Scientific Article   |    
Transepiphyseal Replacement of the Anterior Cruciate Ligament in Skeletally Immature Patients A Preliminary Report
Allen F. Anderson, MD
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Investigation performed at the Tennessee Orthopaedic Alliance/The Lipscomb Clinic, Nashville, Tennessee

Allen F. Anderson, MD
Tennessee Orthopaedic Alliance/The Lipscomb Clinic, 4230 Harding Road, Suite 1000, Nashville, TN 37205. E-mail address: andersonaf@ortholink.net

The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

J Bone Joint Surg Am, 2003 Jul 01;85(7):1255-1263
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Background: Fear of iatrogenic growth disturbance has prevented the routine use, in children, of anatomic methods of anterior cruciate ligament replacement that have proven successful in adults. To minimize the risk of growth disturbance, extra-articular or modified physeal sparing procedures have been performed to stabilize the knee, but these procedures do not provide isometry. This study was performed to evaluate the results of a transepiphyseal replacement of the anterior cruciate ligament in skeletally immature athletes.

Methods: From 1993 to 1999, twelve patients with a mean age (and standard deviation) of 13.3 ± 1.4 years underwent replacement of the anterior cruciate ligament with a quadruple hamstring tendon graft performed with an arthroscopic technique and intraoperative fluoroscopic imaging for precise tunnel placement. The femoral and tibial tunnels went through the epiphyses but avoided the physes. Eight of the twelve patients also had a meniscal repair. All patients returned for follow-up, at a mean of 4.1 ± 1.9 years (range, two to 8.2 years) after surgery.

Results: The mean amount of growth from the time of surgery to the time of follow-up was 16.5 ± 10.0 cm (range, 8 to 38 cm). The difference between the lengths of the lower limbs, as measured on orthoradiographs, was not clinically relevant. The mean score on the International Knee Documentation Committee (IKDC) subjective knee form was 96.5 ± 4.4 points (range, 86 to 100 points). Ligament laxity testing with a KT-1000 arthrometer revealed a mean side-to-side difference of 1.5 ± 1.1 mm. The rating according to the criteria of the objective 2001 IKDC knee form was normal for seven patients and nearly normal for five.

Conclusions: Transepiphyseal replacement of the anterior cruciate ligament, a technically demanding procedure with a small margin of error, should be attempted only by accomplished knee surgeons. The preliminary results in this small series, however, demonstrate that this surgical technique can be performed in prepubescent patients with efficacy and relative safety.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

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    Allen F. Anderson, MD
    Posted on August 20, 2010
    Dr. Anderson responds to Dr. Parikh
    Tennessee Orthopaedic Alliance/The Lipscomb Clinic, Nashville, Tennessee

    I appreciate Dr. Parikh’s thoughtful questions regarding transepiphyseal ACL reconstruction.

    Dr. Parikh's first question concerns the safety of this technique for children in Tanner stage 1 of sexual maturity. Unfortunately, the orthopedic literature is significantly deficient in both age-specific basic science on the effects of physeal injury and clinical studies demonstrating the safety of different surgical techniques used to reconstruct the ACL in pediatric patients. Although the methods of treatment remain controversial, it is widely accepted that the consequences of iatrogenic growth disturbance, should they occur following ACL reconstruction, are greater for younger children. Consequently, my bias in the presence of this uncertainty is to treat high-risk, prepubescent patients in Tanner stages 1 or 2 and intermediate-risk patients in early Tanner stage 3 with this “physeal sparing” procedure. I have performed 50 transepiphyseal ACL reconstructions, 31 of which were in Tanner stages 1 or 2. I have observed no growth disturbances, and the youngest patient was an 8-year-old male. It seems logical to me that this procedure would be as safe in a 5-year-old as it is an 8-year-old, although I have no experience to support this assumption.

    Dr. Parikh also asked how transepiphyseal ACL reconstruction is performed in younger children. I use the same technique in younger children as I use for older patients with an ACL tear prior to tibial tubercle ossification. In the paper, I emphasized the presence of the tibial tubercle apophysis only because the illustrative case was an older child. Even so, it is important to remember that rotation of the C-arm fluoroscope will show the position of the guide pin more distinctly. In pubescent children with ossification of the tibial tubercle, the guide pin may appear to be transgressing the apophysis when viewed with the C-arm in the lateral plane.

    I agree with Dr. Parikh's opinion that the height of the tibial epiphysis is of concern when performing this procedure. I have not measured, nor do I have a minimum criteria for, tibial epiphyseal height. However, I think the more important factor is the height of the epiphysis relative to the size of the drill bit being used, and not the height of the epiphysis. The smallest appropriate drill bit should be used to minimize the potential for physeal injury. Consequently, both ends of each of the hamstring tendons are sutured together with a single #2 Fiberwire rather than using a Fiberwire in each end of both tendons. This technique decreases the tendon suture mass that must be pulled into the tibial hole. Ironically, tibial epiphyseal height is less of a concern in younger children because they have greater epiphyseal height relative to the size of their quadruple hamstring tendons.

    The basic science literature on the effects of graft tension illustrates why Dr. Parikh’s concern about iatrogenic growth disturbance caused by compression of the physis after screw-post fixation is valid. There may be several explanations for why growth disturbance is not being caused by the metaphyseal graft fixation used in our technique. First, it is difficult to tie the sutures with enough tension to inhibit longitudinal growth. Second, the creep and decreased stiffness of this method of fixation makes it more forgiving. More importantly, the graft maintains some cellular viability and it undergoes biomechanical and histological transformation that is related to the mechanical and biochemical environments. Stretching of the graft, without revascularization and remodeling, would result in failure of the reconstruction or a growth disturbance caused by a tethering effect. Again, we have observed no growth disturbances in our series. Consequently, it may be reasonable to presume that the graft progresses through the stages of maturation and continues to grow until skeletal maturity.

    Finally, Dr. Parikh asked why an alternative method of fixation, like an interference screw, is not used in the tibial tunnel. We initially considered interference screw fixation as a method to secure the graft to both the femur and tibia. Our primary reason for rejecting this method of fixation was due to the concern that the screw might compress the physis and cause growth disturbance. Additionally, without drilling a transphyseal hole, an epiphyseal screw would have to be used on the tibial side. The retro screw technique, an even more demanding procedure, requires drilling a guide pin through the tibial physis. Although not optimal, screw-post fixation is technically easier and, in my experience, it is safe and effective for ACL reconstruction in the pediatric age group.

    Shital N. Parikh
    Posted on July 23, 2010
    How Young is Too Young?
    Division of Pediatric Orthopaedic surgery, Cincinnati Children's Hospital Medical Center, Ohio

    To the Editor:

    The article,"Transepiphyseal Replacement of the Anterior Cruciate Ligament in Skeletally Immature Patients: A Preliminary Report", by Anderson describing the preliminary results of transepiphyseal ACL reconstruction in skeletally immature patients has been a great contribution (2003;85:1255-63). However there are two issues that could be addressed by the author for clarification regarding the use of this technique in younger patients. These issues are even more relevant now, as the rate of midsubstance ACL tear in prepubescent children is increasing.

    The author describes the use of biologic age (including Tanner stage) as an indication for surgery. In their report of 12 patients, there were three patients in Tanner stage 1, four patients in Tanner stage 2 and five patients in Tanner stage 3. For Tanner staging, the attainment of certain secondary sexual characteristics marks the onset of Tanner stage 2, and all patients who have not reached Tanner stage 2 are considered Tanner stage 1 (from birth till Tanner stage 2). Similarly, once a person has reached Tanner stage 5, they remain in that stage throughout their adult life (1-3). Though the author has identified Tanner stage 4 and above as a contraindication for this procedure, they have not defined the lower age limit. Does that mean that the author views the technique to be safe in any child who is in Tanner stage 1 (which could mean a child 7 years old)?

    If skeletal age is taken into consideration, the landmark for placement of tibial guide pin, according to the described technique, is to identify the tibial tubercle apophysis in profile. However the tibial tubercle apophysis does not start to ossify until skeletal age 12.5 yrs in males and skeletal age 9.5 yrs in females (4). Since the author has not used skeletal age in defining the lower threshold for their patients, how does the author use his technique in absence of tibial tubercle ossification? The most important factor in determining the safety and feasibility of an epiphyseal tibial tunnel placement should be the height of the tibial epiphysis (5). Do the authors measure or have minimum criteria for tibial epiphysis height under which they would not recommend to drill through the tibial epiphysis?

    The author uses a screw-post fixation below the tibial physis for attachment of their graft. Though they do acknowledge suture slippage as a limitation of this fixation, there are other issues which have been concerning in the literature, like tethering of the physis, compression on the perichondrial ring and growth disturbances according to Heuter-Volkman law (6,7). Though the author has not identified any growth disturbances, why would they not consider an alternate method of fixation like an interference screw in the tibial tunnel?

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.


    1. Marshall WA, Tanner JM. Variations in pattern of pubertal changes in girls. Arch Dis Child. 1969;44:291-303.

    2. Marshall WA, Tanner JM. Variations in the pattern of pubertal changes in boys. Arch Dis Child. 1970;45:13-23.

    3. Tanner JM, Whitehouse RH. Clinical longitudinal standards for height, weight, height velocity, weight velocity, and stages of puberty. Arch Dis Child. 1976;51:170-9.

    4. Pyle SI, Hoerr NL. Radiographic atlas of skeletal development of the knee; a standard of reference. Springfield: Charles C. Thomas; 1955.

    5. Lawrence JT, Bowers AL, Belding J, Cody SR, Ganley TJ. All-epiphyseal anterior cruciate ligament reconstruction in skeletally immature patients. Clin Orthop Relat Res. 2010;468:1971-7.

    6. Edwards TB, Greene CC, Baratta RV, Zieske A, Willis RB. The effect of placing a tensioned graft across open growth plates. A gross and histologic analysis. J Bone Joint Surg Am. 2001;83:725-34.

    7. Gelbke H. The influence of pressure and tension on growing bone in experiments with animals. J Bone Joint Surg Am. 1951;33:947-54.

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