Transphyseal reconstruction of the anterior cruciate ligament in prepubescent children

Abstract

We present the results of 17 children of Tanner stage 1 or 2 who underwent reconstruction of the anterior cruciate ligament between 1999 and 2006 using a transphyseal procedure, employing an ipsilateral four-strand hamstring graft. The mean age of the children was 12.1 years (9.5 to 14). The mean follow-up was 44 months (25 to 100). Survival of the graft, the functional outcome and complications were recorded. There was one re-rupture following another injury. Of the remaining patients, all had good or excellent results and a normal International Knee Documentation Committee score. The mean post-operative Lysholm score was 97.5 (SD 2.6) and the mean Tegner activity scale was 7.9 (SD 1.4). One patient had a mild valgus deformity which caused no functional disturbance. No other abnormality or discrepancy of leg length was seen. Measurements with a KT1000 arthrometer showed no significant difference between the normal and the operated legs. In this small series, transphyseal reconstruction of the anterior cruciate ligament appeared to be safe in these young children.

All-Epiphyseal, All-Inside Anterior Cruciate Ligament Reconstruction Technique for Skeletally Immature Patients

“…The descriptions that do exist limit early weight bearing and ROM. 44,61,62 It is not recommended to follow adult ACL reconstruction guidelines for patients who have received physealsparing ACL reconstruction because of differing fixation technique as well as patient maturity level. Isometric graft placement allows for immediate motion without adverse loads.…”

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).…”

“…We are aware of only 2 studies in which functional preoperative outcome measurements were included, 50,66 while the majority of studies did not include any data on baseline or pretreatment knee function. To our knowledge, no well-designed studies on nonoperative management have been published, and the rates of secondary meniscus injuries in 3 of 4 case series were low.…”

“…12, 31,42,102 In contrast, the sparse descriptions of rehabilitation programs for skeletally immature individuals appear to advocate a more conservative approach, with longer periods of non-weight bearing and bracing, and a later return to sport. 66,67,100 The slower and more conservative protocols for skeletally immature patients who undergo ACL reconstruction may be due to the uncertainty regarding the strength of the graft and the risk of growth disturbances, as well as the lack of evidence-based practice guidelines. Kocher et al 60 published a prospective cohort study of 45 skeletally mature and immature patients with partial ACL injuries that reported excellent outcomes.…”

Revision pediatric anterior cruciate ligament reconstruction after failure of iliotibial band technique treated with all-epiphyseal technique in a prepubescent with Ehlers–Danlos syndrome: a case report

“…Many elegant operative techniques that restore stability to the knee joint while still preserving the physis of these patients have been developed, recently summarized by Gausden et al [7]. These pediatric ACL reconstruction techniques can be broadly categorized as extraphyseal, transphyseal, and epiphyseal; they have been shown to restore stability to the knee joint while resulting in a tolerably low incidence of growth disruption [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26]. Although the predominant pediatric population studied includes Tanner stages 2-3, each category of technique has demonstrated efficacy and minimized growth disturbance in the younger subset of Tanner stages 1 [10,14,17,20,[24][25][26][27].…”