Two-Year Complication Rates for Pediatric Anterior Cruciate Ligament Reconstruction: A Multi-Center Study

Background: Anterior cruciate ligament reconstruction (ACLR) is one of the most common orthopedic knee procedures performed with literature shifting in favor of early ACLR for skeletally immature patients.1,2 Although physeal-sparing techniques limit risk of iatrogenic physeal injury, pediatric ACLRs demonstrate higher overall complication rates than adult ACLRs.2,3 The purpose of this study was to report two-year complication rates for pediatric ACLRs from a large multi-center complication registry. Hypothesis: Pediatric ACLR complication rates will be associated with specific identifiable patient and treatment variables. Methods: The Sports Cohort Outcomes Registry (SCORE) is a prospective registry of consecutive cases from 43 surgeons across 26 institutions in the United States. Demographic, operative, post-operative rehabilitation, and complication data from isolated pediatric ACLR cases between 2018-2023 with minimum 30-month follow-up was collected. The Modified Clavien-Dindo-Sink Complication Classification System was used for grading complications.4 Statistical analysis included Chi-Square tests, Fisher’s Exact test with Bonferroni correction, and Mann-Whitney tests, as appropriate. Results: 1219 patients with a mean age of 14.8 ± 2.2 (range: 5-19) were included. 53.9% were male and average injury-surgery days was 94.70 ± 204.4 (range: 5 - 4384). The overall grade II+ complication rate was 21.9% with 8.5% being grade II and 13.4% being grade III. Patients that were female demonstrated higher overall complication rates (25.8%, p = 0.002). Graft failure rate was 7.6%. Patients with a closing physis (12.3%, p = 0.004), hamstring graft (10.7%, p = 0.027), and a transphyseal tibial technique (10.9%, p = 0.012) demonstrated higher graft failure rates. In particular, pediatric ACLRs using a hamstring graft and transphyseal tibial technique had a 17.3% graft failure rate. Post-operative meniscus tear rate was 2.6% and the rate of arthrofibrosis was 1.7%, with female patients demonstrating higher arthrofibrosis rates (3.0%, p = 0.001). There were no significant differences across the studied complications with respect to incorporating a lateral extra-articular tenodesis. Conclusion: Pediatric ACLRs demonstrate an overall complication rate of 21.9% with a 7.6% graft failure rate, a 2.6% meniscus tear rate, and a 1.7% arthrofibrosis rate. Across all complications, surgeons should be aware of elevated risk in female patients. Additional risk factors for consideration include ACLRs on a closing physis with a hamstring graft and transphyseal tibial technique. With these risk factors in mind, surgeons can optimize pediatric ACLR treatment and rehabilitation.