High Revision Rate After Transphyseal ACL Reconstruction in Skeletally Immature Patients

Abstract

Objectives: There remains considerable debate regarding the optimal management of anterior cruciate ligament (ACL) injuries in skeletally immature patients. This study aims to evaluate the clinical outcomes of transphyseal ACL reconstruction in patients with open growth plates. Methods: This retrospective study included skeletally immature patients with full-thickness ACL tears and confirmed open physis. ACL reconstructions were performed using a four-strand semitendinosus autograft, with an additional gracilis tendon graft if needed. The surgical technique emphasized tibial and femoral physeal-sparing tunnel placement to minimize disruption of the growth plates. Clinical assessment included measurements for limb length discrepancy, knee stability, and growth disturbances. Functional outcomes were evaluated using IKDC 2000, Lysholm, and KOOS scores, while ligament stability was assessed with KT-1000 arthrometer measurements at routine follow-up. Results: A total of 31 consecutive patients (15 females, 16 males; mean age 13.6 ± 1.8 years, range 9-16 years) were included. Mean follow-up was 49 ± 26 months (range 18-93 months). The mean time to return to sports was 8.8 ± 4.4 months. Eight patients (26%) experienced ACL graft rupture and underwent revision ACL reconstruction. One additional patient required partial meniscectomy. The overall revision rate was 29%. The mean subjective IKDC score was 91.8 ± 7.2, with Lysholm and KOOS scores of 96.6 ± 7.9 and 94.2 ± 5.3, respectively. No significant growth disturbances were noted. The mean side-to-side difference in KT-1000 testing was 2.2 ± 1.5 mm. Patients who underwent revision ACL reconstruction showed significantly greater length growth compared with those with intact ACL reconstruction (p = 0.02). Spearman correlation revealed a significant association between length growth and anterior tibial translation (p = 0.02, r = 0.46). Conclusions: Transphyseal ACL reconstruction in skeletally immature patients provides favorable clinical and radiological outcomes, with minimal risk of growth disturbance. Most patients returned to pre-injury levels of athletic activity. However, the high revision rate emphasizes the complexity of managing ACL injuries in this population.

Keywords: ACL reconstruction; adolescent; growth plates; physis; transphyseal drilling.

Figure 1

Example of a 3.0 Tesla knee MRI: (A) coronal PD tse fs, (B) sagittal T2 tse, and (C) conventional X-ray in AP view of 14-year-old male patient with open physis and acute ACL rupture. PD tse fs (proton density-weighted turbo spin echo sequence with fat saturation), T2 tse (T2-weighted turbo spin echo sequence), ap (anterior–posterior); large arrow is ACL rupture; star is bone marrow edema.

Figure 2

Example of a postoperative 3.0 Tesla knee MRI: (A) sagittal and (B) coronal PD tse fs, and (C) sagittal PD tse of a 14-year-old female patient with open physis and postoperative MRI after ACL reconstruction. PD tse fs (proton density-weighted turbo spin echo sequence with fat saturation), PD tse (proton density-weighted turbo spin echo sequence).

Figure 3

Visualization of the distribution of IKDC, Lysholm, and KOOS scores, showing predominantly good to very good results. While the IKDC score displays some variability, the Lysholm and KOOS scores are more consistently clustered near the upper range.