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Pediatric ACL reconstruction produced no leg length discrepancy, angular deformity
About 90% of children with ACL reconstructions attained IKDC grade A scores postoperatively.
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FLORENCE — Orthopaedic surgeons can safely perform ACL reconstruction in prepubescent children, according to results presented by a team of British investigators.
Some clinicians assume the procedure is rarely performed in such young patients, and others usually try to avoid it if possible because they are afraid drilling the tunnels might affect the child’s growth. However, those opinions are gradually changing, noted Sadashiva H. Somayaji, MS, MRCS, lead author of a study that includes follow-up results of ACL reconstructions in 44 children.
“ACL injuries in children should be treated by reconstruction,” Somayaji said at the 2007 International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine Congress, here. “The complete transphyseal technique is safe and can be undertaken in prepubescent children.”
During the discussion period when Somayaji was asked about the possibility of using a double-bundle graft technique in children, he said there is no history of its successful use. Investigators for his study used a single-bundle technique, and nine of the children were younger than 12 years old.
Hamstring grafts
Investigators from the Royal Free Hospital and Wellington Knee Unit in London treated 35 boys and 9 girls with ACL injuries via complete arthroscopic transphyseal reconstruction (range age 9 years to 15.5 years; 13.3 years, average). The surgeries were performed using four-strand hamstring grafts placed across both the tibial and femoral growth plates. Surgeons fixed the grafts proximally with an endo-button [Smith & Nephew] and distally with a spike and washer/screw construct.
The arthroscopic reconstructions were performed 2 months to 48 months after injury (8.2 months, average). Most injuries were sports-related, according to the abstract.
Based on Tanner grading, 10 patients were prepubescent, 25 patients were at puberty age and nine patients had passed puberty.
Investigators diagnosed meniscal tears in 20 patients; 14 of whom underwent concurrent meniscal repairs. Three others had meniscectomies and three tears were left untreated.
Activity returned
Average preoperative Tegner and Lysholm scores were 4 points and 54.6 points, respectively, compared to average postoperative scores of 7.6 points and 93 points, respectively. The average preinjury Tegner scores was 7.7 points.
Postoperative International Knee Documentation Committee grades were A in 40 patients, B in two patients and C in two patients based on arthrometer readings.
Patients were satisfied with their outcomes. One 11-year-old boy’s graft ruptured following a secondary knee injury. “There was no leg length discrepancy or angular deformity in any of the patients,” Somayaji said.
Addressing concerns over drilling the tunnels, he said rabbit studies showed a hole drilled in an animal’s physis that was 7% of its overall size did not affect its growth. “An 8-mm tunnel in humans is only 1% of the cross-sectional area of the physis; hence, the risk of growth plate damage is minimal,” Somayaji noted.
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To perform complete transphyseal ACL reconstruction in skeletally immature patients, surgeons fixed 4-strand hamstring grafts proximally with endo-buttons and distally with spike and washer/screw constructs. | These radiographs show how ACL grafts “grow” with the child. The one on the left was taken immediately postoperatively and the right one was taken just a few years later. Just one graft in the series of 70 children failed. Images: Somayaji SH | |
For more information:Reference:
- Sadashiva H. Somayaji, MD, can be reached at 33 Lawnside, Blackheath, London, England SE3 9HR; +44-208-297-0244; e-mail: sadashivasomayaji@yahoo.co.uk. He has no financial conflicts to disclose.
- Somayaji SH, Utukuri M, Harnett P et al. Pediatric anterior cruciate ligament injuries: A follow-up study. #72. Presented at the 2007 International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine Congress. May 27-31, 2007. Florence.