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Document Title: Kocher-JBJS-Dec07.shtml
Article Title: Transphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Pubescent Adolescents
Authors: Mininder S. Kocher, MD, MPH, Jeremy T. Smith, MD, Bojan J. Zoric, MD, Ben Lee, BA and Lyle J. Micheli, MD
Publication: Journal of Bone and Joint Surgery (American Edition)
Date: December 2007
Volume 89, pages 2632-2639
Keywords: Pediatric ACL, skeletally immature adolescent, ACL reconstruction, open growth plates, epiphyses, Tanner Stage 3.
(Reference-denoting numbers appear in the same font and point size as the document text. As with all Knee Library documents, this article is provided in full-text form, complete with all figures and tables.)
Comments: Reconstructing an ACL in a young patient requires that special consideration be given to the growth-disruption concerns associated with open growth plates. Kocher et al. describe a biomechanically sound, intra-articular reconstruction procedure that brings all the stability and normal-motion benefits of the adult procedure without the problematic compromises inherent to extra-articular (e.g. Tomato Stake) reconstructions. Kocher's hamstring-autograft transphyseal ACL reconstruction uses metaphyseal fixation to bring a superb outcome with very minimal risk of bone-growth disturbance.
Abstract
Background: Management of anterior cruciate ligament injuries in skeletally immature patients is controversial. Conventional surgical reconstruction techniques for adults can cause iatrogenic growth disturbance due to physeal damage in children. The purpose of this study was to evaluate the results of a transphyseal reconstruction technique in pubescent but skeletally immature adolescents.
Methods: Between 1996 and 2004, sixty-one knees in fifty-nine skeletally immature pubescent adolescents (Tanner stage 3) with a mean chronological age of 14.7 years (range, 11.6 to 16.9 years) underwent transphyseal reconstruction of the anterior cruciate ligament with use of an autogenous quadrupled hamstrings-tendon graft and metaphyseal fixation. Thirty-one knees had additional meniscal surgery. The functional outcome, graft survival, radiographic outcome, and any growth disturbance were evaluated at a mean of 3.6 years (range, 2.0 to 10.2 years) after the surgery.
Results: Two patients (3%) underwent revision anterior cruciate ligament reconstruction because of graft failure at fourteen and twenty-one months postoperatively. For the remaining fifty-nine knees, the mean International Knee Documentation Committee subjective knee score (and standard deviation) was 89.5 ± 10.2 points and the mean Lysholm knee score was 91.2 ± 10.7 points. The result of the Lachman examination was normal in fifty-one knees and nearly normal in eight; it was not abnormal or severely abnormal in any knee. The result of the pivot-shift examination was normal in fifty-six knees and nearly normal in three knees; it also was not abnormal or severely abnormal in any knee. The mean increase in total height was 8.2 cm (range, 1.2 to 25.4 cm) from the time of surgery to the time of final follow-up. No angular deformities of the lower extremity were measured radiographically, and no lower-extremity length discrepancies were measured clinically. Complications included three cases of arthrofibrosis requiring manipulation with the patient under anesthesia.
Conclusions: Transphyseal reconstruction of the anterior cruciate ligament with use of an autogenous quadrupled hamstrings-tendon graft with metaphyseal fixation in skeletally immature pubescent adolescents provides an excellent functional outcome with a low revision rate and a minimal risk of growth disturbance.
Level of Evidence: Therapeutic Level IV.
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