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Published on: April 30, 2014
Biomechanical evaluation of pediatric anterior cruciate ligament reconstruction techniques
Abbey Kennedy1, Dezba G Coughlin, Melodie F Metzger
1Department of Orthopaedic Surgery, University of California, San Francisco, California, USA.
Insights
Physeal-sparing anterior cruciate ligament (ACL) reconstruction techniques restore knee stability in skeletally immature patients. The iliotibial band technique offered the best anteroposterior and rotational control, though it may overconstrain the knee.
Area of Science:
- Orthopaedic Surgery
- Sports Medicine
- Biomechanics
Background:
- Rising anterior cruciate ligament (ACL) injury rates in skeletally immature patients necessitate effective treatment.
- Concerns about growth disturbances from traditional ACL reconstruction techniques have led to physeal-sparing methods.
Purpose of the Study:
- To compare the native knee kinematics with those achieved by different physeal-sparing ACL reconstruction techniques.
- To determine which technique best restores knee stability and function in pediatric patients.
Main Methods:
- A controlled laboratory study using six cadaveric knees.
- Measurement of tibial displacement and rotation under various forces and flexion angles.
- Comparison of intact knees, ACL-disrupted knees, and knees reconstructed with all-epiphyseal, transtibial over-the-top, and iliotibial band techniques.
Main Results:
- All physeal-sparing techniques improved anteroposterior (AP) stability compared to ACL-deficient knees.
- The iliotibial band technique demonstrated the lowest AP translation and improved rotational control.
- The all-epiphyseal technique showed increased internal rotation, while the iliotibial band technique decreased it.
Conclusions:
- Physeal-sparing ACL reconstruction techniques provide valuable knee stability.
- The iliotibial band technique appears most effective for restoring AP stability and rotational control.
- Objective kinematic data aids surgeons in selecting optimal ACL reconstruction techniques for pediatric patients.
Background:
Anterior cruciate ligament (ACL) reconstruction rates in skeletally immature patients have risen recently because of increased injury frequency combined with growing awareness of the importance of treating them in an acute setting. Concerns over potential growth disturbances caused by traditional tunnel placement have prompted the description of several partial and complete physeal-sparing techniques.
Hypothesis:
Native knee kinematics will most closely be restored by the all-epiphyseal technique because it best re-creates the intra-articular ACL anatomy.
Study Design:
Controlled laboratory study.
Methods:
Six cadaveric knees were subjected to static anteroposterior, varus, and internal rotation forces at 0°,15°, 30°, 45°, 60°, and 90° of flexion. Displacement and rotation of the tibia with respect to the femur were measured in the intact knee, after ACL disruption, and again after ACL reconstruction using all-epiphyseal, transtibial over-the-top, and iliotibial band physeal-sparing techniques.
Results:
Peak anteroposterior translation in the ACL intact and deficient states was 2.8 ± 1.4 mm and 7.2 ± 2.7 mm, respectively, at 30°. The all-epiphyseal reconstruction had a peak translation of 5.1 ± 2.3 mm at 30°, and the transtibial over-the-top reconstruction had a peak of 4.8 ± 1.8 mm at 30°, both significantly greater than the ACL intact state. The iliotibial band technique had a peak anteroposterior translation of 1.7 ± 1.1 mm at 45°, which was significantly less than the ACL-deficient state. Internal rotation was significantly increased in the all-epiphyseal reconstruction compared with the ACL intact state and significantly decreased at all flexion angles except 0° in the iliotibial band reconstruction. The only technique to affect varus rotation was the iliotibial band reconstruction, which significantly decreased varus rotation from the ACL-deficient state at flexion angles greater than 30°.
Conclusion:
All physeal-sparing reconstruction techniques restored some stability to the knee. The iliotibial band reconstruction best restored anteroposterior stability and rotational control, although it appeared to overconstrain the knee to rotational forces at some flexion angles.
Clinical Relevance:
This study provides orthopaedic surgeons with objective knee kinematic data to help guide them in making more informed decisions on the optimal technique for ACL reconstruction in skeletally immature patients.
