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Physeal Sparing Reconstruction of the Anterior Cruciate Ligament in Skeletally Immature Prepubescent Children and Adolescents

Kocher, Mininder S. MD, MPH; Garg, Sumeet MD; Micheli, Lyle J. MD

Journal of Bone & Joint Surgery - American Volume: November 2005 - Volume 87 - Issue 11 - p 2371–2379
doi: 10.2106/JBJS.D.02802
Scientific Articles
Supplementary Content

Background: The management of anterior cruciate ligament injuries in skeletally immature patients is controversial. Conventional adult reconstruction techniques risk potential iatrogenic growth disturbance due to physeal damage. The purpose of this study was to evaluate the results of a physeal sparing, combined intra-articular and extra-articular reconstruction technique in prepubescent skeletally immature children.

Methods: Between 1980 and 2002, forty-four skeletally immature prepubescent children and adolescents who were in Tanner stage 1 or 2 (with a mean chronological age of 10.3 years) underwent physeal sparing, combined intraarticular and extra-articular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band graft. Twenty-seven patients had additional meniscal surgery. Functional outcome, graft survival, radiographic outcome, and growth disturbance were evaluated at a mean of 5.3 years after surgery.

Results: Two patients underwent a revision reconstruction for graft failure at 4.7 and 8.3 years postoperatively. In the remaining forty-two patients, the mean International Knee Documentation subjective knee score (and standard deviation) was 96.7 ± 6.0 points, and the mean Lysholm knee score was 95.7 ± 6.7 points. The results of the Lachman examination for anterior cruciate ligament integrity was normal for twenty-three patients, nearly normal for eighteen patients, and abnormal for one patient. The results of the pivot-shift examination were normal for thirty-one patients and nearly normal for eleven patients. Four of the twenty-three patients who underwent concurrent meniscal repair had a repeat arthroscopic meniscal repair or partial meniscectomy. The mean growth in total height from the time of surgery to the final follow-up evaluation was 21.5 cm. No patient had an angular deformity measured radiographically or a discrepancy in the length of the lower extremities measured clinically.

Conclusions: Physeal sparing, combined intra-articular and extra-articular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band graft in skeletally immature prepubescent children and adolescents provides excellent functional outcome with a low revision rate and a minimal risk of growth disturbance.

Levels of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

1 Division of Sports Medicine, Department of Orthopaedic Surgery, Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115. E-mail address for M.S. Kocher:

2 Department of Orthopaedic Surgery, Washington University Orthopaedic Residency Program, One Barnes Hospital Plaza, St. Louis, MO 63110

Copyright 2005 by The Journal of Bone and Joint Surgery, Incorporated
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