Athletes at Highest Risk of ACL Reconstruction Failure are Skeletally Immature Adolescents Treated With Complete Transphyseal All-Soft-Tissue Graft.

Abstract

Given the increasing incidence of ACL injuries in skeletally immature patients, improving surgical outcome for ACLR has been at the forefront of orthopaedic pediatric and adolescent sports medicine research. This research has focused upon graft choice, modifiable risk factors, and non-modifiable risk factors. Allograft is contraindicated in these patients, and bone-tendon-bone grafts should be avoided (as bone plugs should be avoided near the growing epiphysis). Due to higher failure rates of hamstring tendon autograft in this cohort, especially in the older cohort of skeletally immature athletes treated with a complete transphyseal ACLR, our preferred technique is quadriceps tendon autograft. Rehabilitation is a modifiable risk factor, and we emphasize a need for return to sport assessment prior to release for sports. Non-modifiable risk factors in this skeletally immature cohort include recurvatum, increased anterior translation (>7mm), high-grade pivot shift, increased lateral posterior tibial slope, high velocity marrow edema patterns involving the lateral femoral condyle and lateral tibial plateau, Beighton score > 4, and the 8th and 9th grade athlete. When these findings are present in an athlete who plans to return to pivoting and contact/collision sports, we indicate a lateral extra-articular tenodesis in the form of a modified Lemaire procedure.