Transphyseal Anterior Cruciate Ligament Reconstruction Research Articles

Transphyseal arthroscopic anterior cruciate ligament reconstruction in children under 12 years.

The incidence of anterior cruciate ligament (ACL) injuries in children is on the rise. Despite this trend, the optimal management of these injuries remains a matter of ongoing debate. In this light, our study seeks to assess the clinical, radiological, and functional outcomes of transphyseal ACL reconstruction in preadolescent patients in the medium-term. This prospective study included preadolescent patients aged up to 12 years who underwent ACL transphyseal reconstruction between 2010 and 2020 and had a minimum follow-up of 2 years. Clinical assessments encompassed joint stability and range of motion. Furthermore, leg length discrepancy (LLD) and femorotibial alignment were evaluated both clinically and radiologically using full-length lower limb standing radiographs. Pre- and postoperative functional outcomes were assessed using the International Knee Documentation Committee (IKDC) and Lysholm scales, and the return to normal sports activity was evaluated using the ACL-Return to Sport after Injury (ACL-RSI) scale. Complications and relevant follow-up data were also recorded. Statistical analyses were conducted to evaluate these outcomes. A total of 35 preadolescent patients, consisting of 24 males and 11 females, with a mean age at surgery of 11.2 ± 0.7 years (8.7-12), were included in the study. The mean follow-up was 52.3 ± 20.7 months (24.1-95.9). No significant growth disturbances or clinically relevant LLD were evidenced. All patients demonstrated clinically stable knees with full range of motion at the 2-year follow-up. There were statistically significant improvements in pre- and postoperative IKDC (39.3 ± 13.5 vs. 99.7 ± 0.8, p < 0.005) and Lysholm scores (48.2 ± 15.1 vs. 99.6 ± 1.4, p < 0.005). All but two patients were able to return to their pre-injury level of sports activity, with a mean ACL-RSI score of 93.5 ± 1.3. The analysis revealed an 8.6% rerupture rate and an11.4% rate of contralateral ACL injuries, with 5-year survival rates of 92.3% and 88.8%, respectively. Subgroup analyses based on age, gender, surgical delay, or associated meniscal lesions did not reveal any significant differences in functional outcomes. Additionally, there was no discernible relationship between age or timing of ACL reconstruction and the risk of meniscal injuries. Our study reinforces the value of ACL reconstruction in skeletally immature preadolescent patients, with transphyseal technique proven to be a safe, effective, and technically simpler option, even for children under the age of 12. The findings indicate excellent functional outcomes, a high rate of successful return to sporting activities, and minimal to no incidence of growth-related complications in the medium-term. Level II, prospective comparative cohort study, before and after intervention.

Graft Type and Diameter Are Predictors of Reinjury After Transphyseal Anterior Cruciate Ligament Reconstruction in Pediatric and Adolescent Patients

PurposeThe purpose of this study were to report the rate of ACL graft failure by physis status (open, closing, closed) and to analyze which factors were associated with higher risk of ACL graft failure. MethodsPatients under 18 years old who underwent transphyseal ACLR between 2000 and 2018 at a single institution were reviewed at minimum 2-years post-ACLR. Patient records were reviewed for anthropometrics, surgical techniques, and ACL graft failure. Patients were subsequently stratified based on physis status (open, closing, closed) and analyzed. ResultsA total of 272 patients (mean age of 15.4 ± 1.3 years) were assessed. Transtibial technique was used in 63.6% of cases. Hamstring autograft was used exclusively in the open physis group. A patellar tendon autograft was used in 65.9% of patients with a closing physis and 80.9% of closed physis patients. The overall graft failure rate was 13.2%, the contralateral ACL injury rate 11.0%. Kaplan-Maier analysis by physis status showed different injury free from ACL reinjury (P<.001). An open physis was associated with increased risk of ACL reinjury (HR 5.2, P<.001) when compared to a closed physis. A closing physis presented a higher hazard ratio, but was not statistically significant (HR 2.6, P = 0.08). Hamstring graft type (P = 0.03) and lower graft diameter (P = 0.04) were significantly related to higher ACL reinjury after adjusting for physis status. ConclusionTransphyseal ACLR is a safe procedure in pediatric patients. The rate of reinjury was 13.2%. This rate decreases with skeletal maturity, use of patellar tendon autograft, and a larger graft diameter. .

Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: 3-Year Clinical and Patient-Reported Outcomes.

The rate of anterior cruciate ligament (ACL) rupture in active, skeletally immature patients is increasing. Although hamstring tendon autograft (HTA) was previously deemed the gold standard, recent studies have shown HTA to have a high failure rate in this high-risk population of young competitive athletes, and quadriceps tendon autograft (QTA) has yielded excellent preliminary outcomes in some studies examining this population. To evaluate 3-year clinical and patient-reported functional outcomes of primary ACL reconstruction (ACLR) with soft tissue QTA in skeletally immature patients. Case series; Level of evidence, 4. Skeletally immature patients who underwent ACLR with a full-thickness soft tissue QTA were included. Preoperative patient and surgical data were collected. The ACLR technique was selected predicated upon skeletal age and included all-epiphyseal and complete transphyseal techniques. Patients were followed for a minimum of 2 years with successive clinical visits or were contacted via telephone. Patients who did not have minimum 2-year follow-up after 3 contact attempts via telephone were excluded. Information regarding return to sports (RTS) and concomitant or subsequent surgical procedures was collected. Pediatric International Knee Documentation Committee (Pedi-IKDC), Hospital for Special Surgery Functional Activity Brief Scale (HSS Pedi-FABS), and Single Assessment Numeric Evaluation (SANE) scores were collected. Of 85 adolescent patients aged 11.1 to 17.6 years (mean age, 14.1 ± 1.2 years), 2 patients were determined to be lost to follow-up after 3 failed contact attempts. Of the patients included in this study (N = 83), 26 patients (31%) underwent all-epiphyseal and 57 patients (69%) underwent complete transphyseal ACLR. Additionally, 48 patients (58%) underwent concomitant lateral extra-articular tenodesis using the iliotibial band with a modified Lemaire technique. The mean follow-up time was 3.7 ± 1.2 years (range, 2-7 years). Twenty (24%) patients had subsequent surgical procedures, of which 3 (4%) were due to graft failures. At a mean 3-year follow-up, the mean Pedi-IKDC, HSS Pedi-FABS, and SANE scores were 90, 23, and 94 respectively; the RTS rate was 100%; and the rate of RTS at the previous level of performance was 93%. Use of a soft tissue QTA for ALCR in a high-risk skeletally immature population of athletes resulted in excellent postoperative outcomes with low rates of graft failure and high return to sport rates.

Pediatric ACL Reconstruction in Children-An Evaluation of the Transphyseal Technique's Efficacy and Safety.

Injuries of the anterior cruciate ligament (ACL) are commonly found in the general population, both among adult and pediatric patients, and their incidence has been increasing in recent years. Most of the late literature agrees that surgical reconstruction of the ACL is effective in improving long-term outcomes in pediatric patients, while others in the past have pleaded for non-surgical management. Our study aims to verify if ACL reconstruction (ACLR) using transphyseal technique in skeletally immature patients will provide angular deviations or growth restrictions. Retrospective cohort study; Level of evidence 4. We perfomed a retrospective study to verify if transphyseal ACLR in children with less than or equal to 2 years of remaining growth leads to either limb length discrepancies or axis deviations. Most patients who were treated using transphyseal technique showed significant improvements in their functional scores. There were statistically significant differences in lateral distal femoral angles (LDFA) and medial proximal tibial angles (MPTA), with no clinical impact. There was no significant limb length discrepancy (LLD) during the 2-year follow-up. Transphyseal ACLR is safe among children who have less than or equal to 2 years of remaining growth and brings no risk of axis deviations or limb length discrepancy.

Children’s orthopaedics

The April 2024 Children’s orthopaedics Roundup360 looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study.

Postoperative Strength Differences at Short-Term Follow-Up Vary Based on Autograft Harvest Site After Adolescent Transphyseal Anterior Cruciate Ligament Reconstruction

PurposeThe purpose of this study was to compare the clinical and patient-reported outcomes of adolescent patients who underwent anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) versus hamstrings tendon (HT) autograft. MethodsThis was a retrospective cohort study of adolescent patients ≤18 years treated at a single tertiary care children’s hospital who underwent primary transphyseal ACLR using QT or HT between January 2018-December 2019. All patients had minimum 6-month follow-up. Outcomes included isokinetic strength testing, postoperative PROMIS and IKDC scores, and complications. These were compared between QT and HT cohorts. ResultsA total of 84 patients were included (44 HT, 40 QT). The QT cohort had a higher proportion of male patients (62.5% vs 34.1%, p=0.01). At 3 months, those with HT had lower Hamstrings/Quadriceps (H/Q) strength ratios (60.7±11.0 vs 79.5±18.6, p<0.01) and flexion-limb symmetry index (LSI) (85.6±16.1 vs 95.5±15.7, p=0.01), while patients with QT had lower extension-LSI (67.3±9.5 vs 77.4±10.7, p<0.01). The H/Q ratio was lower at 6 months for patients with HT (59.4±11.5 vs 66.2±7.5, p<0.01). PROMIS/IKDC scores were not different at 3 months or latest follow-up. Patients with QT had more wound issues (20.0% vs 2.3%, p=0.01). Those receiving HT autograft had more ipsilateral knee injuries (18.2% vs 2.5%, p=0.03), but there was no difference in graft failure for HT and QT ACLR (9.1% vs 2.5%, p=0.36). ConclusionThere were no differences in PROM between patients receiving QT and HT autografts. QT grafts had more post-operative wound issues but a lower rate of ipsilateral knee complications (graft failure or meniscus tear). Differences in quadriceps and hamstrings strength post-operatively compared to the contralateral limb were observed for adolescent ACLR patients receiving QT and HT autografts, respectively. This contributed to higher H/Q ratios seen at 3 and 6 months postoperatively for patients receiving QT autografts. Level of EvidenceLevel III, retrospective comparative therapeutic study

Analysis of Growth After Transphyseal Anterior Cruciate Ligament Reconstruction in Children.

Pediatric transphyseal anterior cruciate ligament reconstruction (ACLR) bears several advantages and is widely used. The main concern is the risk of growth disturbance. Our purpose was to investigate the incidence and risk factors of growth disturbance in skeletally immature patients who underwent transphyseal ACLR. We hypothesized that this procedure would generate neither clinically relevant limb length discrepancy (LLD) nor axis deviation. This prospective, consecutive, single-center series included skeletally immature patients who underwent primary transphyseal ACLR using semitendinosus tendon autograft, with a 2-year follow-up bone length standing radiograph of both lower limbs from pelvis to ankle in anterior posterior view. Lower limb length, mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA) were measured. The definition of postoperative growth disturbance was defined as ≥10mm for LLD or ≥3 degrees for axis deviation in comparison to the contralateral lower limb. Predictive variables included age at surgery, gender, side, and diameter of bone tunnels. Student or Mann-Whitney test was used for numerical variables, and Chi-square test or Fisher exact test was used for categorical variables. P values <0.05 were considered statistically significant. Fifty consecutively treated patients were included. Forty-seven patients (31 boys, 16 girls) with a mean age of 13.2 years (range, 9 to 16) at the time of surgery were available for analysis. Six patients had an LLD of at least 10mm. Twenty-five patients had a difference in MPTA of a least 3 degrees (range, 5 to 8). Sixteen patients had a difference in LDFA of a least 3 degrees (range, 4 to 9). No patients presented with a clinical deformity or related symptoms. Regarding coronal alignment, there was no statistical difference in mechanical axis deviation, LDFA, or MPTA. Gender, side, age, and bone tunnel diameter did not influence growth disturbance. Transphyseal pediatric ACLR generated a high rate of growth disturbances (leg length discrepancy and axis deviation) although none clinically relevant. Mild proximal tibial axis deviation in patients operated on near skeletal maturity should be further investigated. Level III. Case-control study.

Leg-Length and Alignment Changes in Children and Adolescents After Transphyseal Anterior Cruciate Ligament Reconstruction With Soft Tissue Graft: Results at 1-Year Follow-up.

Growth disturbance to leg length or coronal plane alignment are important considerations in pediatric anterior cruciate ligament (ACL) reconstruction (ACLR). The purpose of this study was to investigate the lower limb alignment and leg length of pediatric patients preoperatively and at approximately 1 year after transphyseal ACLR. Our hypothesis was that there would be no significant change in leg-length discrepancy (LLD) or operated-side alignment at follow-up. Case series; Level of evidence, 4. Data were extracted from the prospective Queensland Children's Hospital Pediatric ACL Injury Registry. Long-leg alignment radiographs were captured preoperatively and at an approximately 12-month postoperative follow-up. Radiographic measures included leg length, LLD (injured minus uninjured leg length), mechanical axis deviation (MAD), mechanical and anatomical lateral distal femoral angle (mLDFA and aLDFA, respectively), and medial proximal tibial angle. We evaluated the effect of time (annual vs baseline) on imaging measurements with analysis of covariance, using the covariates of age, sex, and body mass index. Data were available for 104 patients, of whom 34 (33%) had >12 months of skeletal growth remaining based on skeletal age. At an average follow-up time of 14.5 months after ACLR, there were no significant differences in mean lower limb alignment or longitudinal growth compared with baseline. However, seven patients demonstrated clinically significant changes to their mechanical axis or LLD (>10 mm change). A subgroup analysis of patients with >12 months of growth remaining (n = 34) demonstrated no statistically significant changes in mean alignment or LLD. Before surgery, LLD was -1.39 mm and the injured limb was in significantly more valgus compared with the uninjured lower limb (mean difference: MAD, 4.79 mm [95% CI, 2.64 to 6.94 mm]; mLDFA, -0.93° [95% CI, -1.29° to -0.57°], and aLDFA, -0.91° [95% CI, -1.31° to -0.50°]). After ACLR, there were no statistically significant changes in mean alignment or longitudinal growth; however, 7 out of 104 patients (6.7%) demonstrated clinically significant changes in alignment or LLD. Preoperatively, the injured limb was statistically significantly in more valgus compared with the uninjured limb with lateralized MAD.

Transphyseal Anterior Cruciate Ligament Reconstruction in Adolescent Athletes Provides Good Functional Outcomes

Background: In adolescent athletes, the treatment of anterior cruciate ligament (ACL) tear is still a topic of debate. The present study aimed to evaluate the functional outcomes and complications of transphyseal ACL reconstruction (ACLR) in adolescent athletes. Materials and Methods: Thirty-four athletes who underwent transphyseal ACLR using a hamstring tendon graft participated in this study. Functional outcomes (Lysholm and Tegner activity score) and potential complications (graft rupture, angular deformity [AD], or limb length discrepancy) after transphyseal ACLR were assessed at the final follow-up. Results: The average age at the time of the surgery was 13.1 ± 0.8 years. Lysholm and Tegner activity score was 96.5 ± 5 and 8.1 ± 1.4, respectively, at a mean follow-up of 64.9 ± 23.9 months. 27/34 (79%) of patients returned to the same level of sports. The mean time to return to sports was 8.3 ± 1.5 months. Three patients had graft tears, and none of the patients had any deformity. Conclusion: Transphyseal ACLR is a safe procedure with good functional outcomes. Level of Study: Level III.

Techniques in Pediatric Anterior Cruciate Ligament Reconstruction

In recent years, the frequency of anterior cruciate ligament (ACL) tears and ACL reconstruction (ACLR) in skeletally immature patients has increased. Because distal femoral and proximal tibial physes account for the majority of lower-extremity growth, surgical technique and graft selection are crucial to minimize iatrogenic physeal injury. Combined extra- and intra-articular, all-epiphyseal, and transphyseal with soft-tissue grafts are the most common ACLR techniques used in children. Combined extra- and intra-articular ACLR typically is offered to prepubescent patients with ≥2 years of growth remaining. This technique uses iliotibial band (ITB) autograft passed over the lateral femoral condyle and fixed to the anterior tibial periosteum. All-epiphyseal ACLR is similarly used in patients with ≥2 years of growth remaining, provided sufficient epiphyseal maturity to accommodate an all-epiphyseal socket because both the femoral and tibial tunnels are contained within the epiphyses. In postpubertal patients with <2 years of growth remaining, transphyseal ACLR using a soft-tissue autograft (typically hamstring or quadriceps tendon) and metaphyseal femoral fixation can be performed. This minimizes risk of physeal injury. In borderline patients with approximately 2 years of growth remaining, an additional option includes partial transphyseal ACLR, which uses a soft-tissue graft and a transphyseal tibial tunnel, but an all-epiphyseal or over-the-top femoral graft trajectory. Recently, transphyseal ITB ACLR and hybrid transphyseal hamstring with combined over-the-top ITB ACLR also have been described. Existing clinical studies focused on pediatric and adolescent ACL reconstructions have reported a wide range of graft rupture rates for these techniques (4.3%-25%), with contralateral ACL injury rates of 2.9% to 15.6%. Ongoing multicenter research is underway to directly compare surgical techniques for this demographic and quantify graft rupture rates and other clinical outcomes.

Outcomes, Including Graft Tears, Contralateral Anterior Cruciate Ligament Tears, and All-Cause Ipsilateral Knee Operations, are Similar for Adult-type, Transphyseal, and Partial Transphyseal Anterior Cruciate Ligament Reconstruction Using Hamstring Autograft in Pediatric and Adolescent Patients

PurposeTo compare hamstring autograft primary anterior cruciate ligament reconstruction (ACLR) techniques including adult-type/anatomic, transphyseal, and transphyseal techniques by (1) ACL graft tear, (2) contralateral ACL tear, and (3) all-cause ipsilateral reoperation.MethodsA retrospective, single-surgeon review was performed including all ACLR with hamstring autograft in pediatric and adolescent patients from 2011 to 2019. Minimum 2-year follow-up was required for patients unless a tear or reoperation was sustained before that time point. Data collected included demographics and baseline surgical variables, type of reconstruction, sporting activity, and deviations from rehabilitation protocols. Comparisons were made among hamstring autograft reconstruction groups (adult-type/anatomic, transphyseal, and partial transphyseal) for primary outcomes of graft tear, contralateral ACL tears, and all-cause ipsilateral knee reoperations, including hardware removal. Secondary surgeries performed with different surgeons were noted.ResultsIn total, 214 patients of age 15.2 ± 2.0 years with 4.1 ± 1.7-year follow-up were included. Overall graft tear rate was 11.7% (11.0% adult-type vs 19.1% transphyseal vs 5.6% partial transphyseal; P = .18). On univariate analyses, all-cause ipsilateral reoperation did not differ by technique (21.3% vs 31.0% vs 33.3%; P = .20), and neither did contralateral ACL tear (8.1% vs 9.5% vs 0%; P = .17). 21.7% of ipsilateral revision ACLRs (all adult-type) and 16.7% of patients with any reoperations had subsequent procedures performed with a different surgeon.ConclusionsThe graft tear rates in primary hamstring autograft ACLRs in the adolescent population did not significantly differ by technique (11.0% vs 19.1% vs 5.6% in adult-type, transphyseal, and partial transphyseal reconstructions, respectively). Furthermore, contralateral ACL tears (8.1% vs 9.5% vs 0%) and all-cause (including > 1/4 hardware removal) ipsilateral knee reoperations (21.3% vs 31.0% vs 33.3%) did not statistically differ. Higher powered studies may detect statistical significance in the observed differences in this study.Level of evidenceLevel IV, therapeutic case series.

Hybrid Transtibial Femoral Preparation for Transphyseal Anterior Cruciate Ligament Reconstruction: A Radiographic Comparison With the Transtibial and Anteromedial Portal Techniques.

Background:Transphyseal anterior cruciate ligament (ACL) reconstruction remains the most commonly used technique for pubescent patients. The transtibial (TT) drilling technique creates vertical and central femoral tunnels to minimize the physeal area of injury at the expense of a nonanatomic femoral tunnel. The hybrid TT (HTT) technique offers the potential of an anatomic femoral position with tunnel geometry similar to that using the TT technique.Purpose/Hypothesis:The purpose was to perform a radiographic comparison of the HTT technique with TT and anteromedial portal (AM) techniques in adolescent patients undergoing transphyseal ACL reconstruction. It was hypothesized that femoral tunnels created during HTT would be similar to TT tunnels but significantly more vertical and central than AM tunnels.Study Design:Cohort study; Level of evidence, 3.Methods:We retrospectively screened primary transphyseal ACL reconstructions performed in adolescents at our institution between 2013 and 2019. The youngest 20 eligible patients were selected from each technique cohort: TT, AM, and HTT. Postoperative radiographs were assessed for the coronal femoral tunnel angle, as well as the location of the tunnel-physis penetration on the anteroposterior and lateral views. Physeal lesion surface area was calculated. Data were compared among the 3 groups using 1-way analysis of variance followed by pairwise comparisons.Results:Included were 47 patients with a mean ± SD age of 14.3 ± 1.2 years (n = 9 with TT, 18 with AM, and 20 with HTT techniques). The coronal tunnel angle was significantly more vertical in the TT (60.7° ± 7.2°) and HTT (54.4° ± 5.7) groups as compared with the AM group (48.8° ± 5.9; P = .0037 and P = .02, respectively). There was no significant difference between the TT and HTT groups (P = .066). The only significant finding regarding femoral tunnel location was that the HTT tunnels (28.9% ± 4.8%) penetrated the physis more centrally than did the AM tunnels (20.0% ± 5.1%; P = .00002) on lateral radiographs.Conclusion:The HTT technique presents an option for transphyseal ACL reconstruction, with femoral tunnel obliquity and estimated physeal disruption similar to that of the TT technique and significantly less than that of the AM technique. The HTT technique also results in the most central physeal perforation of all techniques, predominantly in the sagittal plane.

Hybrid Transtibial Femoral Preparation for Transphyseal Anterior Cruciate Ligament Reconstruction: A Radiographic Comparison to Transtibial and Anteromedial Portal Techniques

Background:Transphyseal anterior cruciate ligament (ACL) reconstruction remains the most commonly used technique for pubescent patients. The principles of creating vertical and central femoral tunnels are well accepted to minimize physeal area of injury and are typically accomplished with a transtibial (TT) technique. This, however, may come at the expense of a non-anatomic tunnel. The hybrid transtibial (HTT) technique offers the potential of combining an anatomic femoral position with tunnel geometry similar to the TT technique but has never been assessed in a clinical cohort.Hypothesis/Purpose:We hypothesized that tunnels created by a HTT technique would be similar in orientation and physeal location to TT tunnels, but significantly more vertical and central than tunnels created with an anteromedial portal (AM).Methods:We retrospectively screened all ACL reconstructions performed in children aged 10 to 16 years, at our institution between 2013 to 2019, with the requirements of having a transphyseal reconstruction and an available post-operative radiographs. Radiographs were then assessed for the coronal femoral tunnel angle (FTA), as well as the location of the tunnel-physis penetration on the AP (LTAP) and lateral (LTL) views. Physeal lesion surface area was calculated. Data were compared between the three groups using ANOVA.Results:Forty-seven patients met eligibility criteria with 9 TT, 18 AM, and 20 HTT patients. Mean patient age was 14.3 +/- 1.2 years. The FTA was significantly more vertical in the TT (60.7o +/-7.2) and HTT (54.4o +/- 5.7) groups as compared to the AM group (48.8o +/- 5.9); p = 0.0037 and p = 0.02 respectively. There was no significant difference between the TT and HTT groups ( p = 0.066). The LTAP was not significantly different between groups (p = 0.097). The LTL demonstrated that the HTT tunnels penetrated the physis at a more central location in the sagittal plane (28.9% +/- 4.8%) than the AM tunnels (20.0% +/- 5.1%, p = 0.00002), but was statistically indistinguishable from the TT (24.4%+/- 4.0%, p= 0.066) tunnels.Conclusion:The hybrid transtibial technique presents an option for transphyseal ACL reconstruction, with femoral tunnel obliquity and estimated physeal disruption similar to the TT technique, significantly less than the AM technique. The HTT also results in the most central physeal perforation of all techniques, predominantly in the sagittal plane. With the known ability of the HTT technique to recreate an anatomic femoral footprint, this may represent the “best of both worlds” for transphyseal ACL reconstruction.Tables/Figures:Figure 1:Figure 2:Figure 3:Figure 4:

Primary Partial Transphyseal Anterior Cruciate Ligament Reconstruction in Children with Open Physes

The incidence of anterior cruciate ligament (ACL) injuries in skeletally immature patients is increasing, with ACL reconstruction preferred as it has been shown to have chondroprotective benefits in this population. Due to concerns with growth disturbances following ACL reconstruction in skeletally immature patients, results of various physical-sparing, partial-transphyseal, or complete-transphyseal techniques have been explored. Currently, there is no consensus on the most effective ACL reconstruction technique in skeletally immature patients. Therefore, the purpose of this study was to report the outcomes of a partial-transphyseal, over-the-top (OTT) ACL reconstruction in a cohort of skeletally immature patients. All patients with radiographic evidence of open tibial and femoral physes that underwent primary ACL reconstruction using the partial-transphyseal OTT technique between 2009-2018 at a single tertiary-care institution were retrospectively reviewed. Patient demographics, physical examination findings, graft ruptures, return to sport, and Tegner activity levels were analyzed. Statistical significance was defined as p <0.05. Overall, 22 males and 2 females (25 knees) with a mean age of 13.0 years (Standard Deviation [SD], 1.7 years) were included in the study. The mean postoperative follow-up was 2.1 years (SD, 1.7 years). There were four cases of ACL graft rupture (16%). All patients successfully returned to unrestricted sport at an average time of 7.3 months. Preinjury and postoperative Tegner activity levels were documented in 22 knees, of which 21/22 (95%) returned to the same or higher level. There were no documented cases of clinically significant longitudinal or angular growth disturbance. Partial transphyseal ACL reconstruction using a transphyseal tibial tunnel and an extra-articular, OTT position on the femur in skeletally immature affords minimal risk of growth disturbance with a graft rupture rate of 16% and a 95% return to sport at the same or higher level.

Postoperative radiographic observations following transphyseal anterior cruciate ligament reconstruction in skeletally immature patients.

To characterize the changes to bone tunnels, graft fixation devices, and physes that occur on radiographs of skeletally immature individuals at least 2years after transphyseal anterior cruciate ligament reconstruction (ACLR). Skeletally immature patients who underwent transphyseal ACLR were recruited to complete postoperative assessment at ≥ 2years. The dimensions of tibial and femoral bone tunnels, position of graft fixation devices, and presence of growth arrest were assessed on radiographs, and pain visual analog and International Knee Documentation Committee scores were obtained. Paired t tests were used for comparisons. Nine patients were included with an average follow-up of 4.6years postoperatively. There were no cases of premature physeal closure postoperatively and clinical outcome measures were excellent in all patients. The length of the intra-articular portion of anterior cruciate ligament graft increased postoperatively (P = 0.01). Distance between the tibial hardware and proximal tibial physis also increased over time on anteroposterior (P = 0.001) and lateral (P = 0.003) radiographs. However, the distance between the femoral hardware and distal femoral physis was unchanged and in five patients was associated with proximal femoral tunnel enlargement. Proximal femoral tunnel expansion and lack of proximal migration of the femoral button were seen in more than half of our patients. However, these findings had no detrimental effects on clinical outcome measures or remaining skeletal growth.

Transphyseal Anterior Cruciate Ligament Reconstruction in the Skeletally Immature: Quadriceps Tendon Autograft Versus Hamstring Tendon Autograft.

Background:It is unclear what the optimal graft choice is for performing anterior cruciate ligament (ACL) reconstruction in a skeletally immature patient.Purpose:To evaluate outcomes and complications of skeletally immature patients undergoing transphyseal ACL reconstruction with a hamstring tendon autograft versus a quadriceps tendon autograft.Study Design:Cohort study; Level of evidence, 3.Methods:Between 2012 and 2016, 90 skeletally immature patients from a single institution underwent primary transphyseal ACL reconstruction with either a quadriceps tendon autograft or a hamstring tendon autograft based on surgeon preference (n = 3). Patient demographic, injury, radiographic, and surgical variables were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation (SANE), Tegner activity score, pain, satisfaction, and complications such as graft tears and physeal abnormalities.Results:A total of 83 patients (56 hamstring tendon, 27 quadriceps tendon) were available for a minimum follow-up of 2 years or sustained graft failure. The mean age of the patients was 14.8 ± 1.4 years at the time of ACL reconstruction. No differences in chronological age, bone age, sex, patient size, or mechanism of injury were noted between groups. There were no differences in surgical variables, except that the quadriceps tendon grafts were larger than the hamstring tendon grafts (9.6 ± 0.6 mm vs 7.8 ± 0.7 mm, respectively; P < .001). Patient outcomes at a mean follow-up of 2.8 ± 0.9 years revealed no differences based on graft type, with mean Lysholm, SANE, pain, satisfaction, and Tegner scores of 96, 93, 0.6, 9.6, and 6.6, respectively, for the quadriceps tendon group and 94, 89, 0.9, 9.2, and 7.1, respectively, for the hamstring tendon group. While there were no physeal complications in either group, patients undergoing ACL reconstruction with a hamstring tendon autograft were more likely to tear their graft (21% vs 4%, respectively; P = .037).Conclusion:Skeletally immature patients undergoing ACL reconstruction can be successfully managed with either a quadriceps tendon autograft or a hamstring tendon autograft with good short-term outcomes, high rates of return to sport, and low rates of physeal abnormalities. The primary differences between grafts were that the quadriceps tendon grafts were larger and were associated with a lower retear rate. ACL reconstruction performed with a quadriceps tendon autograft may reduce early graft failure in skeletally immature patients.

Concomitant Anterior Cruciate Ligament Reconstruction and Temporary Hemiepiphysiodesis in the Skeletally Immature: A Combined Technique.

Young athletes with an anterior cruciate ligament (ACL) disruption and limb malalignment pose a treatment dilemma. Little has been published regarding limb malalignment in this population. Our aim is to review the results of combined treatment of an ACL deficient knee and genu valgum in skeletally immature patients. A retrospective review of skeletally immature patients who underwent transphyseal ACL reconstruction and concomitant hemiepiphysiodesis between 2004 and 2015 by 1 surgeon at a single institution was performed. Included patients had at least a year of growth remaining and were followed to skeletal maturity. Patients with a diagnosis of a connective tissue disorder were excluded. Knee stability, rate of retear, the rate of mechanical axis correction, and time to full correction were determined. Ninety skeletally immature patients underwent transphyseal ACL reconstruction, 8 of which met inclusion criteria. Mean time to correction of the valgus deformity was 13 months (0.4 degree/mo). No patient required additional surgeries for malalignment. All patients had improvement in knee stability. One patient had a retear of their ACL reconstruction, for a failure rate of 13%. Preoperative mechanical lateral distal femoral angle and mechanical axis deviation corrected to near-neutral alignment for all treated limbs and were significantly different (P=0.001) than those measured preoperatively. Promising results were seen for simultaneous correction of genu valgum and transphyseal ACL reconstruction. Treatment of both pathologies in a concomitant surgery can be considered in the appropriate population, with expected results comparable to each procedure in isolation. Level IV-case series.

Transphyseal anterior cruciate ligament reconstruction in adolescents with substantial remaining growth causes temporary growth arrest resulting in subclinical leg-length discrepancy.

The purpose of the present study was to investigate the characteristics of growth disturbances in patients with remaining growth after transphyseal anterior cruciate ligament (ACL) reconstruction who were confirmed to have no definite postoperative physeal abnormalities on magnetic resonance imaging (MRI).Forty adolescents (mean age 15.6 ± 1.0 years [range 12.2–16.8], mean follow-up 2.7 ± 0.7 years [range 2.0–5.5 years]), who underwent transphyseal ACL reconstruction and were confirmed to have no focal physeal disruptions on follow-up MRIs 6 to 12 months after the operation, were retrospectively evaluated. The patients were grouped according to the leg-length growth of the uninjured side, measured on scanograms, obtained before surgery, and at the final follow-up.Leg-length discrepancies (LLD) at the last follow-up were greater in patients with leg growth ≥4 cm than in those with leg growth <4 cm (5.3 ± 9.0 mm vs −0.3 ± 4.2 mm, P = .033); however, no significant difference was observed between subgroup patients with leg growth of 4 to 6 cm or ≥6 cm (5.6 ± 10.4 mm vs 4.8 ± 7.0 mm, P = .958). On multivariate analysis, leg growth was a significant predictive factor for the final LLD (P = .030).Adolescents with additional leg-length growth after transphyseal ACL reconstructions presented with greater LLDs (as shown in the <4 cm vs ≥4 cm groups), but they also presented a ceiling effect (as shown in the 4–6 cm vs ≥6 cm subgroups). Transphyseal ACL reconstructions appeared to cause temporary growth arrest/disturbances in patients with substantial remaining growth which then resumed resulting in clinically insignificant LLDs.

Partial Transphyseal Anterior Cruciate Ligament Reconstruction: Clinical, Functional, and Radiographic Outcomes

Background: With a steadily increasing rate of anterior cruciate ligament (ACL) injury and reconstruction in the pediatric population, disagreement remains regarding the optimal reconstruction technique for patients with ACL injury and ≥2 years of growth remaining. Purpose: This study aims to quantify the incidence of linear and angular growth disturbance of adolescents undergoing partial transphyseal ACL reconstruction (ACLR) while assessing graft failure rates, reoperation rates, and functional outcomes in the population. Study Design: Case series; Level of evidence, 4. Methods: Consecutive patients undergoing partial transphyseal ACLR by 2 surgeons were retrospectively reviewed. Radiographic outcomes, including bilateral limb length, mechanical axis deviation (MAD), mechanical lateral distal femoral angle (MLDFA), and medial proximal tibial angle (MPTA), were measured on long standing anterior-posterior view radiographs postoperatively. Growth disturbance was defined as ≥1-cm leg length discrepancy, ≥1-cm difference in MAD, or 5° difference in MLDFA or MPTA as compared with the nonoperative side and as MAD, MLDFA, or MPTA outside the established range of reference values. Clinical outcomes, including graft failure and reoperation, were recorded at each follow-up visit. Pediatric International Knee Documentation Committee (Pedi-IKDC) scores were collected electronically after last follow-up. Results: Twenty-four patients (mean ± SD age, 12.3 ± 0.9 years; 79.2% male) with a mean follow-up of 31.5 ± 17.1 months met inclusion criteria for the study. Overall postoperative growth disturbance incidence was 16.7% (4 of 24), but the incidence of growth disturbance was 66.7% (2 of 3) for those patients with >5 years of growth remaining. Seven patients (29.2%) required reoperation, most frequently for hardware removal. Two patients (8.3%) had graft failure with subsequent revision ACL reconstruction. One patient underwent bilateral medial distal femur hemiepiphysiodesis for genu valgum that was present before ACLR, but no other patients required guided growth procedures. In the subset of patients who completed a Pedi-IKDC questionnaire, the mean score was 94.8 ± 5.3. Conclusion: Overall, partial transphyseal ACLR has good functional outcomes and graft failure and reoperation rates, comparable with those seen with transphyseal and all-epiphyseal techniques. While postoperative growth disturbance occurred in 16.7% of the cohort, the severity was mild and well tolerated without necessitating secondary procedures. There is a high rate of growth disturbance of patients with >5 years of growth remaining (66.7%). Partial transphyseal ACLR represents a valid recommendation for adolescent patients with ACL injury and ≤5 years of growth remaining.

Is Anteromedial Drilling Safe in Transphyseal Anterior Cruciate Ligament Reconstruction in Adolescents with Growth Remaining?

Previous reports of transphyseal drilling in anterior cruciate ligament (ACL) reconstruction have demonstrated good clinical outcomes without subjective changes in further skeletal development. The purpose of this study is to evaluate radiographic changes during continued growth following a transphyseal ACL reconstruction using an anteromedial femoral (AM) drilling technique in patients with >18 months of growth remaining. A review of consecutive adolescents who underwent a soft tissue transphyseal ACL reconstruction using an AM drilling technique was performed. Inclusion criteria was 18 months of growth remaining based on radiographic bone age and standing radiographs at least one year from the index procedure. Demographic, preoperative, and postoperative data, and follow-up three-foot standing lower extremity radiographs were reviewed. Radiographic data included femoral length, tibial length, total lower extremity length, mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA). In total 12 adolescent patients with a mean age of 13.4 years (range, 12.3 to 14.4) and bone age of 13.4 years (11.5 to 14) at the time of surgery were included. At an average of 2.27-year follow-up (412 to 1058 d), there was no difference in the total growth of the operative and nonoperative limb (48.5 mm vs. 47 mm; P=0.36). In addition, the average increases in femoral length (23.4 mm) and tibial length (25.8 mm) were not statistically different between the operative and the nonoperative limb (P=0.12; P=0.75). There was no statistical difference in mechanical axis deviation, LDFA, or MPTA between preoperative and postoperative radiographs. Mean differences in operative and nonoperative coronal angular changes were all <1.5 degrees. With at least 2 years of growth remaining, transphyseal ACL reconstruction with anteromedial drilling did not significantly affect the physis or residual growth compared with the contralateral extremity. Although this technique may create a larger defect in the physis, standing radiographs demonstrate there is no change in limb length or angulation in growing adolescents approximately 2 years after surgery. This is a case series; Level IV evidence.