Growth Disturbance Following ACL Reconstruction with Use of an Epiphyseal Femoral Tunnel

Abstract

Anterior cruciate ligament (ACL) tears in skeletally immature patients are increasing in prevalence. This appears to be the result of a heightened suspicion for such injuries, more readily available imaging, and the ever-increasing physical demands and competitiveness of organized youth sports1. As a result, there is increased interest in early ACL reconstruction to potentially prevent further intra-articular damage to the knee2-4. Multiple surgical techniques for ACL reconstruction described for adults are not appropriate in skeletally immature patients because they involve large drill holes across the physis, fixation or bone blocks that cross the physis, or tensioning of a graft across the physis, all of which have been shown to result in growth disturbances5-13. Because of these concerns, multiple surgical techniques to address ACL tears in patients with open physes have been described, including primary repair, extra-articular tenodesis, transphyseal reconstruction, partial transphyseal reconstruction, and physeal sparing techniques. Growth disturbances have been reported with the use of most of these techniques12-14. Anderson described a technique of ACL reconstruction that avoids drilling tunnels across the physis15,16. Theoretically, this should decrease the incidence of growth disturbance following ACL reconstruction in skeletally immature patients. With this technique, both the femoral and the tibial tunnels are drilled entirely within the epiphysis, and an all-soft-tissue graft is used for the reconstruction. Good results were found in twelve patients at the time of follow-up, two to eight years postoperatively15, and to our knowledge a growth disturbance has never been reported after the use of this technique. Here, we describe a case of distal femoral valgus angulation associated with use of an epiphyseal femoral tunnel for a revision ACL reconstruction in an immature patient. The patient and his family …