Younger, older youth athletes show lower revision ACL rates, higher rates of return to sport

Issue: August 2018

SAN DIEGO — Younger athletes who had all-epiphyseal hamstring primary ACL reconstruction showed better outcomes compared to older adolescents who had reconstruction with a hamstring autograft, according to a study results presented here at the American Orthopaedic Society for Sports Medicine Annual Meeting.

Perspective from Darren de SA, MD, FRCSC, and Freddie H. Fu, MD

Frank A. Cordasco

“This confirms for us that the all-epiphyseal is not a bridge to an adult-type reconstruction,” Frank A. Cordasco, MD, MS, said.

In the study cohort of 324 patients younger than 20 years, Cordasco and colleagues evaluated the clinical outcomes of three groups of patients who had primary ACL reconstruction. Group 1 was comprised of prepubescent patients in seventh grade and under who had 3 to 6 years of growth remaining. They received an all-epiphyseal hamstring autograft ACL reconstruction. Patients in group 2 were the young adolescent group, generally in eighth and ninth grade, who had 2 to 3 years of growth remaining. They were treated with a partial transphyseal or complete transphyseal hamstring autograft ACL reconstruction. Patients in group 3 were skeletally mature adolescents who were in 10th grade through college. They were treated with a complete transphyseal ACL reconstruction with bone-tendon-bone autograft. Males represented 55% of the patients and the overall mean age was 15.1 years. There was 100% sports participation in travel club or school-level sports. Mean follow-up was 3.25 years.

The rate of revision ACL was higher in group 2 athletes at 20% as compared to group 1 (6%) and group 3 (6%). Cordasco said the 6% revision ACL reconstruction rates for group 1 and 3 found in this study compare favorably with the literature.

Younger athletes who had all-epiphyseal hamstring primary ACL reconstruction compared to older adolescents who had reconstruction with a hamstring autograft showed better outcomes.

Kristine Houck, MA, ELS

Researchers found group 2 athletes had 86% return to sport compared to 100% for group 1 and 94% for group 3. Athletes in group 2 also had a lower return to sport (75%) at the same level compared to the athletes in groups 1 and 3, which was 96% and 82%, respectively. Group 2 athletes were more likely to have a revision ACL reconstruction compared with group 3 athletes.

“We have identified this group 2 of eighth- and ninth-grade athletes as a particularly high-risk cohort within an already high-risk group of athletes. The etiology is likely multifactorial. However, we believe the level of competition may be factor in that they return to sport with skeletally mature high school cohort that has not lost a year of physically development and sports-specific experience. While hamstring autografts appear to be suitable for the group 1 athlete, it might not be up to task for the group 2 athlete,” he said. – by Kristine Houck, MA, ELS

Reference:

Cordasco FA, et al. Paper 102. Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 5-8, 2018; San Diego.

Disclosure: Cordasco reports he receives royalties from and is a paid consultant for Arthrex; has a publishing relationship with Saunders/Mosby-Elsevier Wolters Kluwer Health and Lippincott Williams & Wilkins; is on the editorial/governing board for the Journal of Shoulder and Elbow Surgery; and is a board/committee member for the American Shoulder and Elbow Surgeons.

Perspective

Darren de SA, MD, FRCSC, and Freddie H. Fu, MD

We read, with great interest, the work of Cordasco and his team; and applaud their study that further identifies a high-risk subset of adolescent ACL patients. Briefly, this study analyzed the single-surgeon, short-term outcomes of patients treated with either an all-epiphyseal hamstring autograft (grade 7 and lower, group 1), partial/complete transphyseal hamstring autograft (grade 8 to grade 9, group 2) or complete transphyseal patellar tendon autograft (grade 10+, group 3). The key finding(s) from this study remain that, in the short-term, group 2 patients experience significantly higher rates of failure and revision surgery, and significantly lower rates of return to sports at pre-injury and any level.

Clearly, the etiology for failure post-ACL reconstruction is multifactorial, with the relative influence of each parameter largely unknown. One must be cognizant that for this study, it is paramount to know group 2’s relative contribution of partial to complete reconstructions. One must also acknowledge the selection bias introduced with three cohorts of varying sample sizes, and potentially variable gender – and/or activity status – amongst other confounders. Lastly, differing mean time points for full return-to-sports activities may vary across the groups.

Nevertheless, they demonstrate the merits of an all-epiphyseal technique in appropriately selected patients. Moreover, they suggest that grade and/or level of competition may more significantly impact outcomes than previously thought, highlighting the importance of physical development or lack thereof. Should we modify adolescent sports age groups to circumvent this potential developmental disadvantage? Lastly, they suggest that graft choice may be dictated by grade and/or level of play; not just physeal status and/or surgeon preference. It would be interesting if any difference existed between group 2 complete transphyseal and group 3 patients or if an alternative soft-tissue autograft (ie, quadriceps tendon) in group 2 matters? Certainly, this study provides valuable information for managing preoperative patient expectations and provides a springboard for future efforts.

Darren de SA, MD, FRCSC, and Freddie H. Fu, MD

University of Pittsburgh Medical Center,

Pittsburgh

Disclosures: de SA and Fu report no relevant financial disclosures.