Open Growth Plates and ACL Surgery
Abstract & Commentary
Synopsis: By avoiding crossing the growth plate with the bone plug or the screw, the authors safely treated 10 patients with endoscopic B-T-B techniques despite significant growth remaining.
Source: Fuchs R, et al. Intra-articular anterior cruciate ligament reconstruction using patellar tendon allograft in the skeletally immature patient. Arthroscopy. 2002;18(8):824-828.
There is lack of consensus regarding the optimal method to treat the occasional skeletally immature patient with an ACL tear and significant remaining growth. Fuchs and colleagues from the University of Miami retrospectively reviewed their experience over a 4-year period, identifying 10 patients (mean age, 13.2; range, 9-15 years of age) surgically treated. To qualify as having significant remaining growth, patients had to have wide-open physes, be premenarchal, or have no pigmented axillary hair. Treatment consisted of standard endoscopic B-T-B technique using patellar allograft, a single incision, 9-mm tunnels, and conventional landmarks. However, they pulled the graft deep within the femur so that both the interference screw and the bone plug were above the physis. By using allograft from an adult in a smaller patient, the graft was long enough for the distal bone plug and screw to also be below the tibial physis. Thus, only patellar tendon crossed the physes.
In no case did the patients develop angular deformity or growth arrest. This is despite averaging 10 cm of growth after the procedure. At an average of 40 months (minimum 2 years), 9 of 10 had good or excellent results by Lysholm scores and IKDC rating, with 1 patient who had more severe meniscal pathology complaining of intermittent swelling. Stability by KT-1000 testing was less than 3 mm in 8 patients and between 3-5 mm in 2. All patients would opt for surgery again.
Comment by David R. Diduch, MS, MD
When the occasional patient with lots of growth left tears their ACL, treatment options include no surgery, delayed surgery, or early surgery that risks growth problems. For those individuals with symptomatic instability, any delay in surgery carries major risk for further permanent damage to menisci and articular cartilage. Indeed, only 1 patient in this study had intact menisci. Bracing and activity modification are difficult propositions in this active and often noncompliant age group. Surgical options such as primary repair or extra-articular reconstructions have been shown to do poorly.
Other authors have demonstrated success with intra-articular reconstructions by using soft tissue grafts, small tunnels, and suspensory fixation distant from the physis, or an "over the top" technique and 2 incisions. While many physicians report good success with B-T-B grafts, their "skeletally immature" patients were really within a year of completing growth. Not so with this study, where the mean growth after reconstruction was 10 cm. It is interesting to look at how far the interference screws get separated at final radiographic follow-up. Given the stable knees, this means either that the graft itself is remodeling and lengthening with growth, or aperture healing of the graft occurs, allowing the growth to occur deeper within the tunnel.
So how did they succeed where others have failed? By adhering to a few proven principals. They used slightly smaller tunnels and avoided any bone or hardware crossing the physis. Growth arrest does not seem to occur if the tendon crosses the physis. Although hamstring would appear to be a good autograft choice, and I much prefer autograft whenever possible, variability in hamstring tendon diameter can be a problem in this age group. Perhaps distal third quad tendon autograft would be another option. Patellar autograft was not ideal given that the tibial tubercle contains the open tibial physis. Certainly this paper’s approach appears to offer a viable alternative to treat a difficult problem.
Dr. Diduch, Associate Professor, Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA, is Editor of Sports Medicine Reports.
There is lack of consensus regarding the optimal method to treat the occasional skeletally immature patient with an ACL tear and significant remaining growth. Fuchs and colleagues retrospectively reviewed their experience over a 4-year period, identifying 10 patients surgically treated.
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