ACL Tears in Children: Transphyseal Reconstruction

Debra Bartley, M.D., FRCSC
London, ON

The adolescent with an anterior cruciate ligament (ACL) injury approaching skeletal maturity presents little controversy among surgeons. The risk of growth arrest causing a significant LLD or angular deformity is low and therefore adult ACL reconstructive techniques are considered safe and appropriate3,4,9,12. Transphyseal reconstruction of the ACL in the skeletally immature athlete remains a subject of debate. The potential risks associated with damage to the physis, including leg length discrepancy (LLD) and angular deformity, lead most surgeons to look for alternative methods of reconstruction. However, transphyseal reconstruction methods are supported in recent literature without a significant incidence of complications leading to growth disturbance. The small number of complications reported have been attributed to correctible technical issues.

The skeletally immature patient is defined by chronological age, bone age, the presence of wide open growth plates on X-ray, and Tanner stage. Transphyseal reconstruction in this population can be divided into two categories, described by Stanitski: 1) complete transphyseal or 2) partial transphyseal techniques4. The complete transphyseal technique is equivalent to the standard adult reconstruction. Partial refers to a transphyseal tibial tunnel and a femoral physeal sparing procedure.

Complete transphyseal reconstruction in the skeletally immature athlete is more prevalent in recent literature. Anatomical graft placement in an isometric position provides the young athlete with the recognized benefits of the standard treatment used in adults. Recent studies support complete transphyseal techniques with hamstring graft, reporting no clinically significant growth disturbances1,3,5,13,14,16. Bone-patellar tendon-bone autograft, once considered a contra-indication, is also being reported without complications6,17.

The most common example of a partial transphyseal technique is transphyseal tibial tunnel combined with over-the-top femoral placement of a soft tissue graft. Both Lo et al11 and Andrews et al2 have reported on this technique in small studies of skeletally immature patients without clinically significant growth disturbance. These authors emphasize the use of small tibial tunnels, drilled centrally and slightly more vertical than normal. Careful dissection to the over-the-top position will avoid damage to the perichondrial ring and femoral physis11,2. This technique spares the femoral physis which is considered more vulnerable and at greater risk due to the peripheral location and obliquity of the femoral tunnel.

There are few reported occurrences of significant growth disturbance after transphyseal ACL reconstruction in the skeletally immature athlete. Lipscombe et al10 reported a clinically significant shortening of 20mm on the operated leg secondary to transfemoral physeal stapling using a partial transphyseal technique. Koman and Sanders8 presented a case report of a progressive distal femoral valgus deformity after complete transphyseal reconstruction with cancellous screw fixation across the femoral physis. In a 2002 survey of The Herodicus Society and The ACL Study Group, Kocher reported 13 cases of growth disturbance after transphyseal ACL reconstruction. All but one were associated with poor technique and iatrogenic injury. The only report of a growth disturbance following a correctly performed transphyseal ACL reconstruction has been ipsilateral femoral overgrowth7.

By eliminating the risks associated with complete transphyseal ACL reconstruction, the skeletally immature athlete can gain the benefits of anatomic isometric ACL graft placement. Smaller tunnels, which are more vertical and centrally placed, are recommended. Keep fixation devices or bony plugs far away from the physis. Ensure that soft tissue crosses the physis. Avoid soft tissue dissection close to the physis, perichondrial ring or tibial tubercle9. While further study is warranted, complete transphyseal ACL reconstruction in the skeletally immature athlete is recommended, using a "physeal-respecting" approach3.

References

  1. Aichroth P.M., Patel D.V., Zorilla P. The Natural History and Treatment of Rupture of the Anterior Cruciate Ligament in Children and Adolescents. A Prospective Review. J Bone Joint Surg Br. 2002 Jan; 84(1):38-41.
  2. Andrews M., Noyes F.R., Barber-Westin S.D. Anterior Cruciate Ligament Allograft Reconstruction in the Skeletally Immature Athlete. Am J Sports Med. 1994 Jan-Feb; 22(1):48-54.
  3. Bales C.P., Guettler J.H., Moorman C.T. 3rd. Anterior Cruciate Ligament Injuries in Children with Open Physes: Evolving Strategies of Treatment. Am J Sports Med. 2004 Dec; 32(8):1978-85. Review.
  4. Dorizas J.A., Stanitski C.L. Anterior Cruciate Ligament Injury in the Skeletally Immature. Orthop Clinic North Am. 2003 Jul; 34(3):355-63. Review.
  5. Edwards P.H., Grana W.A. Anterior Cruciate Ligament Reconstruction in the Immature Athlete: Long-Term Results of Intra-Articular Reconstruction. Am J Knee Surg. 2001 Fall; 14(4):232-7.
  6. Fuchs R., Wheatley W., Uribe J.W., Hechtman K.S., Zvijac J.E., Schurhoff M.R. Intra-Articular Anterior Cruciate Ligament Reconstruction Using Patellar Tendon Allograft in the Skeletally Immature Patient. Arthroscopy. 2002 Oct; 18(8):824-8.
  7. Kocher M.S., Saxon H.S., Hovis W.D., Hawkins R.J. Management and Complications of Anterior Cruciate Ligament Injuries in Skeletally Immature Patients: Survey of the Herodicus Society and The ACL Study Group. J Peditar Orthop. 2002 Jul-Aug; 22(4):452-7.
  8. Koman J.D., Sanders J.O. Valgus Deformity After Reconstruction of the Anterior Cruciate Ligament in a Skeletally Immature Patient. A Case Report. J Bone Joint Surg Am. 1999 May; 81(5):711-5. No abstract available.
  9. Larsen M.W., Garrett W.E. Jr., Delee J.C., Moorman C.T. 3rd. Surgical Management of Anterior Cruciate Ligament Injuries in Patients with Open Physes. J Am Acad Orthop Surg. 2006 Dec; 14(13):736-44. Review.
  10. Lipscomb A.B., Anderson A.F. Tears of the Anterior Cruciate Ligament in Adolescents. J Bone Joint Surg Am. 1986 Jan; 68(1):19-28.
  11. Lo I.K., Bell D.M., Fowler P.J. Anterior Cruciate Ligament Injuries in the Skeletally Immature Patient. Instr Course Lect. 1998; 47: 351-9. Review.
  12. Lo I.K., Kirkley A., Fowler P.J., Miniaci A. The Outcome of Operatively Treated Anterior Cruciate Ligament Disruptions in the Skeletally Immature Child. Arthroscopy. 1997 Oct; 13(5):627-34.
  13. Matava M.J., Siegel M.G. Arthroscopic Reconstruction of the ACL with Semitendinosus-gracilis Autograft in Skeletally Immature Adolescent Patients. Am J Knee Surg. 1997 Spring; 10(2):60-9.
  14. McIntosh A.L., Dahm D.L. Stuart M.J. Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient. Arthroscopy. 2006 Dec; 22(12):1325-30.
  15. Nottage W.M., Matsuura P.A. Management of Complete Traumatic Anterior Cruciate Ligament Tears in the Skeletally Immature Patient: Current Concepts and Review of the Literature. Arthroscopy. 1994 Oct; 10(5):569-73. Review.
  16. Seon J.K., Song E.K., Yoon T.R., Park S.J. Transphyseal Reconstruction of the Anterior Cruciate Ligament Using Hamstring Autograft in Skeletally Immature Adolescents. J Korean Med Sci. 2005 Dec; 20(6):1034-8.
  17. Shelbourne K.D., Gray T., Wiley B.V. Results of Transphyseal Anterior Cruciate Ligament Reconstruction Using Patellar Tendon Autograft in Tanner Stage 3 of 4 Adolescents with Clearly Open Growth Plates. Am J Sports Med. 2004 Jul-Aug; 32(5):1218-22. Epub 2004 May 18.

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