Hamstring Allograft Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient

Abstract

Reconstruction of the anterior cruciate ligament (ACL) remains the most appropriate treatment for adolescent patients who are ACL deficient. This article reviews the indications for adolescent ACL reconstruction, potential risks, and the technique for allograft HISTORICAL PERSPECTIVE In the last 20 years, there has been an increase in the literature pertaining to the management of a skeletally immature patient with anterior cruciate ligament (ACL) injuries. With increasing involvement of children in sports, an increase in ACL injuries in this population has been reported.' In a survey of members of the Herodicus Society and the ACL Study Group, Kocher et al2 reported that the members studied a mean of 5.8 pediatric patients with ACL injuries annually. In addition, 78% of those surveyed stated that they had performed an ACL reconstruction on a skeletally immature patient within the previous year. Historically, ACL reconstruction in skeletally immature patients has been discouraged because of the theoretical risks of damage to the physes and the risk of growth disturbance. However, the case series data available in the literature have not supported a significant pattern of leg length discrepancy or angular deformity caused by ACL reconstruction in adolescent patients.310 Controversy still exists between nonoperative management and surgical reconstruction of these patients based on the potential risks of both treatment options. Nonsurgical treatment risks an unstable knee and further damages the meniscal structures and articular cartilage. Anterior cruciate ligament injuries in adolescents behave similarly to those injuries in adults; chondral and meniscal injuries are common. Operative reconstruction risks potential damage to the growth plate. Previous research has shown that 21% to 100% of pediatric patients with ACL injuries will have a concomitant meniscal injury.1'4'5'1014 In addition, there is a risk of exacerbating initial injury or new meniscal damage if the knee remains chronically unstable.5'15'16 Growth plate arrest after ACL reconstruction, although a concern, has only been infrequently reported.2'17'18 Furthermore, the treatment of physeal arrest is soft tissue interposition, and for this reason, hamstring tendon grafts have