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Document Title: Kocher-JBJS-Nov05.shtml
Article Title: Physeal Sparing Reconstruction of the Anterior Cruciate Ligament in Skeletally Immature Prepubescent Children and Adolescents
Authors: Mininder S. Kocher, MD, MPH, Sumeet Garg, MD and Lyle J. Micheli, MD
Publication: Journal of Bone and Joint Surgery, American Edition
Date: November 2005
Volume 87, pages 2371-2379
Keywords: pediatric ACL reconstruction, children with torn ACL, physeal-sparing technique, avoidance of growth-plate violation, epiphyses.
(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: This article describes a useful method for ACL reconstruction in pediatric patients with open physes. It must be borne in mind that this combination intraarticular-extraarticular method is nonanatomic. In other words, the resulting grafted ACL does not emulate the natural ACL very well, since the grafted ACL is not isometrically located. Therefore, the result of such a reconstruction, though adequate, is biomechanically suboptimal...and so the knee will have some unbidden laxity if it is not to be too tight at certain points in the range of motion. When the patient reaches adulthood, the ACL can be reconstructed using standard intraarticular tendon-grafting, or the knee can be left as is. Please be certain to read the commentary by Dr. Frank Noyes, in particular with regards to long-term follow-up. (Ideally, anyone who incurs any knee injury should be followed up at regular intervals for the rest of their life.) This article also includes a letter to the editor by Charles John Wakeley.
Abstract
Background: The management of anterior cruciate ligament injuries in skeletally immature patients is controversial. Conventional adult reconstruction techniques risk potential iatrogenic growth disturbance due to physeal damage. The purpose of this study was to evaluate the results of a physeal sparing, combined intra-articular and extra-articular reconstruction technique in prepubescent skeletally immature children.
Methods: Between 1980 and 2002, forty-four skeletally immature prepubescent children and adolescents who were in Tanner stage 1 or 2 (with a mean chronological age of 10.3 years) underwent physeal sparing, combined intraarticular and extra-articular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band graft. Twenty-seven patients had additional meniscal surgery. Functional outcome, graft survival, radiographic outcome, and growth disturbance were evaluated at a mean of 5.3 years after surgery.
Results: Two patients underwent a revision reconstruction for graft failure at 4.7 and 8.3 years postoperatively. In the remaining forty-two patients, the mean International Knee Documentation subjective knee score (and standard deviation) was 96.7 ± 6.0 points, and the mean Lysholm knee score was 95.7 ± 6.7 points. The results of the Lachman examination for anterior cruciate ligament integrity was normal for twenty-three patients, nearly normal for eighteen patients, and abnormal for one patient. The results of the pivot-shift examination were normal for thirty-one patients and nearly normal for eleven patients. Four of the twenty-three patients who underwent concurrent meniscal repair had a repeat arthroscopic meniscal repair or partial meniscectomy. The mean growth in total height from the time of surgery to the final follow-up evaluation was 21.5 cm. No patient had an angular deformity measured radiographically or a discrepancy in the length of the lower extremities measured clinically.
Conclusions: Physeal sparing, combined intra-articular and extra-articular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band graft in skeletally immature prepubescent children and adolescents provides excellent functional outcome with a low revision rate and a minimal risk of growth disturbance.
Levels of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
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