Postoperatively, the patient is maintained with touch-down weight-bearing for six weeks. Immediate mobilization is performed, from 0° to 90° for the first two weeks, followed by progression to a full range of motion. Continuous passive motion from 0° to 90° is used for the first two weeks postoperatively to initiate motion and overcome the anxiety associated with postoperative movement in these young children. A protective hinged knee brace is used for six weeks postoperatively with motion limits of 0° to 90° for the first two weeks. Progressive rehabilitation consists of range-of motion exercises, patellar mobilization, electrical stimulation, pool therapy (if available), proprioception exercises, and closed-chain strengthening exercises during the first three months postoperatively followed by straight-line jogging, plyometric exercises, sport cord exercises, and sport-specific exercises. Return to full activity, including sports that involve cutting, is usually allowed at six months postoperatively. A custom-made functional knee brace is used routinely during cutting and pivoting activities for the first two years after the return to sports. Compliance with bracing was not formally assessed.
The mean postoperative duration of follow-up was 5.3 years (range, 2.0 to 15.1 years). The mean duration of the operation was 101 minutes (range, sixty to 140 minutes), and the mean tourniquet time was seventy-two minutes (range, forty-three to 109 minutes). There were no surgical complications, such as infection, failure of graft harvest, or arthrofibrosis. Two patients (4.5%) underwent a revision anterior cruciate ligament reconstruction for graft failure at 4.7 and 8.3 years postoperatively. Both patients had a reinjury and were participating in cutting and pivoting sports. Both had midsubstance rupture of the iliotibial band graft. The grafts appeared well incorporated at the femoral and tibial insertions. Four patients who underwent concurrent meniscal repair during anterior cruciate ligament reconstruction had repeat arthroscopic meniscal repair or partial meniscectomy.
For the remaining forty-two patients without revision anterior cruciate ligament repair, the mean IKDC subjective knee score (and standard deviation) was 96.7 ± 6.0 points (range, 88.5 to 100 points) and the mean Lysholm knee score was 95.7 ± 6.7 points (range, 74 to 100 points). All patients, other than the three patients with congenital limb deficiencies, had returned to cutting or pivoting sports. According to the IKDC criteria, the findings of the Lachman examination were 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. The mean growth in total height from the time of surgery to the final follow-up examination was 21.5 cm (range, 9.5 to 118.5 cm). It should be noted that total height is a combination of trunk and lower extremity lengths. No patient had a substantial angular deformity measured radiographically. No patient had a substantial limb-length discrepancy measured clinically.
There is controversy regarding the management of anterior cruciate ligament injuries in patients with open physes. Nonoperative management, consisting of rehabilitation, bracing, and activity restriction, is often recommended in order to temporize for later conventional reconstruction near skeletal maturity. Nonoperative management of partial tears may be successful in patients with a lower-grade partial tear, in younger children, and in patients with a tear that predominantly involves the anteromedial bundle53. However, nonoperative management of complete tears generally has a poor prognosis, with recurrent instability leading to further meniscal and chondral injury11-17. Graf et al.12, Janarv et al.13, and Mizuta et al.16 reported instability symptoms, subsequent meniscal tears, a decreased activity level, and a need for anterior cruciate ligament reconstruction in skeletally immature patients treated nonoperatively. Similarly, when comparing the results of operative and nonoperative management of complete anterior cruciate ligament injuries in adolescents, McCarroll et al.14 and Pressman et al.17 found that those managed with anterior cruciate ligament reconstruction had less instability, higher levels of activity and return to sports, and lower rates of subsequent reinjury and meniscal tears. These subsequent meniscal and chondral injuries have important implications in terms of the long-term prognosis for the knee and the risk of degenerative joint disease. In addition, compliance with activity restriction is often problematic in the pediatric athlete and is unappealing to the patient's family.
Conventional surgical reconstruction techniques risk potential iatrogenic growth disturbance due to physeal damage. Cases of growth disturbance have been reported in animal models18-20. Animal models have demonstrated mixed results regarding growth disturbances from soft-tissue grafts across the physes. In a canine model with iliotibial band grafts through 0.16-in (4-mm) tunnels, Stadelmaier et al. found no evidence of growth arrest in four animals with a soft-tissue graft across the physis, whereas four animals with drill-holes and no graft demonstrated physeal arrest54. In a rabbit model with use of a semitendinosus graft through 2-mm tunnels, Guzzanti et al. noted cases of growth disturbance; however, they were not common18. Examining the effect of a tensioned soft-tissue graft across the physis, Edwards et al. found a substantial rate of deformity19. In a canine model with an iliotibial band graft tensioned to 80 N, those investigators found increases, compared with the nonoperatively treated control limb, in distal femoral valgus deformity and proximal tibial varus deformity despite no evidence of an osseous bar. Similarly, Houle et al. reported growth disturbance after use of a tensioned tendon graft in a bone tunnel across the rabbit physis20. However, the tension applied to the graft in the studies by Edwards et al. and Houle et al. may have been correspondingly excessive for their animal models, thus resulting in growth disturbance.
Clinical reports of growth deformity after anterior cruciate ligament reconstruction are unusual. In a series of twenty-four skeletally immature patients who had reconstruction with transphyseal semitendinosis and gracilis grafts, Lipscomb and Anderson described one patient who had 20 mm of shortening21. This was associated with staple fixation of a graft across the physis. Koman and Sanders reported the case of a patient who had a distal femoral valgus deformity requiring an osteotomy and contralateral epiphyseodesis after transphyseal reconstruction with a doubled semitendinosus graft22. This deformity was also associated with fixation across the distal femoral physis. In a study based on a survey of experts in the management of anterior cruciate ligament injuries in pediatric patients, Kocher et al. reported the cases of an additional fifteen patients who had growth disturbances, including eight patients who had a distal femoral valgus deformity with an arrest of the lateral distal femoral physis; three patients who had tibial recurvatum with an arrest of the tibial tubercle apophysis; two patients who had genu valgum, without arrest, due to a lateral extra-articular tether; and two patients who had a leg-length discrepancy (one who had shortening and one who had overgrowth)23. Associated factors included fixation hardware across the lateral distal femoral physis in three patients, bone plugs of a patellar tendon graft across the distal femoral physis in three patients, large (12-mm) tunnels in two patients, lateral extra-articular tenodesis in two patients, fixation hardware across the tibial tubercle apophysis in two patients, and suturing near the tibial tubercle apophysis in one patient.
Surgical techniques to address anterior cruciate ligament insufficiency in skeletally immature patients include primary repair, extra-articular tenodesis, transphyseal reconstruction, partial transphyseal reconstruction, and physeal sparing reconstruction. Primary ligament repair24,25 and extra-articular tenodesis alone12,14 in children and adolescents have had poor results, similar to the outcomes seen in adults. Transphyseal reconstructions with tunnels that violate both the distal femoral and proximal tibial physes have been performed with hamstrings autograft, patellar tendon autograft, and allograft tissue11,14,26-35. Partial transphyseal reconstructions damage only one physis with a tunnel through the proximal tibial physis and over-the-top positioning on the femur or with a tunnel through the distal femoral physis with an epiphyseal tunnel in the tibia36,37,39,40. A variety of physeal sparing reconstructions to avoid tunnels across either the distal femoral physis or the proximal tibial physis have been described10,38,41-46.
The management of anterior cruciate ligament injuries in prepubescent children and adolescents is particularly vexing, given the large amount of growth remaining. Most clinical series of skeletally immature patients with anterior cruciate ligament injuries have involved adolescent patients, not prepubescent patients. The consequences of growth disturbance in the prepubescent age-group are substantial, requiring major limb reconstruction with osteotomy and/or limb-lengthening. However, anterior cruciate ligament insufficiency must be adequately corrected with reconstructive techniques in order to avoid subsequent meniscal and chondral injuries, which also have substantial consequences. Case reports or small clinical series of patients in this age-group managed with physeal sparing techniques to provide a stable knee while avoiding violation of the physes have been described. DeLee and Curtis43 used a portion of the patellar tendon without drill-holes. Brief42 and Parker et al.46 used hamstrings tendons, left attached distally, that were brought through the knee under the intermeniscal ligament on the tibial side and the over-the-top position on the femoral side. More recently, physeal sparing reconstruction techniques with use of hamstrings tendon in prepubescent patients were described by Guzzanti et al.38, who used an epiphyseal tibial tunnel with distal femoral epiphyseal fixation, and by Anderson41, who used epiphyseal tibial and femoral tunnels.
In the present study, we report the results of a physeal sparing, combined intra-articular and extra-articular reconstruction technique with use of an autogenous iliotibial band graft in prepubescent, skeletally immature children (Fig. 2). In forty-four children who were followed for a mean of 5.3 years, this technique provided excellent functional outcome with a low revision rate and no growth disturbance. Our rationale for the utilization of this technique is to provide knee stability and improve function while avoiding the risk of iatrogenic growth disturbance in prepubescent, skeletally immature patients with complete intrasubstance injuries of the anterior cruciate ligament who have repairable meniscal tears or who have had failure of nonoperative treatment. This series included three prepubescent patients with congenital insufficiency of the anterior cruciate ligament associated with longitudinal deficiency of the lower extremities. Our indications for reconstruction of the anterior cruciate ligament in a child with congenital deficiency of a limb are symptomatic instability that substantially limits function and is uncontrolled by bracing. In older, skeletally immature adolescents (Tanner stage 3 and 4) with an anterior cruciate ligament injury, we perform transphyseal reconstruction with a quadrupled hamstrings tendon graft with fixation away from the physes. However, in our opinion, the consequences of potential iatrogenic growth disturbance caused by transphyseal reconstruction in prepubescent children are prohibitive and, therefore, we perform the physeal sparing reconstruction. This procedure is nonanatomic as the graft is in the over-the-top position on the femur and under the intermeniscal ligament on the tibia. Although nonanatomic, it provided for a stable knee with excellent function in children who returned to sports that involved cutting and pivoting. We counsel parents that this may be a temporizing procedure for later conventional reconstruction near skeletal maturity; however, this technique has functioned as the definitive reconstruction for most of our patients.
A table showing the Tanner staging system is available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation and click on “Supplementary Material”) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). ▪
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
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Investigation performed at the Division of Sports Medicine, Department of Orthopaedic Surgery, Children's Hospital, Harvard Medical School, Boston, Massachusetts
1. , Micheli LJ, Gerbino P, Hresko MT. Tibial eminence fractures in children: prevalence of meniscal entrapment. Am J Sports Med. 2003;31: 404-7.
2. . Children's fractures. 2nd ed. Philadelphia: Lippincott; 1983.
3. , Foreman ES, Micheli LJ. Laxity and functional outcome after arthroscopic reduction and internal fixation of displaced tibial spine fractures in children. Arthroscopy. 2003;19: 1085-90.
4. , Mandiga R, Klingele K, Bley L, Micheli LJ. Anterior cruciate ligament injury versus tibial spine fracture in the skeletally immature knee: a comparison of skeletal maturation and notch width index. J Pediatr Orthop. 2004;24: 185-8.
5. , Larsen ST, Schmidt MB. The significance of hemarthrosis of the knee in children. Arch Orthop Trauma Surg. 1988;107: 96-8.
6. , Koltai JL, Dittmer H. Significance of arthroscopy in children with knee joint injuries. Eur J Pediatr Surg. 1992;2: 169-72.
7. , DiCanzio J, Zurakowski D, Micheli LJ. Diagnostic performance of clinical examination and selective magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents. Am J Sports Med. 2001;29: 292-6.
8. . Acute traumatic knee effusions in children and adolescents. J Pediatr Orthop. 2003;23: 199-202.
9. , Harvell JC, Fu F. Observations on acute knee hemarthrosis in children and adolescents. J Pediatr Orthop. 1993;13: 506-10.
10. , Kinnuen P, Serlo W. Arthroscopy of the acute traumatic knee in children. Prospective study of 138 cases. Acta Orthop Scand. 1993;64: 580-2.
11. , Patel DV, Zorrilla P. The natural history and treatment of rupture of the anterior cruciate ligament in children and adolescents. A prospective review. J Bone Joint Surg Br. 2002;84: 38-41.
12. , Lange RH, Fujisaki CK, Landry GL, Saluja RK. Anterior cruciate ligament tears in skeletally immature patients: meniscal pathology at presentation and after attempted conservative treatment. Arthroscopy. 1992;8: 229-33.
13. , Nystrom A, Werner S, Hirsch G. Anterior cruciate ligament injuries in skeletally immature patients. J Pediatr Orthop. 1996;16: 673-7.
14. , Rettig AC, Shelbourne KD. Anterior cruciate ligament injuries in the young athlete with open physes. Am J Sports Med. 1988;16: 44-7.
15. , Willis AA, Warren RF. Associated injuries in pediatric and adolescent anterior cruciate ligament tears: does a delay in treatment increase the risk of meniscal tear? Arthroscopy. 2002;18: 955-9.
16. , Kubota K, Shiraishi M, Otsuka Y, Nagamoto N, Takagi K. The conservative treatment of complete tears of the anterior cruciate ligament in skeletally immature patients. J Bone Joint Surg Br. 1995;77: 890-4.
17. , Letts RM, Jarvis JG. Anterior cruciate ligament tears in children: an analysis of operative versus nonoperative treatment. J Pediatr Orthop. 1997;17: 505-11.
18. , Falciglia F, Gigante A, Fabbriciani C. The effect of intra-articular ACL reconstruction on the growth plates of rabbits. J Bone Joint Surg Br. 1994;76: 960-3.
19. , Greene CC, Baratta RV, Zieske A, Willis RB. The effect of placing a tensioned graft across open growth plates. A gross and histologic analysis. J Bone Joint Surg Am. 2001;83: 725-34.
20. , Letts M, Yang J. Effects of a tensioned tendon graft in a bone tunnel across the rabbit physis. Clin Orthop Relat Res. 2001;391: 275-81.
21. , Anderson AF. Tears of the anterior cruciate ligament in adolescents. J Bone Joint Surg Am. 1986;68: 19-28.
22. , Sanders JO. Valgus deformity after reconstruction of the anterior cruciate ligament in a skeletally immature patient. A case report. J Bone Joint Surg Am. 1999;81: 711-5.
23. , Saxon HS, Hovis WD, Hawkins RJ. 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;22: 452-7.
24. , DeLee JC, Sanders B, Neidre A. Knee ligament injuries in children. J Bone Joint Surg Am. 1979;61: 1195-201.
25. , Svenningsen S, Benum P. Poor results of anterior cruciate ligament repair in adolescence. Acta Orthop Scand. 1988;59: 684-6.
26. , Hall DJ. Anterior cruciate ligament injury in children and adolescents. Arthroscopy. 1989;5: 197-200.
27. , Ganley TJ, Goode JR, Gregg JR, Meyer JS. Anterior cruciate ligament reconstruction in adolescents with open physes. Am J Sports Med. 2000;28: 168-75.
28. , Grana WA. Anterior cruciate ligament reconstruction in the immature athlete: long-term results of intra-articular reconstruction. Am J Knee Surg. 2001;14: 232-7.
29. , Wheatley W, Uribe JW, Hechtman KS, Zvijac JE, Schurhoff MR. Intra-articular anterior cruciate ligament reconstruction using patellar tendon allograft in the skeletally immature patient. Arthroscopy. 2002;18: 824-8.
30. , Siegel MG. Arthroscopic reconstruction of the ACL with semitendinosis-gracilis autograft in skeletally immature adolescent patients. Am J Knee Surg. 1997;10: 60-9.
31. , Shelbourne KD, Porter DA, Rettig AC, Murray S. Patellar tendon graft reconstruction for midsubstance anterior cruciate ligament rupture in junior high school athletes. An algorithm for management. Am J Sports Med. 1994;22: 478-84.
32. , Gray T, Wiley BV. Results of transphyseal anterior cruciate ligament reconstruction using patellar tendon autograft in tanner stage 3 or 4 adolescents with clearly open growth plates. Am J Sports Med. 2004;32: 1218-22.
33. , Metcalf MH, Larson RV. Anterior cruciate ligament injuries in the skeletally immature patient. Am J Orthop. 1999;28: 624-8.
34. . Anterior cruciate ligament injury in the skeletally immature patient: diagnosis and treatment. J Am Acad Orthop Surg. 1995;3: 146-58.
35. , Galli M, Bait C, Pozzoni R. Surgical treatment of anterior cruciate ligament injuries in adolescents using double-looped semitendinosis and gracilis tendons: supraepiphysary femoral and tibial fixation. Arthroscopy. 2004;20: 447-9.
36. , Noyes FR, Barber-Westin SD. Anterior cruciate ligament allograft reconstruction in the skeletally immature athlete. Am J Sports Med. 1994;22: 48-54.
37. , Wickiewicz T, Levinson M, Warren R. ACL reconstruction in children with open physes. Orthopedics. 1998;21: 659-63.
38. , Falciglia F, Stanitski CL. Physeal-sparing intraarticular anterior cruciate ligament reconstruction in preadolescents. Am J Sports Med. 2003;31: 949-53.
39. , Falciglia F, Stanitski CL. Preoperative evaluation and anterior cruciate ligament reconstruction technique for skeletally immature patients in Tanner stages 2 and 3. Am J Sports Med. 2003;31: 941-8.
40. , Kirkley A, Fowler PJ, Miniaci A. The outcome of operatively treated anterior cruciate ligament disruptions in the skeletally immature child. Arthroscopy. 1997;13: 627-34.
41. . Transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients. A preliminary report. J Bone Joint Surg Am. 2003;85: 1255-63.
42. . Anterior cruciate ligament reconstruction without drill holes. Arthroscopy. 1991;7: 350-7.
43. , Curtis R. Anterior cruciate ligament insufficiency in children. Clin Orthop Relat Res. 1983;172: 112-8.
44. , Ha KI, Ahn JH, Chang DK. Anterior cruciate ligament reconstruction in the young patient without violation of the epiphyseal plate. Arthroscopy. 1999;15: 792-5.
45. , Rask B, Gerberg L. Anterior cruciate ligament reconstruction in patients who are prepubescent. Clin Orthop Relat Res. 1999;364: 40-7.
46. , Drez D Jr, Cooper JL. Anterior cruciate ligament injuries in patients with open physes. Am J Sports Med. 1994;22: 44-7.
47. , Pyle SI. Radiographic atlas of skeletal development of the hand and wrist. 2nd ed. Stanford: Stanford University Press; 1959.
48. , Whitehouse RH. Clinical longitudinal standards for height, weight, height velocity, and stages of puberty. Arch Dis Child. 1976;51: 170-9.
49. , Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P, Richmond JC, Shelborne KD. Development and validation of the international knee documentation committee subjective knee form. Am J Sports Med. 2001;29: 600-13.
50. , Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10: 150-4.
51. , Darby TA. Lateral substitution reconstruction [abstract]. In: Proceedings and reports of universities, colleges, councils and associations. J Bone Joint Surg Br. 1976;58: 142.
52. , Potter HG, Paletta GA Jr. The relationship of the femoral origin of the anterior cruciate ligament and the distal femoral physeal plate in the skeletally immature knee. An anatomic study. Am J Sports Med. 2001;29: 781-7.
53. , Micheli LJ, Zurakowski D, Luke A. Partial tears of the anterior cruciate ligament in children and adolescents. Am J Sports Med. 2002;30: 697-703.
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54. , Arnoczky SP, Dodds J, Ross H. The effect of drilling and soft tissue grafting across open growth plates. A histologic study. Am J Sports Med. 1995;23: 431-5.