All-epiphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

Abstract

Treating ACL injuries in prepubescent patients requires balancing the risk of chondral and meniscal injuries associated with delaying treatment against the risk of growth disturbance from early surgical reconstruction. Multiple physeal respecting techniques have been described to address this vulnerable population; however, none restore the native ACL attachments while keeping the graft and fixation entirely in the epiphysis. We describe a technique of all-epiphyseal ACL reconstruction for use in prepubescent skeletally immature patients. Intraoperative CT scanning with three-dimensional (3-D) reconstruction was used to confirm the precise localization of the all-epiphyseal femoral and tibial tunnels. The femoral tunnel is drilled entirely in the epiphysis of the lateral femoral condyle. The tibial tunnel is drilled from inside-out to the level of the tibial physis using a retrograde drill. Fixation of the soft tissue graft is achieved with a retrograde interference screw in the tibia and an interference screw in the femur. Case examples are presented for three boys aged 10-12, Tanner Stage 1 development, with a minimum followup of 1 year. All three patients had stable knees based on Lachman and KT-1000 testing and no evidence of growth disturbance. All had full ROM and symmetric strength for knee flexion and extension. All patients returned to their sports activities using a custom ACL brace. Although longer-term followup will be necessary, this technique provides for an anatomic all-epiphyseal-based ACL reconstruction using intraoperative 3-D imaging to minimize the risk of growth disturbance. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.