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CURRENT CONCEPTS

The remaining portion of the graft was then passed through Postoperatively a proper rehabilitation is critical to ensure

an all-epiphyseal tibial tunnel and fixed with a post distal to the success in clinical and functional outcome. Child
the proximal tibial physis. Finally, in a third surgical technique and adolescent athletes are different from adult patients.

combined intra – and extra-articular reconstruction. This Compliance can be problematic in this age group, and
procedure is a modification of the combined intra – and patients must be carefully monitored at school and home

extra-articular reconstruction described by MacIntosh by teachers, parents, and caretakers. Activity restrictions
and Darby. All these techniques showed excellent clinical and compliance with graduated activity levels are critical
results and no reported evidence of growth disturbance. A to successful outcomes. In the first four or six weeks

biomechanical evaluation of these techniques was also postoperatively the use of a brace should be strongly
performed to determine which most closely restored encouraged in this type of patients who are notoriously

native knee kinematics. In a controlled laboratory setting, more hazardous and careless than adult patients. Complete
displacement and rotation of the tibia with respect to weight-bearing is allowed at the end of the first postoperative

the femur were measured in the intact knee after ACL month. Progressive rehabilitation consisting of ROM recovery,
disruption and after ACL reconstruction using all epiphyseal, closed kinetic chain quadriceps and hamstring strengthening,

transtibial over-the-top, and iliotibial band physeal-sparing patellar mobilization, and swimming pool exercises are
techniques. The results showed that, although all physeal- used for the first months postoperatively. Initiation of

sparing reconstruction techniques restored some stability straight-line jogging and plyometrics begins at 4 months
to the knee, the iliotibial band reconstruction best restored after reconstruction. A full return to cutting and pivoting
AP stability and rotation control; however, it appeared to activities and sports is allowed at approximately 7-9 months

slightly overconstrain the knee to rotational forces at some postoperatively.
flexion angles. The partial transphyseal techniques combine

a hybrid of physeal-sparing reconstruction and traditional
transphyseal procedures performed in adults. Usually the

distal femoral physis is left undisturbed, thereby minimizing
the risk of growth arrest. Smaller bone tunnels (6 to 8 mm)

and more vertical tunnels are used to limit to <5% the
overall cross-sectional area of tibial physis that is interrupted.
Also these techniques showed excellent clinical results

and only one patient was reported to suffer a 2-cm limb-
length discrepancy. Complete transphyseal reconstruction

strongly resembles adult-type ACL reconstruction, with
some differences, including smaller, more vertical tunnels, 03

no hardware or bone blocks at the level of the closing In conclusion ACL ruptures in skeletally immature
physis, and metaphyseal fixation. This procedure is
patients are becoming an emerging orthopaedic problem
typically performed on adolescents with little to no growth with increased single-sport concentration, year-round
remaining. Outcomes from transphyseal reconstruction
participation, and less time spent in free play. It is important
have been generally successful, with a mean IKDC score to properly diagnose and manage these injuries. There is
of 91.5, a mean Lysholm score of 93.5, and a return to the
preinjury activity level in 88.8% of patients. The limb-length now considerable evidence in the literature that conservative
management of ACL tears in children produces poor results
discrepancy is typically minimal, averaging 1.2 mm, but with subsequent instability. Nonsurgical management,
the operatively treated limb may range from 7 mm short to
including activity modification, bracing, and physical
7 mm long. Recently several clinical outcome studies tout therapy, shoud best indicated only in patients with partial
the success of complete transphyseal ACL reconstruction
tears involving <50% of the ACL diameter. In patients with
also in prepubescent athletes. In these studies the ACL complete ruptures, chronologic, physiologic, and skeletal
reconstruction was performed following the guidelines for
maturity must be assessed to appropriately address the
ACL reconstruction initially proposed by Meller et al. to avoid injury. Treatment options are defined on assessment of the
growth disturbances in skeletally immature animals. The tibial
patient’s skeletal age and include physealsparing, partial
tuberosity was spared to prevent a genu recurvatum, the or complete transphyseal, and adult-type anatomic ACL
thermal damage to the growth plates was avoided, a small-
diameter drill was used in the center of the growth plate, a reconstruction. Postoperative management includes weight-
bearing and activity modifications, bracing, and a progressive
soft tissue graft was used, the graft fixation was achieved far physical therapy protocol emphasizing ROM, closed kinetic
from the growth plates, the perforated growth plates were
chain strengthening, and a gradual and measured return to
filled by the soft tissue graft, and the graft was moderately sport-specific maneuvers. Surgical complications are rare.
pretensioned before fixation. Following these principles

several authors were able to achieve excellent clinical results 01 MRI sagittal view of an ACL tear in an 11-year girl
in terms of knee stability and sports activity recovery without 02 Intraoperative X-ray view of a femoral tunnel for ACL reconstruction
drilled through the distal femoral epiphysis and a tibia tunnel drilled
any reported evidence of growth disturbance.
through the growth plate in a 13-year old boy

03 X-ray view of an ibrid transphyseal sparing over the top technique
of ACL reconstruction
ISAKOS NEWSLETTER 2014: Volume II 23