Surgical Techniques in Primary ACL Reconstruction: Getting It Right the First Time.

The ideal anterior cruciate ligament reconstruction (ACLR) is an individualized anatomic approach aimed at restoring the native structure and function of the knee. Surgeons are tasked with difficult decisions during operative planning, including the optimal graft choice for the patient and appropriate anatomic tunnel placement. Special considerations should additionally be given for skeletally immature patients and those at high-risk for failure, including younger, active patients participating in pivoting sports. The purpose of this review is to provide an overview of the individualized approach to ACLR, including the necessary preoperative and operative considerations to optimize patient outcomes.

Pediatric ACL Reconstruction in Children-An Evaluation of the Transphyseal Technique's Efficacy and Safety.

INTRODUCTION: Injuries of the anterior cruciate ligament (ACL) are commonly found in the general population, both among adult and pediatric patients, and their incidence has been increasing in recent years. Most of the late literature agrees that surgical reconstruction of the ACL is effective in improving long-term outcomes in pediatric patients, while others in the past have pleaded for non-surgical management. PURPOSE/HYPOTHESIS: Our study aims to verify if ACL reconstruction (ACLR) using transphyseal technique in skeletally immature patients will provide angular deviations or growth restrictions. STUDY DESIGN: Retrospective cohort study; Level of evidence 4. METHODS: We perfomed a retrospective study to verify if transphyseal ACLR in children with less than or equal to 2 years of remaining growth leads to either limb length discrepancies or axis deviations. RESULTS: Most patients who were treated using transphyseal technique showed significant improvements in their functional scores. There were statistically significant differences in lateral distal femoral angles (LDFA) and medial proximal tibial angles (MPTA), with no clinical impact. There was no significant limb length discrepancy (LLD) during the 2-year follow-up. CONCLUSIONS: Transphyseal ACLR is safe among children who have less than or equal to 2 years of remaining growth and brings no risk of axis deviations or limb length discrepancy.

Management of Anterior Cruciate Ligament Tears in Skeletally Immature Patients.

PURPOSE OF REVIEW: Anterior cruciate ligament (ALC) tears are increasingly common in skeletally immature patients, as more children and adolescents participate in intensive sports training and specialization at increasingly younger ages. These injuries were historically treated nonoperatively, given concerns for physeal damage and subsequent growth disturbances after traditional ACL reconstruction techniques. However, there is now sufficient data to suggest superior outcomes with operative treatment, specifically with physeal-sparing and physeal-respecting techniques. This article reviews considerations of skeletal maturity in patients with ACL tears, then discusses surgical techniques, with a focus on their unique indications and outcomes. Additional surgical adjuncts and components of postoperative rehabilitation, which may reduce retear rates, are also considered. RECENT FINDINGS: Current research shows favorable patient-reported outcomes and high return-to-sport rates after ACL reconstruction in skeletally immature patients. Graft rupture (ACL retear) rates are low, but notably higher than in most adult populations. Historically, there has been insufficient research to comprehensively compare reconstruction techniques used in this patient population. However, thoughtful systematic reviews and multicenter prospective studies are emerging to address this deficit. Also, more recent data suggests the addition of lateral extra-articular procedures and stringent return-to-sports testing may lower retear rates. Physeal-sparing and physeal-respecting ACL reconstructions result in stabilization of the knee, while respecting the growth remaining in children or skeletally immature adolescents. Future research will be essential to compare these techniques, given that more than one may be appropriate for patients of a specific age and skeletal maturity.

Return to Sports Activity After Microfracture for Osteochondral Lesion of the Talus in Skeletally Immature Children.

BACKGROUND: Osteochondral lesions of the talus (OLTs) are among the common sports-related injuries. However, there are few reports on the return to sports after OLT surgery in skeletally immature children. This study was performed to evaluate the return to sports after microfracture for OLTs in skeletally immature children. METHODS: This study involved 17 ankles of 16 patients (mean age, 13.2 years; range, 10-16 years) with open tibial epiphyses on magnetic resonance imaging (MRI) who underwent microfracture for OLTs <10 mm in diameter and confirmation of lesion instability under arthroscopy. Nine of 17 ankles had additional lateral ankle ligament stabilization. All patients were participating in some form of sports. The Japanese Society for Surgery of the Foot (JSSF) score, Ankle Activity Score (AAS), return to sports rate, lesion size, grade of subchondral bone marrow edema, and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score on MRI were evaluated after microfracture. The mean postoperative follow-up period was 53.5 months. RESULTS: The mean JSSF score significantly improved from 76.1 points preoperatively to 94.9 points at the final follow-up (P < .01). The mean AAS showed no change from preoperative state to final follow-up. The return to sports rate was 100%. The lesion size significantly decreased from 76.3 to 56.7 mm2 in area (P = .02) and from 283.2 to 185.6 mm3 in volume (P = .05). The bone marrow edema grade decreased in 8 of 17 ankles. The total MOCART score showed a significant improvement from 6 months to 1 year postoperatively (P = .05). CONCLUSION: All skeletally immature children who underwent microfracture for OLTs in this study were able to return to sports activity and showed improvements in clinical scores and MRI parameters. Microfracture may be considered an effective first-line treatment for OLTs <10 mm in diameter in skeletally immature athletes. LEVEL OF EVIDENCE: Level IV, retrospective case-control study.

Arthroscopic Modified Lasso-Loop Stitch Technique for Chronic Lateral Ankle Instability in Skeletally Immature vs Mature Patients.

BACKGROUND: In recent years, arthroscopic lateral ankle ligament repair has become increasingly popular. However, reports on the clinical outcomes of arthroscopic ankle stabilization for skeletally immature patients remain scarce. This study investigated the clinical outcomes of arthroscopic lateral ankle ligaments repair in skeletally immature patients compared to skeletally mature patients. METHODS: Our retrospective analysis compared skeletally immature patients and skeletally mature adults who underwent arthroscopic repair of the ankle lateral ligaments with a modified lasso-loop stitch using a suture anchor. Skeletal immaturity was defined as patients whose epiphyseal line of the distal fibula remained open on plain radiography. Clinical outcomes were evaluated using the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) at 2 years after surgery. The time to postoperative walking, jogging, and return to full sports activities were also evaluated. RESULTS: Sixty-four skeletally immature patients (IM group) and 103 skeletally mature adults (M group) were included. No significant differences were observed during both walking and jogging after surgery between the groups; however, return to full athletic activities was significantly earlier in IM group (P = .05). The mean scores in all SAFE-Q subscales significantly improved in both groups after surgery (P < .001). There were also no statistically significant differences between the groups in the mean postoperative SAFE-Q scores for all subscales. All patients in the IM group returned to playing sports at their preinjury levels postoperatively. CONCLUSION: We found that skeletally immature patients with chronic lateral ankle instability had generally similar responses to arthroscopic lateral ankle as skeletally mature adult patients at minimally 2 years' follow-up with a high rate of successful return to sport. LEVEL OF EVIDENCE: Level III, retrospective case control study.

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.

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.

Radiographic and clinical outcomes after definitive spine fusion for skeletally immature patients with idiopathic scoliosis.

PURPOSE: To assess the intermediate-term radiographic and clinical outcomes of skeletally immature idiopathic scoliosis (IS) patients that underwent definitive fusion (DF). METHODS: A retrospective review of patients with IS who were Risser 0 with open tri-radiate cartilages at the time of DF with minimum 5-year follow-up. Outcomes included Scoliosis Research Society (SRS)-30 scores, major Cobb angle, pulmonary function tests (PFTs), and unplanned returns to the operating room (UPROR). Adding-on was defined as progression of the major Cobb angle > 5° or tilt of the lowest instrumented vertebra > 5°. RESULTS: Thirty-two patients (78% female, mean age 12.2 ± 1.3 years old, mean preoperative major Cobb 64.8° ± 15.9) were included. Of these patients, 20 (62.5%) experienced adding-on and 6 (18.8%) required a revision surgery to correct their progressive spinal deformity. Adding-on was associated with lower 5-year postoperative SRS scores for appearance (3.7 ± 0.7 vs 4.4 ± 0.3, p = 0.0126), mental health (4.2 ± 0.6 vs 4.6 ± 0.3, p = 0.0464), satisfaction with treatment (4.0 ± 0.8 vs 4.7 ± 0.4, p = 0.0140), and total score (4.0 ± 0.4 vs 4.4 ± 0.2, p = 0.0035). The results of the PFTs did not differ between groups. Patients experienced an average of 0.53 UPROR/patient. CONCLUSION: DF in skeletally immature patients results in a high rate of adding-on, which adversely affects Health-Related Quality of Life. However, reoperation rates, both planned and unplanned, remain lower when compared to patients undergoing growth-friendly treatment.

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.

Long-Term Results after Chiari Pelvic Osteotomy in the Skeletally Immature and the Role of the Anti-Chiari Effect.

Several authors observed a loss of correction after performing Chiari pelvic osteotomy (CPO) in young patients. Hence, the aim of this study was to answer two questions: (1) Does the Chiari pelvic osteotomy affect the development of the acetabulum in skeletally immature patients in the long term? (2) Is there any evidence of the previously described "Anti-Chiari" effect after a mean follow-up of 36 years? Data from 21 patients (27 hips) undergoing CPO before the age of 16 years were clinically assessed, and the evolution of radiological parameters over time was analyzed. The mean age at CPO was 11.2 years (±3; 4.4-15.7). The 20- and 30-year survival rates of the CPO were 100% and 92.6%, respectively. Mean postoperative medialization was 54% (±18; 23-99). The average osteotomy angle was 11° (±7; 2-28). No significant changes were found for the center-edge angle (CEA) and acetabular index (AI) over time; the angle of Idelberger and Frank (ACM) almost reached normal values at follow-up (FU); for the acetabular-head index (AHI), a slight shift toward the initial situation could be detected. The morphology of the acetabulum remained unchanged over time. The "Anti-Chiari effect" seems to be primarily caused by insufficient coverage of the femoral head rather than damage to the apophysis due to surgery.

Fractures around the shoulder in the skeletally immature: A scoping review.

Fractures around the shoulder girdle in children are mainly caused by sports accidents. The clavicle and the proximal humerus are most commonly involved. Both the clavicle and the proximal humerus have a remarkable potential for remodeling, which is why most of these fractures in children can be treated conservatively. However, the key is to understand when a child benefits from surgical management. Clear indications for surgery of these fractures are lacking. This review focuses on the available evidence on the management of clavicle and proximal humerus fractures in children. The only strict indications for surgery for diaphyseal clavicle fractures in children are open fractures, tenting of the skin with necrosis, associated neurovascular injury, or a floating shoulder. There is no evidence to argue for surgery of displaced clavicle fractures to prevent malunion since most malunions are asymptomatic. In the rare case of a symptomatic malunion of the clavicle in children, corrective osteosynthesis is a viable treatment option. For proximal humerus fractures in children, treatment is dictated by the patient's age (and thus remodeling potential) and the amount of fracture displacement. Under ten years of age, even severely displaced fractures can be treated conservatively. From the age of 13 and onwards, surgery has better outcomes for severely displaced (Neer types III and IV) fractures. Between 10 and 13 years of age, the indications for surgical treatment are less clear, with varying cut-off values of angulation (30-60 degrees) or displacement (1/3 - 2/3 shaft width) in the current literature.

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.

A Rare Giant Cell Tumour in the Distal Radius of a Seven-Year-Old Girl: A Case Report.

A giant cell tumour (GCT) is a benign and locally aggressive tumour that is usually observable in a skeletally mature patient involving the end of long bones. The reported incidence of this tumour in a skeletally immature patient is extremely rare. However, we report one such case in the distal radius of a seven-year-old female patient. Having presented with painful swelling of the right distal forearm, she underwent clinical and radiological examination, and a diagnosis of distal radius GCT was made. The tumour was treated with curettage, fibular graft, and synthetic bone graft. This case report shows the importance of including GCT in children as a differential diagnosis. This tumour may have a good prognosis if diagnosed and treated early.

Meniscal Allograft Transplants in Skeletally Immature Patients: A Systematic Review of Indications and Outcomes.

Meniscal lesions in skeletally immature patients can lead to joint degradation and knee instability. Meniscal allograft transplant (MAT) surgery is a solution to maintain knee stability. There is a lack of consensus on MAT surgery outcomes in pediatric patients. A systematic review was conducted according to the PRISMA guidelines. PubMed, Scopus and EMBASE databases were searched from 1965 to June 2022. Studies were evaluated using the Newcastle-Ottawa Scale (NOS). Three studies were selected, and 58 patients were included (mean age 15.9 years) in total. The lateral meniscus was involved in 82.8% of all MAT surgeries. Post-meniscectomy syndrome and discoid meniscus were the main indications for MAT surgery. All studies reported improved subjective clinical scores and levels of sport after the surgery. The complication rate was 27.5%. Partial meniscectomy, meniscus knot removal, chondral defect treatment and lysis of adhesions were the most frequent procedures performed during reoperation. MAT surgery can improve clinical outcomes in pediatric patients with strictly selected indications. MAT surgery is safe when there are no limb asymmetries or malalignments, but it remains a challenging procedure with a high complication rate. Long-term follow-up is needed for definitive statements on the use of MAT in skeletally immature patients.

Acute Bilateral Salter-Harris II Distal Radii Fractures in a Skeletally Immature Athlete.

Distal radius fractures are a common location of physeal injuries in skeletally immature adolescents. However, reports of athletics-related acute bilateral distal radius physeal injuries are rare. Therefore, there is a need for further literature to demonstrate both the early recognition and prevention of these injuries to ensure young athletes are able to safely train and compete. We present the case of acute bilateral Salter-Harris II distal radii fractures in a 14-year-old athlete during participation in a high-energy impact sport.

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.

Radiographic Changes After Medial Patellofemoral Ligament Reconstruction in Skeletally Immature Patients Compared With an Age- and Sex-Matched Cohort.

BACKGROUND: Despite recent evidence that medial patellofemoral ligament reconstruction (MPFLR) in the skeletally immature patient is both safe and effective, there are limited data evaluating postoperative coronal- and sagittal-plane growth and radiographic patellofemoral parameters in this population. PURPOSE: The primary purpose was to assess radiographic measures of coronal-plane alignment, longitudinal growth, patellar congruence, and trochlear dysplasia after MPFLR in a skeletally immature population. A secondary purpose was to assess this population compared with a matched cohort with a focus on trochlear dysplasia prevalence and the effect of MPFLR on patellar height. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 28 children with a minimum 1-year follow-up who underwent isolated MPFLR were identified. All patients were skeletally immature, defined as fully open physes on both sides of the knee joint, at the time of surgery. The development of a limb length discrepancy or angular growth abnormalities were assessed on standing hip-to-ankle radiographs, patellar tilt and congruence were measured on the Merchant view of the knee, and the grade of trochlear dysplasia and patellar height were assessed on lateral knee radiographs. A sex- and age-matched group of patients who underwent anterior cruciate ligament reconstruction was formed as a control for patellar height and trochlear dysplasia measurements. RESULTS: The mean patient age was 11.71 ± 2.02 years at the time of surgery with a mean follow-up of 23.54 ± 12.49 months. All but 1 patient in the MPFLR group had preoperative features consistent with trochlear dysplasia. There was no significant difference in limb length or coronal-plane alignment at final follow-up (P = .725 and P > .999, respectively). Both the MPFLR and the anterior cruciate ligament reconstruction groups had a statistically significant decrease in the Caton-Deschamps index between the preoperative and postoperative time points (mean, 0.18 ± 0.20 and 0.11 ± 0.14, respectively; P = .161). CONCLUSION: MPFLR may be safely performed utilizing an epiphyseal femoral socket in a skeletally immature cohort without affecting normal longitudinal growth or coronal limb alignment. The previously reported effect of MPFLR in reducing patellar height may be related to physiological growth based on similar changes noted in a comparison cohort that did not undergo the procedure.

Pediatric anterior cruciate ligament tears and associated lesions: Epidemiology, diagnostic process, and imaging.

The incidence of anterior cruciate ligament injuries in skeletally immature patients has increased in recent years. The gold standard treatment of this type of trauma in children is not yet established. Conservative management may underestimate the risk of new meniscal and chondral tears; on the other hand, a more interventional approach may expose the patient to iatrogenic damage to the growth plate. A correct approach to the skeletally immature patient with knee trauma is therefore essential to guide the decision-making process. This review article aims to present an update on the epidemiology and diagnostic process of pediatric patients with anterior cruciate ligament tears and possible associated injuries. Level of Evidence: V.