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Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients Using an All-Epiphyseal Technique: A
Jorge Knörr1,2,3, Jérôme Sales de Gauzy4, Pedro Doménech5
1Faculty of Medicine, Valencia Catholic University Saint Vincent Martyr, Valencia, Spain.
Insights
This study presents a modified all-epiphyseal anterior cruciate ligament (ACL) reconstruction technique for children, showing excellent outcomes and graft survival without significant growth disturbances. The physeal-sparing approach offers a safe alternative for pediatric ACL repair.
Area of Science:
- Orthopedic Surgery
- Pediatric Orthopedics
- Sports Medicine
Background:
- Transphyseal techniques for pediatric anterior cruciate ligament (ACL) reconstruction risk growth disturbance due to physis proximity.
- Vertical and central tunnel placement, while mitigating growth risk, can compromise graft isometry and lead to frequent ruptures in this age group.
- An all-epiphyseal technique is proposed to achieve favorable graft anatomy and isometry while preserving physeal integrity in young patients.
Purpose of the Study:
- To evaluate the outcomes of a modified all-epiphyseal ACL reconstruction technique in prepubertal patients.
- Assess knee function, graft survival rates, and the technique's efficacy in protecting joint growth.
- Determine the technique's impact on graft isometry and knee stability.
Main Methods:
- A case series of 74 skeletally immature patients with ACL rupture underwent a physeal-preserving, all-epiphyseal technique using semitendinosus-gracilis grafts and resorbable interference screws.
- Preoperative and postoperative assessments included clinical stability, magnetic resonance imaging, isometry measurements, stress radiography, limb axis measurements, Lysholm and Tegner scores, and patient satisfaction.
- Follow-up averaged 4.1 years, with detailed analysis of knee function, graft integrity, and physeal status.
Main Results:
- 91.9% of patients achieved excellent/good Lysholm scores, with stable Tegner activity levels.
- Intraoperative isometry measurements showed minimal graft excursion (<3 mm) in 95.9% of cases.
- Clinical laxity improved, with only 4.1% experiencing abnormal laxity at follow-up. Graft failure occurred in 3 patients. Meniscal tears were present in 27.0% with an 87.5% repair healing rate. No significant physeal alterations were noted, aside from a tendency for subtle overgrowth.
Conclusions:
- The modified all-epiphyseal technique provides excellent functional outcomes and high graft survival in skeletally immature patients.
- The technique effectively preserves physeal integrity, avoiding significant growth disturbances.
- This physeal-sparing approach is a viable and safe option for pediatric ACL reconstruction, offering good isometry and patient satisfaction.
Background:
Transphyseal techniques are the most commonly used for anterior cruciate ligament (ACL) reconstruction in children. To mitigate the risk of growth disturbance, the tunnels should be positioned as vertically and centrally as possible in relation to the physis, potentially compromising the anatomic orientation of the graft and, therefore, its isometry. A graft rupture is frequent in this age group. Even though all-epiphyseal techniques have not clearly demonstrated better isometry, the authors propose an epiphyseal technique that aims for favorable anatomy, and therefore isometry, while avoiding physeal damage in young children with ACL ruptures.
Purpose:
To present the results of a modified all-epiphyseal technique in prepubertal patients, evaluating knee function, graft survival, and joint and growth protection.
Study Design:
Case series; Level of evidence, 4.
Methods:
A total of 74 skeletally immature patients with a traumatic ACL rupture underwent a physeal preserving technique using a semitendinosus-gracilis tendon graft fixed with intra-epiphyseal resorbable interference screws in the femur and tibia, along with associated minimal notchplasty. Preoperative, intraoperative, and postoperative assessments included clinical knee stability and meniscal status, magnetic resonance imaging, isometry measurements, comparative laximetry measurements with stress radiography using the Lerat method, full-length standing radiography, measurements of the axes of the lower limbs, Tegner and Lysholm scores, and patient satisfaction.
Results:
From 2004 to 2014, a total of 74 patients met our inclusion criteria and were followed up for a mean of 4.1 years (range, 2-7 years). Of these patients, 91.9% had an excellent/good postoperative Lysholm score, with similar preoperative and postoperative Tegner activity scores. Intraoperative isometry showed an intratunnel graft excursion <3 mm during extension in 95.9% of cases. Abnormal clinical laxity was observed in 4.1% at final follow-up, with an improvement in side-to-side laxity of 4.8 mm. There were 3 patients who experienced graft failure, with the salvage procedure employing a transphyseal technique in 1 patient. Meniscal tears occurred in 27.0%, with concomitant repair yielding a healing rate of 87.5%. No physeal alterations were observed, except for a tendency toward subtle overgrowth in the affected limb. Also, 90.5% of patients were satisfied or very satisfied with the outcome.
Conclusion:
The proposed all-epiphyseal technique in skeletally immature patients demonstrated excellent overall results with a low incidence of reruptures and meniscal degeneration, without relevant alterations related to growth.
