Adolescent ACL Injury - acldoc.orgacldoc.org/articles3/ACL-Adolescent ACL Injury.pdf · over a 10-year period.52 The authors reported no ACL tears in children aged 10 years, whereas

INTRODUCTION

Anterior cruciate ligament (ACL) injuries in the active,skeletally immature patient present a difficult problem.Nonoperative treatment in sedentary individuals is a viableoption. However, the natural history of the ACL-deficientknee in younger age groups parallels that of the adult pop-ulation and is characterized by recurrent instability, menis-cal tears, and chondral injury. Surgical treatment involvingextraphyseal reconstruction often has less than desirableresults, whereas transphyseal fixation presents the potentialof growth plate disturbance and subsequent limb malalign-ment.

Previous studies of midsubstance tears in the skeletal-ly immature athlete suggest they are uncommon and

occur with a 1%-3% incidence in children aged �14years.15,31 Many authors maintain that tibial spine avul-sion is more likely due to the added strength of the ACLversus the epiphyseal plate. However, a recent literaturereview revealed an increase in midsubstance tears, possi-bly due to increased participation in organized athletics inyounger age groups, increased awareness of such injuries,and improved diagnostic abilities and techniques (eg,magnetic resonance imaging [MRI] and KT-1000).

Traditionally, nonoperative care has been the mainstayof treatment in this age group. Education, activity modifi-cation, and rehabilitation, combined with bracing, havebeen traditionally recommended. However, high noncom-pliance rates combined with functional instability placethese patients at high risk for recurrent knee injury. Studieshave demonstrated an increased incidence of instabilityand meniscal tears despite rehabilitation and bracing.

Fear of premature growth plate closure and angulardeformities and limb-length inequalities have prompted theinvestigation of several nonanatomic, extraphyseal ACLreconstruction techniques as well as several alternativetransphyseal techniques. Many of these studies involving

79

Adolescent ACL InjuryTreatment Considerations

Raymond Pavlovich, Jr, MDSteven H. Goldberg, MDBernard R. Bach, Jr, MD

Drs Pavlovich, Goldberg, and Bach are from the Department ofOrthopedic Surgery, Rush University Medical Center, Chicago, Ill.

Reprint requests: Bernard R. Bach, Jr, MD, Dept of OrthopedicSurgery, Rush University Medical Center, 1725 W Harrison St, Ste1063, Chicago, IL 60612.

ABSTRACT: Anterior cruciate ligament (ACL) injuryin a skeletally immature patient presents unique treat-ment challenges. In many cases, conservative treat-ment with bracing and physical therapy fails, result-ing in recurrent instability, pain, swelling, and menis-cal and chondral injury. The goal of surgical recon-struction is to recreate ACL stability without causinggrowth plate arrest, leg-length discrepancy, or angu-lar deformity. Patient characteristics such as skeletalage, Tanner stage, onset of menses, family memberheight, growth spurt, recent change in foot size, andgrowth charts can help the surgeon approximate thedegree of skeletal maturity and aid in selecting the

timing and safest type of reconstruction. Numeroussurgical techniques, ranging from an extra-articularreconstruction to intra-articular graft passage with-out physeal violation to standard transtibial andtransfemoral tunnel placement with physeal violation,have been popularized. The majority of existing stud-ies are retrospective case series, describing a particu-lar author’s specific technique experience. This articlereviews the basic science and clinical literature, pre-sents a treatment algorithm, and provides several casestudies.

[J Knee Surg. 2004;17:79-93.]

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the skeletally immature patient are limited due to difficultiesin classifying growth potential at the time of injury andtreatment (Table 1A).3,9,19,22,33,37,45,46 Differences in genderand method of reporting age (skeletal versus chronologic)present investigators with a challenge. Various methods ofestimating the degree of skeletal maturity include the deter-mination of skeletal age, gender, parental and siblinggrowth characteristics, degree or stage of secondary sexualcharacteristic growth, occurrence of a growth spurt, changesin shoe size, and postinjury height changes at follow-up.

BackgroundThe differential diagnosis of knee pain and

hemarthrosis in the skeletally immature patient includesligamentous tear, tibial spine avulsion fracture, meniscaltear, patellar sleeve fracture, distal femoral physeal frac-ture, capsular tear, and osteochondral fracture. Anteriorknee instability can arise from ligamentous or bonysources. The differential diagnosis of anterior instabilityincludes an ACL injury, congenital ACL deficiency,excessive hyperelasticity, and periarticular fractures

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THE JOURNAL OF KNEE SURGERY April 2004/Vol 17 No 2

TABLE 1ALITERATURE REVIEW

Avg Chronologic Physiologic Age Study Growth Study Age (y) (range) Determination Size (n) Plate

Aichroth et al1 13 (11-15) Tanner, family growth 47 24 wide opencharacteristics 21 closing

Andrews et al4 13.5 (10-15) Bone age left hand, Tanner, 8 Openfamily growth characteristicslower-limb growth indices

Aronowitz7 13.4 (11-15) Bone age left hand, age �14 y 19 Opento undergo surgery

Brief9 17.2 (14-28) None 9 NS

Graf et al19 14.5 (11.7-16.3) NS 4 Open

Janarv et al22 13 NS 28 OpenLipscomb & 12-15 NS 24 11 wide open

Anderson31 13 partially open

Lo et al33 12.9 (8-14) NS but minimum expected 5 5 wide opengrowth was 5 cm

Matava & 14.7 Secondary sexual characteristics 8 NSSiegel37

McCarroll et al38 13.3 (10-14) Bone age left hand, family growth, 10 OpenTanner

McCarroll et al39 13.7 (13-15) Tanner, family growth, growth 60 NSspurt occurrence, degree ofphyseal opening on radiograph

Micheli et al41 11 (2-14) Bone age left hand 8 NS

Parker et al45 13.3 (10.3-14.1) NS 6 All open

Pressman et al46 14.4 (5-17) NS 23 7 open11 closing/closed

Robert & 9.9 (9.3-13) NS 8 NSBonnard47

Abbreviations: ACL=anterior cruciate ligament, allo=allograft, auto=autograft, avg=average, BPTB=bone-patellar tendon-bone, EA=extra-articular, IA=intra-articular, ITB=iliotibial band, NA=not available, NR=not relevant, NS=not specified, OTT=over-the-top, PT=patellar tendon, and ST/G=semitendinosus gracilis.

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(Figure 1). The collagen fibers in the skeletally immatureACL form a strong connection between ligament, peri-chondrium, and epiphyseal cartilage, whereas in the adultACL, weaker Sharpey’s fibers form the link between lig-ament and bone.11 This difference in ligamentous attach-ment between the adult and child may play a role in thepattern of knee injury seen in each age group.

Kellenberger and von Laer27 observed that tibial spineavulsion occurred 80% of the time in children aged �12years whereas midsubstance tears occurred 90% of the

time in children aged �12 years. The age dependency ofACL injury in skeletally immature children was furtherdemonstrated in another retrospective review of 1273children aged �16 years presenting to a trauma centerover a 10-year period.52 The authors reported no ACLtears in children aged �10 years, whereas they foundoccasional tears in children aged 11-12 years, and anincreased frequency in children aged 13-16 years.52 Raretraumatic ACL injury has occurred in children aged �10years.33,41,46,47

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Adolescent ACL Injury

ReconstructionGraft Type Tibial Femoral Other

ST/G auto Transphyseal, titanium Transphyseal, titanium Nonestirrup positioned away screw aimed away fromphysis from physis

5 freeze-dried fascia lata allo, Transphyseal 7-mm tunnel, OTT fixed w/ staples Some ACLs repaired1 fresh-frozen Achilles allo more vertical fixed w/ or tied over washer2 irradiated Achilles allo staples or tied over washer

Cryopreserved Achilles allo Transphyseal 9-10 mm tunnel Transphyseal 9-10 mm Nonefixed by press-fitting tunnel fixed with staples

ST/G auto released at Passed under anterior OTT fixed w/ staples EA ITB tenodesismusculotendinous junction, horn medial meniscusattached distally

2 modified Andrews ITB NR NR Nonetenodesis, 2 ST passed IA Tibial tunnel OTT fixed to femur

12 ST auto, 4 PT auto, 4 data NA Transepiphysis OTT fixed w/ staples NoneST/G auto Transphyseal 6.4-mm tunnel Transepiphyseal 8-mm 3 Ellison and 18

tunnel (two incision Losee EAtechnique) sutured to augmentationsperiosteum

3 ST/G auto, 2 quadriceps More vertical transphyseal OTT fixed w/ staples Noneand PT auto 6-mm tunnel; tendons

attached distally,supplemental fixation NS

ST/G auto Transphyseal 7-9 mm tunnel Transphyseal 7-9 mm Nonefixed w/ suture over tunnel fixed w/ buttonbutton or staple w/ or w/o staple

3 AO ITB tenodesis, 7 modified NR NR NSAndrews ITB tenodesis

BPTB auto Transphyseal fixed w/ Transphyseal fixed w/ 2 had prior EAinterference screw interference screw reconstruction

ITB Trough in metaphysis made, ITB passed behind OTT Posterolateral cornerITB passed deep to inter- position, into the joint repairmeniscal ligament, sutured and sutured to femurto tibia

5 ST/G auto, 1 doubled loop Groove in tibial ephiphysis, Groove in distal femur in 3 ACLs repairedST auto 5 were left attached, in OTT position fixed w/

1 stapled staples 6 ST auto Transphyseal Transphyseal in 20, None

17 BPTB auto fixation NS OTT in 3Free PT Epiphyseal groove Outside-in extraphyseal None

fixed with staples tunnel, fixed with interference screw

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DiagnosisThe diagnosis of ACL tears should be based primarily

on clinical history and physical examination. The injurymechanism can include a noncontact twisting injury, val-gus blow to the leg with the foot fixed on the ground, orforced knee hyperextension. Usually an audible “pop” isheard at injury. Acutely, the patient presents with pain,knee effusion within hours of injury, decreased range ofmotion, and difficulty bearing weight. Chronically, a childmay present with recurrent effusion and recurrent instabil-ity. Clinically, the diagnosis is established with an asym-metric anterior drawer, Lachman test, pivot shift test, orKT-1000 side-to-side differences �3 mm. Joint line ten-derness and provocative meniscal rotation tests (eg,McMurray test, Apley compression test) should be per-formed to evaluate for associated meniscal tears.

Magnetic resonance imaging of the knee is highlysensitive and specific in evaluating adult knee pathology.However, MRI does not provide increased diagnosticability over clinical examination in children.29 In onestudy, MRI and clinical examination both had a sensitivi-ty of 71% and specificity of 92%. Other studies indicatedthe sensitivity may be as low as 50% and specificity aslow as 64%.28,36,50,55 Variations in developmental anato-my, less experience interpreting MRI in skeletally imma-ture patients, smaller anatomic structures, and a higherincidence of partial ligamentous injuries may contributeto the lower sensitivity and specificity seen in children.29

Additionally, one study showed meniscal signal abnor-malities in 6 of 13 patients, all with normal menisci onarthroscopic examination. This confirmed other reports

that increased meniscal signal in children has a high false-positive rate and may be due to increased vascularitycompared to the adult meniscus.52

McDermott et al40 emphasized the sensitivity, speci-ficity, and accuracy of MRI is in part age-dependent.They reported that MRI evaluation of adolescents (chil-dren aged �15 years) yielded similar results as adultpatients, whereas MRI evaluation of children aged �15years had decreased sensitivity, specificity, positive pre-dictive value, and accuracy for all knee injuries.40 Due tothe difficulties in interpreting knee MRI in youngerpatients, the clinician should be aware of its limitationswhen weighing its importance in the diagnostic scheme.

Arthroscopic evaluation and evaluation under anesthe-sia are valuable diagnostic adjuncts in the young patientwith a hemarthrosis when the clinical examination is equiv-ocal. In one study, in which arthroscopy was performed inskeletally immature patients with a hemarthrosis, 47% hadan ACL tear. Furthermore, examination under anesthesia forevidence of laxity or a pivot shift prior to arthroscopy alsoprovides valuable clinical information to aide in the diagno-sis of an ACL injury. In the majority of cases, arthroscopyis not necessary to diagnose an ACL injury.

Natural HistoryIn the adult, evidence indicates that active patients with

an ACL-deficient knee will experience repeated episodesof instability resulting in chondral injury, meniscal tears,recurrent swelling, and pain.3,8,10,12,25,54 The natural historyof the ACL-deficient knee in the younger population paral-

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Figure 1. High-resolution radiograph of a proximal caninetibia 2 weeks after drilling across the growth plate. The lon-gitudinal arrangement of the trabecular bone in the rapidlydistracting metaphyseal bone is similar to that observedduring distraction osteogenesis. (Reprinted with permissionfrom Stadelmaier DM et al. The effect of drilling and soft tis-sue grafting across open growth plates. A histologic study.Am J Sports Med. 1995;23:431-435. Copyright © 1995.American Orthopaedic Society for Sports Medicine.)

Figure 2. Photomicrogaph of the tibial section seen in Figure1. Note the bony bridge that spans the growth plate (hema-toxylin-eosin, original magnification �40). (Reprinted withpermission from Stadelmaier DM et al. The effect of drillingand soft tissue grafting across open growth plates. A histo-logic study. Am J Sports Med. 1995;23:431-435. Copyright ©1995. American Orthopaedic Society for Sports Medicine.)

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lels that of the adult population. Numerous studies havedocumented poor results with long-term conservative man-agement including physical therapy and bracing.5,19,39,46

Compliance with activity modification often is difficult toachieve in adults and may be even more difficult in chil-dren. Furthermore, committing a young patient to years ofactivity modification and bracing may be unrealistic.

In most case series,19,26 a high incidence of recurrentinstability, pain, swelling, and new meniscal tears occursin skeletally immature patients treated nonoperatively fora complete ACL tear. In one study, all 7 patients with anaverage age of 14.8 years who were treated conservative-ly had fair or poor results. Four patients had definitiveradiographic evidence of arthritis at follow-up.26 In anoth-er study, 8 patients with an average age of 14.5 years andopen physes were treated with supervised physical thera-py and bracing. Seven of 8 patients experienced newmeniscal tears at an average of 15 months from initialinjury.19 Additionally, most children treated conservative-ly have exhibited difficulty in returning to their preinjurylevel of sports participation, as reported by Mizuta et al42

where only 1 of 18 patients returned to the preinjury levelof athletics and 11 of 18 patients had radiographicFairbanks’ criteria of arthritis at minimum 36-month fol-low-up.42 In light of the difficulties involved with conser-vative treatment of ACL injuries in active children, manyclinicians have advocated surgical intervention.

In adults, ACL reconstruction principles involve use ofstrong grafts, anatomically created tunnels, and rigid fixa-tion. In a patient with open physes, creation of femoral ortibial bone tunnels would violate the physes if placed in an

anatomic position. Concerns of possible growth disturbanceas a result of physeal drilling and transphyseal graft place-ment has led many clinicians to avoid such a procedure inthe skeletally immature patient. These concerns haveprompted numerous animal investigations of physeal growthcharacteristics. These studies suggest that physeal defectsize, filling of the defect with soft tissue, and magnitude oftension placed across the physis may significantly affectgrowth plate function.16,21,35 Additionally, abnormal growthmay result in the absence of bony bridge formation.16

Animal StudiesStadelmaier et al49 examined the effect of soft-tissue

grafting on the prevention of physeal bar formation. Eightcanines underwent transphyseal drilling of the tibia andfemur with or without placement of a fascia lata autograftin the drill hole. Drill hole size was calculated to representthe same ratio of hole size to physeal surface area as wouldbe expected in a skeletally immature child. All four non-grafted canines developed bony physeal bridging, whereasthe grafted subjects showed no evidence of bridge forma-tion or alteration of growth plate morphology on eitherradiographic or histologic analysis (Figures 1-4). Thisstudy illustrates the importance of completely filling thedrill hole with soft tissue to prevent bony bar formation.

Other investigators have attempted to quantitate thedegree of physeal destruction that results in growth distur-bance. Makela et al35 showed that growth disturbance,osseous bridging, and epiphyseal cartilage changes werenot observed when drilling across 13% of the transversediameter (3% of total cross-sectional area) of the distal

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Figure 3. High-resolution radiograph of a proximal canine tibia 4 months after placement of a fascia lata graft through adrill hole made across the open growth plate. No bony formation is noted across the growth plate in the bone tunnel.(Reprinted with permission from Stadelmaier DM et al. The effect of drilling and soft tissue grafting across open growthplates. A histologic study. Am J Sports Med. 1995;23:431-435. Copyright © 1995. American Orthopaedic Society for SportsMedicine.) Figure 4. Photomicrograph of the section seen in Figure 4. The graft crosses the growth plate, and no bony for-mation is noted across the physis. Note that the growth plate immediately adjacent to the graft-filled tunnel appears nor-mal (hematoxylin-eosin, original magnification �40). (Reprinted with permission from Stadelmaier DM et al. The effect ofdrilling and soft tissue grafting across open growth plates. A histologic study. Am J Sports Med. 1995;23:431-435. Copyright© 1995. American Orthopaedic Society for Sports Medicine.)

3 4

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femoral physis in rabbits, but the above changes wereobserved when drilling across 20% of the transverse diam-eter (7% of total cross-sectional area). Guzzanti et al21

reported the effect of transphyseal reconstruction of theACL in skeletally immature rabbits using semitendinosustendon autograft and proximal femoral periosteal suturefixation. The procedure resulted in damage to 3% of thecross-sectional area of the femoral physis and 4% of thecross-sectional area of the tibial physis. Histologic exami-nation did not reveal evidence of epiphysiodesis, but 2 of21 rabbits developed tibia valgus and 1 tibia was shortened.These studies demonstrate a critical threshold of cross-sec-tional physeal injury that results in growth abnormalities.From a practical standpoint, a more vertically oriented tib-ial tunnel results in less transphyseal violation.

The physis responds differently to force depending onthe direction in which the force is applied. The Delpechprinciple states a physis will respond to tension withincreased growth.16 Conversely, the Heuter-Volkmanprinciple states the application of compressive force per-pendicular to the physis will inhibit longitudinal growth.6

A recent study involving transphyseal placement of fascialata autograft in the knees of skeletally immature beaglesfollowed by graft tensioning to 80 N resulted in statisti-cally significant distal femoral valgus deformity andproximal tibial varus deformity.16 These growth distur-bances occurred in the absence of radiographic or histo-logic evidence of physeal bar formation, leading theauthors to caution against transphyseal reconstruction inthe skeletally immature patient population.16

Modifications in surgical technique may help minimizephyseal damage if a transphyseal reconstruction is neces-sary in a skeletally immature patient. As animal studiesindicate a critical threshold of physeal damage must occurbefore growth disturbance results, tunnel size can bedecreased to 6-7 mm to limit the physeal surface area that isdamaged by drilling and graft placement.4,33 To minimizedamage to the physis, more vertically oriented tibial andfemoral tunnels will result in smaller, circular physealdefects than more horizontally placed tunnels, which willproduce larger, elliptical defects.4,33 Additionally, choosingan all soft-tissue graft over bone-tendon-bone grafts helpsminimize physeal bar formation.49

Estimation of Bone Age and DeformityAnimal models have generated insight into understand-

ing physeal physiology and response to trauma, but ulti-mately it is unknown exactly how much physeal damagecan occur in humans without producing adverse effects. Toassist physicians in decision making, researchers haveinvestigated means of predicting skeletal growth.

Wester et al53 developed a technique of estimatingmaximal angular deformity and shortening if completegrowth arrest occurs at surgery. They reported that

remaining physeal growth is almost entirely determinedby skeletal age and physeal diameter and is independentof overall leg length. Greater angular deformity is expect-ed in patients with a smaller physeal transverse diameter.Using trigonometry, they generated graphs that predictangular deformity and shortening, which can be used as arough approximation to aid in surgical timing and helpcounsel patients and families on the risks of surgery. Thedistal femur and proximal tibia are responsible for 65% ofthe total leg length, and thus damage to either physis sig-nificantly impacts future limb growth.

Other methods of estimating leg-length inequality canbe used based on the White-Menelaus rule, which statesthe distal femur provides 3/8-inch of growth per yearwhereas the proximal tibia provides 1/4-inch of growthper year. Finally, tables from Green and Anderson can beused to aid in estimation of remaining growth potential.2

In a personal communication, Kuo (K. Kuo, MD)stated that in a patient with 1 year of estimated growthremaining, a growth abnormality does not appear for 6months. However, patients with greater amounts ofgrowth remaining may manifest deformities more quick-ly. This is in agreement with Timperlake et al,51 who stat-ed bony bridge formation after percutaneous epiphys-iodesis occurred within 4-6 months. It is critical to accu-rately estimate remaining growth to make decisions aboutsurgical timing and type of surgical reconstruction.

Most methods of determining remaining growthdepend on accurate determination of bone age.41 Skeletallyimmature patients with an ACL injury should undergo aposteroanterior (PA) radiograph of the left hand and wrist.Bone age can then be determined by comparing this radio-graph to standard images in the Radiographic Atlas ofSkeletal Development of the Hand and Wrist.20

Aside from bone age, numerous secondary factors canalso be used to ascertain the degree of skeletal maturityincluding physeal width on plain radiographs, Tanner stage,parental and sibling height, recent foot growth, growth spurtoccurrence, and menses onset.23,32,39 In females, skeletalgrowth generally occurs for 2 years following menarche. Itis important to remember that skeletal maturity in females(14 years) differs from that in males (16 years).

All of the above clinical information should be used tohelp the surgeon obtain an impression of the degree ofskeletal immaturity to counsel the patient and family andrecommend treatment options. For example, a 12-year-oldpremenarchal patient with a skeletal age of 11 years will betreated differently than a 12-year-old “mature” femalewhose menses began at age 10 years.

SURGICAL TECHNIQUES

Primary ACL RepairPrimary unaugmented ACL repair has been shown to

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have a low probability of long-term success with activitylimitation and instability as the rule. During injury, in addi-tion to the gross mechanical tearing of the ligament, a morediffuse, microscopic deformation and stretching of individ-ual fibers occurs. Fiber elongation results in a functionallengthening of the tendon on suture reapproximation.When the ACL is torn, a loss of the vascular supply alsooccurs due to tearing of branches of the middle genicularartery and the medial and lateral inferior genicular arteries.Finally, the normally extrasynovial ACL becomes intrasyn-ovial as a result of the tearing of its protective synovialsheath. The combination of the collagen fiber stretching,loss of blood supply, and damage to the synovial sheathmakes ACL injury healing unpredictable and unlikely.23

A prospective study of acute repair of the ACL com-pared to acute repair with augmentation was performedon adults in 1990 and is presented for a historical per-spective.24 The augmentation consisted of placing a dis-tally attached strip of patellar retinaculum through tibialand femoral drill holes with imbrication to the repairedACL. In the repair group, 16 of 22 patients decreasedtheir activity level, 15 of 22 had �2� on anterior drawertesting, 10 of 22 had a positive Lachman test, and 8 of 22had a positive pivot shift test at follow-up. The augmen-tation group had improved results in all of the above cat-egories. The unacceptable levels of knee instability andlimitation of activity in the repair group is consistent withother studies of acute ACL repair.18,34,44 Furthermore,Cross et al13 showed that failure of the repaired ligamentoccurred over time with increased anterior tibial transla-tion developing between 2- and 7-year follow-up.

Results of ACL repair in the skeletally immature pop-ulation mirrors that of the adult population. DeLee andCurtis15 treated three patients, aged �12 years, with pri-mary unaugmented ACL repair, and at 20-month follow-up, all three had clinically significant laxity and abnormalLachman testing. Engebretsen et al17 also attemptedunaugmented primary repair in children and reported 8 of8 patients had to modify their activities and 5 of 8 patientshad significant instability. In light of these poor results,most surgeons have directed surgical attempts towardsreconstruction.

Surgical ReconstructionThe literature review regarding ACL reconstruction in

the skeletally immature patient is challenging due to sev-eral factors. The overall low incidence of these injurieslimits study size and power. Limited preoperative assess-ment of skeletal maturity and potential for future growthcombined with the grouping of patients of various agesmakes interpretation of outcomes difficult. Authors oftenhave failed to delineate between pre-and postpubescentpatients. Reporting of chronologic rather than skeletal agehas been a major weakness of some studies. Diverse sur-

gical techniques and varying postoperative evaluationsadd to the complexity in developing conclusions aboutefficacy and safety. Ideally, postoperative scanogramswould most accurately detect any leg-length discrepancy.The above limitations should be considered when criti-cally reviewing the literature regarding ACL injury treat-ment in the skeletally immature patient.

Extraphyseal Reconstruction. To avoid physeal viola-tion and a possible growth disturbance, several investiga-tors have described nonanatomic, nonisometric, extraphy-seal techniques aimed at restoring knee stability.14,15

DeLee and Curtis15 recommended using the iliotibialband by releasing it proximally and passing it through thefemoral notch, proximal to the distal femoral physis andthen under the lateral collateral ligament. The iliotibialband is then fixed to Gerdy’s tubercle with a screw.15

Bergfeld described using a portion of the patellar tendon,which is detached proximally and passed beneath thetransverse ligament (“tomato stake” procedure). It is thenattached in the “over the top” position.14 Drez modifiedBergfeld’s technique by fashioning a groove in the tibialepiphysis and lateral femoral condyle, allowing the graftto lie in a more anatomic position.14

Several extraphyseal reconstruction cases series havebeen published with most authors reporting mixed results(Tables 1A and 1B).9,19,22,38,41,45,47 McCarroll et al38

reported midsubstance ACL tears in 10 patients and Grafet al19 reported 2 patients who underwent extra-articularreconstruction without violating either physes. No leg-length discrepancies or angular deformities were report-ed. Postoperative instability physical examination dataand standardized knee score outcomes were not specifiedor reported. Most patients were able to return to prioractivity (55 [92%] of 60), and only 3 (5%) patients had aKT-1000 �5 mm degree of instability. Three (25%) of 12patients in these studies sustained postoperative meniscaland graft tears requiring revision ACL or meniscalsurgery. Although minimizing the risk of growth-plateinjury, at the expense of continued instability and recur-rent injury, these techniques are limited to prepubescentpatients who have failed conservative treatment.

To improve postoperative stability allowing for a returnto sports while minimizing the risk for growth abnormality,several authors have developed ACL reconstruction tech-niques that use an intra-articular graft passage without phy-seal violation (Figure 5). Brief9 reported 9 patients, Janarvet al22 16 patients, Micheli et al41 8 patients, Parker et al45 6patients, and Robert et al47 8 patients. No leg-length dis-crepancies or angular deformities were reported at follow-up. Physical examination for instability revealed �3-mmmaximum manual difference with KT-1000 testing in mostcases, a Lachman grade of 0 or 1, and a negative pivot shiftphenomenon in instances where it was tested.4,9,22,31,33,39,47

Lysholm scores ranged from 92-97 in three studies.22,41,45

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TABLE 1BLITERATURE REVIEW

Follow-Up KT-1000Leg-Length Angular Side-to-Side

Study Avg (mo) Discrepancy Deformities Difference (mm)

Aichroth et al1 49 None None NS

Andrews et al4 58 1 tibia 10 mm shorter; 1 tibia None 5 �3 mm, 3 3-5 mm8 mm longer; 5/8 femurs different by �7 mm; 2 femursshorter by 10 and 11 mm;1 femur �10 mm

Aronowitz et al7 25 Avg 0.12 cm shorter w/ range None 20-lb force avg 1.7 mm0.7 cm shorter to 0.5 cm longer (range 0-3)

Brief9 (36-78) NS NS Only tested 5 patients:4 max man �3 mm1 max man 5 mm

Graf et al19 23 None None NS

Janarv et al22 30 None None Avg at 89 N 1.5 mm

Lipscomb & 35 No preop data, postop equal Femorotibial valgus Avg at 20-lb force 1.8 Anderson31 in 7; differences of �5 mm angulation equal in 20, mm (range: �7 to 3.5)

in 10; operative limb longer 2 had 1° difference,in 6 and shorter in 4; difference 1 had 2° difference,of 5-10 mm in 5 w/ operative 1 had 3° differencelimb longer in 3, shorter in 2;1.3 cm longer in 1 and 2 cm longer in 1

Lo et al33 87 No subjective complaints No significant deformities Mean 1 mm max manavg �0.8�3.4 mm mean difference 1.0 none w/ difference(range: �5 to 4 mm) (range: �2 to 3) �3 mm

Matava & 32 Overall leg-length avg �1 mm None �5° 5 at 30 lb �3 mmSiegel37 (range: �7 to 7 mm); femur 1 at 30 lb 8 mm

avg �1 mm (range: �7 to 2 had contralateral5 mm); tibia, avg 1 mm injuries not compared(range: �3 to 3 mm)

McCarroll et al38 26 None None NS

McCarroll et al39 49 None �1 cm None 51 �3.5 mm max man,4-5 mm max man in 6�5 mm max man in 3

Micheli et al41 66.5 2 year old with congenitally None Avg max man 1.1 mmabsent ACL developed 2-cm (range: �2 to 4.5 mm)discrepancy thought to be due to congenital disorder and unrelated to surgery

Parker et al45 33 All operative legs 1 cm None Max man 3.6 mm longer

Pressman et al46 64 None �1 cm None ST max man 6.1 mm;PT max man 3.5 mm

Robert & 42 No difference in 4; 0-5-cm None Max man 0 mm in 2Bonnard47 difference in 3; 0.7-cm max man 1 mm in 3

difference in 1 max man 3 mm in 3

Abbreviations: ACL=anterior cruciate ligament, avg=average, dis=displacement, EA=extra-articular, HSS=Hospital for Special Surgery, IA=intra-articular, IKDC=International Knee Documentation Committee, max man=maximum manual, NS=not specified, postop=postoperative, preop=preoperative, PT=patellar tendon graft, and ST=semitendinosus graft.

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SubsequentLachman Pivot Shift Activity Level Final Rating Surgery/Reinjury

16 grade 0, 27 grade 0, NS IKDC: 21 grade A, 3 reruptures, 1 from a20 grade 1 15 grade 1, 15 grade B, fall and 2 from sports-8 grade 2, 2 grade 2, 8 grade C, related injuries;3 grade 3 3 grade 3 3 grade D reconstruction NS

5 grade 0 NR 1 patient limited running and 6 excellent, 4 tibial hardware3 grade 1 turning 1 good, 1 fair removals, 1 arthro-

scopic release, 1 arthroscopic chondro-plasty; 1 ACL reinjury

5 grade 1 All grade 0 16/19 returned to prior level Lysholm avg 97 2 femoral hardware removals; 1 meniscectomy

9 grade 1 NS None returned to prior level w/o 8 satisfied NSbracing 1 dissatisfied

2 grade 1 2 grade 0 4 returned to prior level, 2 EA NS 1 meniscal repair and2 not 2 not reported reconstructions suffered sympto- IA ACL reconstruction;reported matic instability and new meniscal 1 bilateral partial

tears, 2 hybrid asymptomatic meniscectomy with IAACL reconstruction

NS NS Tegner �7 in 9 w/ 2 having lower Lysholm avg 92.6 1 patient w/ meniscal activity than desired; Tegner �6 repair and subsequentin 6 w/ 1 having lower activity reinjury with ACL retearthan desired

11 recorded as 1 positive, 15 w/ return to sport at prior HSS score 45.9 NSabnormal 2 moderate, level; 3 with return to sport w/ (50-pt scale)

3 mild antero- decreased performance; 5 16 excellentmedial returned to all sports except 7 good, 1 fair rotatory football; 1 limited to jogginginstability

4 grade 0 All grade 0 4 returned to prior level; 1 could IKDC score: NS1 grade 1 only perform level III activity 4 Grade A

(due to postop patellar osteo- 1 Grade C chondral fracture)

6 grade 0 1 grade 1, All 8 returned to sports, 3 at same Cincinnati knee 1 recurrent tear; 1 closed1 4-mm dis others NS level, 5 returned to decreased rating: avg 98 manipulation; 1 arthro-1 6-mm dis level for reasons unrelated scopic lysis of

to injury adhesions

NS NS 4 patients with mild instability, NS 1 revision ACL withsurgery needed; 5 asymptomatic PT graft and medialw/ unrestricted activity meniscal repair

NS NS 55/60 returned to prior level NS 3 ACL tears, 1 meniscaltear, 2 arthroscopicreleases

6 grade 0 All grade 0 All returned to sports Lysholm avg 97.4 NS2 grade 1

4 grade 0 All grade 0 4 returned to prior level w/ Lysholm avg 95.2 NS2 grade 1 protective brace, 1 denied

instability but did not return to HSS score 96.6sports to avoid reinjury (100-pt scale)

ST avg 1.9, ST avg 1.4, NS Lysholm: ST 78.6 NSPT avg 1.1 PT avg 0.85 PT 88.4

NS NS Tegner 5 in 1, Tegner 6 in 3 IKDC score: NSTegner 8 in 1, Tegner 9 in 3 5 grade A,

3 grade B

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Four of 5 studies did not comment on reinjury or need forfurther surgery.9,41,45,47 One study reported recurrent menis-cal and ACL tears requiring surgery. These studies suggestthat current intra-articular graft passage techniques mayminimize growth-plate injury and have an improved func-tional outcome compared to an extra-articular reconstruc-tion. A nonanatomic intra-articular reconstruction is, how-ever, inferior to anatomic transtibial and transfemoral tunnelplacement used in skeletally mature patients.

Most reports of extra-articular, nonanatomic knee sta-bilization in the pediatric population with ACL rupturesreveal several deficits. Often, active patients have contin-ued instability resulting in activity modification and areunable to return to preinjury levels of sports participation.Additionally, continued instability may lead to progres-

sive meniscal and articular cartilage pathology. Due tothese limitations, these procedures often are selected foractive, immature patients with a significant potential forfuture growth who have failed conservative treatmentwith the knowledge that future revision surgery may benecessary at skeletal maturity.

Partial Transphyseal Reconstruction. Several reportshave been made involving combined extraphyseal andtransphyseal techniques in skeletally immature individu-als.4,31,33,43 Some authors prefer extraphyseal femoral fix-ation to avoid an eccentrically placed transphyseal tunnel.One reason is the distal femur’s large contribution tooverall leg length (37%)43 in addition to the potential forsubsequent angular deformity that exists with peripheralfemoral tunnel placement. Many authors use transphysealtibial tunnels as the proximal tibia contributes less tooverall leg length (28%)43 and the tunnel is more central-ly placed (Figure 6).

Three studies, with a total of 37 patients, were per-formed by Andrews et al4 (n=8), Lipscomb et al31 (n=24),and Lo et al33 (n=5) using this strategy (Tables 1A and1B). To minimize physeal damage, small transphysealtibial tunnels measuring 6-7 mm were made in a morevertical orientation. Grafts were placed in the over-the-top position on the femur without physeal violation.Additionally, two of the three studies used extra-articularaugmentations or ACL repairs in certain cases. Overall,only 2 patients had �1-cm leg-length discrepancy withsmaller discrepancies noted in many of the other patients.However, Rush and Steiner48 showed that 77% of thegeneral population has a 7-mm leg-length discrepancy.Most studies, unfortunately, did not measure leg lengthspreoperatively. No significant angular deformities werereported. Instability testing revealed a maximum manualdifference of �3 mm on KT-1000 testing in most patientswith a mixture of grades 0 and 1 on pivot shift andLachman testing. The majority of patients had good toexcellent results and were able to return to unrestricted

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Figure 5. Anterior cruciate ligament reconstruction as proposed by Micheli (A). Iliotibial band harvesting (B). The curvedgraft passer is placed around the lateral femoral condyle and through the notch (C). Graft passage around the lateralcondyle and over-the-top position and through the notch (D). Completed reconstruction with the graft sutured to the supe-rior aspect of the lateral femoral condyle and periosteum medial to the tibial tubercle.

A B C D

Figure 6. Graft placement in the over-the-top position ofthe lateral femoral condyle fixated within a cortical troughin the femur.

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activity. Some patients reported no decreased perfor-mance without evidence of instability. One ACL graftreinjury was reported.

All Transphyseal Reconstruction. Several studiesevaluated ACL reconstruction using both tibial andfemoral transphyseal tunnels for graft fixation1,7,37,39,46

(Figure 7). Patients in these studies were typically agedbetween 13 and 14 years and were more likely to havepartially open rather than wide open physes. Patients withwide open physes typically were reconstructed using anall soft-tissue graft whereas those exhibiting characteris-tics consistent with a more skeletally mature age, as wellas the start of physeal closure, were treated with bone-patellar tendon-bone autografts.

Aichroth et al1 (n=47), Aronowitz et al7 (n=19),Matava and Siegel37 (n=8), McCarroll et al39 (n=60),and Pressman et al46 (n=23) represent collectively 157patients with tibial and femoral transphyseal ACLreconstructions. No leg-length inequalities were �1 cmand no angular deformities were reported in these stud-ies. Manual instability testing showed that KT-1000maximum manual differences were typically �3 mm,with �5 mm seen in few patients (Table 1B). The ham-string reconstructions tended to have a slightlyincreased anterior translation on KT-1000 testing(Table 1B). The majority of Lachman and pivot shifttests were grade 0 or 1, with a few grade 2 and 3 results(Table 1B). Several knee score systems were used, andthe majority of patients returned to full activities (Table1B). Seven recurrent ACL tears, 2 meniscal tears, and 4cases of arthrofibrosis requiring arthroscopic debride-ment occurred (Table 1B).

A report of a growth abnormality as a result oftransphyseal ACL reconstruction was published in1999.30 A 14-year-old boy underwent reconstruction witha double-stranded semitendinosus graft anchored with afemoral cannulated screw and tibial staples and cancel-lous bone plug placement in both tunnels. Neither Tannerstage, bone age, family member heights, or an adolescentgrowth spurt were recorded prior to surgery. Two yearslater, despite a stable knee, the patient developed a pro-gressive valgus knee deformity requiring an opening-wedge femoral osteotomy with tricortical bone allograftinterposition and contralateral distal femoral epiphys-iodesis. One year later, the patient was reportedly doingwell without further deformity. Despite the low incidenceof significant leg-length discrepancies or angular defor-mities in the majority of case series, the angular deformi-ty that occurred in this patient emphasizes the theoreticaland real concerns of transphyseal ACL reconstruction inskeletally immature patients.

Treatment AlgorithmBased on the senior author’s (B.R.B.) experience

and review of the available literature, the followingtreatment algorithm has been developed for skeletallyimmature patients with evidence of symptomatic ACLdeficiency.

Initially, the patient’s current skeletal age is deter-mined based on a PA radiograph of the left hand andwrist. Data from Anderson and Green suggests minimalremaining femoral and tibial growth in children with askeletal age of 14 in females and 16 in males (Figure 8).By subtracting their current skeletal age, time to lowerextremity growth completion is estimated. For example,a female patient with a skeletal age of 12 would have anestimated 2 years of remaining lower extremity growth.Thus, a hamstring autograft reconstruction using extra-physeal tibial and femoral graft fixation is recommend-ed. Radiographic appearance of physes, age at menar-che, Tanner stage, a growth spurt, and familial growthcharacteristics are used to further improve the estima-tion of skeletal maturity. Patients with gross instability,unwillingness to comply with activity modification, orboth are treated according to the algorithm in Table 2.

CASE REPORTS

Case 1

A 12-year-old prepubescent boy presented with instabili-ty, catching and locking, pain, and swelling. At priorarthroscopy, an ACL mid-substance tear and displaced

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Figure 7. Guide pin placement used for reaming thetransphyseal tibial tunnel in ACL reconstruction. The tibialentrance site is on the flare of the medial tibial metaphysis.If the tibial tunnel is too steep, the femoral tunnel place-ment may be made too anteriorly with the knee flexed 90°.Similarly, if an appropriate tibial tunnel angle is selected(45°-50°) but the knee is inadequately flexed, posteriorcortical blowout may occur. (Reprinted with permissionfrom Hardin GT et al. Endoscopic single-incision anteriorcruciate ligament reconstruction using patellar tendonautograft: surgical technique. Am J Knee Surg.1992;5:144-155. Copyright © 1992. SLACK Incorporated.)

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peripheral bucket-handle lateral meniscal tear werenoted. He had injured his knee 2 years prior to presenta-tion while attempting to jump over a stream. His motherwas 58 tall and his father was 60. The patient had notyet undergone a growth spurt.

On physical examination, he was 51 tall, weighed 95lbs, and was consistent with a Tanner stage 2. Joint linetenderness, abnormal meniscal rotation signs, painfulrange of motion, and an effusion were noted. A grade 3Lachman, grade 2 anterior drawer, and grade 2 pivot shiftwere noted. KT-1000 testing measurements of 11, 13,and 14 mm were found for the symptomatic knee and 5,5.5, and 6 mm for the contralateral knee at 69 N, 89 N,and maximum manual translation, respectively.

Radiographs exhibited grossly open physes. Due to thepatient’s symptoms and a large repairable meniscal tear,meniscal repair using an inside-out technique and ACLreconstruction using hamstring autograft was performed.Reconstruction was performed using an extraphysealtechnique with transepiphyseal tibial placement (underthe medial meniscus) and over-the-top femoral placementsecured extra-articular fixation (staples/screw and post)(Figure 9).

At 14-month follow-up, KT-1000 measurements were2.5, 3.5, and 4 mm on the affected knee. At 6-year follow-up, the patient had grown 12 inches in height, reported noinstability, and ACL tests were normal. No symptomssuggested meniscal repair failure. Radiographs and phys-ical examination revealed no evidence of growth abnor-mality or angular deformity.

Case 2

A 12-year-old female soccer player presented after aprior slide tackling injury that resulted in persistent painand instability with cutting activities. Menarche hadoccurred 10 months prior to presentation.

On physical examination the patient was 51 tall,weighed 100 lbs, had secondary sexual characteristics ofa Tanner stage 4, and was close in approximation inheight to her mother. She exhibited a full range ofmotion, a grade 3 Lachman, and a grade 1 pivot shift. KT-

1000 measurements were 8, 10, and 14 mm on the affect-ed side and 3, 4, and 6 mm on the contralateral knee at 69N, 89 N, and maximum manual testing, respectively.

Radiographs revealed closing femoral and tibial physeswith an open tibial apophysis. Skeletal age was approxi-mately 14.5 years. Magnetic resonance imaging revealedmidsubstance ACL disruption with a characteristic bonebruise pattern. Due to symptomatic instability and anunwillingness to refrain from sports, ACL reconstructionwas performed.

As she was a petite girl with an open tibial tubercleapophysis, a bone-patellar tendon-bone allograft wasused to avoid injuring the apophysis and to allow for anadequate sized graft. At last follow-up, approximately 13months post-reconstruction, she had returned to soccerwith no symptoms and KT-1000 measurements were 5, 6,and 7 mm on the affected knee, respectively, without evi-dence of growth abnormality or angular deformity.

Case 3

A 12-year-old female softball player presented after acollision while sliding into third base, resulting in imme-diate knee pain and subsequent inability to play. She hadexperienced menarche approximately 1.5 years prior.

Physical examination demonstrated a full range ofmotion, grade 2 Lachman, and grade 2 pivot shift testing.KT-1000 measurements were 5, 7, and 9.5 for the affect-ed knee and 3.5, 4, and 7 mm for the asymptomatic limbat 69 N, 89 N, and maximum manual testing, respective-ly. Tanner stage appeared to be that of a late 3 or early 4.

Radiographs of the knee revealed a closing tibial andclosed femoral growth plates. Her skeletal age was deter-mined to be closer to that of a 14-year-old. Magnetic res-onance imaging revealed a midsubstance ACL injurywith a characteristic bone bruise pattern. Bracing andactivity modification were used initially, however shewas an active athlete, who was unable to comply with thistreatment, thus ACL reconstruction was performed usinga bone-patellar tendon-bone autograft at age 13 years.

At latest follow-up 1 year postoperatively, she had returned

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TABLE 2ALGORITHM FOR ACL RECONSTRUCTION IN THE SKELETALLY IMMATURE PATIENT

Skeletal ReconstructionAge Gender Graft Femoral Tibial

12 Male/Female HS OTT Transepiphyseal13 Male/Female HS OTT Transphyseal tunnel with extraphyseal fixation14 Male HS OTT Transphyseal tunnel with extraphyseal fixation

Female HS/BTB FT Transphyseal tunnel15 Male HS OTT or FT Transphyseal tunnel with extraphyseal fixation

Female HS/BTB FT Transphyseal tunnel16 Male/Female HS/BTB FT Transphyseal tunnel

Abbreviations: BTB=bone tendon bone, FT=femoral tunnel, HS=hamstring, and OTT=over the top.

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to her preinjury level of athletics and was asymptomatic.KT-1000 measurements were 4, 5, and 7 on the affectedknee. Her growth plates had fully closed, and no growthabnormality or angular deformity were noted.

Case 4

A 14-year-old female gymnast presented after a twistinginjury to her left knee during completion of an extensionflip in which her knee gave way causing her to fall. Sheexperienced intense pain, had difficulty ambulating, andquickly developed swelling. She had not yet experiencedmenarche and appeared to be an early Tanner stage 3.

Further examination revealed a knee effusion with limit-ed range of motion. Grade 2 Lachman and grade 1 pivotshift testing were noted. KT-1000 testing measured 6, 8,and 14 mm on the affected knee with values of 3, 4, and5 mm on the asymptomatic limb at 69 N, 89 N, and max-imum manual testing, respectively.

Radiographs revealed open growth plates and a skeletalage of 13 years (Figures 10 and 11). Magnetic resonanceimaging revealed a midsubstance ACL injury (Figures12). Physical therapy and bracing were prescribed, butdespite achieving full range of motion and symmetriclower limb strength, symptomatic instability was report-ed 3 months postinjury.

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Figure 8. Growth chart that may be used as a guide in estimating the amounts of growth that may be inhibited in the dis-tal end of the normal femur or proximal end of the normal tibia by epiphyseal arrest in the skeletal ages indicated on thebase line. (Reprinted with permission from Anderson M et al. Growth and predictions of growth in the lower extremities. JBone Joint Surg Am. 1963;45:1-14. Copyright © 1963. The Journal of Bone and Joint Surgery Incorporated.)

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Anterior cruciate ligament reconstruction was performedusing a hamstring (semitendinosus and gracilis) allograftplaced in the over-the-top femoral and transphyseal tibialpositions with extraphyseal fixation (soft-tissue screwsand washers in combination with staples) (Figure 13).

CONCLUSION

Midsubstance ACL tears in skeletally immaturepatients, although rare, occur and present unique treatmentconsiderations. A careful assessment of the patient’s poten-tial remaining growth and ability to comply with nonoper-ative and operative protocols must be taken. Nonanatomic,extraphyseal attempts at reconstruction appear to decreasethe risk for subsequent growth abnormality, but often aresuboptimal in restoring ACL function. These reconstruc-tions are primarily reserved for prepubescent individualswith larger potentials for growth. When the patient nearsskeletal maturity, more anatomic, transphyseal reconstruc-tions are recommended, as they provide the optimal stabil-ity with minimal risk of growth disturbance.

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Documents

Adolescent ACL Injury - acldoc.orgacldoc.org/articles3/ACL-Adolescent ACL Injury.pdf · over a 10-year period.52 The authors reported no ACL tears in children aged 10 years, whereas