Department of Trauma Surgery, Plastic and Reconstructive Surgery, Georg-August-University, Göttingen, Germany.
Arthroscopy. 2010 Nov;26(11):1539-50. doi: 10.1016/j.arthro.2010.04.077.
The aim of this meta-analysis was to evaluate the clinical outcomes and risks of anterior cruciate ligament (ACL) surgery in children and adolescents.
We electronically searched Medline, the Cochrane Controlled Trial Database, Embase, and Medpilot for studies on surgical treatment for ACL ruptures in skeletally immature patients. We extracted baseline demographics, follow-up intervals, surgical details (i.e., ligament suture or reconstruction, physeal-sparing or transphyseal techniques, type of transplant, and methods of fixation). Endpoints comprised rates of growth disturbances and reruptures, as well as knee function (measured by the International Knee Documentation Committee's documentation system and the Lysholm score). Unweighted overall effect sizes (risks, risk ratios [RRs], and means of functional scores) were estimated by use of crude nominators and denominators, and random-effects meta-regression analysis was used for weighted data synthesis.
A total of 55 articles reporting on 935 patients (median age, 13 years; range, 1.5 to 16 years) were suitable for the study. After a median follow-up of 40 months (range, 14 to 89 months), the weighted rate of leg-length differences or axis deviations was 1.8% (95% confidence interval [CI], 0% to 3.9%] and that of reruptures was 4.8% (95% CI, 2.9% to 6.7%). Excellent or good function (International Knee Documentation Committee grade A or B) was achieved in 84.2% (95% CI, 75.8% to 92.6%) of all knees, and Lysholm scores averaged 96.3 (95% CI, 95.5 to 97.2). Transphyseal reconstruction was associated with a significantly lower risk of leg-length differences or axis deviations compared with physeal-sparing techniques (1.9% v 5.8%; RR, 0.34; 95% CI, 0.14 to 0.81) but had a higher risk of rerupture (4.2% v 1.4%; RR, 2.91; 95% CI, 0.70 to 12.12). Sutures did not result in any growth disturbances, with a weighted rerupture rate of 4.6% (95% CI, 2.6 to 6.7). Fixation far from the joint line fared better than close fixation with regard to this endpoint (1.4% v 3.2%; RR, 0.42; 95% CI, 0.09 to 1.93). Bone-patellar tendon-bone grafts, which are also less likely to fail, were associated with higher risks of leg-length differences or axis deviations than were hamstrings (3.6% v 2.0%; RR, 1.82; 95% CI, 0.66 to 5.03). Meta-regression did not show a significant impact of the publication year on event rates.
This meta-analysis showed low rates of leg-length differences or axis deviations and graft failures after ACL reconstruction in skeletally immature patients. Hamstring transplants may lower the risk of leg-length differences or axis deviations, and physeal-sparing techniques may increase the risk. Randomized controlled trials are needed to clarify important issues in managing ACL ruptures in children and adolescents.
Level IV, meta-analysis of case series.
本荟萃分析旨在评估儿童和青少年前交叉韧带（ACL）手术的临床结果和风险。
我们通过电子检索 Medline、Cochrane 对照试验数据库、Embase 和 Medpilot 中的研究，以寻找针对未成熟骨骼患者 ACL 破裂的手术治疗。我们提取了基线人口统计学资料、随访间隔、手术细节（即韧带缝合或重建、骺板保留或经骺板技术、移植物类型和固定方法）。终点包括生长障碍和再断裂的发生率，以及膝关节功能（通过国际膝关节文献委员会的文献系统和 Lysholm 评分来衡量）。未加权的总体效应大小（风险、风险比 [RR] 和功能评分的平均值）是通过使用粗分子和分母来估计的，而加权数据合成则使用随机效应荟萃回归分析。
共有 55 篇文章报告了 935 例患者（中位数年龄为 13 岁；范围为 1.5 至 16 岁）适合研究。中位随访 40 个月（范围为 14 至 89 个月）后，加权的肢体长度差异或轴偏差率为 1.8%（95%置信区间 [CI]，0%至 3.9%），再断裂率为 4.8%（95% CI，2.9%至 6.7%）。所有膝关节中，84.2%（95% CI，75.8%至 92.6%）达到了优秀或良好的功能（国际膝关节文献委员会分级 A 或 B），Lysholm 评分平均为 96.3（95% CI，95.5 至 97.2）。与骺板保留技术相比，经骺板重建与较低的肢体长度差异或轴偏差风险相关（1.9%比 5.8%；RR，0.34；95% CI，0.14 至 0.81），但再断裂风险较高（4.2%比 1.4%；RR，2.91；95% CI，0.70 至 12.12）。缝线不会导致任何生长障碍，再断裂率加权为 4.6%（95% CI，2.6 至 6.7）。与靠近关节线的固定相比，远离关节线的固定在这个终点上表现更好（1.4%比 3.2%；RR，0.42；95% CI，0.09 至 1.93）。骨-髌腱-骨移植物不太可能失败，与腘绳肌相比，其肢体长度差异或轴偏差的风险更高（3.6%比 2.0%；RR，1.82；95% CI，0.66 至 5.03）。荟萃回归未显示发表年份对事件发生率的显著影响。
本荟萃分析显示，在未成熟骨骼患者中，ACL 重建后肢体长度差异或轴偏差以及移植物失败的发生率较低。腘绳肌移植可能降低肢体长度差异或轴偏差的风险，而骺板保留技术可能增加该风险。需要随机对照试验来阐明儿童和青少年 ACL 破裂管理中的重要问题。
IV 级，病例系列的荟萃分析。
