Intrasubstance Anterior Cruciate Ligament Injuries in the Pediatric Population

Abstract

Pediatric intrasubstance anterior cruciate ligament (ACL) tears have a significant epidemiologic impact as their numbers continue to grow globally. This review focuses on true pediatric intrasubstance ACL tears, which occur >400,000 times annually. Modifiable and non-modifiable risk factors include intercondylar notch width, ACL size, gender, landing mechanisms, and hormonal variations. The proposed mechanisms of injury include anterior tibial shear and dynamic valgus collapse. ACL tears can be associated with soft tissue and chondral defects. History and physical examination are the most important parts of evaluation, including the Lachman test, which is considered the most accurate physical examination maneuver. Imaging studies should begin with AP and lateral radiographs, but magnetic resonance imaging is very useful in confirming the diagnosis and preoperative planning. ACL injury prevention programs targeting high risk populations have been proven to reduce the risk of injury, but lack uniformity across programs. Pediatric ACL injuries were conventionally treated nonoperatively, but recent data suggest that early operative intervention produces best long term outcomes pertaining to knee stability, meniscal tear risk, and return to previous level of play. Current techniques in ACL reconstruction, including more vertically oriented tunnels and physeal sparing techniques, have been described to reduce the risk of physeal arrest and limb angulation or deformity. Data consistently show that autograft is superior to allograft regarding failure rate. Mean durations of postoperative therapy and return to sport were 7 ± 3 and 10 ± 3 months, respectively. These patients have good functional outcomes compared to the general population yet are at increased risk of additional ACL injury. Attempts at primary ACL repair using biological scaffolds are under investigation.

Keywords: Anterior cruciate ligament; Pediatrics; anterior cruciate ligament; anterior cruciate ligament reconstruction; magnetic resonance imaging; pediatric; pediatric intrasubstance anterior cruciate ligament tear; pediatric orthopedics.

Figure 1

Proton-density magnetic resonance imaging (a-f) with fat saturation (except c and e) showing the spectrum of anterior cruciate ligament injuries in the sagittal plane in pediatric patients aged 13-16 years (adapted from Jaremko et al.) (a) intact anterior cruciate ligament; (b) thin, but intact anterior cruciate ligament; (c) surgically confirmed high grade partial anterior cruciate ligament tear with lax fibers; (d) full-thickness midsubstance anterior cruciate ligament tear with some intact fibers near the tibial attachment (arrow); (e) full-thickness tear; (f) full-thickness tear with anteriorly flipped distal ligament fibers (arrow) and anterior tibial translation

Figure 2

Algorithm for treatment of skeletally immature patients with either partial or complete anterior cruciate ligament tear (Adapted with permission from Fabricant et al.)

Figure 3

Diagrammatic representation of physeal sparing techniques for anterior cruciate ligament reconstruction in skeletally immature patients (Reproduced with permission from Fabricant et al.). (a) Kocher technique combines intraarticular with extraphyseal fixation. (b) Anderson technique is intraarticular both for femur and tibia, extraphyseal fixation on the tibia. (c) Ganley technique involves intraarticular all epiphyseal fixation utilizing interference screws. (d) Cordasco-Green utilizes intraarticular all epiphyseal with suspensory fixation