Transphyseal Anterior Cruciate Ligament Research Articles

Tibial tunnel defect size as a risk factor in growth arrest following paediatric transphyseal anterior cruciate ligament reconstruction: an anatomical study.

There is ongoing controversy regarding growth disturbances in younger patients undergoing anterior cruciate ligament reconstructions. Animal models have shown that an injury of 7-9% of the physeal area is a risk factor for growth disturbances. A total of 39 magnetic resonance imaging studies of the knee were examined. The proximal tibial physeal area was determined using a calibrated 'region of interest' ligature encompassing the tibial physis in the axial plane. The potential defect left by commonly used drill sizes was calculated as a percentage of the physeal area. A 7-mm drill leaves a mean defect of 1.45% physeal area (range: 1.11-1.89%, SD: 0.28, 95% CI: ±0.09), 8-mm drill leaves a 1.84% mean defect (range: 1.43-2.49%, SD: 0.38, 95% CI: ±0.12) and a 9-mm drill leaves a 2.30% mean defect (range: 1.83-3.19%, SD: 0.58, 95% CI: ±0.17). At 55°, 7-mm drill leaves a mean defect of 1.96% (range: 1.32-2.28%, SD: 0.37, 95% CI: ±0.12), 8-mm drill leaves a mean defect of 2.19% (range: 1.71-2.95%, SD: 0.46, 95% CI: ±0.14) and a 9-mm drill leaves a mean defect of 2.76% (range: 2.16-3.73%, SD: 0.58, 95% CI: ±0.18). There was a statistically significant difference in the tunnel area with a change of drill angle (7-mm drill P = 0.005, 8-mm drill P = 0.001, 9-mm drill P = 0.001). On the basis of this study in the context of animal model and observational evidence, the area of physeal injury using drill tunnels for anterior cruciate ligament reconstruction would not appear to contribute to potential growth disturbances.

Transphyseal ACL Reconstruction in Skeletally Immature Patients: Does Independent Femoral Tunnel Drilling Place the Physis at Greater Risk Compared With Transtibial Drilling?

Background:Most studies examining the safety and efficacy of transphyseal anterior cruciate ligament (ACL) reconstruction for skeletally immature patients utilize transtibial drilling. Independent femoral tunnel drilling may impart a different pattern of distal femoral physeal involvement.Purpose:To radiographically assess differences in distal femoral physeal disruption between transtibial and independent femoral tunnel drilling. We hypothesized that more oblique tunnels associated with independent drilling involve a significantly larger area of physeal disruption compared with vertically oriented tunnels.Study Design:Cross-sectional study; Level of evidence, 3.Methods:We analyzed skeletally immature patients aged between 10 and 15 years who underwent transphyseal ACL reconstruction utilizing an independent femoral tunnel drilling technique between January 1, 2008, and March 31, 2011. These patients were matched with a transtibial technique cohort based on age and sex. Radiographic measurements were recorded from preoperative magnetic resonance imaging and postoperative radiographs.Results:Ten patients in each group were analyzed. There were significant differences between independent drilling and transtibial drilling cohorts in the estimated area of physeal disruption (1.64 vs 0.74 cm2; P < .001), femoral tunnel angles (32.1° vs 72.8°; P < .001), and medial/lateral location of the femoral tunnel (24.2 vs 36.1 mm from lateral cortex; P = .001), respectively. There was a significant inverse correlation between femoral tunnel angle and estimated area of distal femoral physeal disruption (r = –0.8255, P = .003).Conclusion:Femoral tunnels created with an independent tunnel drilling technique disrupt a larger area of the distal femoral physis and create more eccentric tunnels compared with a transtibial technique.Clinical Relevance:As most studies noting the safety of transphyseal ACL reconstruction have utilized a central, vertical femoral tunnel, surgeons should be aware that if an independent femoral tunnel technique is utilized during transphyseal ACL reconstruction, more physeal tissue is at risk and tunnels are more eccentrically placed across the physis when drilling at more horizontal angles. Prior studies have shown that greater physeal involvement and eccentric tunnels may increase the risk of growth disturbance.

Allograft and Autograft Transphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Outcomes and Complications

The purpose of the study was to evaluate outcomes, graft failure rates, and complications after transphyseal soft-tissue allograft and autograft anterior cruciate ligament (ACL) reconstruction (ACLR) in patients with open growth plates. Twenty-nine skeletally immature athletes (30 knees) with a mean age of 13.9 years (range, 9 to 16 years) underwent transphyseal ACLR (22 with quadrupled hamstring autograft and 8 with tibialis anterior allograft). Of the patients, 5 were Tanner stage I, 17 were Tanner stage II, and 7 were Tanner stage III. Outcomes included KT-1000 (MEDmetric, San Diego, CA) measurements and International Knee Documentation Committee (IKDC), Cincinnati, and Lysholm scoring. Radiographs were evaluated for asymmetrical physeal closure, growth arrest lines, and knee alignment. The mean outcomes scores, excluding the 5 graft failures, were 91.8 points for the IKDC score, 93.0 points for the Cincinnati score, and 91.5 points for the Lysholm score at a mean of 4 years' follow-up (range, 24 to 84 months). The 95% confidence intervals for the differences were-27.7 to-18.0 for the IKDC score,-26.4 to-12.1 for the Cincinnati score, and-20.1 to-6.4 for the Lysholm score. One hundred percent of patients ultimately returned to their prior level of sports, but only 76% maintained that level at most recent follow-up. The mean KT-1000 side-to-side difference at most recent follow-up was 0.4 mm (SD, 1.3 mm; range,-2 to 3 mm) (n= 25). Evaluation at a minimum of 2 years postoperatively showed 4 patients with Harris growth arrest lines and 1 genu valgum deformity that spontaneously corrected at latest follow-up. For the remaining 29 knees, there was a mean side-to-side difference of 1.3° (range, 0° to 4°) in the radiographic tibiofemoral angle and 0.2 cm (range, 0 to 1 cm) for clinical leg-length measurements. Sports-related graft failure occurred at a mean of 24 months after ACLR in 16.7% of patients (37.5% with allografts [3 of 8] v 9% with autografts [2 of 22], P= .10). In 5 patients (16.7%), a contralateral ACL injury was sustained. Transphyseal ACLR in patients with open growth plates resulted in a high rate of return to sports with a low rate of growth arrest and deformity at a mean of 4 years' follow-up. Harris growth arrest lines and a case of genu valgum deformity that spontaneously corrected, however, were observed. Graft failure rates and contralateral ACL tears were not insignificant in this young patient population. Level IV, therapeutic case series.

Intraarticular hamstring graft diameter decreases with continuing knee growth after ACL reconstruction with open physes.

To evaluate the graft diameter size after one-year follow-up or more of patients Tanner II, III, and IV who were submitted to anterior cruciate ligament reconstruction. Ten patients [five males (mean age: 14.4 years) and five females (mean age: 13.6 years)] with open physis and anterior cruciate ligament tear were submitted to transphyseal anterior cruciate ligament reconstruction with quadruple hamstrings graft. During the procedure, graft and tunnel size were recorded. After last clinical follow-up (range 1-11 years), an MRI study was requested and their measurements near the tibial tunnel were compared with the graft diameter measured and used during primary procedure. Four patients had Tanner stage II, four patients Tanner stage III, and two Tanner IV. There were statistically significant decreases in the quadruple hamstrings graft diameter size (average of 25.3%). Mean size at time of surgery was 7.9 mm (±0.87), and mean size measured at different points of follow-up evaluation was 5.9 mm (±0.65). Diameter size of hamstring graft in skeletally immature patients is smaller in most cases. If there is a decrease in the diameter of the graft along postoperative time, the risk of a re-rupture is theoretically further increased. Quadruple hamstring graft decreases a mean 25.3% in diameter from time of anterior cruciate ligament reconstruction surgery until reassessment period in skeletally immature patients. IV.

Articular Sinus Tract with Mycobacterium fortuitum Osteomyelitis After Anterior Cruciate Ligament Reconstruction: A Case Report.

Three weeks after transphyseal anterior cruciate ligament reconstruction with a hamstring autograft, a fourteen-year-old boy presented with fevers, joint effusion, and elevated inflammatory markers. Cultures from an operative debridement grew Mycobacterium fortuitum, for which he received six months of antibiotics. Continued drainage prompted magnetic resonance imaging, which revealed osteomyelitis of the tibial tunnel. This case report describes a postoperative infection with an atypical organism that had a protracted course despite early diagnosis. Complete resolution was achieved following tibial tunnel debridement with a high-speed burr and bone-grafting with an antibiotic-laden allograft.

Return to Play and Clinical Outcomes after All-Inside, Anterior Cruciate Ligament Reconstruction in Skeletally Immature Athletes

Objectives:Anterior cruciate ligament (ACL) injuries in skeletally immature athletes are on the rise because of increased participation and level of competition within sports, sports specialization and societal factors. Conservative treatment of these injuries has a poor natural history due to recurrent instability with meniscal and articular cartilage damage. The purpose of this study was to evaluate the results of an all-inside, physeal-sparing ACL reconstruction in skeletally immature athletes, with a focus on return to play.Methods:Forty-two skeletally immature athletes (mean chronologic age 12.7 yrs, [range 10-15]) were prospectively evaluated following an all-inside ACL reconstruction utilizing hamstring autograft. The mean bone age (Greulich and Pyle method) was 13.5 years. There were 10 females and 32 males. Twenty-six patients had an all-epiphyseal (AE) ACL reconstruction and 16 patients had a partial transphyseal (PTP) ACL reconstruction, which spared the femoral physis but crossed the tibial physis. The PTP option was reserved for patients with minimal proximal tibial growth remaining. Fourteen athletes were involved in recreational sport and 28 participated competitively. Lacrosse (36%) and Soccer (32%) were the two most common sports associated with ACL injury in our cohort. All athletes were evaluated with a physical examination, KT-1000 arthrometry, isokinetic testing, validated outcome scores including the International Knee Documentation Committee score (IKDC), the Lysholm score and Marx activity rating scale. Standing radiographs and SPGR MRI analysis was performed at 6, 12 and 24 months post-op depending upon skeletal age. A ‘Return to Play’ performance analysis was also performed where symmetry, alignment control and the ability to decelerate were assessed during progressively challenging movement patterns encountered in sport.Results:At a mean follow-up of 16.7 months (range 12-24), the mean IKDC score was 92.9 ± 7.2, the mean Lysholm score was 97.7 ± 4.6 and the mean Marx activity rating scale score was 12.4 ± 3.5. Lachman and pivot shift testing was negative in all patients. The mean side-to-side difference in the KT-1000 arthrometry was 0.9 ± 0.7 mm, with the maximum difference in the cohort being 2 mm. Isokinetic testing showed a mean deficit of 4.1% in extension torque and 9.2% in flexion torque at a repetition speed of 180 degrees per second. No angular deformities, significant leg length discrepancy or physeal disturbances were observed on postoperative radiographs or MRI. One athlete had a traumatic graft disruption at 12 months and underwent revision ACL reconstruction and one athlete sustained a contralateral ACL rupture at 11 months. The mean time for return to unrestricted competitive activity after successful completion of the ‘Return to Play’ analysis was 12.5 +/- 1.3 months from the time of surgery.Conclusion:An all-inside, physeal-sparing ACL reconstruction technique using hamstring autograft demonstrates excellent subjective and objective clinical outcomes in skeletally immature athletes without growth disturbance. ‘Return to Play’ assessment is an important tool to guide the young athlete and her or his family regarding resumption of competitive sports. In our experience, athletes were on average released for full return to sport after 1 year from ACL reconstruction.

Mid-term results of transphyseal anterior cruciate ligament reconstruction in children and adolescents

BackgroundOptimal therapy for anterior cruciate ligament (ACL) rupture in the paediatric population still provokes controversy. Although conservative and operative treatments are both applied, operative therapy is slightly favored. Among available surgical techniques are physeal-sparing reconstruction and transphyseal graft fixation. The aim of this study was to present our mid-term results after transphyseal ACL reconstruction. MethodsFifteen young patients (mean age=12.8±2.6, range=6.2–15.8years, Tanner stage=2–4) with open physis and traumatic anterior cruciate rupture who had undergone transphyseal ACL reconstruction with unilateral quadriceps tendon graft were prospectively analyzed. All children were submitted to radiological evaluation to determine the presence of clearly open growth plates in both the distal femur and proximal tibia. Postoperatively, all patients were treated according to a standardized rehabilitation protocol and evaluated by radiographic analysis and the Lysholm–Gillquist and IKDC 2000 scores. Their health-related quality of life was measured using the SF-12 PCS (physical component summary) and MCS (mental component summary) questionnaires. ResultsMean postoperative follow-up was 4.1years. Mean Lysholm–Gillquist score was 94.0. Thirteen of the 15 knees were considered nearly normal on the IKDC 2000 score. The mean SF-12 questionnaire score was 54.0±4.8 for SF-12 PCS and 59.1±3.7 for SF-12 MCS. No reruptures were observed. Radiological analysis detected one knee with valgus deformity. All patients had a normal gait pattern without restrictions. ConclusionTransphyseal reconstruction of the anterior cruciate ligament shows satisfactory mid-term results in the immature patient.

Dynamic Evaluation of Pivot-Shift Kinematics in Physeal-Sparing Pediatric Anterior Cruciate Ligament Reconstruction Techniques

Background: Conventional transphyseal anterior cruciate ligament (ACL) reconstruction techniques in skeletally immature patients have been questioned because of potential physeal injuries. Consequently, multiple alternative reconstruction options have been described to restore stability while sparing the physes in the skeletally immature patient. Hypothesis: All pediatric reconstruction techniques will restore knee stability to intact levels, and the knee stability index (KSI) will discriminate stability patterns between reconstruction techniques. Study Design: Controlled laboratory study. Methods: A novel mechanical pivot-shift device (MPSD) that consistently applies dynamic loads to cadaveric knees was used to study the effect of different physeal-sparing ACL reconstruction techniques on knee stability. Six adult cadaveric fresh-frozen knees were used. All knees were tested with 3 physeal-sparing reconstruction techniques: all epiphyseal (AE), transtibial over the top (TT), and iliotibial band (ITB). The MPSD was used to consistently perform a simulated pivot-shift maneuver. Tibial anterior displacement (AD), internal rotation (IR), posterior translational velocity (PTV), and external rotational velocity (ERV) were recorded using an Optotrak navigation system. The KSI (score range, 0-100; 0 = intact knee) was quantified using a regression analysis of AD, IR, PTV, and ERV. Repeated-measures analysis of variance and logistic regression were used for comparison of kinematics and derivation of KSI coefficients, respectively. Results: ACL deficiency resulted in an increase of 20% to 115% in all primary stability measures tested compared with the ACL-intact state. All reconstructions resulted in a decrease in ADmax and IRmax as well as PTVmax and ERVmax to within intact ranges, indicating that all reconstructions do improve stability compared with the ACL-deficient state. The ITB reconstruction overconstrained AD and IR by 38% and 52%, respectively. The mean (±SD) KSI for the ACL-deficient state was 61.7 ± 22.2 (range, 47-100), while the ITB reconstruction had a mean KSI of 0.82 ± 24.0 (range, −24 to 35), the TT reconstruction had a mean KSI of 13.3 ± 8.9 (range, 0.3-23), and the AE reconstruction had a mean KSI of −4.0 ± 15.2 (range, −24 to 14). The KSI was not significantly different between reconstructions, and all were significantly lower than the ACL-deficient state (P < .0001). Conclusion: Although all reconstruction techniques tested were able to partially stabilize an ACL-deficient knee, the AE reconstruction was most effective in restoring native knee kinematics under dynamic loading conditions that mimic the pivot-shift test. Clinical Relevance: This study provides orthopaedic surgeons with objective dynamic rotational data on the ability of physeal-sparing ACL reconstructions to better determine the ideal technique for ACL construction in skeletally immature patients.

Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients With Transphyseal Tunnels

Our purpose was to evaluate the results of transphyseal anterior cruciate ligament (ACL) reconstruction with hamstring autograft in skeletally immature patients. Eighteen knees in 18 skeletally immature pubescent patients with a mean chronologic age of 14.2 years underwent transphyseal ACL reconstruction with hamstring autograft between 2002 and 2007. Concurrent meniscal surgery was performed in 9 knees. The final patient evaluation occurred at a mean of 43.4 months (range, 24.0 to 86.6 months) and included physical examination, KT-1000 arthrometry testing (MEDmetric, San Diego, CA), and functional outcome instruments, including the International Knee Documentation Committee subjective knee form, the Lysholm knee score, and the Tegner knee activity scale. At the latest follow-up, the mean International Knee Documentation Committee subjective knee score was 92.4 ± 10, the mean Lysholm knee score was 94.3 ± 8.8, and the mean Tegner activity scale score was 8.5 ± 1.4. Lachman and pivot-shift testing were negative in all knees. No restriction in knee range of motion of 5° or greater when compared with the contralateral knee was observed in any patient. The mean manual maximum side-to-side difference with KT-1000 testing was 0.29 ± 1.07 mm, and no patients had a difference greater than 3 mm. No angular deformities were noted, and all leg-length measurements were symmetric bilaterally on clinical examination. No patients had traumatic graft disruption or underwent revision ACL reconstruction, whereas 3 patients sustained an ACL injury in the contralateral leg while participating in sports. Transphyseal ACL reconstruction with autogenous quadrupled hamstring graft with metaphyseal fixation in skeletally immature pubescent patients yielded excellent functional outcomes in a high percentage of patients without perceived clinical growth disturbance. Level IV, therapeutic case series.

Outcome of Anatomic Transphyseal Anterior Cruciate Ligament Reconstruction in Tanner Stage 1 and 2 Patients With Open Physes

Background: Anterior cruciate ligament (ACL) injuries are being seen with increasing frequency in children. Treatment of the ACL-deficient knee in skeletally immature patients is controversial. Purpose: To determine the outcome of all-arthroscopic transphyseal anatomic single-bundle ACL reconstruction in Tanner stage 1 and 2 patients at a minimum of 2 years after surgery. Study Design: Case series; Level of evidence, 4. Methods: Between 2007 and 2008, 16 prepubescent patients underwent ACL reconstruction using soft tissue grafts. All patients were Tanner stage 1 and 2. Outcomes were assessed at a minimum of 2 years after surgery and included limb alignment, limb length, instrumented testing with the KT-1000 arthrometer, and International Knee Documentation Committee (IKDC) score. Results: Mean age at the time of surgery was 12 years (range, 8-14 years). Graft choices included the following: living donor–related hamstring tendon allograft (n = 14), hamstring tendon autograft (n = 1), and fresh-frozen allograft (n = 1). Mean IKDC subjective score was 96 (range, 84-100). All patients had a stable knee postoperatively. Eleven patients had a negative Lachman test result, and 14 had a negative pivot-shift test result. The remainder had grade 1 Lachman and pivot-shift test findings, respectively. At 2 years after surgery, all patients had returned to strenuous activities, and normal or nearly normal overall IKDC score was documented in 94% of patients. There were no cases of limb malalignment or growth arrest. Conclusion: We present a case series of transphyseal anatomic single-bundle ACL reconstruction in Tanner stage 1 and 2 patients at a minimum of 2 years after surgery. Excellent clinical outcomes were obtained with high levels of return to desired activities. Importantly, no growth disturbances were seen in this series of patients.

A Biomechanical Comparison of 2 Femoral Fixation Techniques for Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Over-the-Top Fixation Versus Transphyseal Technique

The purpose of this study was to compare knee kinematics and in situ forces of the graft between 2 femoral fixation techniques of anterior cruciate ligament (ACL) reconstruction: the over-the-top (OTT) fixation and transphyseal (TP) techniques. ACL reconstruction in skeletally immature patients is a challenging procedure. Regarding the femoral fixation techniques, 2 methods are commonly used: the OTT fixation and TP techniques. Ten cadaveric knees (mean age, 57 years; range, 48 to 65 years) were tested with the robotic/universal force-moment sensor system by use of (1) an 89-N anterior tibial load at full extension and 15°, 30°, 60°, and 90° of knee flexion and (2) a combined 7-Nm valgus torque and 5-Nm internal tibial rotation torque at 15° and 30° of knee flexion. Both OTT and TP ACL reconstruction techniques closely restored the intact knee kinematics and had a significant reduction in anterior tibial translation under an anterior tibial load and in coupled anterior tibial translation under a combined rotatory load when compared with an ACL-deficient knee. When both ACL reconstruction techniques were compared, the only difference found was that the in situ force of the ACL graft reconstructed with the OTT technique in response to a combined rotatory load at 30° of flexion was significantly lower than the ACL graft reconstructed with the TP technique (5.3 ± 3.3 N and 10.7 ± 6.0 N, respectively; P = .013). This time 0 testing showed that both ACL reconstruction techniques, OTT and TP, can reproduce the kinematics of the intact knee in response to an anterior tibial load and a combined rotatory load. Both femoral fixation techniques exhibited comparable time 0 kinematics when subjected to simulated clinical examination loading conditions.

Good surgical outcome of transphyseal ACL reconstruction in skeletally immature patients using four-strand hamstring graft

Our purpose was to evaluate the clinical and radiological outcome at maturity of an«adult-like»transphyseal anterior cruciate ligament (ACL) reconstruction performed in skeletally immature patients using four-strand hamstring graft. The records of all skeletally immature patients who underwent transphyseal ACL reconstruction between 2004 and 2006 at our institution were reviewed. Inclusion criteria were age less than 16years and radiographic evidence of open physes. Thirty-eight children and prepubescents were identified. All underwent postoperative clinical evaluation with International Knee Documentation Committee scores and long leg radiographs. Each patient was followed up until skeletal maturity was confirmed. Twenty-eight patients were scored A, four B, and five D according to IKDC. At last follow-up, there was no radiographic evidence of malalignment in any of the patients. Five underwent a reoperation. Three patients suffered traumatic graft disruption and two from post-operative knee instability. Early operative treatment by means of the quadruple hamstring free graft appears to be a safe and relevant procedure for ACL reconstruction even in skeletally immature patients.

Outcomes after Transphyseal Anterior Cruciate Ligament Reconstruction in Patients with Open Growth Plates (SS-42)

Concerns about growth disturbance after transphyseal ACL reconstruction in the presence of open growth plates exist. The hypothesis was that transphyseal soft tissue ACL reconstruction in individuals with open growth plates would result in minimal risk for growth disturbance.

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.

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.

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.

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.