Three-Dimensional Kinematic Gait Analysis in Pediatric Patients With an ACL-Deficient Knee

Background: Pediatric anterior cruciate ligament (ACL) tears are increasingly frequent in young athletes, yet existing biomechanical data remain limited and often rely on adult-based protocols. This study aims to characterize gait-related knee kinematic differences across all 3 anatomic planes during walking in pediatric patients with isolated ACL-deficient (ACLD) knees (ie, knees with a confirmed ACL rupture prior to surgical reconstruction), using a clinically accessible tool, the knee kinesiography examination. Hypothesis: Pediatric patients with ACLD knees demonstrate biomechanical gait patterns comparable to adults while also presenting variations associated with growth and development. Study Design: Cross-sectional study; Level of evidence, 3. Methods: This retrospective, single-center study included pediatric patients with ACLD knees who underwent knee kinesiography (KKG) between January 2023 and January 2025. Controls were patients without knee pathology. Kinematic data were collected in the sagittal, frontal, and transverse planes and analyzed using Statistical Parametric Mapping 1D. Four comparisons were performed: (1) ACLD versus healthy knees, (2) ACLD versus contralateral knees, (3) contralateral versus control knees, and (4) sex comparison. Results: Thirty-nine patients with ACLD knees (15.0 ± 1.8 years) and 15 healthy participants (16.0 ± 1.7 years) were analyzed; 24 of the patients with ACLD knees also underwent contralateral KKG. Compared to controls, ACLD knees showed greater flexion during stance (15.1°± 4.8° vs 9.4°± 4.2°; P < .001) and increased external tibial rotation (1.9°± 4.6° vs −0.1°± 3.4°; P = .026), with no differences in the frontal plane or anteroposterior translation. Contralateral knees also showed greater flexion (12.6°± 5.0° vs 9.4°± 4.2°; P = .002) and anterior translation at heel strike (3.4 ± 4.7 mm vs 1.5 ± 3.8 mm; P = .043), indicating bilateral modifications in gait patterns. No sex differences were observed. Conclusion: This study is the first to analyze the kinematics of pediatric ACLD knees in all 3 anatomic planes using a clinically accessible 3-dimensional gait analysis tool. Pediatric patients with ACLD knees exhibited a flexed-knee gait and increased external tibial rotation, differing from adult patterns. Bilateral gait pattern differences were observed between patients with ACLD knees and healthy controls, underscoring the importance of comprehensive bilateral evaluation and pediatric-specific rehabilitation strategies rather than adult-derived protocols.