Outcomes and Complications After All-Epiphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

Abstract

Background: The safest and most effective technique for anterior cruciate ligament (ACL) reconstruction in skeletally immature patients is currently unknown.

Purpose: To evaluate the functional and patient-reported outcomes of a specific all-epiphyseal ACL reconstruction technique in which the graft, bone tunnels, and fixation do not cross the knee growth plates.

Study design: Case series; Level of evidence, 4.

Methods: Twenty-seven patients (23 boys, 4 girls; mean age, 11 years; range, 8-15 years) underwent an all-epiphyseal ACL reconstruction with a single femoral transverse epiphyseal tunnel and primarily split tibial epiphyseal tunnels. Outcomes were evaluated in terms of the manual Lachman test, range of motion, pain, return to activity, angular or leg-length deformity on imaging, and International Knee Documentation Committee (IKDC) or Pedi-IKDC score an average of 3.8 years postoperatively, with a minimum 2-year follow-up.

Results: The mean IKDC score was 94 ± 11. There were no growth arrests, but 3 patients had knee overgrowth, and 2 required a subsequent guided growth procedure. The ACL graft failed in 4 patients (15%), and 2 patients had contralateral ACL tears (7%). There were 5 subsequent ipsilateral meniscal tears, 4 of which were retears of a repaired meniscus. Ipsilateral knee reinjury significantly correlated with the number of associated injuries at the time of index surgery (P = .040) and the number of sports played (P = .029).

Conclusion: All-epiphyseal ACL reconstruction resulted in excellent long-term functional outcomes, despite a high rate of complications (48%) and secondary procedures (37%) in this highly active cohort. The incidence of graft failure was similar to other standard ACL reconstruction techniques for patients younger than 20 years.

Keywords: ACL; all-epiphyseal; growth plate; pediatric sports medicine; physis; reconstruction.

Figure 1.

The modified all-epiphyseal anterior cruciate ligament reconstruction technique. (A) A femoral tunnel and split tibial tunnel are placed entirely within the distal femoral and proximal tibial epiphysis, respectively. (B) A biocomposite interference screw is used to fix the graft into the femoral tunnel. A 1-cm cortical bone bridge between the 2 tibial tunnels is maintained. (C) Correct position of the femoral tunnel in the lateral plane with the looped end of the graft around the anteromedial tibial epiphysis. Reprinted with permission from Lykissas et al.

Figure 2.

(A and B) Magnetic resonance image of the knee in a 10-year-old boy who underwent a split tibial tunnel all-epiphyseal anterior cruciate ligament (ACL) reconstruction showing the tight fit in the thin proximal tibial epiphysis. (A) The dashed circles on the coronal view mark the 2 split tibial tunnels. (B) The arrows on the lateral view mark 1 of the split tibial tunnels. The split tibial tunnels have a smaller diameter than a single tunnel, usually 4.5 to 5.5 mm for each split tunnel compared with 7 to 8 mm for a single tunnel. (C and D) Radiographs of an 8-year-old boy who underwent a split tibial tunnel all-epiphyseal ACL reconstruction at 2.5 years after surgery. (C) On the anteroposterior radiograph, the dashed arrows mark the inferior edge of the horizontal femoral tunnel, and the dashed lines mark the edges of the split tibial tunnel. (D) On the lateral radiograph, the dashed arrows mark the edges of the femoral tunnel, and the solid arrows mark the edges of the split tibial tunnels, which overlap on this view.

Figure 3.

Knee radiographs of a 9-year-old girl with an anterior cruciate ligament (ACL) tear show proximal tibial bone spur formation (arrow), which appeared preoperatively from (A) the time of injury to (B) 1 week, (C) 1 month, and (D) 8 months later, prior to split tibial tunnel all-epiphyseal ACL reconstruction. (E) Immediate postoperative and (F) 2-year follow-up anteroposterior knee radiographs show increasing bilateral genu valgum. (G) Two-year follow-up anteroposterior lower extremity radiograph shows bilateral genu valgum, which was treated with bilateral hemiepiphysiodesis. (H) At 3.7 years, radiographs continue to show genu valgum and development of a leg-length discrepancy, which was treated with a proximal tibial lateral opening wedge osteotomy. (I) At 5 years, her genu valgum had improved and her leg-length discrepancy had resolved.