Editorial Commentary: Athletes at Greatest Risk of Anterior Cruciate Ligament Reconstruction Failure Are Skeletally...

Given the increasing incidence of anterior cruciate ligament (ACL) injuries in skeletally immature patients, improving surgical outcome for ACL reconstruction has been at the forefront of orthopaedic pediatric and adolescent sports medicine research. This research has focused upon graft choice, modifiable risk factors, and nonmodifiable risk factors. Allograft is contraindicated in these patients, and bone-patellar tendon-bone grafts should be avoided (as bone plugs should be avoided near the open physis). Because of the greater failure rates of hamstring tendon autograft in this cohort, especially in the older cohort of skeletally immature athletes treated with a complete transphyseal ACL reconstruction, our preferred graft choice is quadriceps tendon autograft. Rehabilitation is a modifiable risk factor, and we emphasize a need for return to sport assessment before release for sports. Nonmodifiable risk factors in this skeletally immature cohort include recurvatum, increased anterior translation (>7 mm), 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 eighth- and ninth-grade athletes. 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.