Transphyseal Anterior Cruciate Ligament Reconstruction Research Articles

Transphyseal Anterior Cruciate Ligament Reconstruction in Patients With Open Physes

The purpose of this study was to evaluate the clinical outcomes of transphyseal anterior cruciate ligament (ACL) reconstruction in patients with open physes. Transphyseal ACL reconstruction was performed in 26 patients with open tibial and femoral physes (physis >2 mm) by use of autogenous quadrupled hamstrings as grafts. Meniscal tearing was found in 65.3% of the patients. Partial chondral defect injury on the medial femoral condyle was found 6 months after injury in only 2 patients (7.69% of all patients). The mean follow-up period was 45 +/- 18.3 months. Clinical outcomes were evaluated by use of the International Knee Documentation Committee score and Lysholm Knee Scoring Scale, and the anteroposterior stability was objectively measured by use of KT-1000 arthrometer (MEDmetric, San Diego, CA). Possible length and angular discrepancies were observed by conventional radiography in a long film and scanograms of the lower limbs. The mean length discrepancy between the operated lower limb and the contralateral limb was 1.2 +/- 3.2 mm (range, -7 to 7 mm). The mean angular deviation difference between the lower limbs was 0.46 degrees +/- 1.1 degrees . New traumatic injuries developed in 3 patients, in whom surgical revision was performed; 1 patient underwent a late meniscectomy. The mean difference in KT-1000 measurement was 2.0 +/- 1.0 mm. The mean subjective International Knee Documentation Committee score was 91.5 +/- 5.7, and the mean score on the modified Lysholm scale was 93.5 +/- 4. Of the patients, 3 (11.2% of all patients) could not return to the same level of physical activity as before injury. ACL reconstruction by use of the transphyseal technique in an immature skeleton with a hamstring autograft, with careful attention being paid to the technique, resulted in good clinical outcomes and no growth abnormalities. Level IV, therapeutic case series.

Graft remodeling during growth following anterior cruciate ligament reconstruction in skeletally immature sheep

Ruptures of the anterior cruciate ligament are being diagnosed with increasing frequency in skeletally immature individuals. It was our aim to investigate the graft remodelling process following an autologous, transphyseal reconstruction of the anterior cruciate ligament (ACL) in skeletally immature sheep. We hypothesized that the ligamentisation process in immature sheep is quicker and more complete when compared to adult sheep. Skeletally immature sheep with an age of 4 months underwent a fully transphyseal ACL reconstruction using an autologous tendon. The animals were subsequently sacrificed at 3, 6, 12 and 24 weeks following surgery. Each group was characterised histomorphometrically, by immunostaining (VEGF, SMA), by transmission electron microscopy (TEM) and biomechanically (UFS Roboter). The histomorphometric analysis and presence of VEGF and SMA positive cells demonstrated a rapid return to a ligament like structure. The biomechanical analysis revealed an anteroposterior translation that was still increased even 6 months following surgery. As in adult sheep models, the remodeling of a soft tissue graft used for ACL reconstruction results in a biomechanically inferior substitute. However, the immature tissue seems to remodel faster and more complete when compared to adults.

Hindlimb Growth after a Transphyseal Reconstruction of the Anterior Cruciate Ligament

Background There is a lot of controversy in the recent literature with regard to the optimal treatment of anterior cruciate ligament (ACL) injuries during growth. Iatrogenic growth disturbance due to physeal damage is a potential complication, forcing many orthopaedic surgeons to treat these injuries conservatively. Hypothesis It is possible to perform a fully transphyseal ACL reconstruction in an ovine model with wide-open physes without creating growth disturbances. Study Design Descriptive laboratory study. Materials and Methods Four-month-old skeletally immature sheep underwent a transphyseal ACL reconstruction of the right knee. The surgical technique followed the criteria known to be essential to avoid growth disturbances in humans; the tibial tuberosity was spared to prevent a genu recurvatum, thermal damage to the growth plates was avoided, the physes were perforated with a small-diameter drill in the center of the growth plate, a soft tissue graft was used, graft fixation was achieved far away from the growth plates, the perforated growth plates were filled by the soft tissue graft, and the graft was moderately pretensioned before fixation. The left knee served as a control. A computer-assisted evaluation of long radiographs (frontal and sagittal plane) of the exarticulated hindlimbs was performed to exactly evaluate the limb alignment, joint orientation, and leg length. The animals were sacrificed in groups of 6 after 3, 6, 12, and 24 weeks. Results No angular deformities or leg-length discrepancies occurred after this transphyseal ACL reconstruction procedure throughout the remaining growth. Conclusion This large-animal study supports the clinical observation that it is possible to perform an ACL reconstruction without creating growth disturbances as long as a number of key principles are followed. Clinical Relevance Previous animal studies argued against ACL reconstruction in skeletally immature patients. This large-animal study provides support for early operative treatment of ACL ruptures even in young patients with open physes.

Histologic and Biomechanical Analysis of Anterior Cruciate Ligament Graft to Bone Healing in Skeletally Immature Sheep

It was our aim to establish an animal model and to investigate the tendon graft-to-bone and physis healing process in skeletally immature sheep after reconstruction of the anterior cruciate ligament (ACL). Thirty-two immature sheep aged 4 months underwent a fully transphyseal ACL reconstruction by use of a soft-tissue graft. The animals were subsequently killed after 3, 6, 12, and 24 weeks and analyzed histologically and biomechanically. There was a transient hypertrophy of the physis tissue at the passing site of the graft. Anchoring Sharpey-like fibers evolved as early as 3 weeks after surgery. A strong expression of collagen III messenger ribonucleic acid within the first 6 weeks preceded this anchoring process. The maximum load to failure of the tendon graft in the reconstructed knees initially decreased to 37.8 +/- 17.8 N after 3 weeks and was restored to 522.9 +/- 113 N after 24 weeks. Tendon graft stiffness was restored to 86% when compared with the control knees. The early anchoring by Sharpey fibers was found at 3 weeks with continued maturation to 24 weeks. This development of anchoring fibers corresponded to that of biomechanical strength, starting with 5% of the normal knee at 3 weeks and then 15.2% at 6 weeks, 41.2% at 12 weeks, and 69% at 24 weeks. Tendon graft-to-bone and physis healing in skeletally immature sheep is further characterized by a transient hypertrophy of the physis cartilage. The physis recovers well from the trauma of drilling and placement of a soft-tissue graft. The early development of Sharpey-like fibers results in a solid integration of the graft into bone in a timely manner. ACL reconstruction in skeletally immature individuals is still controversial. This study describes in detail the histologic and biomechanical stages of tendon graft healing to the bone and physis. These data enrich the existing knowledge of previous studies in adult sheep and may provide a basis for further research in the controversial field of ACL reconstruction during growth.

Is ACL Surgery Effective for Skeletally Immature Adolescents?

Source: Kocher MS, Smith JT, Zoric BJ, et al. Transphyseal anterior cruciate ligament reconstruction in skeletally immature pubescent adolescents. J Bone Joint Surg Am. 2007;89(12):2632–2639; doi 10.2106/JBJS.F.01560Management of anterior cruciate ligament (ACL) injuries in skeletally immature patients is controversial. In a retrospective case series from Children’s Hospital, Boston, researchers evaluated the outcome of transphyseal reconstruction of the ACL in adolescents with a complete ACL tear. The study population consisted of 59 patients who underwent similar surgical repairs between 1996 and 2004.The procedure was an arthroscopically assisted transphyseal reconstruction of the ACL with use of an autogenous quadrupled hamstrings-tendon graft through bone tunnels that cross the femoral and tibial physes with metaphyseal fixation. Outcome measures included physical examination for limb length discrepancy, physical measures of knee laxity, and two functional outcome instruments. Angular deformity and growth arrest were evaluated by postoperative radiographs.Sixty-one ACL reconstructions were performed on 23 boys and 36 girls. The mean age of patients at the time of surgery was 14.7 years (range 11.6–16.9) and mean skeletal age was 14.4 years. All patients were Tanner stage 3.1The four most common causes of knee injury were soccer (22), football (8), skiing (6), and basketball (5). Surgery was performed at a mean of 3.8 months (range 0.5–24 months) after injury. There were 31 knees with an associated meniscus injury. Postoperative follow-up occurred at a mean of 3.6 years. None of the knees had abnormal laxity. Only two patients (3% revision rate) had a graft failure that required revision reconstructive surgery. Both of these patients had a re-injury while participating in cutting and pivoting sports and were re-operated on 14 and 21 months after their original surgery.All patients were able to return to their cutting or pivoting sport by six months after surgery. The mean increase in their total height after surgery averaged 8.2 cm (range 1.2–25.4 cm). No postoperative growth disturbances were seen on radiographs, nor were any clinical limb length discrepancies noted. There were no differences in functional outcome measures between boys and girls or between patients younger or older than 14 years. The authors conclude that transphyseal reconstruction of the ACL in skeletally immature pubescent adolescents results in an excellent functional outcome with a low revision rate and a minimal risk of growth disturbance.Dr. Schwend has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Adolescent athletes with an ACL-deficient knee often remain very active and risk sustaining further meniscal and articular cartilage damage unless they receive surgical stabilization before returning to their sports.2However, conventional surgical reconstruction techniques used in adults can cause iatrogenic growth disturbance due to damage to the distal femoral physis and/or the proximal tibial physis in children.3 The results of this study suggest that for a child at Tanner stage 3 development, ACL reconstruction is safe and effective. For the older adolescent (Tanner stages 4 and 5) who is approaching skeletal maturity, standard adult techniques can probably be safely utilized.The authors noted several limitations of this study, including a relatively short follow-up duration as well as collection of data on only 70% of the total eligible patients. Also, there was no comparison group treated by other methods, and the final assessment of outcome was performed by the two surgeons performing the procedures, which could introduce bias.With a mean chronologic age of 14.7 years, it is likely that most girls in this series had already achieved menarche; providing specific information on menses would have been helpful. Because separate results in boys and girls were not reported, the reader cannot determine whether variations in chronological or skeletal bone age impacted outcomes for each group. This is important because the variation in the amount of total height achieved after surgery was considerable.In a larger series some patients with remaining growth might develop a growth abnormality. On the other hand, some younger patients at Tanner stage 2 might do well with this transphyseal soft tissue technique, rather than the less anatomical technique that avoids the physis.The authors’ data support the safety of this surgical technique for the pubescent Tanner stage 3 athlete with an ACL-deficient knee. These patients should be counseled about availability of such surgical treatment and the long-term risks of returning to cutting and pivoting activities without ACL reconstruction.Because pediatricians are often the ones to see adolescents following knee injuries, we need to take our physical examination texts out of the drawer and bone up on the examination of the knee to identify ACL tears, the long-term risks of such injuries, and the surgical techniques for reconstruction so we can give teens and their parents the best possible advice.

The Risk of Growth Changes During Transphyseal Drilling in Sheep With Open Physes

A sheep model was used to evaluate the risk of growth disturbances of transphyseal drilling and anterior cruciate ligament (ACL) reconstruction. In group A, comprised of six 4-month-old Merino sheep, the ACL was resected and 5-mm tunnels were drilled and left empty. Unilateral ACL reconstruction using an autologous Achilles tendon graft, extracortical fixation, and tunnel diameters of 5 mm was performed in group B. A single-stranded graft with a diameter of 5 mm was used in group B-1 (N = 6) and a 3-mm double-stranded graft in group B-2 (N = 6). Six months after the procedure, the animals were euthanized. Growth changes were evaluated macroscopically, by magnetic resonance imaging, and by histology. Central growth plate lesions on the tibia did not induce growth abnormalities. On the peripheral femur, posterolateral growth plate injuries with empty tunnels led to a shortening of the lateral femur of 8 mm (7 to 10 mm), a valgus deformity of 12.8 degrees (12 degrees to 14 degrees ), and a flexion deformity of 8.6 degrees (5 degrees to 15 degrees ). Histology revealed a strong bone bridge over the physis and an injury to the perichondral structures. Transphyseal ACL replacements did not cause growth disturbances on either the tibia or the femur, even if a drilling injury of the perichondral structures occurred. Despite consistent physeal damage, ACL reconstructions did not lead to clinically relevant growth disturbances. The results suggest that transphyseal ACL reconstruction procedures might yield similar results in children with substantial growth remaining.

Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient

Our purpose was to evaluate the results of transphyseal anterior cruciate ligament (ACL) reconstruction with medial hamstring autograft in skeletally immature patients. We reviewed the records of all skeletally immature patients who underwent transphyseal ACL reconstruction with medial hamstring autograft between 1988 and 2002 at our institution. Inclusion criteria were age less than 15 years for male patients, age less than 14 years for female patients, and radiographic evidence of wide open physes. We identified 16 patients (11 male and 5 female). All underwent preoperative and postoperative clinical evaluation (physical examination and modified Lysholm and International Knee Documentation Committee scores), and knee radiographs. Each patient was followed up until skeletal maturity was confirmed, with a mean clinical follow-up of 41.1 months (range, 24 to 112 months). The mean time from ACL injury to reconstruction was 5.6 months (range, 0.7 to 26.9 months). During the preoperative time period, 4 patients (25%) developed meniscal tears that were not visualized on the index magnetic resonance imaging scans. At last follow-up, the mean leg length discrepancy measured 0.62 cm (range, 0.2 to 1.5 cm), and clinical or radiographic evidence of malalignment was not present in any of the patients. In 1 patient a symptomatic 1.5-cm limb overgrowth developed, which was treated with an internal shoe lift. At follow up, the mean modified Lysholm score was 98.8 (range, 94 to 100), and the mean International Knee Documentation Committee score was 89.9 (range, 73.6 to 94.3). Of the patients, 7 (43.8%) underwent a reoperation, and 2 suffered traumatic graft disruption. ACL reconstruction with a medial hamstring autograft via a transphyseal technique yields satisfactory clinical results in skeletally immature patients. No new meniscal tears were identified after ACL reconstruction, and most patients (87.5%) returned to their previous level of activity. The rate of reoperation was high (43.8%). Physeal growth arrest did not occur. Level IV, therapeutic case series.

Results of Transphyseal Anterior Cruciate Ligament Reconstruction Using Patellar Tendon Autograft in Tanner Stage 3 or 4 Adolescents with Clearly Open Growth Plates

Background Drilling across the physes for intra-articular anterior cruciate ligament reconstruction is considered risky for skeletally immature patients. Hypothesis Skeletally immature patients with clearly open growth plates can safely undergo intra-articular anterior cruciate ligament reconstruction with patellar tendon autograft without suffering growth plate disturbance. Study Design Retrospective review of prospectively collected data. Methods Surgery involved drilling tunnels through the tibial and femoral physes, the bone plugs were placed proximal to the physes, and button fixation was placed on the cortex. Of 272 skeletally immature patients, 16 had clearly open growth plates. Tanner stage of physical development was evaluated. Follow-up evaluation included objective and subjective data. Results At the time of surgery, 7 patients were Tanner stage 3 and 9 were Tanner stage 4. Clinical follow-up (mean, 3.4 years after surgery) showed that the mean growth after surgery was 11.7 ± 4.2 cm for boys and 6.6 ± 2.3 cm for girls. No patients had growth plate disturbances, gross leg deformities, or gross leg-length discrepancies. Subjective results (mean, 5.6 years after surgery) showed a mean total score of 97.6 ± 2.9 for the modified Noyes survey and 95.4 ± 6.9 for the International Knee Documentation Committee survey. All patients returned to competitive sports after surgery. Conclusion In 16 skeletally immature patients with clearly open growth plates who were Tanner stage 3 or 4, an intra-articular anterior cruciate ligament reconstruction was performed using a patellar tendon autograft with no gross growth disturbance; however, the surgical technique was meticulous for placing the bone plugs proximal to the physes, and the graft was not overtensioned.

６歳男児の膝ＡＣＬ実質部断裂の１例

This paper presents a six-year-old boy with midsubstantial rupture of the anterior cruciate ligament (ACL). ACL injuries are rare in children younger than eight years. The outcome of non-operative treatment, primary ACL repair and extra-articular reconstruction is unsatisfactory. Transphyseal reconstructive surgery in patients who is not near skeletal maturity can result in leg-length discrepancy and angular deformity. For patients who are near skeletal maturity, transphyseal ACL reconstruction is performed at the appropriate skeletal age. For patients who do not meet the skeletal age requirements for transphyseal reconstruction, modification of sports and activity is the preferred treatment.

Preoperative evaluation and anterior cruciate ligament reconstruction technique for skeletally immature patients in Tanner stages 2 and 3.

Transphyseal anterior cruciate ligament reconstruction in skeletally immature patients carries the risk of adverse sequelae. 1) To provide clinical and radiographic methods to identify skeletally immature patients with significant remaining lower limb growth. 2) To provide a method for calculating the percent area lesion created by a 6-mm distal femoral physeal tunnel. 3) To present a method of partial transphyseal intraarticular anterior cruciate ligament reconstruction with bipolar graft fixation in these patients. 4) To report on clinical, functional, and radiographic results at skeletal maturity. Fourteen adolescents with symptomatic anterior cruciate ligament instability who were identified as being in Tanner stages 2 and 3 underwent partial transphyseal intraarticular anterior cruciate ligament reconstruction with the use of hamstring tendon grafts (transphyseal only in the femur and through the epiphysis in the tibia). At skeletal maturity, 10 patients were asymptomatic and fully active in sports. No patient had significant leg-length inequality or angular deformity after use of a 6-mm femoral physeal tunnel, which represented 1) less than 7% of the frontal plane and 2) less than 1% of the transverse plane cross-sectional femoral physeal areas. The choice of the exposed technique and the method used to select patients permitted us to avoid adverse sequelae.

Intra-articular anterior cruciate ligament reconstruction using patellar tendon allograft in the skeletally immature patient

Purpose: Tears of the anterior cruciate ligament (ACL) are becoming more prevalent in the skeletally immature patient. We report our results with intra-articular transphyseal ACL reconstruction in this patient population. Type of Study: Retrospective analysis. Methods: Ten skeletally immature athletes underwent transphyseal intra-articular ACL reconstruction using patellar tendon allograft. The patients ranged from 9 to 15 years of age. Clinical outcomes were measured using the Lysholm and International Knee Documentation Committee scoring systems, follow-up radiographs, clinical examination, and KT-1000 testing. Results: Mean follow-up was 40 months. The average Lysholm score was 95, and 9 of 10 patients reported normal or nearly normal knee function. There was no clinical or objective evidence of instability, limb-length discrepancy, or early physeal arrest. Nine of 10 patients returned to their preinjury level of athletics. Conclusions: Skeletally immature athletes with symptomatic complete ACL tears who do not want to modify their athletic activity may benefit from intra-articular ACL reconstruction using patellar tendon allografts. Special attention to bone plug and interference screw placement will reduce the risk of early physeal arrest.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 8 (October), 2002: pp 824–828