A Minimally Invasive Technique (“Healing Response”) to Treat Proximal ACL Injuries in Skeletally Immature Athletes

Abstract

This study documents outcomes of athletically active, skeletally immature patients with proximal anterior cruciate ligament (ACL) tears treated with a non-reconstructive technique to promote healing ("healing response").Between 1992 and 1998, 13 skeletally immature athletes with proximal ACL tears underwent a healing response procedure. Patients with previous ACL injury, other concurrent ligament pathology, and/or complete mid-substance ACL tears were excluded. Average preoperative KT-1000 arthrometer manual maximum difference for all patients was 5 mm (range: 3-10 mm). Preoperatively, all patients had a 1ϩ or 2ϩ pivot shift, and all patients reported knee function as abnormal or severely abnormal. Patients were followed prospectively with clinical examinations, KT-1000 testing, and subjective questionnaires. Three (23%) patients had a re-injury 30 to 55 months after the healing response and underwent subsequent ACL reconstruction. Subjective follow-up on the remaining 10 patients at an average of 69 months (range: 26-113 months) postoperatively indicated no patients experienced pain or giving way, and all considered their knee function normal. Average Lysholm score was 96, Tegner score was 8.5 (range: 7-10), and patient satisfaction at follow-up was 9.9 (1ϭvery dissatisfi ed and 10ϭvery satisfi ed). Clinical examination at least one year postoperatively was performed on 7 of 10 patients at 35 months (range: 12-63 months). Five patients had a negative pivot shift and 2 had a 1ϩ pivot shift. KT-1000 measurements improved to 2 mm (range: 0-3 mm).In the athletically active, skeletally immature patient, the healing response procedure can restore stability and knee function, with proper patient selection. In this study group, patients were very satisfi ed with the procedure and returned to a high level of sports and activities.

Meniscal Injury After Adolescent Anterior Cruciate Ligament Injury: How Long Are Patients at Risk?

“…Studies in adult patients [7,8,24,39] and in pediatric patients [12,28,32] have shown an increased incidence of medial meniscal tears with delayed ACL reconstruction. Although the treatment of ACL tears in skeletally immature patients remains controversial [33], the risk of physeal injury and resulting growth disturbance from ACL repair to a patient with open physes is now thought to be small [15,22], and many centers (including our institution) opt for prompt reconstruction before skeletal maturity [9,16,20,25,31,34,40].…”

Management of Anterior Cruciate Ligament Injuries in Skeletally Immature Individuals

“…58 However, the development of new surgical techniques has increased the number of orthopaedic surgeons who advocate treatment algorithms consisting of early ACL reconstruction. 25,38,63,66,83,99 The 3 most commonly reported treatment algorithms are transphyseal (adult) ACL reconstruction, physeal sparing ACL reconstruction, and nonoperative management. Transphyseal ACL reconstructions require the surgeon to drill a hole through both the proximal tibial physis and distal femoral physis to enable an anatomical reconstruction of the native ACL (FIGURE 2).…”

Rehabilitation Following a Minimally Invasive Procedure for the Repair of a Combined Anterior Cruciate and Posterior Cruciate Ligament Partial Rupture in a 15-Year-Old Athlete

“…A mallet was then used to perforate the back of the tibial slope at the insertion of the PCL to create 6 to 10 punctured bleeding holes approximately 2 to 3 mm in diameter and 3 to 4 mm in depth, consistent with the published description of the technique. 41,44 Bleeding commenced immediately, and the presence of fat droplets in the blood indicated the awl penetrated sufficiently into the marrow space. A clot formed in situ within minutes.…”

“…A fibrin clot is formed around the area of the defect and mesenchymal cells eventually differentiate into fibrochondrocytes, resulting in a fibrocartilage repair. 54 The "healing response" 44 is an arthroscopic surgical technique that utilizes these same principles in the repair of partial proximal cruciate ligament tears. This minimally invasive, marrow-stimulating, nonreconstructive technique utilizes an arthroscopic awl to induce bleeding in and around the substance and boney attachments of the injured cruciates to stimulate healing.…”

“…41,44 Thirteen skeletally immature athletes with partial tears of the proximal one third of the ACL were treated with the healing response technique and displayed statistically significant improvements in average Lysholm and Tegner scores, as well as in subjective measures of patient satisfaction and activities of daily living, compared to their preoperative status. 44 In addition, KT-1000 testing revealed an average decrease in anterior tibial translation of 2.6 mm. In a canine model, large partial tears of posterior cruciate ligaments (PCLs) that were treated with the healing response resulted in statistically significant improvements in the healing of the lesion, when compared to untreated PCLs.…”