Document Title: Guzzanti-AJSM-Nov03.shtml
Article Title: Physeal-Sparing Intraarticular Anterior Cruciate Ligament Reconstruction in Preadolescents
Authors: Vincenzo Guzzanti MD, Francesco Falciglia MD and Carl L. Stanitski MD
Publication: American Journal of Sports Medicine, Baltimore, Maryland
Date: November-December 2003
Volume 31, pages 949-953
Keywords: pediatric ACL reconstruction, physeal sparing, epiphyses, growth plates, soft-tissue reconstruction.

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Comments: This method, using a hamstring-type graft but with a staple in the femur (and with an oblique tibial bone tunnel), does bring the advantage of not violating the growth plate. But one very frightening possibility is that the staple conceivably could pull out. And, because at the staple the graft does not make much contact with the bone, secure graft-to-bone healing might not occur. Furthermore, because the graft is looped around the staple, it could rotate around it whenever the knee is moved; this could hamper effective graft incorporation. (Although no evidence of graft impingement was noted in any of the patients, there remains the question of sufficient room for the graft at the femoral end, given that Guzzanti's method did not entail performing notchplasty [i.e. the widening of the intercondylar notch that is a standard part of modern ACL-reconstruction procedures], particularly given that the patient is still growing. Keep in mind that this method involves looping of both the semitendinosus and gracilis tendons [shown together as a single strand in Figure 1 of this article] around a staple, and then sewing them together. This is in contrast to the standard procedure of doubling the tendons and sewing them together before installing them. Additionally, Guzzanti's heavy use of fluoroscopy during the surgery is in itself cause for concern, particularly since the patients are young children. A fluoroscope is basically an X-ray video camera. The problem is that it continually exposes the tissue being imaged to X-rays throughout the viewing period. A standard still-film-type X-ray exposure lasts for 1/50 [using ASA 400 film] or 1/100 of a second [for the newer ASA 800 film], and thus each second that a patient is under a fluoroscope translates into the ionizing-radiation exposure that would have been received with 50 or 100 standard film-type X-ray images!) Long-term follow-up (i.e. at least several decades, and preferably for at least a half-century) of the patients would be needed in order to see whether or not this method results in a permanent surrogate ACL that lasts not only for as long as the child is a child, but for said person's entire adult life as well. (One further point: the graft is obtained by detaching both the semitendinosus and gracilis tendons at their proximal ends, and using them for the grafting directly. Because the tendons remain connected at the distal end, they still have a blood supply and hence don't die off like in the standard autografting procedure, which entails stripping out a tendon portion and implanting the resulting dead sliver of tissue. However, the loss of both the semitendinosus and gracilis tendons in their entirety is worrisome, given that this will permanently reduce hamstring-group strength. The hamstrings are essential in protecting the ACL (whether natural or a surrogate obtained through reconstruction), and any loss in hamstring-group strength is very worrisome.

ABSTRACT

Background: In the very young patient in need of anterior cruciate ligament reconstruction, the option of reconstruction with physeal-sparing techniques is valid because it is not known what percentage of physeal transgression causes adverse growth consequences.

Purpose: To report our experience with an intraarticular technique for anterior cruciate ligament reconstruction that spares the open femoral and tibial physes yet allows soft tissue graft fixation in the femoral and tibial tunnels.

Methods: Eight preadolescents underwent physeal-sparing intraarticular reconstruction for anterior cruciate ligament insufficiency with the use of semitendinosus and gracilis tendon grafts. All eight patients were in Tanner stage 1 with an average chronologic age of 11.15 years and average bone age of 10.9 years. Preoperative prediction of lower limb growth averaged 10.8 cm.

Results: Five of the eight patients had reached skeletal maturity at follow-up, which was at an average of 69.2 months postoperatively. For these five, the Orthopadische Arbeitsgruppe Knie (OAK) score averaged 97 and the average KT-2000 arthrometer difference was 1.8 mm. Average growth in total height from surgery to final follow-up was 21.7 cm. No patient had a leg-length discrepancy or angular deformity, as verified by clinical or teleroentgenogram measurements.

Conclusions: The technique presented in this study provided graft isometry and stability without adverse physeal consequences. Additional research is needed to determine the threshold percentage of physeal transgression for avoiding growth disturbances in humans.

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Copyright American Journal of Sports Medicine, American Orthopaedic Society for Sports Medicine, November/December 2003. For details regarding copyright as it applies to this page, please visit the page entitled Site Terms of Use and Aspects of Copyright on this site.

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