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Published 8/1/2016
Peter Pollack

Pediatric ACL Revision Linked to Suboptimal Results

"ACL [anterior cruciate ligament] reconstruction is on the rise in pediatric and adolescent populations," said Melissa A. Christino, MD, who presented findings from scientific paper SS-10, "Revision ACL Reconstruction in Children and Adolescents," at the annual meeting of the Arthroscopy Association of North America. "The purpose of our study was to assess demographics, techniques, and outcomes of ACL revision in children and adolescents."

Patient profiles
Dr. Christino and her colleagues conducted a retrospective case series and outcomes assessment study of 88 patients (90 revision ACL reconstructions) aged 18 years or younger who underwent surgery at Boston Children's Hospital.

"All patients had their first-time revision surgery performed at a single institution with minimum 1-year follow-up," explained Dr. Christino. "We reviewed charts for patient and injury characteristics, operative details for revision surgery, and information on the index procedure, when available. We also assessed patients for level of skeletal maturity and postoperative complications."

Patient-oriented outcome measures included the Pediatric IKDC Subjective Knee Form (Pedi-IKDC), the Tegner Activity Scale, the Lysholm Knee Score, and an institution-designed physical activity survey to assess rate of return to sport. The average patient age at the time of revision was 16.6 years; 28.8 percent of the studied patients were determined to be skeletally immature at the time of revision.

The mean time to failure following the index procedure was 1.28 years, and the most common mechanism of failure was noncontact sports injuries.

"The most common graft used for revision surgeries was allograft, [which was used] in 61.1 percent of patients," observed Dr. Christino, followed by patellar tendon, hamstring, and iliotibial band (Fig. 1). "This stands in contrast to hamstring being the most popular graft choice for the primary procedure," she added.

Need for improvement
"Following revision, we found a 20 percent graft reinjury rate, including both complete and partial tears," she said. "We noted that 25.5 percent of patients had to return to the operating room [OR] for an additional procedure following revision. In addition, 20 percent of patients were found to have a contralateral ACL tear—a rate that increased to 33 percent among patients who injured their revision graft."

When each patient in the study was later surveyed regarding his or her outcome, 50 percent of patients responded, at an average 5.1-years after the revision surgery. Of those, the mean outcome scores were as follows:

  • Pedi-IKDC: 77.5 (standard deviation [SD]: 12.6)
  • Lysholm Knee Score: 79 (SD: 13.2)
  • Tegner Activity Scale: 6.6 (range: 6–10)

"We found a 69 percent return to sport rate among patients in our study," said Dr. Christino, "with an average time to return of 8.9 months. However, of the patients who did go back to sports, only 55.2 percent were able to return to their previous level of play.

"This is the first study to report characteristics and outcomes of revision ACL reconstruction in an exclusively pediatric and adolescent population," she continued. "We found that revision ACL surgery in children and adolescents is associated with suboptimal patient outcomes, higher retear rates, high complication and return to OR rates, significant rates of contralateral ACL injury, and compromised return to sport rates.

"With increasing numbers of ACL tears seen in young athletes, revision surgery is going to become more and more common," she explained. "More research is needed to systematically evaluate revisions in these young patients so we can optimize results and return them to their activities."

Dr. Christino's coauthors are Frances Tepolt, MD; Lyle J. Micheli, MD; and Mininder S. Kocher, MD.

Peter Pollack is the electronic content specialist for AAOS Now. He can be reached at ppollack@aaos.org

Bottom Line

  • ACL reconstruction is on the rise in pediatric and adolescent populations, leading to an increase in the number of revision surgeries.
  • Following revision in this study of pediatric and adolescent patients, 20 percent of patients reinjured their graft, and 25.5 percent had additional surgery.
  • The researchers also found that 69 percent of patients were able to return to sport, but only 55.2 percent returned to their previous level.
  • More research is needed to optimize revision ACL outcomes for younger patients.