Preoperative Evaluation and Anterior Cruciate Ligament Reconstruction Technique for Skeletally Immature Patients in Tanner Stages 2 and 3

ArticleinThe American Journal of Sports Medicine 31(6):941-8 · November 2003with6 Reads
Impact Factor: 4.36 · DOI: 10.1177/03635465030310063301 · Source: PubMed
Abstract

Transphyseal anterior cruciate ligament reconstruction in skeletally immature patients carries the risk of adverse sequelae. 1) To provide clinical and radiographic methods to identify skeletally immature patients with significant remaining lower limb growth. 2) To provide a method for calculating the percent area lesion created by a 6-mm distal femoral physeal tunnel. 3) To present a method of partial transphyseal intraarticular anterior cruciate ligament reconstruction with bipolar graft fixation in these patients. 4) To report on clinical, functional, and radiographic results at skeletal maturity. Fourteen adolescents with symptomatic anterior cruciate ligament instability who were identified as being in Tanner stages 2 and 3 underwent partial transphyseal intraarticular anterior cruciate ligament reconstruction with the use of hamstring tendon grafts (transphyseal only in the femur and through the epiphysis in the tibia). At skeletal maturity, 10 patients were asymptomatic and fully active in sports. No patient had significant leg-length inequality or angular deformity after use of a 6-mm femoral physeal tunnel, which represented 1) less than 7% of the frontal plane and 2) less than 1% of the transverse plane cross-sectional femoral physeal areas. The choice of the exposed technique and the method used to select patients permitted us to avoid adverse sequelae.

    • "...lly done by placing tunnels proximally to the tibial physis and distal from the femoral physis. 31,32,47,49,53 The mean age of this group was 12.7 1.8 years. No limb-length or angular deformities were s..."
      Five articles include at least 1 group of patients undergoing intra-articular, physeal-sparing, transosseous stabilization, which is usually done by placing tunnels proximally to the tibial physis and distal from the femoral physis. 31,32,47,49,53 The mean age of this group was 12.7 1.8 years. No limb-length or angular deformities were seen in this group.
    [Show abstract] [Hide abstract] ABSTRACT: PURPOSE: The objective of this study was to assess the effect of absorbable or nonabsorbable sutures in bioenhanced anterior cruciate ligament (ACL) repair in a skeletally immature pig model on suture tunnel and growth plate healing and biomechanical outcomes. METHODS: Sixteen female skeletally immature Yorkshire pigs were randomly allocated to receive unilateral, bioenhanced ACL repair with an absorbable (Vicryl) or nonabsorbable (Ethibond) suture augmented by an extracellular matrix-based scaffold (MIACH). After 15 weeks of healing, micro-computed tomography was used to measure residual tunnel diameters and growth plate status, and biomechanical outcomes were assessed. RESULTS: At 15 weeks postoperatively, there was a significant difference in tunnel diameter with significantly larger diameters in the nonabsorbable suture group (4.4 ± 0.3 mm; mean ± SD) than in the absorbable group (1.8 ± 0.5 mm; P < .001). The growth plate showed a significantly greater affected area in the nonabsorbable group (15.2 ± 3.4 mm(2)) than in the absorbable group (2.7 ± 0.8 mm(2), P < .001). There was no significant difference in the linear stiffness of the repairs (29.0 ± 14.8 N/mm for absorbable v 43.3 ± 28.3 N/mm for nonabsorbable sutures, P = .531), but load to failure was higher in the nonabsorbable suture group (211 ± 121.5 N) than in the absorbable suture group (173 ± 101.4 N, P = .002). There was no difference between the 2 groups in anteroposterior laxity at 30° (P = .5117), 60° (P = .3150), and 90° (P = .4297) of knee flexion. CONCLUSIONS: The use of absorbable sutures for ACL repair resulted in decreased physeal plate damage after 15 weeks of healing; however, use of nonabsorbable sutures resulted in 20% stronger repairs. CLINICAL RELEVANCE: Choice of suture type for ACL repair or repair of tibial avulsion fractures may depend on patient skeletal age and size, with absorbable sutures preferred in very young, small patients at higher risk with physeal damage and nonabsorbable sutures preferred in larger, prepubescent patients who may place higher loads on the repair.
    Full-text · Article · Nov 2012 · Arthroscopy The Journal of Arthroscopic and Related Surgery
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    • "...els drilled only in the tibia. Both techniques have demonstrated satisfactory results [14, 17, 40, 41]. ..."
      Several studies utilize this method, which has been described both with tunnels drilled only through the femoral epiphyses and with tunnels drilled only in the tibia. Both techniques have demonstrated satisfactory results [14, 17, 40, 41].
    [Show abstract] [Hide abstract] ABSTRACT: The incidence of ACL tears is rising in the pediatric and adolescent populations as these individuals succumb to traumatic and nontraumatic athletic injuries. Management of this condition in the skeletally immature patient poses a challenge and is controversial. Operative reconstruction carries the concern for damage to the physis with resultant limb length inequality and angular joint deformity but provides stability to the knee and allows return of function in most patients. On the other hand, nonoperative treatment has been shown to carry an increased risk of meniscal and articular cartilage damage and is difficult from a compliance standpoint in this demographic. For the majority of skeletally immature patients, operative treatment is recommended as it has shown good clinical and functional results with minimal risk of growth disturbance. This paper aims to address the natural course of ACL injuries in the skeletally immature patient, treatment options with associated complications, and current preventative strategies.
    Full-text · Article · Jan 2012 · International Journal of Pediatrics
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  • [Show abstract] [Hide abstract] ABSTRACT: RESUMEN INTRODUCCIÓN La rotura del ligamento cruzado anterior en individuos con fisis abiertas, aparece en edades cada vez más tempranas, con frecuencia creciente. Una reparación anatómica, con un riesgo mínimo de lesión fisaria, sería la técnica ideal. OBJETIVOS Principal: 1ª Parte: estudiar el efecto de la perforación transfisaria femoral distal en individuos con alto potencial de crecimiento y el posible efecto protector del injerto tendinoso. 2ª Parte: investigar las variaciones de magnitud de la lesión fisaria que pueden producirse aleatoriamente debido a la configuración tridimensional de la fisis, en relación con la localización e inclinación del túnel . Secundario: probar que el modelo experimental propuesto es válido y la rata Sprague-Dawley es útil. HIPÓTESIS 1ª Parte: en individuos muy inmaduros esqueléticamente, la perforación transfisaria constituye una agresión cuyos efectos pueden aminorarse mediante injerto tendinoso del túnel. 2ª Parte: la relación tridimensional entre túnel y fisis en el fémur sería capaz de provocar una variación inconstante del tamaño del área de lesión fisaria de suficiente entidad como para producir resultados impredecibles. FASE DE ESTUDIO PREVIO SOBRE EL DESARROLLO DEL FÉMUR. DISEÑO DEL MODELO EXPERIMENTAL Ambos fémures de la rata tienen longitudes muy similares; presentan un crecimiento continuado a lo largo de toda su vida, lo que las convierte en animales especialmente interesantes para el estudio del crecimiento óseo y de las circunstancias que pueden alterarlo. Se diseña el modelo experimental. MATERIAL Y MÉTODO Se intervinieron 108 ratas Sprague-Dawley. Cuatro grupos. I: ARTROTOMIA. Se realizó la artrotomía; no se lesionó el hueso. II: FRENADO FISARIO. Artrotomía, perforación del túnel femoral de dos milímetros de diámetro, relleno con tornillos de 2,5 mm. III: TUNELIZACIÓN. Túnel, sin relleno. IV: INJERTO TENDINOSO. Relleno del túnel con tendón autólogo de la cola de la rata. DESARROLLO DEL CÁLCULO MATEMÁTICO SOBRE LAS POSIBILIDADES EXTREMAS DE VARIACIÓN DEL ÁREA DE INTERSECCIÓN DEL TÚNEL FEMORAL CON LA FISIS RESULTADOS El grupo Artrotomía y el grupo injerto tendinoso muestran diferencias significativas respecto de los otros tres respectivamente (p<0.05), pero no la hay entre los grupos tunelización y frenado fisario. Según el lugar donde se realice la perforación y su inclinación, el área de fisis lesionada puede variar aumentando hasta más de ocho veces. DISCUSIÓN La rata Sprague-Dawley es un animal de características adecuadas. La artrotomía de la rodilla provoca dismetrías por hipercrecimiento del fémur. El frenado fisario ha resultado efectivo en el 100% de los individuos. La tunelización es capaz de provocar detenciones del crecimiento muy considerables. Rellenar el túnel con tendón ejerce un efecto protector, pero no siempre: es imprevisible. La estructura tridimensional de la fisis tiene implicaciones muy importantes y supone variaciones severas en el tamaño del área lesionada al realizar perforaciones, dependiendo del lugar y la inclinación del túnel. CONCLUSIONES La tunelización en sí misma es capaz de provocar detenciones del crecimiento muy considerables en individuos con elevado potencial de crecimiento residual. El hecho de rellenar el túnel labrado a través de la fisis con tendón autólogo ejerce un efecto protector sobre el crecimiento, aunque no asegura que no se afecte. La configuración tridimensional de la fisis, junto con la orientación y localización del túnel femoral tienen implicaciones de gran trascendencia en el tamaño del área de la fisis que se lesione. La localización y orientación del túnel deberán buscar, en caso de intersectar la fisis, hacerlo produciendo un área de lesión lo menor posible y para ello se deberán diseñar persiguiendo dos objetivos: perpendicularidad y seguridad. APLICACIÓN CLÍNICA En pacientes muy inmaduros debemos ser cautos al indicar un tratamiento quirúrgico. Debemos estudiar y tener en cuenta las relaciones tridimensionales de la fisis femoral con las tunelizaciones. ____________________________________________________________________________________________________ SUMMARY INTRODUCTION The incidence of anterior cruciate ligament injuries in immature patients is increasing. PURPOSE To correlate variations in the injured physeal area that can be produced because of the relationship between tunnel placement and tilt and physeal 3-D configuration. To investigate the potential protector effect of filling that tunnel with a tendon graft. To validate the proposed experimental model and the Sprague-Dawley rat choice. HYPOTHESYS 1st part: Transphyseal drilling in skeletically very immature individuals is an aggression whose effects can be limited by filling the tunnel with a tendon graft. 2nd part: the relationship between both tunnel and femoral physis varies so much as to rend the estimation of the physeal injury area ant the arresting results very unpredictable. FEMUR GROWING PREVIOUS STUDY. EXPERIMENTAL MODEL DESIGN. MATERIAL AND METHODS 108 Sprague-Dawley male rats were operated on. Four groups: I: ARTHROTOMY, II: PHYSEAL ARREST, III: FEMUR DRILLING, IV: TENDON GRAFTING. DEVELOPMENT OF THE MATHEMATICAL CALCULUS ON THE EXTREME POSSIBILITIES OF VARIATION OF THE INTERSECTIONAL AREA BETWEEN THE FEMORAL TUNNEL AND THE PHYSIS. RESULTS There is statistical significant difference between the arthrotomy group and the other ones (p<0.05); so it is between the tendon grafting group and the rest; but there is no significant difference between the physeal arrest and femoral drilling groups. Size variation in the area of the physeal injury will depend on femur tunnel placement and tilting; its rate can range as high as 1:8. DISCUSSION The Sprague-Dawley rat has shown to be adequate. Arthrotomy alone causes femoral overgrowth. Physeal arrest has been effective in the whole series. Femur drilling can produce growth stop. Tendon grafting protects growing, but not in all the cases. Three-dimensional physeal structure has very important implications and can produce huge variations in the size of the physeal injury area depending on placement and tilting of the femoral tunnel. CONCLUSSIONS Femur drilling alone can produce important growth arrest in skeletally very immature individuals. Tendon autograft protects growth, but not in all the cases. Placement and tilting of femur tunnel should be designed, in case of transphyseal techniques to cause the smallest physeal injury area.
    Preview · Article · Jan 2005
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  • [Show abstract] [Hide abstract] ABSTRACT: Anterior cruciate ligament (ACL) injuries in skeletally immature patients are being observed with increased frequency. The management of these injuries is controversial. Nonreconstructive treatment of complete tears typically results in recurrent functional instability with risk of injury to meniscal and articular cartilage. A variety of reconstructive techniques have been used, including physeal sparing, partial transphyseal, and transphyseal methods using various grafts. Conventional adult ACL reconstruction techniques risk potential iatrogenic growth disturbance because of physeal violation. Growth disturbances after ACL reconstruction in skeletally immature patients have been reported. In this review, I discuss our approach to ACL injuries in the skeletally immature patient. Specifically, surgical techniques in the prepubescent patient and in the adolescent patient are detailed.
    Preview · Article · Oct 2005 · Operative Techniques in Sports Medicine
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  • [Show abstract] [Hide abstract] ABSTRACT: 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. 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. 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. 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.
    Preview · Article · Dec 2005 · The Journal of Bone and Joint Surgery
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  • [Show abstract] [Hide abstract] ABSTRACT: 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. 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. 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. 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. There were 7 articles that provided comparisons between surgical and nonsurgical treatment in order to answer the question. 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.
    No preview · Article · Dec 2006 · Clinical Journal of Sport Medicine
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