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Adolescent athletes may have higher revision, lower return-to-sport rates after ACL reconstruction
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Adolescent athletes experienced a higher rate of revision ACL reconstruction and significantly lower return-to-sport rates compared with prepubescent athletes and skeletally mature athletes, according to published results.
“We concluded that this is the first report to clearly demonstrate that younger athletes who have had an all-epiphyseal reconstruction with a hamstring autograft had better outcomes than older adolescents who had a hamstring autograft who again were not skeletally mature,” Frank A. Cordasco, MD, professor of orthopedic surgery at Weill Cornell Medical College and attending orthopedic surgeon in the sports medicine and shoulder service at Hospital for Special Surgery, told Healio.com/Orthopedics.
Revision rates
Cordasco and colleagues categorized 324 athletes younger than 20 years of age who underwent ACL reconstruction into three groups based on whether they were prepubescent athletes with 3 to 6 years of growth remaining (group 1, n=49), young adolescents with 2 to 3 years of growth remaining (group 2, n=66) or skeletally mature athletes who were typically in high school or college (group 3, n=209). Researchers selected the surgical technique based on skeletal age, including the all-epiphyseal technique with hamstring autograft in group 1, the partial transphyseal and complete transphyseal with hamstring autograft in group 2 and bone-tendon-bone autograft in group 3.
Cordasco noted that all of the athletes participated in travel, club or school levels of competition and that 75% of the athletes participated in soccer, lacrosse, basketball or football. Return to sport was defined as playing 1 full season in the same sport that the athlete was injured in, according to Cordasco.
“When we looked at revision rates, the revision ACL reconstruction rate in group 1 was 6% and in group 3 was 6%, and those are favorable compared to the revision rates reported in the literature,” Cordasco said.
However, he noted that patients in group 2 experienced a failure rate of 20%. The high failure rate among these athletes may be caused by multiple factors, according to Cordasco, including the transition into a higher level of competition and use of hamstring autografts.
“Hamstring autografts in general in ... recreational adults seem to be a reasonable graft, but in this high-risk level of competition, these youngsters seem to be particularly at risk,” Cordasco said.
Return to sport
He added athletes in group 2 also had a return-to-sport rate of 85% compared with 100% in group 1 and 94% in group 3. The return-to-sport rate at the same level was also lower in group 2 (74%) vs. group 1 (92%) and group 3 (80%).
Multivariate logistic regression showed athletes in group 2 had a four-times rate of failure as it related to revision ACL reconstruction compared with group 3.
“When we did the same multivariate logistic regression regarding contralateral ACL reconstruction, we found a 2.8 odds ratio for ... females compared to males and that was statistically significant,” Cordasco said. – by Casey Tingle
Disclosures: Cordasco reports he receives royalties from Conmed/Linvatec, Arthrex, Wolters/Kluwer Lippincott Williams and Wilkens and Saunders Mosby Elsevier, and has received consulting and speakers fees from Arthrex. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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Volker Musahl, MD
As increasing evidence demonstrates the issues with nonoperative management of pediatric ACL injury, including long-term chondral and meniscal damage, there is a trend toward operative management. In their study performed at Hospital for Special Surgery, Cordasco and colleagues found a higher rate (20%) of revision ACL reconstruction among an adolescent group, mean skeletal age of 14 years, treated with partial or complete transphyseal hamstrings ACL reconstruction, as compared to a younger group, mean skeletal age of 12 years, treated with all-epiphyseal hamstrings ACL reconstruction (6%) and an older skeletally mature group treated with transphyseal bone-tendon-bone ACL reconstruction (6%). They also found a lower return-to-sport rate (85% vs. 100% and 94%). The findings are of great interest and could be attributed to the difference in graft selection, hamstrings vs. bone-tendon-bone and surgical technique, sparing the femoral physis vs. transphyseal.
There is growing evidence that quadriceps autograft may be a better choice than hamstrings autograft, and quadriceps is our soft tissue graft of choice. If a physeal-sparing technique is used, the surgeon should remain focused on an anatomical reconstruction. An individualized, anatomic ACL reconstruction approach is recommended, recognizing the morphology of the knee and restoring the native biology.
University of Pittsburgh, department of orthopedic surgery
Medical director, UPMC Rooney Sports Complex
Pittsburgh
Orthopedic sports medicine fellow
University of Pittsburgh, department of orthopedic surgery
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