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

Cruz, Aristides I.; Lakomkin, Nikita; Fabricant, Peter D.; Lawrence, J. Todd R.

doi:10.1016/j.arthro.2016.03.043

Cited by 11 publications

(14 citation statements)

References 30 publications

(39 reference statements)

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“…This oblique angle increases the risk of physeal injuries and possibly injuries to the perichondral ring. 1,40 A recent study by Cruz et al 10 found increased physeal disruption when independent tunnel drilling was employed compared with a transtibial technique in skeletally immature patients. Additionally, despite its history of good to excellent results, more recent data have called into question the safety of transphyseal drilling for patients 2 to 3 years away from achieving skeletal maturity.…”

Section: Discussionmentioning

confidence: 98%

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

Willson

Kostyun

Milewski

et al. 2018

Orthopaedic Journal of Sports Medicine

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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.

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Section: Discussionmentioning

confidence: 98%

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

Willson

Kostyun

Milewski

et al. 2018

Orthopaedic Journal of Sports Medicine

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“…Traditional transtibial drilling of the femoral tunnel for ACLR results in longer and more vertical tunnel trajectories in the coronal plane versus AM or outside-in techniques, implying increased safety in the context of open physes. 7 , 19 However, transtibial drilling has been shown to consistently result in less accurate positioning of the femoral tunnel with respect to the native ACL footprint, as well as reduced knee rotational stability compared with the tibial-independent drilling technique. 20 , 21 Thus, a hybrid transtibial technique appears to offer the best of both worlds, consistently reproducing the native ACL trajectory and footprint while reducing tunnel obliquity (and the associated risk of physeal injury) and maintaining the technical advantages of traditional transtibial ACLR.…”

Section: Discussionmentioning

confidence: 99%

“…One of the key principles is to maintain a drilling path as perpendicular as possible to the physis to minimize the surface area of injury. 7 Thus, most descriptions of the transphyseal technique use a transtibial femoral drilling strategy to minimize femoral tunnel obliquity. Unfortunately, this comes at the expense of femoral tunnel accuracy and recapitulation of knee stability, given that it is well documented that reaching the anatomic center of the femoral ACL footprint is difficult or sometimes impossible using a transtibial strategy.…”

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confidence: 99%

Transphyseal Anterior Cruciate Ligament Reconstruction Using Hybrid Transtibial Femoral Drilling and a Quadriceps Tendon Autograft

Johnston

Gregory

et al. 2020

Arthroscopy Techniques

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Significant controversy exists regarding the optimal surgical technique for anterior cruciate ligament (ACL) reconstruction in adolescents with 1 to 3 years of skeletal growth remaining. Graft choice and physeal injury remain primary concerns given significantly elevated rates of failure of hamstring autograft reconstructions in this population, as well as risks of leg-length discrepancy and growth axis deviation. Traditional (more vertical) transtibial drilling of the femoral tunnel can reduce risks of physeal injury but has been shown to have less accuracy restoring the native femoral ACL footprint and associated incomplete knee stabilization. On the other hand, anteromedial and outside-in drilling yields improvements in the tunnel location and biomechanics but at the cost of a more oblique trajectory and greater risk of physeal injury. A hybrid transtibial pin technique using a Pathfinder guide facilitates femoral drilling with the “best of both worlds,” allowing for reproduction of the native ACL footprint and a more physeal-respecting femoral tunnel. When combined with an all–soft tissue quadriceps tendon autograft and suspensory fixation, the hybrid transtibial method yields a reliable, safe, and robust construct with promising results for the young athlete. We describe our preferred graft harvest, tunnel drilling, and fixation techniques to minimize physeal risks and optimize outcomes.

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“…However, this may also be accomplished with independent tunnel-drilling tech-niques with a vertical trajectory. Regardless, the clinical impact of the drilling technique in humans in the setting of soft-tissue grafts and metaphyseal fixation is not yet known 115 . Meticulous attention to developmental and skeletal age allows the surgeon to select the appropriate approach and to know when the amount of growth remaining will not lead to length or angular limb deformity with transphyseal techniques.…”

Section: Transphyseal Reconstructionmentioning

confidence: 99%

Management of ACL Injuries in Children and Adolescents

Fabricant

Kocher

2017

The Journal of Bone and Joint Surgery

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ä Children and adolescent athletes constitute the largest demographic of patients who sustain anterior cruciate ligament (ACL) tears, and the frequency is increasing. ä In ACL-deficient children and adolescents, continued symptoms of instability can result in progressive meniscal and cartilage damage as well as arthritic changes. ä Growth disturbance can occur after ACL surgery in children, and includes tibial recurvatum due to tibial tubercle apophyseal arrest as well as limb-length discrepancy and/or angular deformity due to physeal arrest or overgrowth. ä Several "physeal sparing" and "physeal respecting" ACL reconstruction techniques have been developed for use in skeletally immature patients to minimize the risk of growth disturbance, with favorable clinical outcomes. ä ACL injury prevention strategies include neuromuscular conditioning and may be performed to prevent both initial ACL injury as well as reinjury and injury of the contralateral ACL after reconstruction. Disclosure: No internal or external funding was provided for this project. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked "yes" to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/B603).

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

Cited by 11 publications

References 30 publications

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

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

Transphyseal Anterior Cruciate Ligament Reconstruction Using Hybrid Transtibial Femoral Drilling and a Quadriceps Tendon Autograft

Management of ACL Injuries in Children and Adolescents

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