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All-inside ACL demonstrates safety in skeletally immature athletes
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For skeletally immature athletes, use of an all-inside ACL reconstruction technique demonstrated safety at short-term follow-up, according to study results.
Researchers prospectively evaluated 23 skeletally immature patients after all-inside ACL reconstruction, of whom 15 underwent an all-epiphyseal (AE) ACL reconstruction and eight underwent a partial transphyseal (PTP) ACL reconstruction. The researchers performed MRI using 3-D fat-suppressed spoiled gradient recalled echo sequences and full-length standing radiographs to assess graft survival, growth arrest, physeal violation, angular deformity and leg length discrepancy at 6 and 12 months postoperatively. Mean follow-up was 18.5 months.
Results showed 10 patients in the AE group and all patients in the PTP group experienced minimal tibial physeal violation. In the AE group, the researchers found a mean area of tibial physeal disturbance of 57.8 mm2 vs. 145.1 mm2 in the PTP group. One case in the PRP group and no cases in the AE group had a 1.5% compromise of the femoral physis.
MRI showed no cases of growth arrest, articular surface violation or avascular necrosis, and the researchers also observed no postoperative angular deformities or significant leg length discrepancies. – by Casey Tingle
Disclosure: Nawabi has no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
Back to TopFreddie H. Fu, MD, DSc(Hon), DPs(Hon)
I applaud studies that utilize 3-D imaging techniques to evaluate the anatomy of the knee and in this case, an application that has the potential to evaluate damage to the growth plate as opposed to 2-D imaging is an improvement. In this regard, attempting to differentiate open from closing physes is clinically important and the decision to proceed with a particular surgical technique can be challenging due to the possibility of injuring a structure with complex 3-D anatomy, such as the physis. Xerogeanes and colleagues also utilized 3-D imaging techniques and noted that changes in diameter as well as angle of tunnel placement can result in subtle violations of the physis.
Intraoperatively, it is difficult to assess the growth plate and even fluoroscopic-guided drilling can result in damage to the growth plate, particularly with anatomic drilling. At our institution, we have had two cases with complex deformities and growth disturbances as a result of physeal sparing techniques. These cases are devastating to young patients. In the current study, the sample size is quite small and therefore, further research is needed to validate this application. The authors are also encouraged to report their clinical results, including long cassette radiographs, in addition to these imaging outcomes.
Using anatomical physeal sparing techniques can fulfill the goal of proper tunnel placement, but the technique is very complex and the risk of limb malalignment is high. Koch and colleagues reported that, despite using epiphyseal sparing techniques, 54% of their patient developed some sort of limb-length discrepancy. Over-the-top may be a safer, alternative technique for pediatric patients with open physes as it avoids drilling through the femoral physis and allows the graft to heal in an anatomic position with excellent clinical results.
References:
Kercher J, et al. J Pediatr Orthop. 2009;doi: 10.1097/BPO.0b013e3181982228.
Koch PP, et al. Knee Surg Sports Traumatol Arthrosc. 2014;doi:10.1007/s00167-014-3396-4.
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