Outcomes and Complications After All-Epiphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

Abstract

Background:The safest and most effective technique for anterior cruciate ligament (ACL) reconstruction in skeletally immature patients is currently unknown.Purpose:To evaluate the functional and patient-reported outcomes of a specific all-epiphyseal ACL reconstruction technique in which the graft, bone tunnels, and fixation do not cross the knee growth plates.Study Design:Case series; Level of evidence, 4.Methods:Twenty-seven patients (23 boys, 4 girls; mean age, 11 years; range, 8-15 years) underwent an all-epiphyseal ACL reconstruction with a single femoral transverse epiphyseal tunnel and primarily split tibial epiphyseal tunnels. Outcomes were evaluated in terms of the manual Lachman test, range of motion, pain, return to activity, angular or leg-length deformity on imaging, and International Knee Documentation Committee (IKDC) or Pedi-IKDC score an average of 3.8 years postoperatively, with a minimum 2-year follow-up.Results:The mean IKDC score was 94 ± 11. There were no growth arrests, but 3 patients had knee overgrowth, and 2 required a subsequent guided growth procedure. The ACL graft failed in 4 patients (15%), and 2 patients had contralateral ACL tears (7%). There were 5 subsequent ipsilateral meniscal tears, 4 of which were retears of a repaired meniscus. Ipsilateral knee reinjury significantly correlated with the number of associated injuries at the time of index surgery (P = .040) and the number of sports played (P = .029).Conclusion:All-epiphyseal ACL reconstruction resulted in excellent long-term functional outcomes, despite a high rate of complications (48%) and secondary procedures (37%) in this highly active cohort. The incidence of graft failure was similar to other standard ACL reconstruction techniques for patients younger than 20 years.

Use of a Modified All-Epiphyseal Technique for Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient

“…Several reports in the literature have shown good clinical outcomes, with high Lysholm scores, satisfaction scores, and rates of return to sport. 2 , 3 , 11 , 18 The results of our proposed technique are similar to these previously published results demonstrating good patient outcomes, high rates of return to sport, and a low rate of complication.…”

“…A second advantage is that unlike an iliotibial band technique, an all-epiphyseal technique uses a single femoral tunnel and a single tibial osseous tunnel, which potentially allows better graft incorporation into a circumferential tunnel surrounded by cancellous bone. Additionally, the use of a single tibial tunnel simplifies our proposed technique compared with the technique described by Wall et al, 18 which requires 2 tibial tunnels. The modification of the all-epiphyseal approach used at our institution has the further advantage of maximizing graft length in both the femoral and tibial tunnels, with soft tissue, which may be beneficial for graft incorporation, traversing the entire length of the tunnels.…”

“…Multiple variations of the all-epiphyseal ACL reconstruction have been described over the past 15 years, all with reported good outcomes. 1 , 2 , 18 The main advantage of this strategy over the other strategies is that it does not place any fixation across the physis, theoretically reducing the risk of physeal disruption. The primary disadvantage is that the reported techniques are technically demanding.…”

Evidence too weak to guide surgical treatment decisions for anterior cruciate ligament injury: a systematic review of the risk of new meniscal tears after anterior cruciate ligament injury

“…Seventy-five studies were included in the systematic review for qualitative synthesis (figure 1), and 54 studies (9624 patients) were appropriate for quantitative synthesis (meta-analysis). The reasons for excluding articles from meta-analysis were clinical diagnosis of meniscal tear only (10 studies35 50–58 and 1 additional study arm24), other ACL surgery than ACL reconstruction (4 studies)59–62 or both (2 studies) 63 64. We excluded studies if there was an unknown number of patients with new meniscal injuries (four studies) 65–68.…”

“…At least 4143 (35%) patients were women; sex was not reported in 10 studies. Six studies included only patients who were skeletally immature as defined by remaining growth based on hand X-rays (n=3),52 57 70 open growth plates at X-rays and Tanner staging (n=2)53 71 or open growth plates at MRI (n=1) 72. Twenty-seven studies included only skeletally mature patients and 27 studies included a mixed population of patients aged under and over 16 years and did not clarify skeletal maturity.…”