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Pediatric anterior cruciate ligament reconstruction

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Abstract

An increasing number of anterior cruciate ligament (ACL) injuries are seen in children now than in the past due to increased sports participation. The natural history of ACL deficient knees in active individuals, particularly in children is poor. Surgical management of ACL deficiency in children is complex due to the potential risk of injury to the physis and growth disturbance. Delaying ACL reconstruction until maturity is possible but risks instability episodes and intra-articular damage. Surgical options include physeal-sparing, partial transphyseal and complete transphyseal procedures. This article reviews the management of ACL injured skeletally immature patients including the functional outcome and complications of contemporary surgical techniques.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Micheli LJ, Foster TE. Acute knee injuries in the immature athlete. AAOS Instr Course Lect. 1993;42:473–81.

    CAS  Google Scholar 

  2. Mohtadi N, Grant J. Managing anterior cruciate ligament deficiency in the skeletally immature individual: a systematic review of the literature. Clin J Sport Med. 2006;16:457–64.

    Article  PubMed  Google Scholar 

  3. Andrish JT. Anterior cruciate ligament injuries in the skeletally immature patient. Am J Orthop. 2001;30:103–10.

    PubMed  CAS  Google Scholar 

  4. DeLee JC, Curtis R. Anterior cruciate ligament insufficiency in children. Clin Orthop Relat Res. 1983;172:112–8.

    PubMed  Google Scholar 

  5. Lipscomb AB, Anderson AF. Tears of the anterior cruciate ligament in adolescents. J Bone Joint Surg Am. 1986;68:19–28.

    PubMed  CAS  Google Scholar 

  6. Graf BK, Lange R, 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.

    Article  PubMed  CAS  Google Scholar 

  7. Kannus P, Jarvinen M. Knee ligament injuries in adolescents: eight year follow-up of conservative management. J Bone Joint Surg Br. 1988;70:772–6.

    PubMed  CAS  Google Scholar 

  8. Aichroth PM, 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.

    Article  PubMed  CAS  Google Scholar 

  9. • Henry J, Chotel F, Chouteau J, et al.: Rupture of the anterior cruciate ligament in children: early reconstruction with open physes or delayed reconstruction to skeletal maturity? Knee Surg Sports Traumatol Arthrosc 2009, 17:748–755. Retrospective comparison of 2 groups of patients with open physes. Group 1 managed with acute ACL reconstruction and group 2 managed with ACL reconstruction at skeletal maturity. Results indicate higher number of meniscal tears and meniscectomies and lower subjective IKDC scores in group 2.

    Article  Google Scholar 

  10. McIntosh AL, Dahm DL, Stuart MJ. Anterior cruciate ligament reconstruction in the skeletally immature patient. Arthroscopy. 2006;22:1325–30.

    Article  PubMed  Google Scholar 

  11. Pressman AE, Letts RM, Jarvis JG. Anterior cruciate ligament tears in children: an analysis of operative versus nonoperative treatment. J Pediatr Orthop. 1997;17:505–11.

    Article  PubMed  CAS  Google Scholar 

  12. Larsen MW, Garrett Jr WE. Delee JC, Moorman CT 3rd: surgical management of anterior cruciate ligament injuries in patients with open physes. J Am Acad Orthop Surg. 2006;14:736–44.

    PubMed  Google Scholar 

  13. Diméglio A. Growth in pediatric orthopaedics. In: Morrissey RT, Weinstein SL, editors. Lovell and winter’s pediatric orthopaedics. 5th ed. Philadelphia: Lippincott; 2001. p. 33–63.

    Google Scholar 

  14. Stanitski CL. Correlation of arthroscopic and clinical examinations with magnetic resonance imaging findings of injured knees in children and adolescents. Am J Sports Med. 1998;26:2–6.

    PubMed  CAS  Google Scholar 

  15. Boden BP, Dean GS, Feagin JA, Garret WE. Mechanisms of anterior cruciate ligament injury. Orthop Jun. 2000;23:573–8.

    CAS  Google Scholar 

  16. Stanitski CL, Harvell JC, Fu F. Observations on acute knee hemarthrosis in children and adolescents. J Pediatr Orthop. 1993;13:506–10.

    Article  PubMed  CAS  Google Scholar 

  17. Luhmann SJ. Acute traumatic knee effusions in children and adolescents. J Pediatr Orthop. 2003;23:199–202.

    Article  PubMed  Google Scholar 

  18. Hinton RY, Rivera VR, Pautz MJ, Sponseller PD. Ligamentous laxity of the knee during childhood and adolescence. J Pediatr Orthop. 2008;28:184–7.

    Article  PubMed  Google Scholar 

  19. Manner HM, Radler C, Ganger R, Grill F. Dysplasia of the cruciate ligaments: radiographic assessment and classification. J Bone Joint Surg. 2006;88:130–7.

    Article  PubMed  Google Scholar 

  20. Kocabey Y, Tetik O, Isbell WM, Atay A, Johnson DL. The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture. Arthroscopy. 2004;20:696–700.

    PubMed  Google Scholar 

  21. Kocher MS, 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.

    PubMed  CAS  Google Scholar 

  22. Kim HK, Laor T, Shire NJ, Bean JA, Dardzinski BJ. Anterior and posterior cruciate ligaments at different patient ages: MR imaging findings. Radiology. 2008;247:826–35.

    Article  PubMed  Google Scholar 

  23. Coursey Jr RL, Jones EA, Chaljub G, et al. Prospective analysis of uncomplicated bone bruises in the pediatric knee. Emerg Radiol. 2006;12:266–71.

    Article  PubMed  Google Scholar 

  24. Lee K, Siegel MJ, Lau DM, et al. Anterior cruciate ligament tears: MR imaging-based diagnosis in a pediatric population. Radiology. 1999;213:697–704.

    PubMed  CAS  Google Scholar 

  25. Major NM, Beard Jr LN, Helms CA. Accuracy of MR imaging of the knee in adolescents. AJR Am J Roentgenol. 2003;180:17–9.

    PubMed  Google Scholar 

  26. McCarroll JR, Shelbourne KD, Porter DA, Retting AC, Murray S. Patellar tendon graft reconstruction for mid-substance anterior cruciate ligament rupture in junior high school athletes. An algorithm for management. Am J Sports Med. 1994;22:478–84.

    Article  PubMed  CAS  Google Scholar 

  27. Mizuta H, Kubota K, Shiraishi M, et al. The conservative treatment of complete tears of the anterior cruciate ligament in skeletally immature patients. J Bone Joint Surg Br. 1995;77:890–4.

    PubMed  CAS  Google Scholar 

  28. Woods GW, O’Connor DP. Delayed anterior cruciate ligament reconstruction in adolescents with open physes. Am J Sports Med. 2004;32:201–10.

    Article  PubMed  Google Scholar 

  29. Moksnes H, Engebretsen L, Risberg MA. Performance-based functional outcome for children 12 years or younger following anterior cruciate ligament injury: a two to nine-year follow-up study. Knee Surg Sports Traumatol Arthrosc. 2008;16:214–23.

    Article  PubMed  Google Scholar 

  30. Langenskiöld A. The possibilities of eliminating premature partial closure of an epiphyseal plate caused by trauma or disease. Acta Orthop Scand. 1967;38:267–79.

    Article  Google Scholar 

  31. Österman K. Healing of large surgical defects of the epiphyseal plate. Clin Orthop Relat Res. 1994;300:264–8.

    PubMed  Google Scholar 

  32. Peterson HA. Partial growth plate arrest and its treatment. J Pediatr Orthop. 1984;4:246–58.

    Article  PubMed  CAS  Google Scholar 

  33. Campbell CJ, Grisolia A, Zanconato G. The effects produced in the cartilaginous epiphyseal plate of immature dogs by experimental surgical traumata. J Bone Joint Surg Am. 1959;41:1221–42.

    PubMed  Google Scholar 

  34. Stadelmaier DM, 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.

    Article  PubMed  CAS  Google Scholar 

  35. Seil R, Pape D, Kohn D. The risk of growth changes during transphyseal drilling in sheep with open physes. Arthroscopy. 2008;24:824–33.

    Article  PubMed  Google Scholar 

  36. Edwards TB, 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.

    PubMed  Google Scholar 

  37. Makela EA, Vainionpaa S, Vihtonen K, Mero M, Rokkanen P. The effect of trauma to the lower femoral epiphyseal plate: an experimental study in rabbits. J Bone Joint Surg Br. 1988;70:187–91.

    PubMed  CAS  Google Scholar 

  38. Makela EA, Vainionpaa S, Vihtonen K, et al. The effect of a penetrating biodegradable implant on the growth plate. An experimental study on growing rabbits with special reference to polydioxanone. Clin Orthop Relat Res. 1989;241:300–8.

    PubMed  Google Scholar 

  39. Janarv PM, Wikstrom B, Hirsch G. The influence of transphyseal drilling and tendon grafting on bone growth: an experimental study in the rabbit. J Pediatr Orthop. 1998;18:149–54.

    Article  PubMed  CAS  Google Scholar 

  40. Brief LP. Anterior cruciate ligament reconstruction without drill holes. Arthroscopy. 1991;7:350–7.

    Article  PubMed  CAS  Google Scholar 

  41. Parker AW, Drez Jr D, Cooper JL. Anterior cruciate ligament injuries in patients with open physes. Am J Sports Med. 1994;22:44–7.

    Article  PubMed  CAS  Google Scholar 

  42. Kocher MS, Garg S, Micheli LJ. Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Joint Surg Am. 2005;87:2371–9.

    Article  PubMed  Google Scholar 

  43. Guzzanti V, Falciglia F, Stanitski CL. Physeal-sparing intraarticular anterior cruciate ligament reconstruction in preadolescents. Am J Sports Med. 2003;31:949–53.

    PubMed  Google Scholar 

  44. Anderson AF. Transepiphyseal replacement of the anterior cruciate ligament using quadruple hamstring grafts in skeletally immature patients. J Bone Joint Surg Am. 2004;86:201–9.

    PubMed  Google Scholar 

  45. • Kennedy A, Coughlin DG, Metzger MF, et al.: Biomechanical evaluation of pediatric anterior cruciate ligament reconstruction techniques. Am J Sports Med 2011, In press. Three pediatric ACL reconstruction techniques (all epiphyseal, transtibial over-the-top, IT band extra/intraarticular physeal sparing) were compared in biomechanics lab. All epiphyseal and transtibial techniques improved AP translation but not to ACL intact state. IT band technique best restored AP translation but may overconstrain the knee to rotational forces.

  46. Andrews M, Noyes FR, Barber-Westin SD. Anterior cruciate ligament allograft reconstruction in the skeletally immature athlete. Am J Sports Med. 1994;22:48–54.

    Article  PubMed  CAS  Google Scholar 

  47. Bonasia DE, Rossi R, Wolf BR, Amendola A: Pediatric anterior cruciate ligament reconstruction. Presented at 2011 American academy of orthopaedic surgeons annual meeting multimedia education center. San Diego, USA; February 15-19, 2011.

  48. Lo IK, 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.

    Article  PubMed  CAS  Google Scholar 

  49. Lipscomb AB, Anderson AF. Tears of the anterior cruciate ligament in adolescents. J Bone Joint Surg Am. 1986;68:19–28.

    PubMed  CAS  Google Scholar 

  50. Aronowitz ER, 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.

    PubMed  CAS  Google Scholar 

  51. Cohen M, Ferretti M, Quarteiro M, et al. Transphyseal anterior cruciate ligament reconstruction in patients with open physes. Arthroscopy. 2009;25:831–8.

    Article  PubMed  Google Scholar 

  52. Courvoisier A, Grimaldi M, Plasweski S. Good surgical outcome of transphyseal ACL reconstruction in skeletally immature patients using four-strand hamstring graft. Knee Surg Sports Traumatol Arthrosc. 2011;19:588–91.

    Article  PubMed  Google Scholar 

  53. Fuchs R, Wheatley W, Uribe JW, et al. Intra-articular anterior cruciate ligament reconstruction using patellar tendon allograft in the skeletally immature patient. Arthroscopy. 2002;18:824–8.

    Article  PubMed  Google Scholar 

  54. Gaulrapp HM, Haus J. Intraarticular stabilization after anterior cruciate ligament tear in children and adolescents: results 6 years after surgery. Knee Surg Sports Traumatol Arthrosc. 2006;14:417–24.

    Article  PubMed  CAS  Google Scholar 

  55. Kocher MS, Smith JT, Zoric BJ, Micheli LJ. Transphyseal anterior cruciate ligament reconstruction in skeletally immature pubescent adolescents. J Bone Joint Surg Am. 2007;89:2632–9.

    Article  PubMed  Google Scholar 

  56. • Liddle AD, Imbuldeniya AM, Hunt DM: Transphyseal reconstruction of the anterior cruciate ligament in prepubescent children. J Bone Joint Surg Br 2008, 90:1317-1322. 17 Tanner 1 and 2 patients underwent transphyseal ACL reconstruction with quadrupled hamstring autograft. Lysholm, IKDC, Tegner activity scores and KT1000 measurements were excellent. There was one rerupture and one asymptomatic mild valgus deformity.

    Article  PubMed  CAS  Google Scholar 

  57. Nikolaou P, Kalliakmanis A, Bousgas D, Zourntos S. Intraarticular stabilization following anterior cruciate ligament injury in children and adolescents. Knee Surg Sports Traumatol Arthrosc. 2011. doi:10.1007/s00167-010-1375-y.

  58. • Streich NA, Barie A, Gotterbarm T, Keil M, Schmitt H: Transphyseal reconstruction of the anterior cruciate ligament in prepubescent athletes. Knee Surg Sports Traumatol Arthrosc 2010, 18:1481-1486. Comparison between nonoperative and operative management (Transphyseal hamstring autograft) in Tanner 1 and 2 patients was performed. Early reconstructions were performed on those patients with other intra-articular pathology (meniscus tear, osteochondral fracture), whereas nonoperative management was undertaken in those patients with isolated ACL tears. Outcome scores were significantly improved in the operative groups. 58% on the nonoperative group underwent sub-acute ACL reconstruction due to ongoing instability and 86% of this group had meniscal tears at the time of operation.

    Article  PubMed  Google Scholar 

  59. Kaeding CC, Flanigan D, Donaldson C. Surgical techniques and outcomes after anterior cruciate ligament reconstruction in preadolescent patients. Arthroscopy. 2010;26:1530–8.

    Article  PubMed  Google Scholar 

  60. Kocher MS, 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.

    Article  PubMed  Google Scholar 

  61. Barber FA, Sanders JO, Clark R. Anterior cruciate ligament reconstruction in the skeletally immature high performance athlete. What to do and when to do it? Arthroscopy. 2000;16:391–4.

    Article  PubMed  CAS  Google Scholar 

  62. Koman JD, Sanders JO. Valgus deformity after reconstruction of the anterior cruciate ligament in a skeletally immature patient. A case report. J Bone Joint Surg. 1999;81:711–5.

    PubMed  CAS  Google Scholar 

  63. Chotel F, Henry J, Seil R, et al. Growth disturbances without growth arrest after ACL reconstruction in children. Knee Surg Sports Traumatol Arthrosc. 2010;18:1496–500.

    Article  PubMed  Google Scholar 

  64. Frosch KH, Stengel D, Brodhun T, et al. Outcomes and risks of operative treatment of rupture of the anterior cruciate ligament in children and adolescents. Arthroscopy. 2010;26:1539–50.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, 2701 Prairie Meadow Drive, Iowa City, IA, 52242, USA

    Mark O. McConkey

  2. Ist Department of Orthopaedics, CTO hospital, University of Turin Medical School, Via Lamarmora 26, Torino, 10128, Italy

    Davide Edoardo Bonasia

  3. Department of Orthopaedics and Rehabilitation, UI Sports Medicine Center, 2701 Prairie Meadow Drive, Iowa City, IA, 52242, USA

    Annunziato Amendola

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  1. Mark O. McConkey
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  2. Davide Edoardo Bonasia
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  3. Annunziato Amendola
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Correspondence to Annunziato Amendola.

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McConkey, M.O., Bonasia, D.E. & Amendola, A. Pediatric anterior cruciate ligament reconstruction. Curr Rev Musculoskelet Med 4, 37–44 (2011). https://doi.org/10.1007/s12178-011-9076-9

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