Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Early Results Using a Hybrid Physeal-Sparing Technique

Abstract

Background:Reconstruction of the anterior cruciate ligament (ACL) in the skeletally immature patient is frequently performed in hopes of preventing new or additional chondral damage and meniscal injuries. Patients within a few years of skeletal maturity are more at risk for ACL injuries than prepubescent patients, about whom several physeal-sparing techniques have been described. Reconstruction techniques in the former higher risk group need to be better understood.Purpose:To review a series of adolescent patients with ACL injuries surgically treated with the hybrid physeal-sparing technique.Study Design:Case series; Level of evidence, 4.Methods:Surgical logs of ACL reconstructions (ACLRs) performed at a single pediatric/adolescent sports medicine center over a 6-year period were reviewed. Patients with open physes who had undergone ACLR with a femoral physeal-sparing tunnel and transphyseal tibial tunnel were identified. Their demographics, operative reports, rehabilitative course, time to return to play, outcome scores, and postoperative radiographs were collected and analyzed.Results:Twenty-three patients with a mean chronological age and bone age of 13.0 and 13.6 years, respectively, were identified. Examination and subjective outcome scores were obtained at a mean of 19 months and overall demonstrated positive results, with a mean Pediatric International Knee Documentation Committee (Pedi-IKDC) score of 96.0 and a mean Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) score of 89.1. Full-length mechanical axis films obtained at a mean 21 months postoperatively demonstrated no leg-length discrepancies or angular deformities in 21 of 23 patients. Two patients had an identified growth disturbance in the form of femoral and tibial growth acceleration on the ACL-reconstructed limb.Conclusion:The femoral physeal-sparing with transphyseal tibial drilling “hybrid” technique in skeletally maturing patients appears to have a high rate of success with low morbidity. However, the possibility of physeal abnormalities does exist, which demonstrates the importance of a close postoperative follow-up and evaluation until skeletal maturity is achieved. ACLR in skeletally immature patients is performed on an increasingly regular basis. Establishing the best and safest technique to do so is therefore important.

Outcome Measures After ACL Injury in Pediatric Patients: A Scoping Review

“…Three of the identified PROMs were specific measures for pediatric patients—that is, the Pedi-IKDC, 41 Knee injury and Osteoarthritis Outcome Score for Children (KOOS-Child), 70 and the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS). 22 These PROMs were used in 5, 40,61,93,98,99 1, 85 and 1 16 of the 68 studies, respectively. Of the 5 studies including the Pedi-IKDC as an outcome measure, 1 was published in 2013, 61 1 in 2015, 98 1 in 2017, 93 and 2 in 2018 40,99 .…”

“…In our review, this scale was identified as an outcome measure in 2 of the included studies—both published in 2018. 40,99 The psychological aspect of return to sport is important to include in the evaluation of the pediatric patient; however, to our best knowledge, the current version of the ACL-RSI was not developed for children and has not been validated in pediatric patients, which is why future work should address this issue.…”

“…＃References 1, 4, 6, 7, 11 –21, 23 –27, 29 –34, 39, 40, 42 –52, 54, 56 –59, 61, 63, 66, 67, 72, 74 –78, 80, 81, 83 –85, 87, 89, 91 –93, 98, 99, 101, 102.…”

Current Strategies and Future Directions to Optimize ACL Reconstruction in Adolescent Patients

“…This technique provides an anatomic reconstruction that minimizes the risk of physeal damage but is also reproducible and less technical than the aforementioned physeal-sparing techniques. Willson et al posits this technique provides high success rates with low morbidity in adolescents nearing skeletal maturity ( 22 ).…”

Modification of the Hybrid Anatomic Technique for Anterior Cruciate Ligament Reconstruction in Pediatric Patients

“… 1 , 2 To stabilize the knee, different surgical techniques have been developed for ACL reconstruction in the pediatric population. 3 , 4 , 5 , 6 According to published results, 7 the use of a hybrid anatomic technique, intra-epiphyseal in the femur and transphysis in the tibia, has been recommended as the technique of choice to reconstruct the ACL in these patients. Despite the favorable results, this technique is not exempt from complications.…”