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Clinical Features, Debates & Research / Débats, recherche et articles cliniques
Paediatric ACL Reconstruction An introduction to this edition’s debate
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nee injuries in the paediatric population are being progressively diagnosed and treated. Due to increased early sports specialization and more intense training, injuries such as anterior cruciate ligament (ACL) ruptures are being sustained by younger patients. Consequently, determining the best surgical technique to stabilize the knee while preserving normal growth potential is important. In this edition’s
debate, experts from the University of Toronto and McMaster University discuss the best surgical strategies for ACL reconstruction in the paediatric population. Femi Ayeni, M.D., FRCSC Scientific Editor, COA Bulletin
Transphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients Ryan O’Shea, M.D. Clinical Fellow Hospital for Sick Children University of Toronto Lucas Murnaghan, M.D., MEd, FRCSC Fellowship Program Director, Division of Orthopaedics Assistant Professor, Department of Surgery Hospital for Sick Children and Women’s College Hospital University of Toronto Toronto, ON
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anagement of anterior cruciate ligament (ACL) injuries in patients with open physes is challenging and raises the concern of growth disturbance. It is important to note that not all paediatric ACL injuries are created equal; as patients with more growth remaining generate greater concern for a potential growth disruption. In skeletally immature patients, the surgeon must consider the physiologic age of the patient to select the appropriate surgical reconstruction technique with minimal complications.
Physeal-sparing techniques are usually reserved for younger patients (Tanner stages 1-2) and include the Micheli-Kocher and the all-epiphyseal ACL reconstruction techniques7,8. The Micheli-Kocher method uses the iliotibial band for combined intra- and extra-articular reconstruction9, and the all-epiphyseal reconstruction method involves drilling bone tunnels confined to the epiphysis10. Alternatively, the transphyseal technique involves drilling across the femoral and tibial physes11. A partial transphyseal technique is a hybrid of physeal-sparing and transphyseal approaches and involves drilling across either the distal femoral or proximal tibial physis on one side and using a physeal-sparing technique on the opposite side7. Consider this scenario: A 12-year-old female presents to the clinic with a one-year history of symptomatic knee instability after a non-contact soccer injury. She is healthy, premenarchal, and her mother explains she hasn’t yet hit her “growth spurt.” On physical exam, she has full range of motion, a positive pivot shift, and a positive Lachman. Radiographs demonstrate open physes and an MRI reveals a complete ACL tear in conjunction with a posterior horn medial meniscus tear (Figure 1).
Historically, paediatric patients with ACL injuries were initially treated nonoperatively with management focused on activity modification, bracing, and physiotherapy. Nonoperative management has now largely fallen out of favour due to the risk of recurrent instability1,2, secondary meniscal tears1,3, chondral injuries3,4, and cessation of sport participation5. Multiple studies have demonstrated a superior clinical result with surgical treatment of ACL injuries in the skeletally immature population2,5,6. The treatment paradigm for ACL ruptures in skeletally immature patients has now shifted toward operative intervention to restore knee stability, prevent secondary intra-articular injury, and facilitate return to sport. Various techniques for ACL reconstruction in the paediatric population have been described and are generally categorized as: physeal-sparing, partial transphyseal, or complete transphyseal techniques.
COA Bulletin ACO - Winter / Hiver 2016/2017
Figure 1 A, B: Radiographs of a 12-year-old female with an ACL injury and open physes. C, D: Representative coronal and sagittal MRI slices demonstrating an ACL injury.