Original Article
Transphyseal Anterior Cruciate Ligament Reconstruction in Patients With Open Physes

https://doi.org/10.1016/j.arthro.2009.01.015Get rights and content

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° ± 1.1°. 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.

Section snippets

Methods

We retrospectively evaluated 26 skeletally immature patients who underwent a transphyseal ACL reconstruction from July 2000 to July 2006 and who agreed to participate in this study. Inclusion criteria for the study included a minimum of 2 years' follow-up and age of 15 years or less for male patients and 14 years or less for female patients. No patient had any symptom or history of knee injury before the occurrence of ACL rupture. All patients underwent a radiologic study to evaluate bone

Radiologic Assessment

The length of the operated limb was increased compared with that of the contralateral limb. The total mean length difference was 1.2 ± 3.2 mm (range, −7 to 7 mm), but this was not statistically significant (P = .227). The length of the operated limb was decreased compared with the contralateral limb in only 5 patients. The mean length difference in the patients with decreased operated limb length was 3.6 mm (range, 2.0 to 7.0 mm). Eight patients had no difference in the lengths of their lower

Discussion

ACL injury in patients with open physes is an important topic in the clinical orthopaedic literature, because it may cause complications with both surgical and conservative treatments.12, 13, 14, 15, 16 Although there exists the option of performing ACL surgery only after the physes have matured, this method is no longer advocated because of poor clinical outcomes.12, 13, 22 Nonoperative treatment with modification of physical activities may be an effective way to prevent further damage to the

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.

References (32)

  • M.S. Kocher et al.

    Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents

    J Bone Joint Surg Am

    (2005)
  • M.S. Kocher et al.

    Transphyseal anterior cruciate ligament reconstruction in skeletally immature pubescent adolescents

    J Bone Joint Surg Am

    (2007)
  • F. Gebhard et al.

    Multicenter-study of operative treatment of intraligamentous tears of the anterior cruciate ligament in children and adolescents

    Knee Surg Sports Traumatol Arthrosc

    (2006)
  • H. Mizuta et al.

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

    J Bone Joint Surg Br

    (1995)
  • S. Chudik et al.

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

    Arthroscopy

    (2007)
  • M.S. Kocher et al.

    Management and complications of anterior cruciate ligament injuries in skeletally immature patients: Survey of the Herodicus Society and the ACL Study Group

    J Pediatr Orthop

    (2002)
  • Cited by (104)

    • Multiligament Knee Injuries in Young Athletes

      2022, Clinics in Sports Medicine
    • Outcomes, Including Graft Tears, Contralateral Anterior Cruciate Ligament Tears, and All-Cause Ipsilateral Knee Operations, are Similar for Adult-type, Transphyseal, and Partial Transphyseal Anterior Cruciate Ligament Reconstruction Using Hamstring Autograft in Pediatric and Adolescent Patients

      2022, Arthroscopy, Sports Medicine, and Rehabilitation
      Citation Excerpt :

      Surgical technique selection in the pediatric and adolescent population is dictated in large part by estimated growth remaining. Although growth abnormalities are legitimate concerns of transphyseal drilling and fixation that may be under-reported,46 many studies demonstrate that in the appropriate patient, minimal clinically relevant growth abnormalities may be noted using appropriate transphyseal techniques.15,40,47-50 A magnetic resonance imaging study demonstrated physeal violations with transphyseal techniques on both the femoral and tibial sides to be less than 4%, suggesting low likelihood of noticeable abnormality.51

    • Knee and Leg Injuries

      2020, Emergency Medicine Clinics of North America
      Citation Excerpt :

      Previous guidelines advised delayed reconstruction until skeletal maturity had been achieved. However, current recommendations encourage immediate reconstruction, because this approach has shown a significantly lower rate of postinjury meniscal tears.58,59 Orthopedic surgeons use a variety of ACL reconstruction techniques.

    • The Paediatric Knee

      2020, Evidence-Based Management of Complex Knee Injuries: Restoring the Anatomy to Achieve Best Outcomes
    View all citing articles on Scopus

    The authors report no conflict of interest.

    View full text