The conservative treatment of complete tears of the anterior cruciate ligament in skeletally immature patients

Management of anterior cruciate ligament injuries in skeletally immature individuals

Anterior cruciate ligament (ACL) injuries in skeletally immature individuals remain a challenge for the child, the parents, orthopaedic surgeons, and physical therapists. The main challenges are the potential risk of recurrent instability, secondary injuries following nonoperative treatment, and the risks involved with surgical treatment due to the vulnerability of the epiphyseal growth plates. We first present the physiological background for considerations that must be made when advising on treatment alternatives for skeletally immature individuals after ACL injury. The implications of continuous musculoskeletal development for treatment decisions are emphasized. No randomized controlled trials have been performed to investigate outcomes of different treatment algorithms. There is no consensus in the literature on clinical treatment decision criteria for whether a skeletally immature child should undergo transphyseal ACL reconstruction, physeal sparing ACL reconstruction, or nonoperative treatment. Additionally, well-described rehabilitation programs designed for either nonoperative treatment or postoperative rehabilitation have not been published. Based on the currently available evidence, we propose a treatment algorithm for the management of ACL injuries in skeletally immature individuals. Finally, we suggest directions for future prospective studies, which should include development of valid and reliable outcome measures and specific rehabilitation programs.

Degeneration of the knee joint in skeletally immature patients with a diagnosis of an anterior cruciate ligament tear: is there harm in delay of treatment?

BACKGROUND

In skeletally immature patients with an anterior cruciate ligament (ACL) tear and significant growth remaining, the risk of inducing a growth disturbance with early reconstruction must be balanced against the risk of further intra-articular damage by delaying treatment until closer to skeletal maturity.

HYPOTHESIS

Increased time from injury to ACL reconstruction in children ≤14 years of age will be associated with increased meniscal and chondral injuries at the time of reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

With institutional review board approval, the records of a consecutive series of patients 14 years of age and younger who underwent ACL reconstruction between 1991 and 2005 were reviewed. Demographic, magnetic resonance imaging (MRI), and intraoperative findings were analyzed. Meniscal and articular cartilage injuries were graded. Logistic regression models using both univariable and multivariable regression procedures were used to identify factors independently associated with intra-articular lesions. Fisher exact test and Kaplan-Meier analysis were used to test for differences in intra-articular injuries by time from injury to surgery.

RESULTS

Seventy patients were identified. Twenty-nine patients (41%) underwent reconstruction more than 12 weeks from the time of injury. Logistic regression analysis revealed time to surgical reconstruction (odds ratio, 4.1) and a history of a sense of knee instability (odds ratio, 11.4) to be independently associated with medial meniscal tears. Time to surgical reconstruction was also independently associated with medial and lateral compartment chondral injuries (odds ratios, 5.6 and 11.3, respectively). Testing time as a continuous variable, survivorship analysis also confirmed a significant association of time to reconstruction with medial meniscal injury as well as lateral and patellotrochlear cartilage injuries. When present, a delay in treatment of over 12 weeks (29 patients) was associated with an increase in the severity of medial meniscal tears (P = .011) and higher grade lateral and patellotrochlear chondral injuries (P = .0014 and P = .038, respectively).

CONCLUSION

Young patients who underwent surgical reconstruction of an acute ACL tear >12 weeks after the injury were noted to have a significant increase in irreparable medial meniscal tears and lateral compartment chondral injuries at the time of reconstruction. When a subjective sense of knee instability was present, this association was even stronger.

Growth plate disturbance after transphyseal reconstruction of the anterior cruciate ligament in skeletally immature adolescent patients: an MR imaging study

BACKGROUND

There are concerns of potential growth disturbance after transphyseal reconstruction of the anterior cruciate ligament in skeletally immature patients. The authors used magnetic resonance (MR) imaging to evaluate growth disturbance and associated physeal abnormalities after index surgery.

METHODS

We retrospectively reviewed the follow-up MR imaging studies of 43 patients who underwent transphyseal reconstruction of the anterior cruciate ligament using a soft-tissue graft at the mean age of 14.8 years (range, 12.4 to 16.5 y). Mean time from surgery to follow-up MR imaging was 16 months (range, 6 to 36 mo). Bone tunnel to growth plate cross-sectional area ratios were calculated as percentages. Focal growth disturbances were assessed in the follow-up MR images in terms of physeal tenting, the presence of a focal bone bridge, an asymmetric growth arrest line of Harris, and metaphyseal extension of physeal cartilage. Physeal angles with respect to the longitudinal axes of the corresponding bones were measured in preoperative MR images and compared with those measured in follow-up images. Premature physeal closure was assessed using the proximal fibular growth plate as an internal control. Clinically, growth disturbances were assessed with physical examinations regarding standing pelvic heights and alignments of the lower extremities.

RESULTS

The bone tunnel to growth plate ratio was < 3% for proximal tibia and distal femur. A focal bone bridge was observed in 5 patients-4 at the tibial physis and 1 at the femoral physis. Physeal angles did not change significantly during follow-up in either the coronal or sagittal plane. Earlier physeal closure than other physes was observed in 2 proximal tibiae. Clinically, there were no perceived growth disturbances.

CONCLUSIONS

MR imaging revealed that focal physeal disruption developed after index procedure in 5 of 43 adolescent patients (11.6%) without a perceived clinical growth disturbance. The results suggest that transphyseal reconstruction of the anterior cruciate ligament may not be a benign procedure that can be applied safely to younger children with substantial growth remaining.

LEVEL OF EVIDENCE

Retrospective Case Series, Therapeutic Level IV.

Pediatric anterior cruciate ligament reconstruction

An increasing number of anterior cruciate ligament (ACL) injuries are seen in children now than in the past due to increased sports participation. The natural history of ACL deficient knees in active individuals, particularly in children is poor. Surgical management of ACL deficiency in children is complex due to the potential risk of injury to the physis and growth disturbance. Delaying ACL reconstruction until maturity is possible but risks instability episodes and intra-articular damage. Surgical options include physeal-sparing, partial transphyseal and complete transphyseal procedures. This article reviews the management of ACL injured skeletally immature patients including the functional outcome and complications of contemporary surgical techniques.

Transphyseal anterior cruciate ligament reconstruction in a skeletally immature knee using anterior tibialis allograft

Anterior cruciate ligament (ACL) injury in the skeletally immature individual is being recognized with increasing frequency. Nonoperative treatment of ACL injuries in skeletally immature patients have not been favorable. Surgical treatment options for complete ACL tears include primary ligament repair, extraarticular tenodesis, transphyseal reconstruction, partial transphyseal reconstruction, and physeal-sparing reconstruction. The advantage of transphyseal reconstruction is placement of the graft tissue in an isometric position, which provides better results, according to the literature. The potential disadvantage is angular or limb-length discrepancy caused by physeal violation. Controversy exists in allograft selection about whether bone or soft tissue passes into physes. The use of standard tunnels provides reliable results, but carries the risk of iatrogenic growth disturbance from physeal injury.This article presents 4 cases of transphyseal ACL reconstruction using anterior tibialis allograft in skeletally immature patients that had satisfactory functional outcomes with no growth disturbances. This is the first report of transphyseal ACL reconstruction using anterior tibialis allograft in skeletally immature patients in the English-speaking literature. All patients underwent transphyseal ACL reconstruction using anterior tibialis tendon allograft. None of the patients had angular deformities. No early physeal arrest was measured between the preoperative and postoperative radiographs. At last follow-up, the results of the Lachman test were normal for 3 patients and nearly normal for 1 patient. All patients demonstrated full range of knee motion (comparing the reconstructed knee to the contralateral knee). The results of the pivot-shift test were normal for 3 patients and nearly normal for 1 patient. No patients reported giving way.

Treating anterior cruciate ligament tears in skeletally immature patients

PURPOSE

To systematically review the current evidence for conservative and surgical treatment of anterior cruciate ligament (ACL) tears in skeletally immature patients.

METHODS

A systematic search of PubMed, CINAHL, EMBASE, CCTR, and CDSR was performed for surgical and/or conservative treatment of complete ACL tears in immature individuals. Studies with less than six months of follow-up were excluded. Study quality was assessed and data were collected on clinical outcome, growth disturbance, and secondary joint damage.

RESULTS

We identified 48 studies meeting the inclusion criteria. Conservative treatment was found to result in poor clinical outcomes and a high incidence of secondary defects, including meniscal and cartilage injury. Surgical treatment had only very weak evidence for growth disturbance, yet strong evidence of good postoperative stability and function. No specific surgical treatment showed clearly superior outcomes, yet the studies using physeal-sparing techniques had no reported growth disturbances at all.

CONCLUSIONS

The current best evidence suggests that surgical stabilization should be considered the preferred treatment in immature patients with complete ACL tears. While physeal-sparing techniques are not associated with a risk of growth disturbance, transphyseal reconstruction is an alternative with a beneficial safety profile and a minimal risk of growth disturbance. Conservative treatment commonly leads to meniscal damage and cartilage destruction and should be considered a last resort.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Intraarticular stabilization following anterior cruciate ligament injury in children and adolescents

PURPOSE

Significant controversy exists regarding the potential harm to the growth plate following reconstruction of the anterior cruciate ligament in skeletally immature patients. This study was performed to evaluate the results of a transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients.

METHODS

Ninety-four skeletally immature patients (56 male and 38 female) with median age 13.7 years (range, 11.6-15.9 years) who underwent arthroscopic transphyseal reconstruction of anterior cruciate ligament with four-strand medial hamstring autograft between 1999 and 2006 were reviewed. All patients had been followed up until skeletal maturity was confirmed.

RESULTS

The average follow-up was 38 months (range 24-60 months). Neither leg length discrepancy nor angular deformities were noted on radiological or clinical measurement. Two patients had radiographic evidence of mild arthrosis at final follow-up. New traumatic injuries occurred in 4 patients, in whom surgical revision was performed. Ligament laxity testing with a KT 1000/2000 arthrometer showed no significant difference between the normal and the operated legs. At follow-up, the median Lysholm score was 89 (range 77-100), and the median Tegner activity score was increased from 3 to 6. The International Knee Documentation Committee score was A in 79 patients (84%) and B in 6 patients (6%) and C in 9 patients (9%). Of the 94 patients, 73 (78%) returned to their similar preoperative sport activities and 90% returned to their preoperative level of daily activities.

CONCLUSIONS

ACL reconstruction with medial hamstring autograft via transepiphyseal drilling and grafting yielded satisfactory clinical results with no growth defects in skeletally immature patient. The preliminary results of this series demonstrated that this surgical technique can be performed in prepubescent patients with efficacy and safety.

LEVEL OF EVIDENCE

IV.

Biomechanical evaluation of pediatric anterior cruciate ligament reconstruction techniques

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.

Anterior cruciate ligament reconstruction using quadriceps tendon autograft for adolescents with open physes- a technical note

Background

One major concern in the treatment of ACL lesions in children and adolescents with open physes is the risk of iatrogenic damage to the physes and a possibly resulting growth disturbance.

Purpose

The primary purpose of this article is to describe our technique of a transphyseal ACL reconstruction using quadriceps tendon-bone autograft in children and adolescents with open growth plates. The secondary aim is to report our early results in terms of postoperative growth disturbances which are considered to be a major concern in this challenging group of patients. It was our hypothesis that with our proposed technique no significant growth disturbances would occur.

Methods

From January 1997 to December 2007 49 consecutive children and adolescents with open growth plates were treated for a torn ACL using the aforementioned surgical technique. The patients (28 males and 21 females) with a median age at surgery of 13 (range 8-15) years were retrospectively evaluated. Outcome measures were follow-up radiographs (weight-bearing long leg radiographs of the injured and uninjured knee, anteroposterior and lateral views, a tangential view of the patella and a tunnel view of the injured knee) and follow-up notes (6 weeks, 3, 6, 12 months and until closing of physes) for occurrence of any tibial and/or femoral growth changes.

Results: All of the 49 patients had a sufficient clinical and radiological follow-up (minimum 5 years, rate 100%). 48 cases did not show any clinical and radiological growth disturbance. One case of growth disturbance in a 10.5 years old girl was observed. She developed a progressive valgus-flexion deformity which was attributed to a malplacement of the autograft bone block within the femoral posterolateral epiphyseal plate leading to an early localized growth stop. None of the patients were reoperated due to ACL graft failure. Five of the patients underwent revision ACL surgery due to another adequate sports trauma after the growth-stop. The tibial fixation screw had to be removed under local anaesthesia in 10 patients.

Conclusions

The described ACL reconstruction technique represents a promising alternative to previously described procedures in the treatment of children and adolescents with open growth plates. Using quadriceps tendon future graft availability is not compromised, as the most frequently used autograft-source, ipsilateral hamstring tendons, remains untouched.

Good surgical outcome of transphyseal ACL reconstruction in skeletally immature patients using four-strand hamstring graft

PURPOSE

Our purpose was to evaluate the clinical and radiological outcome at maturity of an « adult-like » transphyseal anterior cruciate ligament (ACL) reconstruction performed in skeletally immature patients using four-strand hamstring graft.

METHODS

The records of all skeletally immature patients who underwent transphyseal ACL reconstruction between 2004 and 2006 at our institution were reviewed. Inclusion criteria were age less than 16 years and radiographic evidence of open physes. Thirty-eight children and prepubescents were identified. All underwent postoperative clinical evaluation with International Knee Documentation Committee scores and long leg radiographs. Each patient was followed up until skeletal maturity was confirmed.

RESULTS

Twenty-eight patients were scored A, four B, and five D according to IKDC. At last follow-up, there was no radiographic evidence of malalignment in any of the patients. Five underwent a reoperation. Three patients suffered traumatic graft disruption and two from post-operative knee instability.

CONCLUSION

Early operative treatment by means of the quadruple hamstring free graft appears to be a safe and relevant procedure for ACL reconstruction even in skeletally immature patients.

Surgical techniques and outcomes after anterior cruciate ligament reconstruction in preadolescent patients

PURPOSE

To determine whether any anterior cruciate ligament (ACL) reconstruction technique is clinically superior in skeletally immature patients with wide-open physes.

METHODS

We searched Medline and Embase from 1966 to mid July 2009. Inclusion criteria required clinical studies of ACL reconstructions to define skeletally immature patients as having at least 1 of the following criteria: (1) chronologic age of less than 15 years in boys or less than 14 years in girls; (2) bone age of less than 15 years in boys or less than 14 years in girls; (3) Tanner stage I, II, or III; and (4) at least 10 cm of total growth after the reconstruction. Thirteen case series were identified and were evaluated for patient characteristics, surgical technique, clinical outcomes, and bone growth results.

RESULTS

Four studies used physeal-sparing techniques. Six studies used transphyseal techniques. Two studies used a combined technique, and a multicenter study reported results of both techniques. Within the physeal-sparing group, there were 2 studies that used an entirely extra-epiphyseal technique and 2 studies that used intra-epiphyseal techniques. Overall clinical outcomes were excellent, with growth complications being very rare in all of these series.

CONCLUSIONS

Both physeal-sparing and transphyseal reconstructions can produce excellent clinical outcomes with a very low incidence of growth complications in Tanner stage II and III patients. Tanner stage I patients had excellent clinical results with physeal-sparing techniques (both extra- and intra-epiphyseal techniques). Not enough Tanner stage I patients underwent transphyseal techniques to support or discourage their use. This evidence supports considering the expansion of transphyseal reconstruction indications from Tanner stage IV patients to Tanner stage II and III patients. More studies evaluating transphyseal techniques in Tanner stage I patients are needed at this time.

LEVEL OF EVIDENCE

Level IV, systematic review.

Transphyseal reconstruction of the anterior cruciate ligament in prepubescent athletes

ACL reconstruction in adolescents undergoing or being beyond the final growth spurt can be performed as in adults without major concern of growth disturbance. Whereas for the young athlete with wide-open physis a lot of controversy still exists about the technical aspect of the procedure to minimise the risk of growth disturbance. Between 10/1997 and 10/2002 31 children graded Tanner stage 1 or 2 (median age 11 years) with an intraligamental rupture of the anterior cruciate ligament were enrolled. Seventeen patients with coexisting intraarticular damage (meniscus, osteochondral flake) underwent transphsyeal reconstruction of the ACL with the use of an autogenous semitendinosus tendon graft, whereas 14 patients without coexisting pathologies received a nonoperative regime. Growth disturbance, functional and radiographic outcome could be evaluated in 28 patients at a median of 70 months after initial treatment. No patient had clinical or radiological evidence for varus/valgus malalignment or leg length discrepancy. The mean of subsequent body growth within the study population was 20.3 cm. Patients operated on revealed significant (P < 0.05) better clinical (KT-1000 side-to-side difference, pivot shift) and functional results according to the IKDC (median, 95 vs. 87), Lysholm (median, 93 vs. 84) and the Tegner score. More than half of the conservatively treated patients (58%) had subsequent surgery due to persistent instability. Transphyseal reconstruction of intraligamental ACL ruptures with an autologous ST graft yielded superior clinical results if compared to a nonoperative treatment in immature prepubescent patients being Tanner stage 1 and 2.

Outcomes and risks of operative treatment of rupture of the anterior cruciate ligament in children and adolescents

PURPOSE

The aim of this meta-analysis was to evaluate the clinical outcomes and risks of anterior cruciate ligament (ACL) surgery in children and adolescents.

METHODS

We electronically searched Medline, the Cochrane Controlled Trial Database, Embase, and Medpilot for studies on surgical treatment for ACL ruptures in skeletally immature patients. We extracted baseline demographics, follow-up intervals, surgical details (i.e., ligament suture or reconstruction, physeal-sparing or transphyseal techniques, type of transplant, and methods of fixation). Endpoints comprised rates of growth disturbances and reruptures, as well as knee function (measured by the International Knee Documentation Committee's documentation system and the Lysholm score). Unweighted overall effect sizes (risks, risk ratios [RRs], and means of functional scores) were estimated by use of crude nominators and denominators, and random-effects meta-regression analysis was used for weighted data synthesis.

RESULTS

A total of 55 articles reporting on 935 patients (median age, 13 years; range, 1.5 to 16 years) were suitable for the study. After a median follow-up of 40 months (range, 14 to 89 months), the weighted rate of leg-length differences or axis deviations was 1.8% (95% confidence interval [CI], 0% to 3.9%] and that of reruptures was 4.8% (95% CI, 2.9% to 6.7%). Excellent or good function (International Knee Documentation Committee grade A or B) was achieved in 84.2% (95% CI, 75.8% to 92.6%) of all knees, and Lysholm scores averaged 96.3 (95% CI, 95.5 to 97.2). Transphyseal reconstruction was associated with a significantly lower risk of leg-length differences or axis deviations compared with physeal-sparing techniques (1.9% v 5.8%; RR, 0.34; 95% CI, 0.14 to 0.81) but had a higher risk of rerupture (4.2% v 1.4%; RR, 2.91; 95% CI, 0.70 to 12.12). Sutures did not result in any growth disturbances, with a weighted rerupture rate of 4.6% (95% CI, 2.6 to 6.7). Fixation far from the joint line fared better than close fixation with regard to this endpoint (1.4% v 3.2%; RR, 0.42; 95% CI, 0.09 to 1.93). Bone-patellar tendon-bone grafts, which are also less likely to fail, were associated with higher risks of leg-length differences or axis deviations than were hamstrings (3.6% v 2.0%; RR, 1.82; 95% CI, 0.66 to 5.03). Meta-regression did not show a significant impact of the publication year on event rates.

CONCLUSIONS

This meta-analysis showed low rates of leg-length differences or axis deviations and graft failures after ACL reconstruction in skeletally immature patients. Hamstring transplants may lower the risk of leg-length differences or axis deviations, and physeal-sparing techniques may increase the risk. Randomized controlled trials are needed to clarify important issues in managing ACL ruptures in children and adolescents.

LEVEL OF EVIDENCE

Level IV, meta-analysis of case series.

Effects of maturation on the mechanical properties of regenerated and residual tissues in the rabbit patellar tendon after resection of its central one-third

BACKGROUND

The central one-third portion of the patellar tendon is commonly used as a graft for the reconstruction of the anterior cruciate ligament. Although several studies have been carried out on mechanical properties of healing tendons in mature animals, there have been no studies on regenerated and residual tissues in the immature patellar tendon after the removal of its central portion.

METHODS

An entire one-third defect was made in the patellar tendon of 2-, 3- and 6-month-old rabbits. After 3 weeks, the tissue regenerated in the defect and the residual tissue were biomechanically and histologically evaluated.

FINDINGS

The length of patellar tendons in 6-month-old animals after the resection of its central one-third was significantly longer than that in age-matched controls. The cross-sectional area of all operated tendons was significantly larger compared to age-matched controls. There were no significant effects of maturation on the mechanical properties of regenerated and residual tissues in operated tendons, although tensile strength and tangent modulus of normal tendons were significantly greater in 6-month rabbits than in immature ones. The histology of each of regenerated and residual tissues was similar in the three groups.

INTERPRETATION

There were no remarkable effects of maturation on regenerated and residual tissues after the removal of the central one-third tendon. However, the strength and the modulus of normal tendons are significantly lower in immature patients than in mature ones. Therefore, surgeons should take account of the inferior mechanical properties of the tendon in skeletally immature patients at the time of surgeries for the reconstruction of the anterior cruciate ligament.

Valgus and flexion deformity after reconstruction of the anterior cruciate ligament in a skeletally immature patient

Anterior cruciate ligament reconstruction in children with open physes is still a topic of debate. We report a unique case of growth disturbance in valgus and flexion of the distal femoral epiphysis, after an ACL reconstruction in a 14.5-year-old boy. The Clocheville technique using the patellar tendon was performed. The femoral tunnel and tibial groove were both positioned above the growth plates. Eighteen months after ACL reconstruction, the patient had to be re-operated on for a valgus and flexion deformity of the femoral epiphysis. The clinical, radiological and aesthetic results were satisfactory. The angular deformity was caused by the fact that either the femoral tunnel was too close to the posterolateral femoral growth plate or an excessive eccentric traction of the graft in relation to the central point of the knee.

[Rupture of the anterior cruciate ligament. Diagnostics and therapy]

Rupture of the anterior cruciate ligament (ACL) is the most common ligamentous knee injury. The knee is stabilized by the cruciate ligaments and the collateral ligaments. The ACL originates from the inner surface of the lateral condyle of the femur, runs in an anterior medial direction and inserts at the tibial plateau in the intercondyle area. The most common injury is an indirect knee trauma, typically a joint torsion in sports. Patients often describe a snapping noise followed by hemarthrosis. Concomitant injuries are lesions of the medial collateral ligament, the medial meniscus (unhappy triad) and chondral fractures. The age peak is between 15 and 30 years with a higher incidence in females. The cardinal symptom of the ACL rupture is the giving way phenomenon. The clinical diagnosis is provided by a positive Lachman test, a positive pivot shift test and the anterior drawer test. Fractures can be excluded by X-ray examination. Magnetic resonance imaging (MRI) allows the evaluation of the internal knee structures. ACL repair is carried out by arthroscopically assisted bone-tendon-bone or semitendinosus grafting techniques. Early rehabilitation is important for a good functional outcome.

Current Concepts of Diagnosis and Management of ACL Injuries in Skeletally Immature Athletes

Anterior cruciate ligament (ACL) injuries in skeletally immature athletes are encountered with increasing frequency. The management of such injuries is controversial. Nonsurgical management often results in functional instability and a higher risk of meniscal and chondral injury to the knee. Conventional methods of ACL reconstruction carry the risk of growth disturbance because of iatrogenic damage to the physes around the knee. Multiple cases of growth disturbance have been reported. This article discusses the relevant anatomy, natural history, risk factors, treatment, and prevention of ACL injuries in skeletally immature patients. Surgical treatment is based on physiologic age. For prepubescent patients, we recommend physeal-sparing combined intra-articular/extra-articular reconstruction with autogenous iliotibial band. In adolescent patients with significant growth remaining, we recommend transphyseal ACL reconstruction with hamstrings autograft and fixation away from the physes. In older adolescent patients, we recommend conventional adult ACL reconstruction with autogenous hamstrings or patellar tendon.

Volumetric injury of the physis during single-bundle anterior cruciate ligament reconstruction in children: a 3-dimensional study using magnetic resonance imaging

PURPOSE

To determine the volume of injury to the physis during anterior cruciate ligament (ACL) reconstruction in pediatric patients.

METHODS

Magnetic resonance imaging scans of 10 pediatric knees were converted into 3-dimensional models. Computer-aided design/computer-aided manufacturing software placed drill holes (6, 7, 8, and 9 mm in diameter) in these models, simulating tunnels used for ACL reconstruction. The software was used to calculate total physeal volume and volume of physis removed by the tunnel. The ratio of physeal volume removed to the total physeal volume was determined.

RESULTS

For 6-, 7-, 8-, and 9-mm-diameter drill holes, the mean percent of physeal volume removed/total physeal volume was 1.6%, 2.2%, 2.9%, and 3.8%, respectively, for the tibia and 2.4%, 3.2%, 4.2%, and 5.4%, respectively, for the femur. For all subjects, the volume removed was less than 7.0% for the tibia and 9.0% for the femur by use of drill holes from 6 to 9 mm. The tibial drill hole was centrally placed in all cases compared with a more peripheral drill hole placement of the femur.

CONCLUSIONS

Drill hole placement during ACL reconstruction produces a zone of physeal injury. The overall volume of injury is relatively low, which reduces the risk of physeal arrest. With careful drill hole placement, the region of injury is central on the tibia, and the total volume of injury can be less than 5.0% of the physeal volume. For the femur, the total volume can be less than 5.0% as well. However, the region of injury is peripheral, which carries a higher risk of physeal arrest.

CLINICAL RELEVANCE

A better understanding of the relation between the ACL and physis may guide the placement of drill holes, which have a lower risk of producing physeal arrest.

Has platelet-rich plasma any role in anterior cruciate ligament allograft healing?

PURPOSE

The aim of this study was to evaluate and compare the clinical and inflammatory parameters with the addition of platelet-derived growth factor (PDGF) in primary anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone allograft.

METHODS

We prospectively randomized 100 patients undergoing arthroscopic patellar tendon allograft ACL reconstruction to a group in whom platelet-enriched gel was used (n = 50) and a non-gel group (n = 50). The platelet concentration was 837 x 10(3)/mm(3), and the gel was introduced inside the graft and the tibial tunnel. Demographic data were comparable between groups. The mean follow-up was 24 months for both groups and included a history, clinical evaluation with the International Knee Documentation Committee score, radiographs, and magnetic resonance imaging.

RESULTS

There were no differences in the number of associated injuries. The results did not show any statistically significant differences between the groups for inflammatory parameters (perimeters of the knee and C-reactive protein level), magnetic resonance imaging appearance of the graft, and clinical evaluation scores (visual analog scale, International Knee Documentation Committee, and KT-1000 arthrometer [MEDmetric, San Diego, CA]).

CONCLUSIONS

At this time, the therapeutic role of PDGF in ACL reconstruction remains unclear. The use of PDGF, on the graft and inside the tibial tunnel, in patients treated with bone-patellar tendon-bone allografts has no discernable clinical or biomechanical effect at 2 years' follow-up. More clinical studies will be needed to show the efficacy and use of these factors in daily practice in ACL reconstruction.

LEVEL OF EVIDENCE

Level I, prospective, randomized, double-blind study.

The effects of anterior cruciate ligament lesion on the articular cartilage of growing goats

Treatment of anterior cruciate ligament (ACL) injury in skeletally immature patients is controversial. The growth plate could be damaged if treated with the reconstruction techniques used to treat instability in adults. For this reason, many authors postpone surgical treatment until skeletal maturity, but the acceptable length of time that treatment can be postponed without causing irreversible damage to the articular cartilage in children with ACL injury is unknown. Until now, no studies have described the pathological findings and the evolution of the lesions of the articular cartilage during the growing period. For this reason, an experimental study on 16 6-month-old, skeletally immature goats was performed. A complete ACL lesion was achieved by removing the ligament. Two animals per group were sacrificed at intervals of 1, 3, 6, and 9 months postoperatively, and macroscopic and microscopic evaluations were performed. The presence of meniscal injury and articular cartilage lesions with progressive aspects were histologically underlined. The hystological observations showed that the complete ACL lesion causes irreversible articular cartilage alterations in growing goats 3 months after injury. These experimental data suggest that ACL reconstruction in growing patients with ACL injury and instability should be indicated without waiting until skeletal maturity.

The effects of timing of pediatric knee ligament surgery on short-term academic performance in school-aged athletes

BACKGROUND

Orthopaedic injuries negatively affect the academic lives of children.

HYPOTHESIS

The timing of anterior cruciate ligament (ACL) and medial patellofemoral ligament (MPFL) reconstructions affects academic performance in school-aged athletes.

STUDY DESIGN

Cohort study; Level of evidence, 2. Methods Records of patients < or = 18 years old who underwent ACL or MPFL reconstructions from 2001-2007 were reviewed retrospectively. Subjects had been administered a unique questionnaire to evaluate school life in the immediate postoperative period as well as International Knee Documentation Committee (IDKC), Lysholm, and Kujala knee-specific questionnaires. Patients were in 1 of 3 study cohorts: group A (surgery during school year), group B (surgery during school holiday), and group C (surgery during summer break).

RESULTS

There were 62 subjects (53 ACL and 12 MPFL reconstructions). A higher proportion of patients in group A required being driven to school (88.5%) than groups B (63.6%) or C (64.7%) (P < .05). A lower proportion of patients in group A returned to school immediately after surgery (3.8%) than groups B (36.4%) or C (88.2%) (P < .005). Among children who had never failed a test before surgery, a higher proportion of patients in group A failed a test (36.4%) after return to school than groups B (0%) or C (0%) (P < .05). Patients in group C had higher mean Likert scores (4.5) than groups A (3.8) or B (3.7) (P = .05) in response to the question "my grades suffered in my classes." Delay in surgery was negatively correlated with IKDC, Lysholm, and Kujala questionnaire scores (P < .05).

CONCLUSION

In school-aged athletes with ligamentous knee injuries receiving operative treatment, surgery on a school day causes more academic difficulties than surgery during a holiday or summer break. Academic benefits of delaying surgery during the school year must be weighed against potentially worse outcomes encountered with prolonged surgical delay.

Transphyseal anterior cruciate ligament reconstruction in patients with open physes

PURPOSE

The purpose of this study was to evaluate the clinical outcomes of transphyseal anterior cruciate ligament (ACL) reconstruction in patients with open physes.

METHODS

Transphyseal ACL reconstruction was performed in 26 patients with open tibial and femoral physes (physis >2 mm) by use of autogenous quadrupled hamstrings as grafts. Meniscal tearing was found in 65.3% of the patients. Partial chondral defect injury on the medial femoral condyle was found 6 months after injury in only 2 patients (7.69% of all patients). The mean follow-up period was 45 +/- 18.3 months. Clinical outcomes were evaluated by use of the International Knee Documentation Committee score and Lysholm Knee Scoring Scale, and the anteroposterior stability was objectively measured by use of KT-1000 arthrometer (MEDmetric, San Diego, CA). Possible length and angular discrepancies were observed by conventional radiography in a long film and scanograms of the lower limbs.

RESULTS

The mean length discrepancy between the operated lower limb and the contralateral limb was 1.2 +/- 3.2 mm (range, -7 to 7 mm). The mean angular deviation difference between the lower limbs was 0.46 degrees +/- 1.1 degrees . New traumatic injuries developed in 3 patients, in whom surgical revision was performed; 1 patient underwent a late meniscectomy. The mean difference in KT-1000 measurement was 2.0 +/- 1.0 mm. The mean subjective International Knee Documentation Committee score was 91.5 +/- 5.7, and the mean score on the modified Lysholm scale was 93.5 +/- 4. Of the patients, 3 (11.2% of all patients) could not return to the same level of physical activity as before injury.

CONCLUSIONS

ACL reconstruction by use of the transphyseal technique in an immature skeleton with a hamstring autograft, with careful attention being paid to the technique, resulted in good clinical outcomes and no growth abnormalities.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Rupture of the anterior cruciate ligament in children: early reconstruction with open physes or delayed reconstruction to skeletal maturity?

The purpose of this study was to compare two different strategies of management for ACL rupture in skeletally immature patient. In group 1, patients were treated in a children hospital by ACL reconstruction with open physis. In group 2, patients were treated in an adult hospital by delayed reconstruction at skeletal maturity assessed radiologically. Fifty-six consecutive patients were included in this retrospective study. Mean time from injury to surgery in group 1 and 2 was, respectively, 13.5 and 30 months. Patients from group 2 exhibited a higher rate of medial meniscal tears (41%) compare to group 1 (16%) and higher rate of meniscectomy. Both groups had the same rate of lateral meniscal tears. A temporary tibial valgus deformity was reported which was subsequently spontaneously resolved. No definitive growth disturbance was noticed. At 27 months mean follow-up, a best subjective IKDC score was found in group 1. Objective IKDC and radiological results were similar in both groups. Early ACL reconstruction is therefore a recommended option.

Anterior cruciate ligament reconstruction in the skeletally immature: an anatomical study utilizing 3-dimensional magnetic resonance imaging reconstructions

INTRODUCTION

Anatomic anterior cruciate ligament (ACL) reconstruction has proven to be a reliable method to restore knee stability. However, the risk of physeal arrest with transphyseal tunnel placement in skeletally immature patients has raised concern regarding this technique. Conservative nonoperative management also has its limitations resulting in meniscal and chondral damage that may lead to degenerative joint disease and poor return to sport. Researchers have used animal models to study the threshold of physeal damage producing growth deformity. The purpose of this study was to examine the distal femoral and proximal tibial physes and determine the damage produced by drilling transphyseal tunnels. In addition, we attempted to find a reproducible angle at which to drill the tibial tunnel for safe interference screw placement. To do this, we used a custom software module.

METHODS

A custom software package designed by our team was used: Module for Adolescent ACL Reconstructive Surgery (MAARS). This module created a 3-dimensional model of the distal femur and proximal tibia. The data required for MAARS were sagittal and coronal T1 magnetic resonance imagings of at least 1.5 T. Thirty-one knee magnetic resonance imaging studies from patients aged 10 to 15 years old were used. The physes were segmented out to obtain volumetric measurements. Transphyseal tunnels were simulated based on the anatomic trajectory of the native ACL. The module calculated volume of physis was removed with the use of an 8-mm tunnel and the optimum angle for trajectory.

RESULTS

Average volume of the tibial and femoral physis was 12,683.1 microL and 14,708.3 microL, respectively. The volume increased linearly with age. Average volume removed from the tibial and femoral physis was 318.4 microL and 306.29 microL, respectively. This represented 2.4% of the distal femoral physis and 2.5% of the proximal tibial physis. The volume percent removed decreased linearly with age.Manipulation of the variables demonstrates graft radius is the most critical parameter affecting the volume of physeal injury. Variation of graft diameter from 6 mm to 11 mm will increase volume percent removed from 2.3% to 7.8%, which averages 1.1% for every 1 mm increase. Increasing tunnel drill angle from 45 degrees to 70 degrees will decrease volume percent removed from 4.1% to 3.1% which averages 0.2% removed for each 5 degrees increase in drill angle. The average angle to maintain a distance of 20 mm from the proximal tibial physis was 65 degrees with a range of 40 degrees to 85 degrees.

DISCUSSION

Less than 3% injury occurs when drilling an 8-mm tunnel across the physis. A vertical tunnel has minimal effect, but the tunnel diameter is critical. Interference screws can be placed safely to avoid the physis but requires careful planning. The MAARS module may be helpful in preoperative planning.

LEVEL OF EVIDENCE

Diagnostic, level IV.

Hindlimb growth after a transphyseal reconstruction of the anterior cruciate ligament: a study in skeletally immature sheep with wide-open physes

BACKGROUND

There is a lot of controversy in the recent literature with regard to the optimal treatment of anterior cruciate ligament (ACL) injuries during growth. Iatrogenic growth disturbance due to physeal damage is a potential complication, forcing many orthopaedic surgeons to treat these injuries conservatively.

HYPOTHESIS

It is possible to perform a fully transphyseal ACL reconstruction in an ovine model with wide-open physes without creating growth disturbances.

STUDY DESIGN

Descriptive laboratory study.

MATERIALS AND METHODS

Four-month-old skeletally immature sheep underwent a transphyseal ACL reconstruction of the right knee. The surgical technique followed the criteria known to be essential to avoid growth disturbances in humans; the tibial tuberosity was spared to prevent a genu recurvatum, thermal damage to the growth plates was avoided, the physes were perforated with a small-diameter drill in the center of the growth plate, a soft tissue graft was used, graft fixation was achieved far away from the growth plates, the perforated growth plates were filled by the soft tissue graft, and the graft was moderately pretensioned before fixation. The left knee served as a control. A computer-assisted evaluation of long radiographs (frontal and sagittal plane) of the exarticulated hindlimbs was performed to exactly evaluate the limb alignment, joint orientation, and leg length. The animals were sacrificed in groups of 6 after 3, 6, 12, and 24 weeks.

RESULTS

No angular deformities or leg-length discrepancies occurred after this transphyseal ACL reconstruction procedure throughout the remaining growth.

CONCLUSION

This large-animal study supports the clinical observation that it is possible to perform an ACL reconstruction without creating growth disturbances as long as a number of key principles are followed.

CLINICAL RELEVANCE

Previous animal studies argued against ACL reconstruction in skeletally immature patients. This large-animal study provides support for early operative treatment of ACL ruptures even in young patients with open physes.

Transphyseal reconstruction of the anterior cruciate ligament in prepubescent children

We present the results of 17 children of Tanner stage 1 or 2 who underwent reconstruction of the anterior cruciate ligament between 1999 and 2006 using a transphyseal procedure, employing an ipsilateral four-strand hamstring graft. The mean age of the children was 12.1 years (9.5 to 14). The mean follow-up was 44 months (25 to 100). Survival of the graft, the functional outcome and complications were recorded. There was one re-rupture following another injury. Of the remaining patients, all had good or excellent results and a normal International Knee Documentation Committee score. The mean post-operative Lysholm score was 97.5 (SD 2.6) and the mean Tegner activity scale was 7.9 (SD 1.4). One patient had a mild valgus deformity which caused no functional disturbance. No other abnormality or discrepancy of leg length was seen. Measurements with a KT1000 arthrometer showed no significant difference between the normal and the operated legs. In this small series, transphyseal reconstruction of the anterior cruciate ligament appeared to be safe in these young children.

Living related donor allograft for revision anterior cruciate ligament reconstruction in a child: a case report

Revision ACL reconstruction poses several challenges for the surgeon in terms of the timing of surgery and the limited graft choices. To our knowledge, there is currently no published data with regards to revision ACL reconstruction in a child. We describe the case of a 12-year-old girl who had a re-injury 4.5 months after her index primary ACL reconstruction at the age of 11 years. She sustained a repeat injury to the reconstructed knee following a road traffic accident and developed significant instability despite an intensive rehabilitation program. After careful consideration of the available graft materials--known all the advantages and disadvantages of the autografts, allografts and synthetic materials--we decided to use the patient's mother's hamstrings as a graft. The parents of our patient refused the use of allograft and synthetic materials. We discuss our management of this case, the reasons for our revision graft choice, and the theoretical disadvantages of some of the alternative graft choices available in this scenario. We believe in such cases, performing ACL revision with a donor graft of the patient's mother could be good alternative to allografts or synthetic grafts.

The risk of growth changes during transphyseal drilling in sheep with open physes

PURPOSE

A sheep model was used to evaluate the risk of growth disturbances of transphyseal drilling and anterior cruciate ligament (ACL) reconstruction.

METHODS

In group A, comprised of six 4-month-old Merino sheep, the ACL was resected and 5-mm tunnels were drilled and left empty. Unilateral ACL reconstruction using an autologous Achilles tendon graft, extracortical fixation, and tunnel diameters of 5 mm was performed in group B. A single-stranded graft with a diameter of 5 mm was used in group B-1 (N = 6) and a 3-mm double-stranded graft in group B-2 (N = 6). Six months after the procedure, the animals were euthanized. Growth changes were evaluated macroscopically, by magnetic resonance imaging, and by histology.

RESULTS

Central growth plate lesions on the tibia did not induce growth abnormalities. On the peripheral femur, posterolateral growth plate injuries with empty tunnels led to a shortening of the lateral femur of 8 mm (7 to 10 mm), a valgus deformity of 12.8 degrees (12 degrees to 14 degrees ), and a flexion deformity of 8.6 degrees (5 degrees to 15 degrees ). Histology revealed a strong bone bridge over the physis and an injury to the perichondral structures. Transphyseal ACL replacements did not cause growth disturbances on either the tibia or the femur, even if a drilling injury of the perichondral structures occurred.

CONCLUSIONS

Despite consistent physeal damage, ACL reconstructions did not lead to clinically relevant growth disturbances.

CLINICAL RELEVANCE

The results suggest that transphyseal ACL reconstruction procedures might yield similar results in children with substantial growth remaining.

Changes in the four-strand hamstring graft in anterior cruciate ligament reconstruction in the skeletally-immature knee

The potential harm to the growth plate following reconstruction of the anterior cruciate ligament in skeletally-immature patients is well documented, but we are not aware of literature on the subject of the fate of the graft itself. We have reviewed five adolescent males who underwent reconstruction of the ligament with four-strand hamstring grafts using MR images taken at a mean of 34.6 months (18 to 58) from the time of operation. The changes in dimension of the graft were measured and compared with those taken at the original operation. No growth arrest was seen on radiological or clinical measurement of leg-length discrepancy, nor was there any soft-tissue contracture. All the patients regained their pre-injury level of activity, including elite-level sport in three. The patients grew by a mean of 17.3 cm (14 to 24). The diameter of the grafts did not change despite large increases in length (mean 42%; 33% to 57%). Most of the gain in length was on the femoral side. Large changes in the length of the grafts were seen.

There is a considerable increase in the size of the graft, so some neogenesis must occur; the graft must grow.

Performance-based functional outcome for children 12 years or younger following anterior cruciate ligament injury: a two to nine-year follow-up study

There is limited scientific knowledge on ACL injuries in children 12 years or younger. Substantial controversy exists on treatment algorithms and there are no published data on performance-based functional outcome. Classification of adult ACL injured subjects as copers and non-copers is common, but no study has classified knee function in children using performance-based functional test after ACL injury. The aim of the present study was to evaluate the medium-term functional outcome among children with ACL injury and to classify them as copers and non-copers. Children 12 years or younger who were referred to our institution from 1996 to 2004 with an ACL injury were included. Twenty non-operated subjects (21 knees) and six ACL reconstructed subjects (7 knees) were examined at a minimum of 2 years after ACL injury or reconstruction. Four single-legged hop tests, isokinetic muscle strength measurements, and three functional questionnaires (IKDC 2000, KOS-ADLS and Lysholm) were used as outcome measurements. Children who had resumed their pre-injury activity level and performed above 90% on all hop tests were classified as copers following non-operative treatment and ACL reconstruction. The 26 children were on average 10.1 years at the time of injury. Of the non-operated children, 65% had returned to pre-injury activity level, and 50% were classified as copers. Copers scored significantly better than non-copers on single hop for distance, IKDC 2000, and Lysholm score. Of the non-operated children, 9.5% had suffered a secondary meniscus injury. Of the ACL reconstructed subjects, 67% were classified as copers at follow-up. Non-operated ACL-deficient children demonstrated excellent knee function on performance-based single-legged hop tests and 65% had returned to pre-injury activity level. Delayed ACL reconstruction resulted in success for a majority of the ACL-reconstructed children. Treatment algorithms for ACL-injured children are discussed.

The influence of femoral technique for graft placement on anterior cruciate ligament reconstruction using a skeletally immature canine model with a rapidly growing physis

PURPOSE

The purpose of this study was to evaluate 3 different femoral techniques of anterior cruciate ligament (ACL) reconstruction using a skeletally immature canine model.

METHODS

A soft-tissue autograft ACL reconstruction was performed in 25 ten-week-old canines via a central transphyseal tibial tunnel and 1 of 3 femoral techniques: epiphyseal, over the top, or transphyseal. The contralateral hind limbs served as controls. The canines were killed at 16 weeks postoperatively and evaluated by gross inspection, plain radiographs, photography, magnetic resonance imaging, and histomorphometry.

RESULTS

There were no significant differences in femoral longitudinal growth; however, tibial growth was significantly greater on the experimental side relative to controls (P = .001). Angular and rotational deformities were noted on the femoral side but not on the tibial side. The epiphyseal technique resulted in less angular deformity and most closely maintained the anatomic position of the ACL graft with growth; however, this technique exhibited increased femoral rotational deformity. All techniques exhibited a high rate of graft failure. Magnetic resonance imaging revealed chondral and subchondral injuries to the lateral femoral condyle, most frequently in the epiphyseal group.

CONCLUSIONS

From the results of our study, we cannot advocate any single femoral reconstructive technique. An epiphyseal femoral technique may reduce the risk of angular deformity and allow a more optimal femoral graft position after growth as opposed to transphyseal and over-the-top techniques. However, the epiphyseal technique may possess an increased risk for rotational deformity, physeal injury, and articular surface injury. Metaphyseal fixation of ACL grafts traversing rapidly growing physes may be responsible for the observed abnormalities in graft integrity, femoral graft position, and femoral angulation and rotation.

CLINICAL RELEVANCE

ACL reconstruction in the skeletally immature individual is complicated by the presence of active physeal and epiphyseal cartilage surrounding the growing knee, the pathophysiologic consequences of injury to these developing structures, and the final effect on the anatomy and function of the graft, bone, and articular surface. Animal models can provide insight and direction as we develop and evaluate our treatment methods for this clinical problem, but these animal models have anatomic and physiologic differences that limit direct comparison to humans.

[Isolated congenital aplasia of the anterior cruciate ligament treated by reconstruction in a 5-year-old boy]

Agenesia of the anterior cruciate ligament is a rare entity which is exceptionally symptomatic. We report a case observed in a 5-year-old boy who presented an unstable knee which was treated by Clocheville ligamentopàlasty. At five years followup, the functional outcome was satisfactory. The patient was symptom free and practiced sports activities. He did not develop any complications excepting flexion which was limited to 130 degrees . Magnetic resonance imaging demonstrated good integration of the autograft. Anterior instability in the child limits physical activity and can cause meniscal injury and early osteoarthritis. The Clocheville technique is adapted for pediatric patients with knee instability caused by a congenital defect or injury.

The anatomy of the proximal tibia in pediatric and adolescent patients: implications for ACL reconstruction and prevention of physeal arrest

Although the treatment of anterior cruciate ligament (ACL) tears in skeletally immature patients is still controversial, several studies have advocated ACL reconstruction in selected patients to prevent secondary injury. The proximal tibial physis is a structure at risk during ACL reconstruction in young patients, and physeal growth complications have been reported after surgery in this area. The relationship between the ACL and the proximal tibial physeal/apophyseal regions is poorly understood. This study examined the MRI anatomy of the ACL and the proximal tibia apophysis and epiphysis. MRIs of 59 skeletally immature knees were reviewed (Average age = 12.75 years, range 6-15) to define the anatomy of the epiphyseal and apophyseal regions. Measurements were recorded in three parasagittal planes: (1) at the lateral border of the patellar tendon, (2) the lateral edge of the ACL insertion, and (3) the medial edge of the ACL insertion. A single three-dimensional (3D) computed tomography (CT) scan was used to evaluate the position of standard drill holes used in ACL reconstruction to assess for potential degree of injury to the epiphyseal and apophyseal growth plates. In the parasagittal planes, the average height of the epiphysis was 19.6, 20.7, and 21.5 mm at the lateral border of the patellar tendon, the lateral border of the ACL, and the medial border of the ACL, respectively. At the level of the same landmarks, the apophysis extended below the physis at an average of 20.2, 16.8, and 7.0 mm, respectively. Expressed as a percentage of epiphysis height this was an average of 104, 82, and 33%, respectively. Examination of 3D CT images revealed that variations in drill hole placement had effects on the volume of injury to the proximal tibial physis and apophysis. Drill holes that started more medial, distal, and with a steeper angle of inclination reduced the amount of physis and apophysis violated when compared with holes placed more lateral, proximal, and with a shallow angle of inclination. The proximal tibial physis and apophysis is vulnerable to injury by drill hole placement during ACL reconstruction in skeletally immature patients. This paper defines the anatomic relationship of the apophyseal and epiphyseal regions of the physis in the proximal tibia. The volume of injury to the physis can be reduced by avoiding tunnel placement that is too lateral or too proximal on the tibia. A better understanding of these relationships may guide the placement of tibial drill holes, which have a lower risk of producing significant physeal damage.

Meniscal tears in children and adolescents: results of operative treatment

The goal of this study was to evaluate the results of meniscal repair in children and adolescents by a retrospective case series. Twelve arthroscopic-assisted meniscal repairs were performed on 12 patients younger than 17 years of age (8-16 years, mean 13 years). The anterior cruciate ligament was torn in three cases. Eight lesions involved the lateral meniscus and four involved the medial meniscus; there were no discoid menisci. All patients were seen at an average of 3 years 1 month follow-up (range, 2-4 years 10 months). Three patients required subsequent surgery for partial meniscectomy. We evaluated the remaining nine patients by clinical examination, International Knee Documentation Committee clinical score, Lyshölm score, Tegner's activity, and by computed tomography arthrogram or magnetic resonance imaging. Seven patients were asymptomatic at follow-up, two reported occasional pain, and none had experienced symptoms of locking. Their average Lyshölm score and Tegner's activity were 96.3 and 6.6, respectively. Eight patients were International Knee Documentation Committee A and one was International Knee Documentation Committee B. Healing status was assessed at follow-up in eight patients by computed tomography arthrogram or magnetic resonance imaging: the tear was considered as completely healed in three patients. The apparent failure rate was 66%. Indications for meniscal repair in children are not actually established. The pejorative outcome of meniscectomy at a young age has led us to consider symptomatic meniscal tears for repair. Objective results of meniscal healing are poor. The method to assess healing of the repaired menisci objectively is still a matter of debate.

Managing anterior cruciate ligament deficiency in the skeletally immature individual: a systematic review of the literature

OBJECTIVE

To perform a systematic review of the literature to answer whether early ACL reconstruction for a skeletally immature individuals result in improved outcome compared with nonsurgical treatment or delaying the reconstruction until skeletal maturity in the pediatric athlete.

DATA SOURCES

Articles were restricted to the English language, and 6 databases were searched (MEDLINE, CINAHL, EMBASE, ACP Journal Club, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews). The following keywords were used: anterior cruciate ligament, ACL, child, immature, pediatric, pediatric, and young.

SELECTION CRITERIA

All studies examining the ACL reconstruction in skeletally immature individuals, including citations describing complications. Excluded were articles looking at ACL repairs and ACL avulsion injuries. All types of study design, including review articles, were included. Comparative studies were reviewed in detail and analyzed qualitatively.

DATA EXTRACTION AND SYNTHESIS

A total of 615 articles were identified. Sixty-six articles met the inclusion and exclusion criteria. There were no articles with levels of evidence better than level III. The majority of the articles represented case series and reviews with expert opinion.

RESULTS

There were 7 articles that provided comparisons between surgical and nonsurgical treatment in order to answer the question.

CONCLUSIONS

The study designs are inadequate to answer the question of whether early or delayed ACL reconstruction results in the best possible outcome in skeletally immature individuals. Future prospective studies are required to answer the question adequately. A proposed algorithm was described to deal with the question.

Update on paediatric ACL injuries

In the last two decades there has been an increase in the incidence of anterior cruciate ligament (ACL) injuries in children. This may be due to increased awareness, more participation in high demand contact and non-contact sports at an earlier age and better diagnosis as a result of better imaging. A review of the literature suggests that the long-term results of non-operative treatment are poor. While the short to medium-term results of ACL reconstruction in children are encouraging, the long-term results are unknown. In this review, the current trends in the management of paediatric ACL injuries are discussed with particular emphasis on the natural history, surgical techniques, the effect of surgery on the growth plate and complications.

Multicenter-study of operative treatment of intraligamentous tears of the anterior cruciate ligament in children and adolescents: comparison of four different techniques

Tears of the anterior cruciate ligament in skeletally immature patients were operated with four different methods and their outcome compared to each other. Sixty-eight patients (33 males, 35 females), mean 12.5 years, were treated in four different centers from 1984 to 2001. Twenty-eight patients underwent the ACL-reconstruction with hamstring grafts, 16 patients with bone-patella-bone autografts, 12 patients with quadriceps grafts and 12 patients with facia lata. The mean follow-up was 32 months. Postoperative evaluation included radiographs, KT-1000/2000 stability measurements, Lysholm score, The Tegner activity scale and IKDC score. Neither leg length discrepancy nor angular deformities were noted. Mean KT-1000 difference was 2.1 mm, mean postoperative Lysholm knee score 93.3, IKDC 87% normal or nearly normal. The Tegner index decreased from 6.6 to 5.7. In total, six patients developed instability due to an adequate trauma 1 year after the index operation. Two patients showed mild arthrotic changes. All but two patients were able to return to the same level of preoperative sports participation. None of the four methods studied showed major differences in outcome compared to the other. No growth disturbance could be noted.

The functional outcome of total tears of the anterior cruciate ligament (ACL) in the skeletally immature patient

Tears of the anterior cruciate ligament (ACL) in the skeletally immature patient are becoming more prevalent. The aim of this study was to describe the functional outcome and to evaluate the best management of total tears of the ACL in skeletally immature patient. Twenty consecutive, skeletally immature patients with a clinically evident rupture of the anterior cruciate ligament were followed up for a mean of 5.4 years. The mean age at the time of injury was 13.9 years old. The study group consisted of 13 girls and 7 boys, who were treated either conservatively, by ACL reconstruction, by primary repair or by delayed ACL reconstruction after skeletal maturity had been reached. Clinical outcomes were measured using the International Knee Documentation Committee Scoring System (IKDC) and the Knee Injury and Osteoarthritis Outcome Scoring System (KOOS). The radiological evaluation was performed using Jaeger and Wirth's criteria, and instrumented laxity testing was carried out with a Rolimeter. Five of the eight patients treated conservatively showed poor function of the knee, and this resulted in instability. Concerning the patients treated by primary repair, delayed ACL reconstruction or arthroscopic debridement, we also found none of the results to be satisfactory (seven of eight patients). The patients that were treated by a reconstruction had the best results. This was confirmed by clinical examination (Lachmann grade 1), by the IKDC (grade B) and by the KOOS with the best quality of life and no giving-way attacks. The level of evidence was therapeutic level III.

Intraarticular stabilization after anterior cruciate ligament tear in children and adolescents: results 6 years after surgery

Tear of the anterior cruciate ligament (ACL) secondary to knee sprain injury is also quite common among children and adolescents. Whether reconstruction is indicated and which technique should be employed is still controversial. The debate focuses on the possible risk of growth plate damages due to intraarticular operative reconstruction techniques. For more details on benefit and risks of operative stabilization, our clinic's large number of surgical results was to be evaluated retrospectively. In a total of 437 knee joint arthroscopies performed between 1982 and 1992 in children and adolescents with open physes, aged 3-16 years, 63 surgical repair/reconstructions according to an algorithm were carried out. The average age at surgery was 13.8 years. Follow-up an average 6.5 years after the operation consisted of clinical and radiological examination, Lysholm, Tegner, and IKDC scores. This report focuses on intraarticular ligament reconstruction methods. Forty-four patients could be followed up, comprising of five reinsertions, ten internal fixations, 15 cases semitendinosus tendon (ST) augmentations, and 14 primary reconstructions with the middle one-third of the patellar tendon (PT). In every ST and PT case, transtibial and transfemoral tunnels were drilled. The clinical stability examination was supplemented by KT-1000 arthrometer measurements and radiography in two planes. Averaged for all surgical techniques, good and very good results were obtained in over 75% of cases. There were no major growth defects and rarely signs of osteoarthrosis. According to literature, conservative treatment of ACL tears and even primary ACL repair is not infrequently followed by re-ruptures. Therefore, reconstruction is the preferred procedure for patients aged 12 years or more. As most authors hesitate to possibly block the physes by obtaining and anchoring patellar tendon grafts, the ST should be preferred. This study demonstrates in a large number of ACL stabilizations, despite transepiphyseal drilling and grafting, very good stabilization is achieved, but no growth defects have to be expected.

Treatment of anterior cruciate ligament injuries, part I

Anterior cruciate ligament injuries are common among athletes. Although the true natural history remains unclear, anterior cruciate ligament injuries are functionally disabling; they predispose the knee to subsequent injuries and the early onset of osteoarthritis. This article, the first in a 2-part series, was initiated with the use of the PubMed database and a comprehensive search of articles that appeared between January 1994 to the present, using the keywords anterior cruciate ligament. A total of 3810 citations were identified and reviewed to determine the current state of knowledge about the treatment of these injuries. Articles pertaining to the biomechanical behavior of the anterior cruciate ligament, the prevalence of anterior cruciate ligament injury, the natural history of the anterior cruciate ligament-deficient knee, injuries associated with anterior cruciate ligament disruption, risk factors for anterior cruciate ligament injury, indications for treatment of anterior cruciate ligament injuries, and nonoperative and operative treatments were obtained, reviewed, and served as the basis for part I. Part II, to be presented in another issue of this journal, includes technical aspects of anterior cruciate ligament surgery, bone tunnel widening, graft healing, rehabilitation after reconstruction, and the effect of sex, age, and activity level on the outcome of surgery. Our approach was to build on prior reviews and to provide an overview of the literature for each of the before-mentioned areas of study by summarizing the highest level of scientific evidence available. For the areas that required a descriptive approach to research, we focused on the prospective studies that were available; for the areas that required an experimental approach, we focused on the prospective, randomized controlled trials and, when necessary, the highest level of evidence available. We were surprised to learn that considerable advances have been made during the past decade regarding the treatment of this devastating injury.