Graft choices for paediatric anterior cruciate ligament reconstruction: State of the art.

The paediatric population is at particularly high risk for anterior cruciate ligament (ACL) injuries due to high rates of sports participation. Other risk factors for ACL injuries in children include but are not limited to being female, generalised ligamentous laxity, a high body mass index (BMI), and poor neuromuscular control. ACL reconstruction (ACLR) is commonly done to treat ACL injuries and allow for return to sports and daily activities. ACL repair is another option with ongoing techniques being developed. The high rates of graft failure in children reported in recent publications on ACL repair are very concerning. Special consideration must be taken in ACLR in the skeletally immature patient due to the risk of growth-related complications, such as limb deformity or growth arrest, that can arise from drilling across or disrupting the physis. Graft choices for paediatric ACLR include iliotibial band (ITB) over the top and over the front, hamstring autograft, bone patellar tendon bone (BTB) autograft, quadriceps tendon autograft, and allograft. Factors for each graft choice to consider include graft size, graft failure rates, donor site morbidity, requirement for bony tunnels, the post-op rehabilitation process, and return to sport outcomes. Each graft has its benefits and disadvantages for the individual patient, depending on age, skeletal maturity, and goals for recovery. Lateral extra-articular tenodesis (LET) is another option to consider with paediatric ACLR because LET has been shown to decrease the re-rupture rate in adult ACLR. After surgery, patient follow-up until at least the growth plates are closed is important. This article aims to provide an overview and comparison of the various graft types to aid in the graft choice decision making process for paediatric ACLR.

Return to sport soccer after anterior cruciate ligament reconstruction: ISAKOS consensus.

INTRODUCTION: Many factors can affect the return to pivoting sports, after an Anterior Cruciate Ligament Reconstruction. Prehabilitation, rehabilitation, surgical and psychological aspects play an essential role in the decision to return to sports. The purpose of this study is to reach an international consensus about the best conditions for returning to sports in soccer-one of the most demanding level I pivoting sports after anterior cruciate ligament (ACL) reconstruction. METHODS: 34 International experts in the management of ACL injuries, representing all the Continents were convened and participated in a process based on the Delphi method to achieve a consensus. 37 statements related to ACL reconstruction were reviewed by the experts in three rounds of surveys in complete anonymity. The statements were prepared by the working group based on previous literature or systematic reviews. Rating agreement through a Likert Scale: strongly agree, agree, neither agree or disagree, disagree and strongly disagree was used. To define consensus, it was established that the assertions should achieve a 75% of agreement or disagreement. RESULTS: Of the 37 statements, 10 achieved unanimous consensus, 18 non-unanimous consensus and 9 did not achieve consensus. In the preoperative, the correction of the range of motion deficit, the previous high level of participation in sports and a better knowledge of the injury by the patient and compliance to participate in Rehabilitation were the statements that reached unanimous consensus. During the surgery, the treatment of associated injuries, as well as the use of autografts, and the addition of a lateral extra-articular tenodesis in some particular cases (active young athletes, <25 years old, hyperlaxity, high rotatory laxity and revision cases) obtained also 100% consensus. In the postoperative period, psychological readiness and its validation with scales, adequate physical preparation, as well as not basing the RTSS purely on the time of evolution after surgery, were the factors that reached unanimous Consensus. CONCLUSIONS: The consensus statements derived from this international ISAKOS leaders, may assist clinicians in deciding when to return to sports soccer in patients after an ACL reconstruction. Those statements that reached 100% consensus have to be strongly considered in the final decision to RTS soccer.