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ACL reconstruction in children with living donor allograft is a viable alternative
Investigators reported that the technique is transphyseal and permits patients to return to high-level activities.
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TORONTO — The 2-year results of ACL reconstruction performed in 29 children using their parents’ living donor hamstring tendon allografts showed 94% of patients could return to strenuous activities and had near normal IKDC scores.
Justin P. Roe, FRACS, reported at the International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine (ISAKOS) Congress, here, that all the patients had normal limb alignment without any postoperative leg-length discrepancy.
He told Orthopaedics Today Europe in an interview that the adolescents’ IKDC scores were about 90. “That is what you would expect your IKDC scores to be at that level. In adult follow-up using IKDC, you would expect about 80.”
Image: Rapp S, Orthopaedics Today Europe
At the meeting, Roe said, “This technique certainly results in good subjective and objective outcomes that are equivalent with other series. The rate of ACL graft re-injury of 6% at 2 years compares favorably with other series.”
He noted the technique permitted surgeons to harvest the semitendinosus tendon alone or the semitendinosus tendon and the gracilis tendon to create hamstring tendon allograft constructs that matched the size needed for the recipients.
Roe and colleagues at North Sydney Orthopaedic & Sports Medicine Centre, in New South Wales, Australia, received the ISAKOS Scientific Research Award for this study.
According to Roe, the allograft harvest process carried out in 26 fathers and six mothers of the patients enrolled in the study was done under general anesthesia and was typical of hamstring tendon autograft harvest surgery.
All the patients were less than 17 years old and skeletally immature at the time of surgery with a mean age of 13 years.
Investigators conducted preoperative serological testing for viruses and blood typing in the child and the hamstring tendon donor.
“The operative technique for the child was a transphyseal ACL reconstruction using an all-inside technique,” Roe said. The surgeons placed the anterolateral portal high and the anteromedial portal low for the procedure, he said.
“This is typical of our adult reconstruction except ... the knee was flexed to about 110° rather than the normal about 145° for the femoral tunnel drilling to avoid oblique crossing of the growth plate on the femoral side,” Roe said in his presentation.
Surgeons drilled the tibial tunnels line-to-line at a low speed using an Acufex Tibial drill guide (Smith & Nephew; Memphis, Tenn., USA) and made the tunnels steeper than they are in adult ACL reconstruction. Femoral fixation was achieved proximal to the physis with an RCI Screw (Smith & Nephew) in 20 patients, an endo-button in eight patients and a staple in one patient.
Tibial fixation was distal to the physis and achieved with an RCI Screw in 14 patients and a staple in 15 patients.
Harvest procedure set-up
Roe told Orthopaedics Today Europe the harvests and surgeries were done in adjacent operating rooms routinely. The harvest process takes about 15 minutes and the graft, once harvested, is carried to the adjacent operating room by the surgeon under strict sterile conditions. The duration of the ACL reconstruction is then 30 minutes to 40 minutes. However, he said the procedures could be completed in a single operating room if there is not a sterile area or field available in which to transfer the graft.
“It provides an alternative to the ACL reconstruction using traditional allografts in patients under the age of 21 [years] in an attempt to see whether using allograft tissue will decrease the re-injury rate. It also avoids the traditional problems of allograft — sterilization and irradiation — which we know affects the integrity of the tissue. To prove it, we have to have long-term follow-up,” Roe said.
Mitigates graft issues
The high rate of ACL graft failure, the challenges associated with revision ACL reconstructions in this patient population and the difficulty of obtaining specifically sized allografts for an optimal outcome in these patients inspired Roe and his colleagues, which includes Leo A. Pinczewski, MD, to investigate this technique.
The mean graft diameter was 7.2 mm. Surgeons used 15 four-strand grafts, six three-strand grafts and eight two-strand grafts in the 29 patients who reached the 2-year follow-up, at which time the radiographs showed open growth plates in 14 patients and closed growth plates in 11 patients.
At the last follow-up, 24 donors reported no donor site morbidity and five donors had mild symptoms. “Twenty-eight of 29 donors would undergo the same procedure in the same circumstances,” Roe said. – by Susan M. Rapp
- References:
- Goddard M. Am J Sports Med. 2013; doi:10.1177/0363546512473576.
- Roe JP. Paper #38. Presented at: International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine Congress; May 12-16, 2013; Toronto.
- For more information:
- Justin P. Roe, FRACS, can be reached at North Sydney Orthopaedic & Sports Medicine Centre, Suite 2, Mater Clinic, Rocklands Rd., North Sydney NSW 2060, Australia; email: jroe@nsosmc.com.au.
Disclosure: Roe receives research or institutional support from Stryker.
Perspective
Back to TopFreddie H. Fu, MD, DSc(Hon), DPs(Hon)
Hamstring autografts in children can be of insufficient size for use after harvest. While the majority of grafts in this study measured less than 8-mm diameter, a low failure rate was reported. Use of a living donor depends on a countrys health care and insurance system. Thus, depending on these factors, and when allograft tissue is not available, this represents one potential alternative. Reconstruction with autogenous grafts, such as iliotibial band and quadriceps tendon, has also shown good results. Clinical studies comparing these grafts are necessary to justify living-donor morbidity.
Perspective
Back to Top
Philippe Beaufils, MD
This paper is very questionable. Ethically speaking, it is difficult to accept harvesting a hamstring tendon in a live patient knowing the potential detrimental effect it has (muscle strength, neural injury, etc). We must remember ACL reconstruction is only done to restore function.
However, allografts or living donor grafts could be accepted if we did not have the currently available possibilities for good and reliable autograft in children. The last point, which is important, is that this study does not demonstrate any superiority since it is a single arm study. The results given are more or less comparable to those obtained with autografts in terms of function and iterative tear. Truly, this technique poses an ethical question; a comparative study would have been mandatory. Therefore, I cannot support the investigators proposal.
Perspective
Back to TopDavide E. Bonasia, MD
In recent decades, sports medicine surgeons observed an increased incidence of ACL rupture in pediatric patients. Unstable knees may predispose to further meniscal and chondral injuries. For this reason, ACL reconstruction in this population should be considered. Common concerns regarding the procedure include ACL re-rupture and lower limb growth disturbances. In this well-designed study, the authors describe the results of anatomic ACL reconstruction in children using living donor hamstring tendon allografts harvested from the patients parents. The main limitation of this study is the heterogeneity of the study group in terms of age, Tanner stage and graft fixation techniques. However, having a homogeneous study group with this population of patients is almost impossible. In addition, the readers would like to learn about the safeness of the surgical procedure in young children with open physes mostly regarding growth disturbances and limb malalignment. Although the authors did not evaluate long leg radiographs in this study, they addressed this issue in a previous paper. In my opinion, the described technique is a valuable, ethical and cost-effective treatment option in pediatric patients with ACL rupture.
Reference:
Hui C. Am J Sports Med. 2012; doi:10.1177/0363546512438508.
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