library and LISTA). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to guide the screening of the literature. Studies about functional and surgical treatments were included with a minimum of 5 years of mean follow-up. Methodological quality of individual studies was assessed with the Methodological Index for Non-Randomized Studies scale. RESULTS: Ten studies were included, corresponding to a total of 217 patients. All studies were retrospective with level 4 evidence. Seven studies reported results of a transphyseal technique reconstruction, two studies a physeal-sparing reconstruction, and one studied the results of a repair (« healing response ¼). Only one study compared functional treatment and surgery. The mean age of patients at the time of surgery was 12.29 years (range 2-16) with a mean follow-up of 7.9 years (range 5.5-18.3). Return to sport was possible for 80 to 100% of patients (average of 91.7%) at the final follow-up but the level for return to sport was reported in only four studies and found between 61 and 89% for return to the same level and at 42% for return to a competitive level. Evolution of the Tegner score was analyzed in five studies and was reported to decrease at the follow-up in three studies. ACL re-ruptures can be considered as failure of the graft (nine studies with surgical technique) and occurred with an average of 16%. CONCLUSION: This review demonstrate that ACL reconstruction is superior to conservative treatment and 'healing response' in terms of revision rates and knee laxity. Return to sport is possible for more than 4/5 of patients but only two thirds of them were able to return to the same level or to competitive level, and failure rates of the graft were not superior to global population. However, qualities of included studies and variability of treatment limited the clinical application of results. Despite this, patients and parents should be informed that ACL injuries are lesions that may influence the level of sport at a 5-year follow-up. LEVEL OF EVIDENCE: Level IV, systematic review.

The Association of Finger Growth Plate Injury History and Speed Climbing in Youth Competition Climbers.

INTRODUCTION: Finger growth plate injuries are the most common injury among youth climbers, and the association between these injuries and speed climbing, a mandatory discipline in the 2021 Olympics, has not been examined previously. Our primary purpose was to examine the demographic and training characteristics of adolescent competition climbers who reported a history of a finger growth plate injury compared to those who did not report a history of a finger growth plate injury. Our secondary purpose was to determine whether training characteristics differed between adolescent competition climbers who did and did not report speed climbing. METHODS: Our study was a cross-sectional study design. We surveyed adolescent climbers who competed in the 2017 USA Climbing Sport and Speed Youth National Championships. Questions assessed climbing injury history and current rock-climbing training characteristics. RESULTS: Two-hundred sixty-seven adolescent competition climbers, 14±3 (9-18) y of age (mean±SD with range), completed the survey. Those with a history of a finger growth plate injury reported greater approximate time spent speed climbing throughout the year (ß=1.28, 95% CI 0.11-2.46, P=0.032) and training regularly on the International Federation of Sport Climbing speed wall (adjusted odds ratio=3.95, 95% CI 1.14-13.7, P=0.031). CONCLUSIONS: Training regularly at practices on the speed wall was associated with a self-reported history of finger growth plate injuries among elite youth competition climbers. Speed climbing should be limited, especially during periods of rapid growth.

Anterior cruciate ligament reconstruction with an all-epiphyseal "over-the-top" technique is safe and shows low rate of failure in skeletally immature athletes.

PURPOSE: The aim of this study was to follow up, clinically and radiographically, skeletally immature patients who underwent ACL reconstruction with an all-epiphyseal "over-the-top" technique. METHODS: Twenty athletes aged between 8 and 13 years were enrolled and retrospectively evaluated. The subjects underwent surgical ACL reconstruction between 2009 and 2013. The surgical technique consisted of a single-bundle all-epiphyseal ACL reconstruction with an extra-articular lateral tenodesis. The mean follow-up was 54 months [34-123] after surgery. Clinically, the patients were evaluated pre- and post-operatively with Lysholm and KOOS scores; sport activity level was evaluated using the pre-injury, pre-operative and post-operative Tegner scores. Objective IKDC was calculated post-operatively. The joint laxity was evaluated by KT1000 and Rolimeter arthrometers. Panoramic AP standing radiographs of the lower limbs and lateral knee radiographs were also taken at the follow-up to evaluate limb length discrepancies (LLD) and axial malalignment. Normally distributed parameters were presented as mean ± standard deviation, while the non-normally distributed parameters were presented as median [25° percentile, 75° percentile]. RESULTS: Clinical scores showed significant (P < 0.01) improvement: Lysholm and KOOS scores improved from 40 [22; 65] and 59 [42, 73], respectively, to 100 [95; 100] and 99 [97;100] after surgery. Tegner score improved from 2 [2; 2] pre-operatively to 7 [3; 9] at follow-up (P < 0.01). At follow-up, IKDC score was A for 19 patients and one who scored B. All patients returned to sport activity and had good stability at follow-up: the KT1000 showed a median side-to-side difference of 0.0 mm [- 0.4; 1.0] for the standard force evaluation and 0.0 mm [- 1.0; 0.8] for manual-maximum test. The Rolimeter showed median side-to-site difference of 0.0 mm [- 1.0; 0.8]. Three minor leg length discrepancies and axial deviations were observed at the radiograph: one patient had 0.6 cm lengthening and 4° of varus, one had 1 cm lengthening, and one had 3° of varus (in comparison with the non-operated limb). No re-injury was observed. CONCLUSION: This study demonstrates that the modified all-epiphyseal single-bundle "over-the-top" technique is a viable and safe option for ACL reconstruction in pediatric subjects. These results support once more that not only ACL reconstruction is a safe procedure in skeletally immature patients, but also it is highly recommended for those who want to pursue an active and sportive life. LEVEL OF EVIDENCE: Case series, IV.

Surgical management for recurrent patellar dislocations in skeletally immature patients.

BACKGROUND: Due to his multifactorial aetiology, treating patellofemoral instability can be a challenge for the orthopaedic surgeon. The incidence of patellofemoral instability shows a peak during adolescence, especially from 11 to 14 years old. AIM: Several clinical studies focusing on recurrent patellar dislocations in skeletally immature patients have been published, reporting inconsistent or controversial results. Currently, there is a lack of consensus regarding the surgical management of these patients. The purpose of this study is to update current evidence and systematically review indications, treatments, and outcomes of surgical management for recurrent patellar dislocations in skeletally immature patients. METHODS: A comprehensive review of the literature was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis, the PRISMA Statement. The following electronic databases were accessed in February 2019: PubMed, Scopus, Google Scholar, CINAHL, EMBASE. All the articles treating surgical management for recurrent patellar dislocations in skeletally immature patients were considered for inclusion. For the methodological quality assessment, we referred to the Coleman Methodology Score (CMS). For the statistical analysis, we referred to the unpaired t-test to establish whether the results are statistically significant. RESULT: The overall CMS resulted in 52.78 points, attesting a satisfactory methodological quality assessment to this systematic review. A total of 21 articles including 623 patients (577 knees) were evaluated. The overall mean age was 13.02 years. The mean follow-up was 46.61 months. The mean Kujala score improved from 58.94 ± 10.38 to 87.07 ± 7.68 points. The Lysholm score reported a pre- and post-operative mean values of 49.54 ± 14.20 and 88.32 ± 8.80, respectively. The mean Tegner Activity Scale scored 4.28 ± 1.22 at baseline, improving to 5.26 ± 0.83 post-operatively. A total of 4.19% of patients incurred into a major complication, while 9.6% sustained a minor one. We observed a total of 89 re-dislocations above 692 treated knees (12%). CONCLUSION: The main findings of this study are that surgical procedures for skeletally immature patients affected by recurrent patellar dislocations are feasible and effective. Complications and re-dislocations occurred infrequently. It is of fundamental importance to treat precociously these patients in order to reduce the risk of further recurrences, to increase the level of sporting activity and improving the quality of life.

Clinical and radiological outcomes of arthroscopically assisted cannulated screw fixation for tibial eminence fracture in children and adolescents.

BACKGROUND: The purpose of this study was to determine the efficacy and complications of arthroscopically assisted reduction and fixation with cannulated screws for tibial eminence fracture in skeletally immature patients. METHODS: This was a retrospective case series study. Forty-eight patients who were skeletally immature at the time of tibial eminence fracture were treated in a tertiary children's hospital between May 2004 and August 2015. Twenty-one patients were excluded due to non-operative treatment (n = 10), other surgical treatments (n = 9), multiple fracture (n = 1), and follow-up < 1 year (n = 1). Twenty-seven knees of 27 patients were analyzed. Avulsed fragment was reduced arthroscopically. One to three cannulated screws (4.0 mm or 5.0 mm in diameter) were used for fixation. Passive knee motion was started in 3-4 weeks. Clinical outcomes were evaluated by Lysholm score, instability of the knee, and complications. Radiological outcomes including nonunion and malunion of the avulsed fragment and physeal growth disturbance were evaluated. RESULTS: Mean age at the time of surgery was 10.1 years (range, 6.2 to 13.8 years). Patients were followed up for a mean of 3.9 years (range, 1.0 to 7.6 years). Fracture types included type III (n = 13), type II (n = 12), and type IV (n = 2) according to Zaricznyj modification of Meyers and McKeever classification. Meniscus was entrapped in five patients. Six patients showed concomitant meniscal tear. Mean Lysholm score at the latest follow-up was 95 (range, 78 to 100). Joint instability was not observed in any patient except one (instability of 5-10 mm). All patients showed full range of knee motion except one (10 degrees of flexion contracture). Screw head impingement against intercondylar notch of the femur was observed in two patients during screw removal procedure. Five knees showed prominent tibial eminence without symptoms. The injured lower limb was longer than the contralateral normal side by a mean of 6.2 mm (range, - 4 to 18 mm). CONCLUSIONS: Arthroscopically assisted reduction and fixation with cannulated screws is an effective and safe surgical option for treating tibial eminence fracture with few complications.

High rate of recurrent patellar dislocation in skeletally immature patients: a long-term population-based study.

PURPOSE: Patellar dislocation can occur in isolation or be associated with chronic instability. The goals of this study are to describe the rate and factors associated with additional patellar instability events (ipsilateral recurrence and contralateral dislocation), as well as the development of patellofemoral arthritis in patients who are skeletally immature at the time of first patellar dislocation. METHODS: The study included a population-based cohort of 232 skeletally immature patients who experienced a first-time lateral patellar dislocation between 1990 and 2010. A chart review was performed to collect information related to the initial injury, treatment, and outcomes. Subjects were followed for a mean of 12.1 years to determine the rate of subsequent patellar dislocation (ipsilateral recurrence or contralateral dislocation) as well as clinically significant patellofemoral arthritis. RESULTS: 104 patients had ipsilateral recurrent patellar dislocation. The cumulative incidence of recurrent dislocation was 11% at 1 year, 21.1% at 2 years, 37.0% at 5 years, 45.1% at 10 years, 54.0% at 15 years, and 54.0% at 20 years. Patella alta (HR 10.6, 95% CI 3.6, 36.1), TT-TG ≥ 20 mm (HR 18.7, 95% CI 1.7, 228.2), and trochlear dysplasia (HR 23.7, 95% CI 1.0, 105.2) were associated with recurrence. Similarly, 18 patients (7.8%) had contralateral patellar dislocation. The cumulative incidence of patellofemoral arthritis was 0% at 2 years, 1.0% at 5 years, 2.0% at 10 years, 10.1% at 15 years, 17% at 20 years, and 39.0% at 25 years. Osteochondral injury was associated with arthritis (HR 25.7, 95% CI 6.2, 143.8). There was no association with trochler dysplasia (HR 1.2, 95% CI 0.2, 5.0), recurrent patellar instability (HR 1.2, 95% CI 0.2, 7.2), gender (HR 1.3, 95% CI 0.3, 5.6), or patellar-stabilizing surgery (HR 0.7, 95% CI 0.2, 3.5) and arthritis. CONCLUSION: Skeletally immature patients had a high rate of recurrent patellar instability that was associated with structural abnormalities such as patella alta,TT-TG ≥ 20 mm, and trochlear dysplasia. Approximately 10% of patients experienced a contralateral dislocation and 20% of patients developed arthritis by 20 years following initial dislocation. Osteochondral injury was associated with arthritis. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

The angle of inclination of the native ACL in the coronal and sagittal planes.

PURPOSE: The purpose of this cross-sectional study was to evaluate the angle of inclination of the native anterior cruciate ligament (ACL) in both the sagittal and coronal planes and to evaluate these findings based on sex, height, BMI, and skeletal maturity. METHODS: Inclusion criteria for the study included patients undergoing routine magnetic resonance imaging (MRI) of the knee at a single outpatient orthopedic center who had an intact ACL on MRI. Measurements of the angle of inclination were made on MRIs in both the sagittal and coronal planes. Patients were compared based on sex, height, BMI, and skeletal maturity. RESULTS: One-hundred and eighty-eight patients were included (36 skeletally immature/152 skeletally mature; 98 male/90 female). The overall angle of inclination was 74.3° ± 4.8° in the coronal plane and 46.9° ± 4.9° in the sagittal plane. Skeletally immature patients (coronal: 71.8° ± 6.1°; sagittal: 44.7° ± 5.5°) were significantly different in both coronal and sagittal planes (P = 0.04 and 0.01, respectively) from skeletally mature patients (coronal: 75.3° ± 4.7°; sagittal: 47.4° ± 4.7°). There were no differences based on sex, height, or BMI. CONCLUSIONS: There are differences between the angle of inclination findings in this study and other studies, which could be due to MRI and measurement techniques. Clinically, skeletal maturity may be important to account for when using the ACL angle of inclination to evaluate anatomic ACL reconstruction. LEVEL OF EVIDENCE: Prognostic retrospective study, Level of evidence III.

Rapidly growing giant cell tumor of bone in a skeletally immature girl.

Giant cell tumor of bone (GCTB) in skeletally immature patients is rare, and little is known regarding how fast GCTB can grow. We report a case of a 10-year-old skeletally immature girl with pathologically proven GCTB with obvious growth plate invasion that showed surprisingly rapid growth over only 14 days. A radiograph of the left knee revealed well-circumscribed, geographic bone destruction at the distal metaphysis of the femur with a focal cortical defect, suggesting a pathologic fracture. No abnormal mineralization or periosteal reaction was seen. A CT without contrast and an MRI demonstrated a homogeneous lesion with cortical disruption posteriorly and laterally with a slight soft tissue extension. Biopsy showed numerous multinucleated giant cells and spindle-shaped mononuclear cells without any sign of malignancy, suggesting GCTB. However, rapid lesion enlargement and destruction of the surrounding cortex were noted 14 days after biopsy. Considering the amount of bone destruction, traditional treatment of curettage and bone cement would not suffice to sustain structural strength. In addition, considering the patient's age, the tumor location, and the aggressive course, a malignant tumor, especially a giant cell-rich osteosarcoma, could not be excluded. Therefore, en bloc resection, including the growth plate and prosthetic replacement, were performed. Confirmation of GCTB was made from a pathologic evaluation, and a breach to the growth plate was identified. Since very little inflammatory reaction, degenerative change, or aneurysmal, bone, cyst-like change was found, the growth plate invasion was confirmed as due to GCTB extension, not due to the preoperative biopsy.

Surgical management of isolated popliteus tendon injuries in paediatric patients.

Isolated popliteus avulsion injuries are a rare occurrence, especially in the skeletally immature population. Two cases of isolated popliteus tendon avulsion injuries in paediatric patients were identified and successfully managed with suture anchor reattachment of the avulsed fragment in the anatomic position. The objective of this case report is to raise awareness of orthopaedic surgeons to the rarely encountered isolated popliteus tendon injury that can occur in paediatric patients. Level of evidence Expert opinion, Level V.