Anterolateral augmentation procedures during anterior cruciate ligament reconstructions in skeletally immature patients: Scoping review of surgical techniques and outcomes.

Purpose: Graft failure rates after anterior cruciate ligament reconstruction (ACLR) in children and adolescents are higher compared to adults. Anterolateral augmentation procedures have recently generated increased focus regarding their ability to reduce graft failure rates. Concerns in skeletally immatures are potential growth disturbances and overconstraint after anterolateral augmentation. The aim of this scoping review is to provide an overview of all current anterolateral augmentation procedures in skeletally immature patients and to discuss surgical techniques, clinical and biomechanical outcomes. Methods: This scoping review was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement extension for scoping reviews. On 22 December 2022, an information specialist performed a systematic literature search in Cochrane, PubMed (Medline) and EMBASE databases. Inclusion criteria were anterolateral augmentation procedures, including lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), in combination with ACLR in skeletally immatures. Results: Twenty studies were included after screening 1.485 abstracts. Seventeen studies describe LET techniques, four studies ALLR techniques and one study both techniques. Biomechanical data is scarce and shows conflicting results. Two studies compared ACLR with LET to ACLR in skeletally immatures with promising results in favour of the combined procedure. There were no differences in outcomes between LET and ALLR. Conclusions: Several LET and ALLR techniques have been described for skeletally immature patients and the first clinical data on LET and ALLR is available, which showed promising results. Further research is necessary to evaluate the risk of growth disturbances and overconstraint in skeletally immatures. Level of Evidence: Level IV.

Height is a predictor of hamstring tendon length and ACL graft characteristics in adolescents.

BACKGROUND: Knowing the potential hamstring tendon length is relevant for planning ligament reconstructions in children and adolescents, as it is not uncommon to encounter small hamstring tendons intraoperatively. The aim of this study is to predict semitendinosus and gracilis tendon length based on anthropometric values in children and adolescents. The secondary aim is to analyse hamstring tendon autograft characteristics in a closed socket anterior cruciate ligament reconstructions and to evaluate the relationship with anthropometric variables. The hypothesis of this study was that height is predictor of hamstring tendon length and thereby graft characteristics. METHODS: This observational study included two cohorts of adolescents undergoing ligament reconstructions between 2007-2014 and 2017-2020. Age, sex, height and weight were recorded preoperatively. Semitendinosus and gracilis tendon length and graft characteristics were measured intraoperatively. Regression analysis was performed on tendon length and anthropometric values. Subgroup analyses of the closed socket ACL reconstruction were performed and the relation between anthropometric values and graft characteristics were analysed. RESULTS: The population consisted of 171 adolescents from 13 to 17 years of age, with a median age of 16 years [IQR 16-17]. The median semitendinosus tendon length was 29 cm [IQR 26-30] and gracilis tendon length was 27 cm [IQR 25-29]. Height was a significant predictor of semitendinosus and gracilis tendon length. Subgroup analysis of the closed socket ACL reconstructions showed that in 75% of the procedure, the semitendinosus tendon alone was sufficient to create a graft with a minimum diameter of 8.0 mm. CONCLUSIONS: Height is a significant predictor of semitendinosus and gracilis tendon length in adolescents between 13 and 17 years of age and outcomes are similar to data in adults. In 75% of the closed socket ACL reconstructions, the semitendinosus tendon alone is sufficient to create an adequate graft with a minimum diameter of 8 mm. Additional use of the gracilis tendon is more often necessary in females and shorter patients.

Anterior Cruciate Ligament Rehabilitation for the 10- to 18-Year-Old Adolescent Athlete: Practice Guidelines Based on International Delphi Consensus.

Background: There are 2 treatment options for adolescent athletes with anterior cruciate ligament (ACL) injuries-rehabilitation alone (nonsurgical treatment) or ACL reconstruction plus rehabilitation. However, there is no clear consensus on how to include strength and neuromuscular training during each phase of rehabilitation. Purpose: To develop a practical consensus for adolescent ACL rehabilitation to help provide care to this age group using an international Delphi panel. Study Design: Consensus statement. Methods: A 3-round online international Delphi consensus study was conducted. A mix of open and closed literature-based statements were formulated and sent out to an international panel of 20 ACL rehabilitation experts. Statements were divided into 3 domains as follows: (1) nonsurgical rehabilitation; (2) prehabilitation; and (3) postoperative rehabilitation. Consensus was defined as 70% agreement between panel members. Results: Panel members agreed that rehabilitation should consist of 3 criterion-based phases, with continued injury prevention serving as a fourth phase. They also reached a consensus on rehabilitation being different for 10- to 16-year-olds compared with 17- and 18-year-olds, with a need to distinguish between prepubertal (Tanner stage 1) and mid- to postpubertal (Tanner stages 2-5) athletes. The panel members reached a consensus on the following topics: educational topics during rehabilitation; psychological interventions during rehabilitation; additional consultation of the orthopaedic surgeon; duration of postoperative rehabilitation; exercises during phase 1 of nonsurgical and postoperative rehabilitation; criteria for progression from phase 1 to phase 2; resistance training during phase 2; jumping exercises during phase 2; criteria for progression from phase 2 to phase 3; and criteria for return to sports (RTS). The most notable differences in recommendations for prepubertal compared with mid- to postpubertal athletes were described for resistance training and RTS criteria. Conclusion: Together with available evidence, this international Delphi statement provides a framework based on expert consensus and describes a practice guideline for adolescent ACL rehabilitation, which can be used in day-to-day practice. This is an important step toward reducing practice inconsistencies, improving the quality of rehabilitation after adolescent ACL injuries, and closing the evidence-practice gap while waiting for further studies to provide clarity.

Diagnostic values of history taking, physical examination and KT-1000 arthrometer for suspect anterior cruciate ligament injuries in children and adolescents: a prospective diagnostic study.

BACKGROUND: Diagnosing anterior cruciate ligament (ACL) injuries in children and adolescents are more challenging compared to adults. Delayed diagnosis may result in meniscal or chondral injuries. The aim of this study was to determine the diagnostic values of history taking, physical examination and KT-1000 arthrometer for suspect ACL injuries in children and adolescents. METHODS: In this prospective diagnostic study, all children and adolescents (< 18 years) with post-traumatic knee complaints presenting at the out-patient department of the Máxima MC were eligible for inclusion. One experienced knee specialised orthopaedic surgeon was blinded and performed history taking, physical examination and KT-1000 arthrometer measurement. All patients had a magnetic resonance imaging (MRI) for the final diagnosis. Diagnostic values of interest were sensitivity, specificity, positive and negative predictive values (PPV and NPV). The outcomes of the KT-1000 arthrometer were drafted in a relative operating characteristics (ROC) curve to determine the optimal cut-off points. RESULTS: Sixty-six patients were included, of which 50 had an ACL rupture and 16 had no ACL rupture on MRI. Report of a popping sensation during trauma had a specificity and PPV of 100% for diagnosing ACL injuries. The PPV and NPV of the Lachman test (in case of describing end-feel) were 95 and 82%, of the anterior drawer test 87 and 90% and of the pivot shift test 95 and 81% respectively. The optimal cut-off point of the KT-1000 arthrometer at 133 N force was an absolute translation of ≥7 mm with a PPV and NPV of 97 and 88% respectively. CONCLUSIONS: Report of a popping sensation during trauma has a specificity and PPV of 100% for diagnosing ACL injuries in children and adolescents. Although potentially difficult in children, the Lachman test, anterior drawer test and pivot shift test have a high PPV and NPV when performed by an experienced orthopaedic surgeon. An absolute anterior translation of ≥7 mm of the injured knee in the KT-1000 arthrometer at 133 N has the highest diagnostic values of all tests for diagnosing ACL injuries.

Translation and transcultural validation of the Dutch hospital for special surgery paediatric functional activity brief scale (HSS Pedi-FABS).

BACKGROUND: There is a need for a validated simple Dutch paediatric activity scale. The purpose was to translate and transculturally validate the Dutch Hospital for Special Surgery Paediatric Functional Activity Brief Scale (HSS Pedi-FABS) questionnaire in healthy children and adolescents. METHODS: The original HSS Pedi-FABS was translated forward and backward and was transculturally adapted after performing a pilot study among children and professionals. The final version of the Dutch HSS Pedi-FABS was validated in healthy children and adolescents aged 10 to 18 years old. Children who had any condition or injury limiting their normal physical activity were excluded. The interval between the first questionnaire T0 (HSS Pedi-FABS, Physical Activity Questionnaire for children or adolescents (PAQ-C/A) and Tegner activity scale) and the second questionnaire T1 (HSS Pedi-FABS) was 2 weeks. Construct validity, interpretability and reliability were evaluated. Content validity was evaluated through cognitive interviews among a smaller group of children and through a questionnaire among professionals. RESULTS: To evaluate content validity, 9 children and adolescents were interviewed, and 30 professionals were consulted. Content validity among professionals showed a relevance of less than 85% for most items on construct. However, content validity among children was good with a 92% score for item relevance. Readability was scored at a reading level of 11- to 12-year-olds. The validation group consisted of 110 healthy children and adolescents (mean age of 13.9 years ±2.6). Construct validity was considered good as 8 out of 10 hypotheses were confirmed. The Dutch HSS Pedi-FABS showed no floor or ceiling effect. Analysis of the internal consistency in the validation group resulted in a Cronbach's alpha of 0.82. Test-retest reliability was evaluated among 69 children and adolescents and revealed an Intraclass Correlation Coefficient (ICC) of 0.76. CONCLUSION: The Dutch HSS Pedi-FABS showed good psychometric properties in a healthy Dutch paediatric and adolescent population. Limitations of the current Dutch HSS Pedi-FABS are content validity on construct of items reported by professionals.

Current State of Care for Pediatric ACL Ruptures in the Netherlands: A Survey.

The management of anterior cruciate ligament (ACL) injuries in the skeletally immature patient is an area of controversy. The purpose of this survey is to inventory the current state of care for pediatric ACL injuries in the Netherlands. This survey was conveyed by e-mail among all members of the Dutch Arthroscopy Society (Nederlandse Vereniging van Arthroscopie [NVA]) and promoted on the Web site of the NVA. It was developed by the scientific committee of the NVA by a consensus meeting discussing relevant topics in pediatric ACL injuries. All members of the NVA received the survey (n = 540). A total of 158 (29%) members responded to the survey, of which 143 were completed. A total of 126 responses were analyzed after exclusion. The main finding of this survey is that 78% of the respondents tend to treat children with open physes nonoperatively, while 65% tend to treat children with closed physes operatively. The most frequently performed procedure is the transphyseal reconstruction. Many considerations were involved in choosing operative treatment. The postoperative follow-up period varies from less than 1 year (24%) until fully grown (27%). In conclusion, this survey shows that the current state of care for pediatric ACL injuries is variable and a matter of debate in the Netherlands. Although the response rate seems low, this survey provides an overview of the opinions of specialized orthopaedic surgeons in the Netherlands. The results of this survey led to the development of the national registry for pediatric ACL in the Netherlands. The level of evidence for this study is V.

Limited evidence for return to sport testing after ACL reconstruction in children and adolescents under 16 years: a scoping review.

Specific return to sport criteria for children and adolescents after anterior cruciate ligament injury and reconstruction are unknown. The aim of this scoping review is to provide an overview of current tests regarding return to sport for children and adolescents. This scoping review was performed according to the PRISMA statement. A systematic search was performed on PubMed and EMBASE. The inclusion criteria were diagnostic and prognostic studies evaluating tests regarding return to sport after ACL injury and reconstruction in children/adolescents (age < 18 years). Twenty-six studies were included, of which 22 studies evaluated tests in the age category of 16 to 18 years. All studies evaluated tests after ACL reconstruction, no studies have been conducted in non-operative patients. Strength tests, movement quality and patient reported outcomes measures (PROMs) are investigated most frequently. Clearance for return to sport should be based on a test battery including strength tests, movement quality during sport-specific tasks and (paediatric) patient reported outcome measures. There are no recommendations on which specific tests regarding quantity and quality of movement should be used. Future research should aim at at developing and validating a test battery including movement quality and neuromotor control in a sport-specific context for both younger children and adolescents after both operative and non-operative treatment.

The difference between native septic arthritis and prosthetic joint infections: A review of literature.

Current literature occasionally considers septic arthritis in native joints and prosthetic joint infections as equal pathologies. However, significant differences can be identified. The aim of this review of literature is to describe these differences in definitions, pathology, diagnostic workups, treatment strategies, and prognosis.

Arteriovenous Fistula after Anatomic All-Inside Anterior Cruciate Ligament Reconstruction.

We present the first case of an arteriovenous fistula after an all-inside anterior cruciate ligament (ACL) reconstruction. A seventeen-year-old boy had an uneventful ACL reconstruction. Four weeks after surgery, the patient was seen with a pulsating swelling at the lateral distal upper leg. Vascular consultation led to the diagnosis of pseudoaneurysm and arteriovenous fistula of the lateral superior genicular artery. Most likely, fistula is caused by the stab incision for preparation of the femoral tunnel, and no anatomical cause was found. The clinical presentation, previous cases of arteriovenous fistula after arthroscopic ACL reconstruction, possible causes, and management are discussed.

Acute Mono-Arthritis of the Knee: A Case Report of Infection with Parvimonas Micra and Concomitant Pseudogout.

Parvimonas micra is a rare pathogen for septic arthritis and is known for its subacute onset. We report a case of acute arthritis of the knee caused by P. micra and pseudogout. Initially, calcium pyrophosphate crystals were found in the knee, which were successfully treated with a steroid injection. Only anaerobic cultures became positive. A 16S rRNA PCR-analysis was necessary to identify P. micra as causative agent, a method which is never described before in similar cases. The infection was treated with clindamycin for 6 weeks. This is the third case report of a septic arthritis caused by P. micra and the second which also reports concomitant pseudogout.